What Independence in Dialysis Should Really Mean

I have been thinking a lot lately about what it actually means to be an independent dialysis provider in South Africa.

The word independent can create a particular picture. A small operator. A standalone unit. Perhaps a business without the infrastructure, resources or buying power of one of the large dialysis groups.

But I don’t think that is what independence should mean at all.

Independence, when it is done well, should mean being agile enough to respond to the needs of a particular community, while having strong enough systems, governance and clinical oversight to make sure that the quality of care is never dependent on the size of the organisation behind it.

It should mean having the freedom to make good decisions — and accepting the responsibility that comes with making them.

And I think there is an important conversation for our sector to have about that.

The good part of being independent

There are some things I genuinely love about working in the independent dialysis space.

We are close to our units.

We know the teams. We know many of the patients. We know when a water system is giving trouble, when a supplier has let a unit down, when a staffing arrangement is not working and when something that looks perfectly sensible on a spreadsheet simply isn’t working on the ground.

That proximity matters.

It allows an independent provider to adapt.

Not every dialysis unit operates in the same environment. A unit in a large metropolitan hospital has different challenges to a unit serving a smaller community. Staffing availability is different. Referral networks are different. Transport is different. Patient demographics are different. Even something as seemingly straightforward as getting an technician to attend to a machine issue can look completely different depending on where the unit is situated.

Independence gives us the ability to work with those realities rather than trying to force every unit into exactly the same mould.

It also creates space to innovate.

When you are close enough to the operational problems, you start looking for better ways to solve them. Better systems. Better reporting. Better communication. Better use of technology. Clearer accountability. Better ways of monitoring what is happening across a unit before a problem becomes a crisis.

Some of the best improvements we have made at Renal SA have come from very ordinary questions:

Why are we doing it this way?

Where does this information go?

Who is responsible for acting on it?

How would we know if this wasn’t being done?

Those questions are not particularly glamorous, but answering them properly is where good healthcare operations are built.

And then there is the other side of independence

Being independent also means there is nowhere for the problems to hide.

If the numbers don’t work, you have to understand why.

If a supplier fails, you have to find an alternative.

If there is a staffing problem, a reimbursement problem, a technical problem, a compliance issue or a piece of equipment that suddenly needs replacing, it is your problem to solve.

There is no enormous corporate structure sitting behind the unit absorbing every shock.

And dialysis has plenty of shocks.

It is a clinically complex service wrapped inside an equally complex operational environment. Water quality, equipment, consumables, staffing, infection prevention, clinical governance, medical oversight, stock management, billing, funders, maintenance, emergency planning and regulatory compliance all have to work together.

A beautiful dialysis unit with poor systems is still a poor dialysis service.

Excellent clinical people without operational support will eventually become frustrated.

And very good operations without proper clinical governance are simply not enough.

One of the biggest lessons we have learned over the years is that sustainable dialysis sits somewhere in the middle of all of this.

It is not only clinical.

It is not only operational.

And it is certainly not only financial.

All three have to work.

Independent should never mean isolated

Perhaps this is the distinction I feel most strongly about.

Independence should not mean trying to do everything alone.

In fact, I think strong independent providers should be exceptionally good at partnership.

We need good relationships with nephrologists and other referring doctors. We need hospitals. We need funders. We need suppliers and technical partners. We need landlords who understand the very particular requirements of healthcare facilities. We need regulators. We need excellent clinical professionals.

And increasingly, I think independent providers also need to become better at collaborating with each other.

There is room in the South African dialysis landscape for independent businesses that remain independent while sharing knowledge, systems, purchasing opportunities, technology, standards and experience.

Independence does not have to mean fragmentation.

That, for me, is an important part of what Renal SA is trying to build.

We are interested in the infrastructure that allows good dialysis businesses to remain responsive and entrepreneurial without having to reinvent every operational process themselves.

Because independence without structure can become chaos.

But structure without independence can become bureaucracy.

The interesting space is somewhere between the two.

Independence also has to mean accountability

There is another part of this conversation which perhaps receives less attention.

If independent providers want to have a meaningful place in the future healthcare system, we also have to be prepared to demonstrate that we deserve one.

That means governance.

It means data.

It means knowing what is happening in our units.

It means documented systems, proper escalation processes, financial discipline, clinical oversight and a willingness to measure ourselves against appropriate standards.

It means being able to answer an investor, regulator, hospital, funder or patient who asks:

How do you know that this unit is operating safely and effectively?

“We have good people” is not enough.

Good organisations have good people and systems that support those people to do good work consistently.

That becomes even more important as an independent provider grows.

What works when one owner knows everything happening in one dialysis unit will not work across five, ten or twenty units.

If we want an independent dialysis sector that is investable and scalable, we have to build businesses that are not entirely dependent on the person who started them.

That means systems.

That means governance.

And sometimes it means accepting that the informal way we have always done something has to change.

Then there is the uncertainty ahead

This conversation is particularly relevant now because the regulatory environment around dialysis in South Africa may be changing.

Draft Regulations relating to Renal Dialysis were published on 29 May 2026 and, at the time of writing, remain open for public comment until 27 August 2026.

Like many people in the sector, we are working through what the final regulations could mean in practice.

There are important questions around licensing, clinical supervision, staffing, reporting, accountability and how different professional roles within dialysis will be recognised.

There are also practical questions.

What will implementation look like?

How will existing units transition?

How will requirements work in parts of the country where specialist healthcare resources are already scarce?

And, importantly, how do we make sure that regulation improves the quality and safety of dialysis without unintentionally making access to dialysis more difficult?

I am strongly in favour of appropriate regulation.

Dialysis is too complex, and patients are too vulnerable, for us not to have meaningful standards.

But good regulation needs to understand the environment it is regulating.

A regulatory framework designed around what is possible in a large metropolitan healthcare network may have very different consequences when applied to an independent provider trying to deliver care in a smaller town.

We should be able to hold two thoughts at the same time:

Patients deserve consistently high standards of dialysis care.

And:

Those standards need to be implemented in a way that supports sustainable access to dialysis across South Africa.

Those ideas are not in conflict.

In fact, our challenge as a sector is to make sure they are not allowed to become so.

There is an opportunity in this

Uncertainty is uncomfortable, particularly when you are running a business and making investment decisions.

But I also think this period presents an opportunity.

It is an opportunity for independent providers to become clearer about what we stand for.

Not independence from standards.

Not independence from oversight.

Not independence from accountability.

But independence as the ability to build responsive, well-governed healthcare businesses that understand their communities and can adapt without compromising care.

For investors looking at this sector, I think that distinction matters too.

The opportunity is not simply to open more dialysis units.

The opportunity is to build the infrastructure that allows dialysis units to operate consistently, transparently and sustainably — while retaining enough flexibility to respond to the communities they serve.

That requires more than capital.

It requires operational knowledge.

Clinical understanding.

Systems.

Technology.

Governance.

Relationships.

And probably a fair amount of resilience.

What I hope independence comes to mean

My hope is that, as the South African dialysis landscape evolves, we don’t reach a point where independent becomes shorthand for small or unsophisticated.

I would like it to mean something quite different.

Responsive.

Accountable.

Innovative.

Collaborative.

Well governed.

Close enough to the patient and the unit to understand what is really happening, but structured enough to see the bigger picture.

That is the kind of independent provider we are trying to build at Renal SA.

We certainly haven’t solved every problem. I am not sure anyone operating in dialysis could honestly claim that.

But perhaps that is part of good leadership too.

To keep asking the difficult questions.

To build better systems when something isn’t working.

To learn from the units and the people closest to the work.

And to remain independent enough to change when the answer tells us that we should.