A cost-benefit and sustainability model for high-efficiency reverse osmosis implementation in Moroccan Dialysis Centers

BACKGROUND: Standard reverse osmosis systems for hemodialysis operate at 60-75% recovery rates, wasting 25-40% of feed water as brine. This inefficiency poses a critical challenge in water-scarce regions like Morocco, where freshwater availability is projected to fall below 500 m³ per capita by 2030. METHODS: This study assessed all 437 dialysis centers across Morocco, analyzing current reverse osmosis system capacity, water rejection rates, and operating hours to calculate the potential benefits of switching to high-efficiency systems with rejection rates below 15%. RESULTS: Upgrading to high-efficiency reverse osmosis systems could reduce annual reject water by 576 850 m³ (52.4%) relative to baseline, conserve 1.92 × 106 m³ of freshwater, cut 1340 t CO₂-eq annually, and generate 13.15 million Moroccan Dirhams (MAD) (€1.2 million) in yearly savings. Comparative analysis of various manufacturers revealed investment payback periods of 8.36 years for Riv-ROS, 10.24 years for DWA-MS, and 12.11 years for Nip-Ph1, with sensitivity analyses accounting for water price fluctuations (±20%) and equipment lifespan variations, confirming Riv-ROS and DWA-MS as the best financially viable options. CONCLUSION: These findings present a compelling case for nationwide implementation, offering Morocco's healthcare sector a scalable solution to address water sustainability and operational costs while maintaining treatment quality standards. The projected 52.4% reduction in reject water and associated savings support urgent policy action to modernize hemodialysis water purification systems as a model for water-scarce regions.