Nature Medicine Commission on dialysis policy in low- and middle-income countries

Abstract

The global demand for kidney replacement therapy (KRT) continues to increase, yet access remains limited in many low- and middle-income countries. Thailand has been recognized for integrating a sustainable KRT delivery model into its Universal Health Coverage scheme through a peritoneal dialysis–first (‘PD-First’) policy adopted in 2008. In 2022, the policy was revised to allow individuals to choose between hemodialysis or peritoneal dialysis as their first-line treatment. The intention was to improve patient choice and avoid high out-of-pocket costs, but the policy produced unintended consequences for the health system and patients. A Commission was convened to first assess the impact of the policy change and provide policy recommendations to the Thai government and, second, provide lessons for countries working to expand equitable access to KRT within national universal health coverage frameworks. Drawing on empirical data, the Commission—composed of Thai and international multidisciplinary experts—employed a structured deliberative process to inform policy interventions. The process and findings underscore the importance of participatory policymaking, underpinned by evidence and a systematic process, and monitoring and evaluation in managing complex policy transitions.