Jeerath Phannajit

An abrupt policy change in 2022 — allowing patients to choose between peritoneal dialysis or hemodialysis — created severe unintended consequences for the Thai health system. A multidisciplinary commission found that interacting factors in the system were overlooked and that future dialysis policies must integrate more-diverse evidence and stakeholder views, prioritizing care quality and ethics while balancing equity and sustainability.

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.

Announced in this Comment and in collaboration with Nature Medicine is the convening of the Access to Dialysis in Low- and Middle-Income Countries Commission, which will explore Thailand’s experiences with changing its dialysis coverage policy, offering lessons for other countries with universal health coverage systems.