Abstract
Background End- stage kidney disease ( ESKD) is a life- threatening condition that affects many individuals,
requiring kidney replacement therapy ( KRT) to prolong their lives. Thailand began offering KRT under the
National Health Security System in 2008. Patients with ESKD who chose peritoneal dialysis ( PD) as their first
treatment option received it at no cost, which increased access to KRT for many. However, some patients who
did not meet the criteria were required to co- pay for dialysis. By 2022, the healthcare fund revised its KRT
policy, allowing patients to claim treatment costs regardless of the dialysis method selected. This policy change
raises questions about whether it truly improves service accessibility and its potential impacts.
Objective The aim of this study is to draw lessons from Thailand’s KRT policy from 2008 to 2022 to understand
the policy environment and its operations. The findings may provide valuable insights for future policy analysis
in Thailand and other low- and middle-income countries. Additionally, the study seeks to identify factors that
support or hinder the inclusion of KRT services in the National Health Security System.
Methods This research adopts a mixed- method approach, combining both qualitative and quantitative
techniques. It is divided into five sections: a literature review, in-depth interviews and focus group discussions,
analysis of KRT service utilization data, the development of policy recommendations, and the organization of
committee meetings to learn from Thailand’ s KRT policy and draft proposals in alignment with the study’ s
objectives.
Results The 2022 KRT policy resulted in increased access to hemodialysis ( HD) , with the number of ESKD
patients rising from 50,478 to 68,238. More private- sector HD service units were established. However, the
number and rate of dialysis- related deaths, particularly within 90 days of starting HD, also increased. The
financial burden on the healthcare fund for providing KRT services grew, while the capacity to deliver PD services
declined rapidly. Financial incentives influenced nephrologists’ decisions in recommending KRT methods and
service units to patients.
Conclusion The 2022 KRT policy changes had both positive and negative impacts across medical, economic,
social, and ethical dimensions, affecting patients, healthcare facilities, and other stakeholders. While it is a
resource-intensive policy with fewer overall health benefits compared to the 2008 policy, the main advantage
is that it allows patients to choose between HD and PD, aligning with the principle of patient autonomy and
reducing disparities in access to KRT when compared to other healthcare schemes in the country.
