Abstract
This study applies the Distributional Cost-Effectiveness Analysis (DCEA) framework to
Thailand’s dialysis policy, marking the country’s first empirical DCEA. Comparing peritoneal
dialysis (PD) and hemodialysis (HD) as case studies, this DCEA revisits Thailand’s landmark PDfirst policy (introduced in 2007 under the Universal Coverage Scheme (UCS)) which prioritized
PD for patients with end-stage renal disease (ESRD). While previous evaluations assessed
efficiency alone, this study explicitly incorporates equity considerations, demonstrating how
integrating fairness into economic evaluations can influence health policy decisions.
Specifically, building on the original 2007 cost-effectiveness analysis (CEA), this DCEA
compares PD and HD from a societal perspective, assuming uniform cost, outcome (mortality
and quality-adjusted life year (QALY)), and treatment uptake across wealth quintiles in the
base case, with additional scenario analyses exploring variations in mortality and uptake rate
by wealth. Palliative treatment serves as the comparator, reflecting the non-dialysis alternative
used in the earlier analysis.
Results from the CEA confirm that PD achieved similar or higher QALYs compared with
HD while generating cost savings, making PD the more efficient option. The DCEA findings
further reveal that health gains are greatest among the most deprived quintile whereas the
least deprived benefit least. Because PD yielded system-wide cost savings, its implementation
also increased total health opportunity across the population. Overall, PD has been shown to
be both more efficient and more equitable, with the PD-first policy delivering
disproportionately larger benefits to lower wealth groups.
Scenario analyses reinforce these findings when socioeconomic differences in mortality
were modeled, PD remained the dominant, equitable option. However, when uptake
disparities were introduced, the equity advantage diminished, highlighting that equitable policy
outcomes depended on effective implementation and targeted efforts to improve PD access
among poorer populations.
The study demonstrated that DCEA is feasible and policy-relevant in Thailand’s
context and provides a transparent framework for balancing efficiency with fairness (equity) in
health technology assessment. Despite data limitations and simplifying assumptions, the
results validate the rationale for maintaining a PD-first approach, aligning with Thailand’s
commitment to universal and equitable healthcare.
By illustrating how DCEA can quantify the distributional effects of health policies, this
study sets a methodological precedent for integrating equity into conventional economic
evaluations. Future applications across other interventions could strengthen Thailand’s
evidence base for socially just and efficiency-informed resource allocation under the Universal
Coverage Scheme.
