The Success Paradox: Thailand's dialysis policy evolution and implications for modality choice reforms.

Area of Science:

• Health Policy and Systems Research
• Nephrology
• Public Health

Background:

• Thailand's Universal Coverage Scheme (UCS) implemented a successful "PD-First" policy from 2008-2021, significantly increasing peritoneal dialysis (PD) use.
• This policy expansion achieved comparable outcomes to global benchmarks, serving as an international model for home dialysis.

Purpose of the Study:

• To analyze the impact of Thailand's PD policy transitions on utilization, clinical outcomes, and fiscal expenditures.
• To evaluate the consequences of policy liberalization and subsequent reforms on dialysis quality, equity, and sustainability.

Main Methods:

• Utilized aggregated national registry data from three distinct policy periods: PD-First (2008-2021), 2022 Policy (2022-2024), and 2025 Reform (2025).
• Examined changes in PD utilization rates, 90-day mortality risk, dialysis expenditures, and access to permanent dialysis access.

Main Results:

• The 2022 policy liberalization led to a sharp decline in PD utilization (50% to 14%), a rise in 90-day mortality (9% to 13%), and increased dialysis costs.
• Shift towards hemodialysis post-2022 revealed inadequate vascular surgery capacity, reduced permanent access rates, and higher early mortality.
• Preliminary 2025 Reform data indicate a positive trend, with 90-day mortality risk decreasing to 7%.

Conclusions:

• Rapid policy liberalization without aligning infrastructure capacity can destabilize dialysis systems, increasing mortality and costs.
• Thailand's experience underscores the necessity of sequenced policy reforms, infrastructure readiness, and adaptive governance for sustainable home dialysis programs.
• Sustainable patient choice in dialysis requires careful policy implementation that balances access, quality, equity, and fiscal responsibility.