As populations age and chronic diseases rise, health systems face growing demand for long-term, high-cost care such as kidney replacement therapy, including dialysis, as well as conservative care. These demographic shifts amplify existing inequities in access to essential treatments, particularly in low- and middle-income countries, where health systems must balance expanding coverage while ensuring financial sustainability.

Thailand’s experience with kidney replacement therapy policy reform in 2022 offers insights into this challenge, where access expansion brought significant clinical and financial implications. The Nature Medicine’s Commission for Access to Dialysis in Low- and Middle-Income Countries examines Thailand’s reform journey and policy challenges and illustrates the process of evidence generation and deliberation in making recommendations to mitigate the circumstances. The report also provides valuable lessons for the global community on advancing equitable dialysis access and strengthening evidence-informed health policy processes.

Announcement and background of the Commission can be found here: https://www.nature.com/articles/s41591-024-03448-y.

Further readings 
Below is a collection of the Commission’s published studies (as of December 2025):
•    Botwright, S., et al. Understanding healthcare demand and supply through causal loop diagrams and system archetypes: policy implications for kidney replacement therapy in Thailand. BMC Med 23(1), 231 (2025). (https://link.springer.com/article/10.1186/s12916-025-04054-6)
This paper analyzed the dynamic interactions in the Thai dialysis system to uncover the impact of the 2022 dialysis policy and propose policy solutions.
•    Yongphiphatwong, N., et al. The way home: a scoping review of public health interventions to increase the utilization of home dialysis in chronic kidney disease patients. BMC Nephrol 26(1), 169 (2025). (https://link.springer.com/article/10.1186/s12882-025-04072-9)
This review identified policy alternatives to increase the uptake and utilization of PD, which informed some policy options for this study. 
•    Chawla, N., et al. Policy strategies to enhance uptake of conservative kidney management in advanced chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 26(1), 388 (2025). (https://link.springer.com/article/10.1186/s12882-025-04297-8)
This review identified policy alternatives to increase the uptake and utilization of conservative care, which informed some policy options for this study.
•    Botwright, et al. Balancing patient choice and health system capacity: a system dynamics model of dialysis in Thailand. BMC Med 23(1), 646 (2025). (https://link.springer.com/article/10.1186/s12916-025-04522-z#citeas)
This study projected the impact of the selected policy options on the Thai dialysis system over time.