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

Thailand's peritoneal dialysis (PD) policy evolution illustrates how apparent policy success can mask underlying system vulnerabilities. Between 2008 and 2021, Thailand's PD-First policy under the Universal Coverage Scheme (UCS) became an international model, expanding PD utilization from 2760 to over 25,000 patients while maintaining outcomes comparable to global benchmarks. In February 2022, the 2022 Policy removed PD-First restrictions to enhance patient choice. Within 3 years, PD utilization among incident UCS patients declined from 50% to 14%, 90-day mortality risk rose from 9% to 13%, and dialysis expenditures increased to 12% of the total UCS budget. These outcomes prompted the 2025 Reform in April 2025, following a review commissioned by the National Health Security Office and conducted by the Health Intervention and Technology Assessment Program (HITAP), with expert input from the Nephrology Society of Thailand (NST) and other stakeholders. Using aggregated national registry data across three periods-the PD-First period (2008-2021), the 2022 Policy period (2022-2024), and the 2025 Reform period (2025)-we examined utilization patterns, clinical outcomes, and fiscal impacts associated with these transitions. The temporal patterns suggest that rapid policy liberalization may expose and amplify existing capacity imbalances. Following the 2022 transition, utilization shifted toward existing hemodialysis infrastructure despite inadequate vascular surgery capacity, coinciding with reduced rates of permanent access and increased early mortality. Preliminary post-reform data show encouraging recovery, with 90-day mortality risk falling to 7%. Thailand's experience may inform countries expanding home dialysis through policy reforms, highlighting that sustainable choice requires sequenced policy liberalization, infrastructure capacity alignment, and responsive governance to maintain dialysis quality, equity, and fiscal stability.