The hidden financial catastrophe of chronic kidney disease under universal coverage and Thai Peritoneal Dialysis First Policy

ObjectiveUniversal health coverage can decrease the magnitude of the individual patient's financial burden of chronic kidney disease (CKD), but the residual financial hardship from the patients' perspective has not been well-studied in low and middle-income countries (LMICs). This study aimed to evaluate the residual financial burden in patients with CKD stage 3 to dialysis in the PD First Policy under Universal Coverage Scheme (UCS) in Thailand. MethodsThis multicenter nationwide cross-sectional study in Thailand enrolled 1,224 patients with pre-dialysis CKD, hemodialysis (HD), and peritoneal dialysis (PD) covered by UCS and other health schemes for employees and civil servants. We interviewed patients to estimate the proportion with catastrophic health expenditure (CHE) and medical impoverishment. The risk factors associated with CHE were analyzed by multivariable logistic regression. ResultsUnder UCS, the total out-of-pocket expenditure in HD was over two times higher than PD and nearly six times higher than CKD stages 3-4. HD suffered significantly more CHE and medical impoverishment than PD and pre-dialysis CKD [CHE: 8.5, 9.3, 19.5, 50.0% (p < 0.001) and medical impoverishment: 8.0, 3.1, 11.5, 31.6% (p < 0.001) for CKD Stages 3-4, Stage 5, PD, and HD, respectively]. In the poorest quintile of UCS, medical impoverishment was present in all HD and two-thirds of PD patients. Travel cost was the main driver of CHE in HD. In UCS, the adjusted risk of CHE increased in PD and HD (OR: 3.5 and 16.3, respectively) compared to CKD stage 3. ConclusionsDespite universal coverage, the residual financial burden remained high in patients with kidney failure. CHE was considerably lower in PD than HD, although the rates remained alarmingly high in the poor. The PD First' program could serve as a model for other LMICs. However, strategies to minimize financial distress should be further developed, especially for the poor.

Automated summary

Universal health coverage can reduce the financial burden of chronic kidney disease for patients, but the residual financial hardship in low and middle-income countries has not been well-studied. This study in Thailand found that under the Universal Coverage Scheme, patients receiving hemodialysis had significantly higher medical expenditure compared to other stages of CKD, with travel costs being a major factor contributing to catastrophic health expenditure. Despite universal coverage, patients with kidney failure still faced high financial burden, especially in the poorest quintile.