Guidelines for the Use of Economic Evaluation to Inform Policies Around Access to Treatment for Kidney Failure

Kidney replacement therapy (KRT) saves lives, but they are expensive and often requires long-term, resource-intensive care. In high-income countries, about 70% of patients with kidney failure receive KRT, whereas only 2 - 21% of patients with kidney failure receive KRT in many low- and middle-income countries [1]. Without public financing, many patients are unable to afford these treatments, making government decisions on coverage critical. As countries consider different policy options for financing and delivering KRT services, they must weigh costs, health outcomes and equity considerations. Economic evaluation can show the trade-offs between cost and benefit across different policy options, which can be a powerful tool to inform decisions.

Although there is extensive guidance on economic evaluation, KRT presents challenges that generic approaches do not always address well. Unlike one-off interventions, KRT involves long-term treatment pathways where patients may transition between dialysis modalities and transplantation over time. In many low- and middle-income countries (LMICs), limited data and health system constraints further complicate analysis and decision-making. This guideline was developed to address these challenges by providing recommendations tailored to the realities of KRT policy and service delivery.

To address these challenges, this guideline provides practical, context-specific guidance on applying economic evaluation to inform KRT policy decisions in resource-constrained settings. Designed for policymakers, clinicians and analysts, the guideline was developed through umbrella reviews, Delphi panels involving health economists and 13 LMIC clinicians and policymakers, and rounds of discussion within a multidisciplinary task force. The task force comprised Thai and international experts in nephrology, health economics, health systems and policy.

This guideline walks you through a step-by-step process for designing and conducting an analysis, with recommendations on how to define the decision problem, select appropriate methods, and interpret results for policy use, while accounting for constraints commonly faced in low- and middle-income countries. Recommendations are graded as Strong, Moderate or Conditional, reflecting the strength of the underlying evidence and the extent to which recommendations are expected to apply across different contexts.

Read the full paper here: https://www.nature.com/articles/s41581-025-01000-w

References

[1] Teerawattananon Y, Chavarina KK, Phannajit J, et al. Nature Medicine Commission on dialysis policy in low- and middle-income countries. Nat Med. 2026;32:58–71. https://doi.org/10.1038/s41591-025-04084-w