Achievement of equity in health requires development of a health system in which everyone has a fair opportunity to attain their full health potential. The current, large country-level variation in the reported incidence and prevalence of treated end-stage kidney disease indicates the existence of system-level inequities. Equitable implementation of kidney replacement therapy (KRT) programs must address issues of availability, affordability, and acceptability. The major structural factors that impact equity in KRT in different countries are the organization of health systems, overall health care spending, funding and delivery models, and nature of KRT prioritization (transplantation, hemodialysis or peritoneal dialysis, and conservative care). Implementation of KRT programs has the potential to exacerbate inequity unless equity is deliberately addressed. In this review, we summarize discussions on equitable provision of KRT in low- and middle-income countries and suggest areas for future research.

Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary Alberta Canada

Department of Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada

Department of Nephrology General University Hospital Charles University Prague Czech Republic

Department of Pediatrics Pediatric Nephrology Indiana University Medical Center Indianapolis Indiana USA

Department of Pediatrics University of Port Harcourt Teaching Hospital Port Harcourt Nigeria

Division of Nephrology and Hypertension Department of Internal Medicine American University of Beirut Beirut Lebanon

Division of Nephrology Department of Medicine Faculty of Medicine and Health Sciences Stellenbosch University and Tygerberg Academic Hospital Cape Town South Africa

Division of Nephrology Queen's University Kingston Ontario Canada

Faculty of Medicine and Biomedical Sciences Yaounde General Hospital University of Yaounde Yaounde 1 Cameroon

Fondazione Ricerca Molinette Regina Margherita Hospital Turin Italy

French Renal Epidemiology and Information Network Registry Biomedicine Agency Paris France

George Institute for Global Health India New Delhi India

Home Hemodialysis for Home Dialysis Al Ain United Arab Emirates

Hospital Privado Universitario de Cordoba and Instituto Universitario de Ciencias Biomédicas Cordoba Argentina

Imperial College Healthcare National Health Service Trust London UK

Institute of Biomedical Ethics and the History of Medicine University of Zurich Zurich Switzerland

Intensive Care Nephrology and Transplantation Department Hopital Tenon Assistance Publique Hôpitaux de Paris Paris France

Key Laboratory of Chronic Kidney Disease Prevention and Treatment Ministry of Education of China Beijing China

Key Laboratory of Renal Disease Ministry of Health of China Beijing China

Manipal Academy of Higher Education Manipal Karnataka India

Mount Sinai Icahn School of Medicine New York New York USA

National Health and Medical Research Council Clinical Trials Centre Faculty of Medicine and Health University of Sydney Camperdown New South Wales Australia

Nephrology Department Ghent University Hospital Ghent Belgium

NephroPlus Dialysis Centres Hyderabad India

Nuffield Department of Clinical Medicine University of Oxford Oxford UK

Otto Loewi Research Center Medical University of Graz Graz Austria

Renal Division Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA

Renal Division Department of Medicine Peking University 1st Hospital Beijing China

Renal Unit Greys Hospital Pietermaritzburg South Africa

SEHA Dialysis Services Abu Dhabi United Arab Emirates

Servicio de Nefrologia Hospital Civil de Guadalajara Fray Antonio Alcalde University of Guadalajara Health Sciences Center Hospital 278 Guadalajara Jalisco Mexico

Sorbonne Université Paris France

State Key Laboratory of Organ Failure Research National Clinical Research Center for Kidney Disease Division of Nephrology Nanfang Hospital Southern Medical University Guangzhou China

The Heart Medical Center Al Ain United Arab Emirates

Wolfson Palliative Care Research Centre Hull York Medical School University of Hull Hull UK

Comment In

Kidney Int Suppl (2011). 2020 Mar;10(1):e1-e2. doi: 10.1016/j.kisu.2019.09.001. PubMed

See more in PubMed

World Health Organization Health equity. https://www.who.int/topics/health_equity/en/ Available at:

Vandertol A., Lameire N., Morton R.L. An international analysis of dialysis services reimbursement. Clin J Am Soc Nephrol. 2019;14:84–93. PubMed PMC

Jha V., Arici M., Collins A.J., for the KDIGO Conference Participants Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2016;90:1164–1174. PubMed

Ashuntantang G., Osafo C., Olowu W.A. Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review. Lancet Glob Health. 2017;5:e408–e417. PubMed

Couser W.G., Remuzzi G., Mendis S. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011;80:1258–1270. PubMed

Swanepoel C.R., McCulloch M.I., Abraham G. Challenges for sustainable end-stage kidney disease care in low-middle-income countries: the problem of the workforce. Kidney Int Suppl. 2020;10:e49–e54. PubMed PMC

Pan American Health Organization Health Economics and Financing (HEF) Health care expenditure and financing in Latin America and the Caribbean (fact sheet), December 2012. https://www.paho.org/hq/dmdocuments/2013/FactsheetHEFJan31.pdf Available at:

World Bank Group Countries and economies. Colombia. https://data.worldbank.org/country/colombia?view=chart Available at:

World Bank Group Countries and economies. Mexico. https://data.worldbank.org/country/mexico?view=chart Available at:

Guerrero R., Prada S.I., Perez A.M. Universal health coverage assessment. Colombia. November 2015. https://www.icesi.edu.co/proesa/images/GNHE%20UHC%20assessment_Colombia%204.pdf Available at:

World Health Organization Global health expenditure database. http://apps.who.int/nha/database/Select/Indicators/en Available at:

World Bank Group Countries and economies. South Africa. https://data.worldbank.org/country/south-africa?view=chart Available at:

Mills A., Ally M., Goudge J. Progress towards universal coverage: the health systems of Ghana, South Africa and Tanzania. Health Policy Plan. 2012;27(suppl 1):i4–i12. PubMed

World Health Organization African regional health expenditure dashboard. 2017. https://www.who.int/health_financing/topics/resource-tracking/African-Regional-Health-Expenditure-Dashboard.pdf Available at:

World Bank Group Countries and economies. Thailand. https://data.worldbank.org/country/thailand?view=chart Available at:

World Health Organization Health financing profile 2017. Thailand. https://apps.who.int/iris/bitstream/handle/10665/259645/HFP-THA.pdf Available at:

World Bank Group Countries and economies. India. https://data.worldbank.org/country/india?view=chart Available at:

World Health Organization Health financing profile 2017. India. https://apps.who.int/iris/bitstream/handle/10665/259642/HFP-IND.pdf?sequence=1&isAllowed=y Available at:

Gupta I., Bathia M. The Indian health care system. https://international.commonwealthfund.org/countries/india/ Available at:

Cuenta de Alto Costo. Bogota: Fondo Colombiano de enfermedades de Alto Costo. Situacion de la enfermedad renal cronica, la hipertension arterial y la diabetes mellitus en Colombia, 2016. http://www.cuentadealtocosto.org/index.php/publicaciones Available at:

Saran R., Robinson B., Abbott K.C. US Renal Data System 2016 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2017;69(suppl 1):A7–A8. PubMed PMC

Lopera-Medina M. La enfermedad renal cronica en Colombia: necesidades en salud y respuesta del Sistema General de Seguridad Social en Salud. Rev Gerenc Polit Salud. 2016;15:212–233.

Organization for Economic Cooperation and Development OECD reviews of health systems: Mexico 2016. https://www.oecd-ilibrary.org/social-issues-migration-health/oecd-reviews-of-health-systems-mexico-2016_9789264230491-en Available at:

Frenk J., González-Pier E., Gómez-Dantés O. Comprehensive reform to improve health system performance in Mexico. Lancet. 2006;368:1524–1534. PubMed

Seguro Popular. Anexo I. Intervenciones del fondo de proteccion contra Gastos Catastroficos. 2018. http://www.seguropopularcolima.gob.mx/segpop/pdf/intervencionesGastosCatastroficos.pdf Available at:

Garcia-Garcia G., Chavez-Iñiguez J.S. The tragedy of having ESRD in Mexico. Kidney Int Rep. 2018;3:1027–1029. PubMed PMC

Davids M., Marais N., Jacobs J. South African Renal Registry annual report 2015. Afr J Nephrol. 2017;20:201–213.

Moosa M.R., Kidd M. The dangers of rationing dialysis treatment: the dilemma facing a developing country. Kidney Int. 2006;70:1107–1114. PubMed

Moosa M.R., Maree J.D., Chirehwa M.T. Use of the 'accountability for reasonableness' approach to improve fairness in accessing dialysis in a middle-income country. PLoS One. 2016;11 PubMed PMC

Equitap. Equity in financing health care: impact of universal access to healthcare in Thailand. 2005. http://www.equitap.org/publications/docs/EquitapWP16.pdf Available at:

Chuengsaman P., Kasemsup V. PD first policy: Thailand's response to the challenge of meeting the needs of patients with end-stage renal disease. Semin Nephrol. 2017;37:287–295. PubMed

Kumar V., Jha V. End-stage renal disease care in South Asia: demographics, economics, and opportunities. Clin Nephrol. 2016;86:23–26. PubMed

Essue B.M., Jha V., Oommen J. Universal health coverage and chronic kidney disease in India. Bull World Health Organ. 2018;96:442. PubMed PMC

Bradshaw C., Gracious N., Narayanan R. Paying for hemodialysis in Kerala, India: a description of household financial hardship in the context of medical subsidy. Kidney Int Rep. 2019;4:390–398. PubMed PMC

Shaikh M., Woodward M., Oommen J. Utilization, costs, and outcomes for patients receiving publicly funded hemodialysis in India. Kidney Int. 2018;94:440–445. PubMed

Rosa-Diez G., Gonzalez-Bedat M., Ferreiro A. Burden of end-stage renal disease (ESRD) in Latin America. Clin Nephrol. 2016;86(suppl 1):29–33. PubMed

Méndez-Durán A., Ignorosa-Luna M.H., Pérez-Aguilar G. Current status of alternative therapies renal function at the Instituto Mexicano del Seguro Social. Rev Med Inst Mex Seguro Soc. 2016;54:588–593. PubMed

Garcia-Garcia G., Garcia-Bejarano H., Breien-Coronado H. End-stage renal disease in Mexico. In: Garcia-Garcia G., Agodoa L., Norris K., editors. Chronic Kidney Disease in Disadvantaged Populations. Elsevier; New York, NY: 2017. pp. 77–82.

Cueto-Manzano A.M., Rojas-Campos E. Status of renal replacement therapy and peritoneal dialysis in Mexico. Perit Dial Int. 2007;27:142–148. PubMed

United States Renal Data System 2018 USRDS annual data report: epidemiology of kidney disease in the United States. https://www.usrds.org/2018/view/Default.aspx Available at: PubMed PMC

Cuenta de Alto Costo. Bogota: fondo Colombiano de enfermedades de Alto Costo. https://cuentadealtocosto.org/site/index.php/normatividad Available at:

Erk T. Success stories showing the diversity of kidney foundations: Turkish Kidney Foundation. Clin Nephrol. 2016;86:61–63. PubMed

Abraham G., Vijayan M., Ravi R. The impact of kidney foundations in alleviating the burden of CKD in India—an example, Tamilnad Kidney Research Foundation. Clin Nephrol. 2016;86(suppl 1):74–77. PubMed

Rashid H.U., Arefin S., Hasan S. The role of the Kidney Foundation of Bangladesh in promoting kidney care in a resource-limited environment. Clin Nephrol. 2016;86(suppl 1):64–68. PubMed

Carter M., Levin N.W., Carter C.S. The Sustainable Kidney Care Foundation's contribution to the improvement of AKI management in developing countries using peritoneal dialysis. Clin Nephrol. 2016;86:78–83. PubMed

Luyckx V.A., Miljeteig I., Ejigu A.M. Ethical challenges in the provision of dialysis in resource-constrained environments. Semin Nephrol. 2017;37:273–286. PubMed

Etheredge H., Paget G. Ethics and rationing access to dialysis in resource-limited settings: the consequences of refusing a renal transplant in the South African State sector. Dev World Bioeth. 2015;15:233–240. PubMed

Keliddar I., Mosadeghrad A.M., Jafari-Sirizi M. Rationing in health systems: a critical review. Med J Islam Repub Iran. 2017;31:47. PubMed PMC

Andrade M.V., Junoy J.P., Andrade E.I. Allocation of initial modality for renal replacement therapy in Brazil. Clin J Am Soc Nephrol. 2010;5:637–644. PubMed PMC

Feehally J., Brusselmans A., Finkelstein F.O. Improving global health: measuring the success of capacity building outreach programs: a view from the International Society of Nephrology. Kidney Int Suppl. 2016;6:42–51. PubMed PMC

Calvillo-Arbizu J., Roa-Romero L.M., Estudillo-Valderrama M.A. User-centred design for developing e-Health system for renal patients at home (AppNephro) Int J Med Inform. 2019;125:47–54. PubMed

Bonner A., Gillespie K., Campbell K.L. Evaluating the prevalence and opportunity for technology use in chronic kidney disease patients: a cross-sectional study. BMC Nephrol. 2018;19:28. PubMed PMC

Singh K., Diamantidis C.J., Ramani S. Patients' and nephrologists' evaluation of patient-facing smartphone apps for CKD. Clin J Am Soc Nephrol. 2019;14:523–529. PubMed PMC

Topf J.M., Hiremath S. Got CKD? There's an app for that! Clin J Am Soc Nephrol. 2019;14:491–492. PubMed PMC

Stenberg K., Hanssen O., Edejer T.T. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. Lancet Glob Health. 2017;5:e875–e877. PubMed PMC

Essue B.M., Laba M., Knaul F. Economic burden of chronic ill health and injuries for households in low- and middle-income countries. In: Jamison D.T., Gelband H., Horton S., editors. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd ed. The International Bank for Reconstruction and Development/The World Bank; Washington, DC: 2017. chapter 6. PubMed

World Health Organization Making fair choices on the path to universal health coverage 2014. http://apps.who.int/iris/bitstream/handle/10665/112671/9789241507158_eng.pdf;jsessionid=8F2198910317B81AFED26226564A61E9?sequence=1 Available at: PubMed PMC

World Health Organization Americas regional health expenditure dashboard (North, Central and South America) https://www.who.int/health_financing/topics/resource-tracking/Americas-Region-Health-Expenditure-(North-Central-and-South-America)-Dashboard.pdf?ua=1 Available at:

Garcia G.G., Harden P., Chapman J., World Kidney Day Steering Committee The global role of kidney transplantation. Lancet. 2012;379:E36–E38. PubMed

Correa-Rotter R. The cost barrier to renal replacement therapy and peritoneal dialysis in the developing world. Perit Dial Int. 2001;21(suppl 3):S314–S317. PubMed

Kaur G., Prinja S., Ramachandran R. Cost of hemodialysis in a public sector tertiary hospital of India. Clin Kidney J. 2018;11:726–733. PubMed PMC

Hole B., Hemmelgarn B., Brown E. Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the world. Kidney Int Suppl. 2020;10:e86–e94. PubMed PMC

Tantivess S., Werayingyong P., Chuengsaman P. Universal coverage of renal dialysis in Thailand: promise, progress, and prospects. BMJ. 2013;346:f462. PubMed

World Health Organization Health workforce; strategic directions. https://www.who.int/hrh/strategy/directions/en/ Available at:

Harris D.C.H., Davies S.J., Finkelstein F.O. Increasing access to integrated ESKD care as part of universal health coverage. Kidney Int. 2019;95:S1–S33. PubMed