OBJECTIVES: The Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide. SETTING: A cross-sectional global survey. PARTICIPANTS: Key stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included. PRIMARY OUTCOMES: Primary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries. RESULTS: 160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries. CONCLUSION: Significant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

Bhumirajanagarindra Kidney Institute Bangkok Thailand

Centre for Kidney Disease Research The University of Queensland Saint Lucia Queensland Australia

Centre for Transplantation and Renal Research Westmead Institute for Medical Research Westmead New South Wales Australia

Department of Community Health Sciences University of Calgary Calgary Alberta Canada

Department of Infection Inflammation and Immunity University of Leicester Leicester UK

Department of Intensive Care Austin Health Heidelberg Victoria Australia

Department of Internal Disease and Nephrology North Western State Medical University named after 1 I Mechnikov Sankt Peterburg Russia

Department of Internal Medicine Saint Louis University Saint Louis Missouri USA

Department of Internal Medicine The Specialty Hospital Amman Jordan

Department of Medical Informatics Academic Medical Center University of Amsterdam Amsterdam Netherlands

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

Department of Medicine King Chulalong Memorial Hospital Bangkok Thailand

Department of Medicine Monash University Clayton Victoria Australia

Department of Medicine University of Alberta Faculty of Medicine and Dentistry Edmonton Alberta Canada

Department of Medicine University of Hong Kong Hong Kong Hong Kong

Department of Nephrology Charles University Praha Czech Republic

Department of Nephrology Kidney Foundation Hospital and Research Institute Dhaka Bangladesh

Department of Nephrology Monash Medical Centre Clayton Clayton Victoria Australia

Department of Nephrology St Michael's Hospital Toronto Ontario Canada

Dialysis Unit CASMU IAMPP Montevideo Uruguay

Division of Nephrology and Hypertension University of California Irvine Medical Center Orange California USA

Division of Nephrology and Immunology University of Alberta Edmonton Alberta Canada

Division of Nephrology and Immunology University of Alberta Faculty of Medicine and Dentistry Edmonton Alberta Canada

Division of Nephrology Bezmialem Vakif Universitesi Istanbul Turkey

Division of Nephrology University of British Columbia Vancouver British Columbia Canada

Division of Nephrology University of Toronto Faculty of Medicine Toronto Ontario Canada

Faculty of Biology Medicine and Health The University of Manchester Manchester UK

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

George Institute for Global Health New Dehli India

Hasheminejad Kidney Center Iran University of Medical Sciences Tehran Iran

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

Intensive Care Nephrology and Transplantation Department Assistance Publique Hopitaux de Paris Paris France

Kidney Research Center Chang Gung University College of Medicine Taoyuan Taiwan

Medicine University of Alberta Edmonton Alberta Canada

Medicine University of Cape Town Cape Town South Africa

Metro South Integrated Nephrology and Transplant Services Princess Alexandra Hospital Woolloongabba Queensland Australia

Monash Health Clayton Victoria Australia

Nephrology Development Clinical Center Tbilisi State Medical University Tbilisi Georgia

Nephrology Memphis VA Medical Center Memphis Tennessee USA

Oxford Kidney Unit Oxford University Hospitals NHS Trust Oxford UK

Population Health Sciences University of Bristol Bristol UK

Renal Division Peking University 1st Hospital Peking University Institute of Nephrology Beijing China

Salford Royal Hospitals NHS Trust Salford UK

The George Institute for Global Health Newtown New South Wales Australia

Urinary Tract Diseases Department University of Hassan 2 Casablanca Faculty of Science Ain Chock Casablanca Morocco

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Inequities in kidney health and kidney care

National health policies and strategies for addressing chronic kidney disease: Data from the International Society of Nephrology Global Kidney Health Atlas