1. Demand for Renal Replacement Therapy International Health Policy Program Source: Witt K. Demand for RRT. IHPP [presentation] 2004.

2. Incidence (new cases) of end-stage renal disease (ESRD) In USA In USA 82 pmp.* in 1980 82 pmp.* in 1980 203 pmp. in 1990 203 pmp. in 1990 334 pmp. in 2001 334 pmp. in 2001 European Union (EU) European Union (EU) 120 pmp. in 1995 120 pmp. in 1995 From 68 pmp. in Finland to 163 pmp. in Germany From 68 pmp. in Finland to 163 pmp. in Germany * per million population

3. Incidence in Thailand In Thailand In Thailand From 49.4 pmp.* to 107 pmp.** in 1998 From 49.4 pmp.* to 107 pmp.** in 1998 Damrongkitchaiporn et al. 2004 reported incidence at 222 pmp. Damrongkitchaiporn et al. 2004 reported incidence at 222 pmp. * Average from 3 provinces: Songkla, Ubonrachatani, and Nakornsawan. ** in Chiengmai

4. Access to renal replacement therapy (RRT) in Thailand From Thailand Renal Replacement Therapy Registry (TRT) in 2004 From Thailand Renal Replacement Therapy Registry (TRT) in 2004 Incidence 62.5 pmp. ( 3,998 cases) Incidence 62.5 pmp. ( 3,998 cases) Prevalence 175.2 pmp (11,208 cases) Prevalence 175.2 pmp (11,208 cases) Source: Witt K. Demand for RRT. IHPP [presentation] 2004.

5. Burden of disease in Thailand From TRT report in 2004, incidence of RRT was 62.5 PMP and the proportion of non-UC population was one-fourth in 2003. From TRT report in 2004, incidence of RRT was 62.5 PMP and the proportion of non-UC population was one-fourth in 2003. Incidence should be 250 PMP. Incidence should be 250 PMP. However, some UC patients also had access to RRT, therefore 250 PMP may be a high estimation. However, some UC patients also had access to RRT, therefore 250 PMP may be a high estimation.

6. Cost of kidney transplantation (KT) Surgery cost 165,479 baht Surgery cost 165,479 baht Organ harvesting would be 50,000 baht Organ harvesting would be 50,000 baht Follow up cost 14,668 baht/visit: Follow up cost 14,668 baht/visit: 16 times in the first year 234,688 baht 16 times in the first year 234,688 baht 6 times in the following year 88,008 baht 6 times in the following year 88,008 baht Total cost in the first year Total cost in the first year 450,167 baht

7. Cost from Societal Perspective (Baht/patient/yr) HD CAPD (Baht/patient/yr) HD CAPD Medical cost 248,000 220,000 Medical cost 248,000 220,000 Non-Medical cost 65,000 6,000 Non-Medical cost 65,000 6,000 Total Cost 313,000 226,000 Total Cost 313,000 226,000

8. Cost of a program to support RRT At incidence of ESRD 150 - 250 pmp. At incidence of ESRD 150 - 250 pmp. Cost of dialysis at 250,000 baht/year Cost of dialysis at 250,000 baht/year Survival rate of dialysis patients was derived from TRT data. Survival rate of dialysis patients was derived from TRT data. Cost of a program to support all ESRD patient would be 10,000 million baht within 3-5 years and 20,000 million baht within 7-10 years. Cost of a program to support all ESRD patient would be 10,000 million baht within 3-5 years and 20,000 million baht within 7-10 years.

9. An Estimation of ESRD Patients by the Year 2024 at 150 PMP

10. An Estimation of the Number of ESRD Patients to the Year 2024 at 250 PMP

11. Cost of a Program to Support all ESRD Patient; Incidence at 150 PMP and 250,000 baht/patient

12. Cost of a program to Support all ESRD patient; Incidence at 250 PMP and 250,000 baht/patient

13. Summary Estimated burden of disease Estimated burden of disease Incidence of RRT was 62.5 PMP (3,998 cases) in 2004. Incidence of RRT was 62.5 PMP (3,998 cases) in 2004. Incidence of ESRD was estimated from 150 to 250 PMP (9,795 to 15,992 cases) in the year 2004. Incidence of ESRD was estimated from 150 to 250 PMP (9,795 to 15,992 cases) in the year 2004. Prevalence of RRT is 175.2 PMP (11208 cases) Prevalence of RRT is 175.2 PMP (11208 cases) Prevalence of RRT is estimated to be 1487 to 2479 PMP (107,003 to 178,339 cases) in the year 2024 Prevalence of RRT is estimated to be 1487 to 2479 PMP (107,003 to 178,339 cases) in the year 2024

14. Summary Financial burden Financial burden If the government intends to support all ESRD patients, the financial burden in 2020 for RRT would range from 24,068 - 40,115 million baht that are If the government intends to support all ESRD patients, the financial burden in 2020 for RRT would range from 24,068 - 40,115 million baht that are 3.8 to 6.4 % of total health expenditure (628,047 million baht in 2020) for a group of 0.2% of population (70.2 million in 2020). 3.8 to 6.4 % of total health expenditure (628,047 million baht in 2020) for a group of 0.2% of population (70.2 million in 2020). 15 to 25% of expenditure of universal coverage program (159,003 million baht in 2020). 15 to 25% of expenditure of universal coverage program (159,003 million baht in 2020).

15. Discussion What are appropriate approaches to increase access to RRT? What are appropriate approaches to increase access to RRT? Does cost-effectiveness analysis help us to answer this? Does cost-effectiveness analysis help us to answer this? Is rationing health care inevitable? Is rationing health care inevitable? If it is inevitable to ration care, how can we make it acceptable? If it is inevitable to ration care, how can we make it acceptable? Do we have other ways to choose? Do we have other ways to choose?

16. a Monetary value in US$ at year 2002