Table 1:

Overview of the tiered barriers to preventing access to PD. To achieve equitable access it is necessary to tackle every level where a problem exists.

Level	Nature of barrier	Potential solutions
High level (region/country/jurisdiction)	Lack of universal healthcare coverage for dialysis	Government to negotiate private–public partnerships that specify a proportion of PD use, or with PD manufacturers to develop PD-first or PD-preferred approaches. Avoid creating perception of PD as a second-class treatment
	High cost of PD solutions	Within-country production Development of low-cost point-of-care dialysis fluid generation
	Reimbursement models that favour private in-centre HD provision over community PD (or home HD)	Payers to negotiate reimbursement models that reflect the cost–utility benefits of PD
	No opportunity for the collective patient voice to be heard	Develop national patient organisations with the confidence and ability to influence development
	Lack of knowledge and education or lack of training opportunities	Implementation of national training curricula. Ensure that home dialysis is part of the training
Dialysis provider level	Does not provide PD	Centres must be held accountable professionally to ensure that, where feasible, all kidney replacement therapy modalities, including home dialysis and transplantation are available
	PD program very small (<20 patients) or lack of staff	Develop networks with other local providers to develop critical mass, experience (follow the example of paediatric units)
	No structured pre-dialysis education program	Centres must provide this alongside provision of the modality
	No PD-responsive services	Non-surgical routes to PD catheter insertion, urgent start PD
	No assisted PD	Develop an assisted PD program
	Poor organisation culture that does not empower patients	Multiple: Support patient empowerment and presumption of eligibility if this is what the patient wants, address unconscious bias, use decision aids, provide peer support and engage in quality improvement
Patient level	Out-of-pocket expenses	Patient/family contribution to their care should be equitable across the treatment modalities, preferably zero or adjusted to ability to pay
	Ethnic minority or more socio-economically disadvantaged	The principle of equity should be applied—more disadvantages groups will require more support. These groups may need additional support to develop trust, e.g. through employment of ethnically diverse staff or collaboration with community groups