Disease Burden and Disparities of Care for Kidney Health in the Asian Pacific Region: Summary Report From the Diversity and Equity Committee of APSN

ABSTRACT

Aim

The Diversity and Equity Committee (DEC) of the Asian Pacific Society of Nephrology (APSN) conducted a regional review to characterise disparities in kidney disease burden, healthcare access and nephrology service delivery across the Asia‐Pacific (AP) region.

Methods

A descriptive summary was compiled using national reports, registries, and expert inputs from DEC representatives. Data included kidney disease prevalence, dialysis and transplant modalities, healthcare system characteristics and disparity‐related indicators. Comparative insights were drawn across countries using structured tables and narrative synthesis.

Results

The AP region exhibits a disproportionate burden of chronic kidney disease (CKD) and kidney failure with marked heterogeneity in disease aetiology, healthcare financing, and infrastructure. High‐income countries such as Japan, Korea, Taiwan and Australia demonstrate mature universal insurance systems, comprehensive dialysis networks and national CKD prevention programs. Middle‐ and lower‐income countries—including Indonesia, Myanmar, Mongolia and parts of South and Southeast Asia—face critical challenges such as workforce shortages, limited dialysis and transplant capacity and geographic inequities. Despite these challenges, several countries have introduced exemplary models to enhance equity and sustainability in kidney care: PD‐first policies (Hong Kong, Thailand), pay‐for‐performance CKD programs (Taiwan), Kidney Health Plan 2033 (Korea), HALT‐CKD (Singapore), and ACT‐KID (Malaysia), indigenous kidney health efforts in Australia and the inclusion of additional insurance points for patient education in Japan. Persistent gaps remain in early detection, transplantation access, rural care and minority equity.

Conclusion

Kidney disease care in the Asia–Pacific region reflects both diversity and disparity. Although universal health coverage and national kidney health initiatives have improved access in many countries, substantial inequities persist across geography, income and cultural groups. The collective experiences highlight both common challenges and innovative solutions. Strengthening regional collaboration, policy‐driven efforts and sustainable workforce development are essential to achieving equitable kidney health for all.

Summary at a Glance

This report from the Diversity and Equity Committee (DEC) of the Asian Pacific Society of Nephrology (APSN) highlights the burden of kidney disease and inequities in nephrology care across the Asia‐Pacific region. Drawing on national data and expert insights from APSN member societies, it outlines substantial disparities in disease prevalence, healthcare access, and outcomes due to geographic, socioeconomic, gender and cultural factors. Despite these challenges, several countries have implemented innovative policies and programs—such as PD‐first in Hong Kong, CKD prevention incentives in Taiwan, Indigenous Transplant Initiatives in Australia and the inclusion of additional insurance points for patient education in Japan—that offer scalable solutions. The report calls to action to prioritise kidney care and underscores the urgent need for collaborative regional strategies to promote equitable, accessible and sustainable kidney health systems.

1. Disparity of Care in Nephrology

Substantial disparities are present in the burden and outcome of kidney diseases among patients of different populations [1]. The Asia‐Pacific (AP) region accounts for 60% of the world's population and has a significant proportion of global dialysis patients. According to the United States Renal Database System, six countries of the AP Region (Taiwan, Japan, Korea, Singapore, Malaysia and Hong Kong) are on the list of the top‐10 countries for prevalence of kidney failure worldwide [2]. The Asian Pacific Society of Nephrology (APSN) is composed of 22 national societies of nephrology (Australia, Bangladesh, Brunei, Cambodia, China, Fiji, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Mongolia, Myanmar, Nepal, Pakistan, the Philippines, Singapore, Sri Lanka, Taiwan, Thailand and Vietnam) with the common aim of promoting and encouraging the advancement of scientific knowledge and research in all aspects of nephrology in the AP area. The detailed kidney disease burden in 22 countries of the AP region was provided with the courtesy of members of the Diversity and Equity Committee (DEC) of APSN or retrieved from the ISN‐Global Kidney Health Atlas (Table 1, Figure 1). Genetic, environmental and sociocultural factors are some of the relevant factors affecting the disease history of kidney patients [1]. For example, carriers of APOL1 risk alleles can be found in 13%–15% of African Americans and are strongly linked to risks of Focal Segmental Glomerulosclerosis, HIV‐associated nephropathy and hypertensive kidney disease [3]. However, these gene variants are seldom present in the Asian population. Primary IgA nephropathies are most common in East Asia [4]. Chronic kidney disease of unknown aetiology (CKDu) has been emerging in Sri Lanka and India, particularly among agricultural workers and is inherent to particular environmental characteristics [5]. Urothelial cancer due to aristolochic acid exposure is related to the traditional medicine of Asian countries [6]. Table 2 summarises the most common primary diseases of kidney failure among different countries of the AP region. Other factors are included in line to affect the burden of disease. Lower‐income individuals often are prone to limited access to primary and specialty care, less health literacy and fewer resources for managing chronic illness [7]. Minority patients are less likely to be referred to a nephrologist early, receive preemptive kidney transplantation, or home dialysis options [8]. Women are less likely to receive living‐donor kidney transplants than men, even though they are equally or more likely to donate kidneys [9]. Differences in healthcare systems and insurance coverage can also contribute to delayed diagnosis, fewer treatment choices, and worse outcomes [8]. Residents of rural or underserved urban areas may have fewer nephrologists, dialysis centers or transplant programs affecting kidney care. Language barriers can also impact migrants from various cultural backgrounds, affecting treatment adherence, understanding of the disease and trust in providers [10]. Several policy innovations and scalable care models (Peritoneal dialysis, PD‐first policy in Hong Kong, national CKD prevention program in Taiwan, high‐quality dialysis care in Japan and sophisticated transplant medicine in Australia) can also inform global strategies in promoting kidney health [11]. Equitable access to sustainable and affordable kidney care is a common goal for the global nephrology community to combat the growth in kidney failure. This article aims to address discrepancies in healthcare infrastructure, key nephrology disease characteristics and pressing challenges in kidney care among most countries of the AP region. The data of the present study were selected from societies involved in the DEC of APSN. Although the information is highly selective, it remains crucial in advancing regional kidney health and fostering care quality through learning from international peers.

TABLE 1.

Overall and Gender‐specific Burden of Kidney Disease.

Country	CKD				Prevalent patients on haemodialysis				Prevalent patients on peritoneal dialysis				Prevalent patients on transplantation
	Prevalence rate (%)	Man, (%)	Women, (%)	References	Overall, n	Man, n (%)	Women, n (%)	References	Overall, n	Man, n (%)	Women, n (%)	References	Overall, n	Man, n (%)	Women, n (%)	References
Japan	20%	No data	No data	Clinical practice guidebook for diagnosis and treatment of chronic kidney disease 2024	334 653	222 930 (66.6%)	111 723 (34.4%)	2022 Annual Dialysis Data Report, JSDT Renal Data Registry	10 531	6590 (65.7%)	3444 (34.3%)	2022 Annual Dialysis Data Report, JSDT Renal Data Registry	1782	1072 (60,2%)	614 (39.8%)	Annual Progress Report from the Japanese Renal Transplant Registry: Number of Kidney transplantations in 2022 and Follow‐up Survey, https://www.jstage.jst.go.jp/article/jst/58/3/58_189/_pdf/‐char/en
Taiwan	11.9%	12.9%	11.0%	Wen CP et al., Lancet, 2008	83 020	44 542 (53.7%)	38 478 (46.3%)	2023 Annual Report of TWRDS	6713	3352 (49.9%)	3361 (50.1%)	2023 Annual Report of TWRDS	3217	1796 (55.8%)	1421 (44.2%)	2023 Annual Report of TWRDS
Australia	11%	Equal Male and females (higher in men in age 54–74 years group)	Equal Male and females (higher in men in age 54–74 years group)	Australian Institute of Health and Welfare (2024) Chronic kidney disease: Australian facts, AIHW, Australian Government, accessed 26 January 2025. Based on 2011–12 Australian Health Survey data.	12 949	7815 (60.4%)	5134 (39.6%)	ANZDATA Registry 2023 Report	2674	1655 (61.9%)	1019 (38.1%)	ANZDATA Registry 2023 Report	13 648	8368 (61.3%)	5280 (38.7%)	ANZDATA Registry 2023 Report
Hong Kong	No data	No data	No data		2462	1411 (57.3%)	1051 (47.3%)	2023 Hong Kong Renal Registry	5280	3158 (59.8%)	2122 (40.2%)	2023 Hong Kong Renal Registry	3478	1979 (56.9%)	1499 (43/1%)	2023 Hong Kong Renal Registry
Malaysia	15.5%	16.1%	18.9%	Saminathan, T.A. et al. BMC Nephrol 21, 344 (2020).	46659.0	24 589 (52.7%)	22 070 (47.3%)	31th Report of the Malaysian Dialysis and Transplant Registry 2023	6551	3367 (51.4%)	3184 (48.6)%	31th Report of the Malaysian Dialysis and Transplant Registry 2023	2101	1240 (59%)	861 (41%)	31th Report of the Malaysian Dialysis and Transplant Registry 2023
Singapore	No data	No data	No data		7745	4.427 (57.2%)	3.318 (42.8%)	Singapore Renal Registry 2022. National Registry of Diseases Office, Health Promotion Board, Singapore.	1133	588 (51.9%)	545 (48.1%)	Singapore Renal Registry 2022. National Registry of Diseases Office, Health Promotion Board, Singapore.	1611	863 (53.6%)	748 (46.4%)	Singapore Renal Registry 2022. National Registry of Diseases Office, Health Promotion Board, Singapore.
Korea	6.5%	7.4%	5.6%	Sci Rep 13, 5831 (2023)	110 443	67 370 (61%)	43 073 (39%)	2023KORDS (https://ksn.or.kr)	5253	3047 (58%)	2206 (42%)	2023KORDS (https://ksn.or.kr)	22 009	13 205 (60%)	8804 (40%)	2023KORDS (https://ksn.or.kr)
Thailand	17.5%	16.3%	18.5%	Thai SEEK study. Nephrol Dial Transplant. 2010	129 113	52.3% a	46.1% a	Thailand renal replacement therapy registry 2023	14 779	50.8% a	48.2% a	Thailand renal replacement therapy registry 2023	7555	60.7% a	39.3% a	Thailand transplantation registry 2023
Mongolia	8.68%	No data	No data	Kidney International Supplements Volume 11, Issue 2, May 2021, Pages e77‐e85	1295	757 (58.4%)	538 (41.6%)	2022 Mongolian dialysis registry	114	54 (47.4%)	60 (52.6%)	2022 Mongolian dialysis registry, Mongolian Nephrology Association www.nephrology.mn	40 (2022 incident total number)	31 (77.5%)	9 (22.5%)	Department for regulating cell, tissue and organ transplantation, Center for Health Development, Mongolia, https://hdc.gov.mn/page/139/

^a The Thailand Renal Replacement Therapy Registry only presents data stratified by gender in percentages. Missing data were attributed to the incomplete data collection during the reimbursement procedure.

FIGURE 1.

Prevalence of CKD in the 22 countries integrating the Asian Pacific Society of Nephrology. Data were provided by the Diversity and Equity Committee's representative of each society or retrieved from the ISN‐Global Kidney Health Atlas, 2023 (for Bangladesh, Brunei, Cambodia, China, Fiji, India, Indonesia, Myanmar, Nepal, Singapore, Sri Lanka, Pakistan, Philippines and Vietnam). Prevalence data is not available for Hong Kong. The red dot for Malaysia represents the overall prevalence of CKD in this country, including West and East Malaysia.

TABLE 2.

Top‐5 primary diseases of end‐stage kidney disease.

Country	Overall	Man	Women	References
Japan	1, 2, 3, 6, 5	1, 2, 3, 6, 5	1, 2, 3, 6, 5	Annual Dialysis Data Report, JSDT Renal Data Registry, 2022
Taiwan	1, 3, 2, 6, 4	No data	No data	Annual Report of Taiwan Renal Database System, 2023
Australia	1, 2, 3, 8, 4	No data	No data	Australia and New Zeeland Dialysis and Transplant Registry, 2023
Hong Kong	2, 1, 6, 3, 5	1, 2, 6, 3, 5	2,1,6,3,5	Hong Kong Renal Registry, 2023
Malaysia	1, 3, 6, 2, 7	No data	No data	Malaysian Dialysis and Transplant Registry, 2023
Singapore	1, 3, 2, 5, 9	1, 3, 2, 9, 5	1, 3, 2, 5, 9	Singapore Renal Registry, 2022
Korea	1, 3, 2, 5, 6	1, 3, 2, 5, 6	1, 3, 2, 5, 6	Korean Renal Data System, 2023
Thailand	1, 3, 6, 2, 10	No data	No data	Thailand renal replacement therapy registry, 2023
Mongolia	2, 1, 3, 5, 6	No data	No data	Mongolian dialysis registry, 2022

Note: The numbers denote disease category sorted in descending order. 1, Diabetes; 2, Glomerulonephritis; 3, Hypertension; 4, Tubulo‐interstitial disease; 5, Cystic disease; 6, Unknown; 7, Autoimmune disease; 8, Hereditary disease; 9, Obstructive uropathy; 10, Others.

2. Value and Objectives of the Diversity and Equity Committee (DEC)

The DEC of APSN is dedicated to promoting, achieving, and supporting diversity, equity and inclusion among the members of APSN.

The committee acknowledges diversity as encompassing all the differences that constitute individual identities, including variations in age, ability, career stage, gender, sexual orientation, culture, religion and socioeconomic background. It is posited that organisations comprising members with diverse skills, experiences and perspectives will benefit and succeed at both organisational and individual levels.

The APSN DEC collects and validates data on diversity and equity within APSN, and establishes and works towards achieving diversity goals for APSN leadership positions, committee membership, and speakers and moderators at educational events (Figure 2). Furthermore, the committee endeavours to encourage and support individuals from underrepresented groups to fully participate in APSN. Through these initiatives, it is anticipated that APSN's commitment to diversity will contribute to promoting the health of all individuals with kidney disease and foster organisational growth by incorporating a variety of perspectives.

FIGURE 2.

Composition of main societies of nephrology in Asian Pacific region.

3. Health System Characteristics and Disparities of Kidney Care in Different Areas of the AP Region

3.1. Japan

The Japanese Society of Nephrology (JSN) has implemented nationwide CKD countermeasures to reduce the burden of kidney failure and ensure equitable access to medical care. CKD has a very high prevalence in Japan, with an estimated 20 million patients (one in five adults). Hypertension, diabetes and ageing are the primary factors, and the proportion of elderly CKD patients continues to increase.

Japan operates a universal health insurance system established in 1961 that guarantees medical access to the entire population. Patients can freely choose medical institutions regardless of their socioeconomic status, and the high‐cost medical expense system sets upper limits on out‐of‐pocket costs based on age and income. This system, in principle, ensures equitable access without gender or racial disparity. However, regional disparities persist. Although urban areas have dense networks of medical facilities, patients in rural areas face difficulties in accessing hospitals [12].

Haemodialysis (HD) is the predominant treatment for kidney failure, accounting for more than 95% of kidney failure, whereas PD remains a minority (about 3%), and home‐HD is rare [13]. Kidney transplantation is limited, with around 2000 procedures performed annually. The low number of kidney transplants is linked to cultural and religious beliefs regarding deceased donors. The number of HD patients exceeded 340 000 in 2023, but this figure has been declining since 2022. Additionally, the number of new dialysis patients has decreased in recent years. This reflects advances in CKD management, improved control of diabetes and hypertension, and the introduction of new drug therapies, such as SGLT2 inhibitors.

The JSN regularly publishes its CKD clinical practice guidelines to provide strategies for diagnosis, drug therapy, nutritional management, and patient education; the latest version was released in 2023 [14]. Furthermore, policy measures such as reimbursing sessions for multidisciplinary patient education and kidney failure treatment choices based on shared decision‐making aim to improve disease awareness and promote better clinical choices. Furthermore, disease registries maintained by the JSN and the Japanese Society for Dialysis Therapy systematically collect information on treatment practices and outcomes related to kidney biopsies, CKD management, and kidney failure therapies. These data contribute to policy formulation and promote continuous quality improvement within the healthcare system.

Moreover, in Japan, a nation frequently affected by natural disasters, a nationwide dialysis facility network has been established for crisis management. This network enables real‐time information sharing on facility status and is actively utilised to transfer dialysis patients from disaster‐stricken areas to safe facilities, ensuring continuity of life‐sustaining therapy during emergencies.

Overall, Japan's integrated CKD strategy, grounded in universal health insurance, robust dialysis infrastructure, unique clinical practice guidelines, and continuous data‐driven improvement, provides equitable care for CKD and kidney failure patients. However, it must adapt to meet the needs arising from demographic pressures, stronger preventive measures, earlier specialist referrals, and the expansion of transplantation and home‐based therapy.

3.2. Taiwan

Taiwan launched a single‐payer nationwide health insurance (NHI) system in 1995. The main goals of NHI were to improve the efficiency of the Taiwanese healthcare system and to improve social justice by increasing healthcare coverage. This insurance system is universal and mandatory for all citizens and covers almost 99% of the population, except for prisoners or people who reside overseas. The insured are classified into six main categories based on their job and income. However, there are special programs of subsidies for low income and disadvantaged populations. The NHI is characterised by good accessibility, comprehensive disease coverage, short waiting times, low cost, and national data collection systems for planning and research. Pitfalls are short consultation times and poor gatekeeping of medical services to avoid hospital shopping [15]. Implementation of pay for performance, capitation, and bundle payment are strategies to promote the efficient use of medical resources in Taiwan.

The NHI system ensures that patients requiring dialysis or kidney transplantation receive care without copayments, alleviating financial burdens associated with kidney replacement therapy. Approximately 90% of kidney failure patients are treated with HD in Taiwan. As a small island, the patients have access to a wide network of dialysis facilities, with approximately 700 centers across Taiwan. The coverage includes vascular access management, dialysis treatment and transplantation‐related medical and surgical care, eliminating out‐of‐pocket expenses for patients. To enhance medical care quality, several national pays for performance programs were implemented in collaboration with the Taiwan Society of Nephrology since 2001 for chronic illness (for diabetes in 2001, for pre‐ESRD in 2006, early‐CKD in 2010, for Diabetic Kidney Disease in 2021). These programs have effectively promoted the multidisciplinary team care by providing financial incentives to healthcare providers, leading to enhancement of the medical management of patients and improvement of the quality of care [16, 17]. Incentives for home‐based modalities, such as PD and home‐HD have also been implemented since 2023. In addition, Taiwan's renal care system operates as a learning healthcare model, utilising the Taiwan Renal Registry Data System to collect and analyse patient data. This approach facilitates evidence‐based policy‐making and continuous improvement in patient outcomes [18]. Overall, Taiwan's integrated approaches, combining universal insurance coverage, proactive CKD management, data‐driven practices and accessible dialysis services, ensure equity of medical care for every kidney patient.

3.3. Korea

The healthcare system in South Korea operates under a single‐payer model, where the government provides universal health insurance coverage to all citizens through the NIH Corporation since 2000. Under this system, all Korean citizens are automatically eligible for health insurance benefits as long as they meet certain legal requirements such as residency status and income levels. According to income level, the Korean healthcare insurance coverage is divided into two categories based on income levels: NHI and Medical Aid. Medical Aid is provided to individuals who either have no one to financially support them or lack the ability to support themselves, and whose income is below 40% of the median income. However, a Medical Aid beneficiary can get access to all outpatient and inpatient healthcare services just like those on NHI [19].

Despite the universal coverage, there are some out‐of‐pocket costs for certain services, including certain medications, dental treatments, and elective procedures such as cosmetic surgery. Therefore, discrepancies exist in terms of non‐covered medical expenses according to socioeconomic status or income level. In addition, most tertiary hospitals are concentrated in large cities, making access to healthcare more difficult for people living in rural areas. For foreigners living in Korea who are not under the Korean healthcare insurance coverage, they have limited access to medical services because they should pay all the expenses out of pocket. The healthcare service is provided equally according to ethnicity or sex. However, unmet needs are present for the lesbian, gay, bisexual, transgender, and immunodeficiency virus (HIV) disease population. Limited hospitals and clinicians are devoted to their medical care, especially for kidney replacement therapy.

Korean government has tried to provide a good quality of medical care to all patients with kidney failure. The Health Insurance Review and Assessment Service has performed HD quality assessment regularly since 2009 and the HD unit accreditation program since 2016. High assessment rating [20], number of dialysis specialists [21] and nurse caseload [22] were factors associated with patient mortality. For PD treatment, the South Korean Ministry of Health and Welfare launched a Homecare Pilot Project for healthcare providers and patients in 2019 [23]. The program provides continuous educational consultations using a multidisciplinary team care and regular remote patient monitoring approaches and has significantly improved clinical outcomes for patients on PD.

Apart from the governmental efforts, the Korean Society of Nephrology (KSN) launched the Kidney Health Plan 2033 (KHP 2033), which aims to address the growing burden of CKD and kidney failure in Korea by focusing on prevention, slowing disease progression, especially in diabetic kidney disease, and expanding home therapy options. This initiative seeks to reduce the socioeconomic impact of kidney disease and enhance patients' quality of life [24]. The KSN also operates a national kidney failure registry named Korean Renal Data System (KORDS), covering demographic information of HD, PD and transplantation populations. These annual reports have been used to improve patient outcome such as infection control and minimal catheter use [25].

3.4. Australia

Australia's universal healthcare system, underpinned by Medicare, provides most Australians broad access to healthcare services. This is supported by a robust welfare system that ensures a safety net for vulnerable populations. However, significant disparities remain, particularly for Indigenous Australians, rural and remote populations and culturally and linguistically diverse (CALD) communities. Although Medicare covers healthcare activities, access to specialised care for chronic conditions such as CKD and kidney failure is often influenced by socioeconomic, geographic, and cultural factors.

The annual cost of CKD was estimated to be AUD$9.9 billion in Australia in 2021, equivalent to an average cost per person living with CKD (across all stages) of nearly AUD$4800 [26]. This rises to over AUD$182000 for those with stage 5 CKD, owing primarily to the high cost associated with kidney replacement therapy. The Medicare Benefits Scheme funds dialysis and transplantation services, as well as all outpatient care. Hospital care is free in public hospitals; there is a comprehensive private hospital and private outpatient system for those with self‐funded insurance. Individuals in lower income brackets or vulnerable socio‐demographic cohorts can face challenges in affording out‐of‐pocket costs for additional health care costs not covered by Medicare [27]. Geographic isolation exacerbates inequities, as rural and remote communities often lack access to nephrologists, dialysis centers, and transplantation services, leading to delays in diagnosis and care. Indigenous Australians bear a disproportionate burden of CKD and kidney failure and face systemic barriers to culturally appropriate healthcare. CALD communities, including migrant populations, encounter additional challenges such as language barriers, limited health literacy and difficulties navigating the healthcare system.

Australia has implemented several measures to ensure access to kidney care. The Pharmaceutical Benefits Scheme (PBS; https://www.pbs.gov.au/pbs/home) subsidises essential medications, including those for kidney disease, making treatments more affordable. There is excellent coverage for most essential drugs. The Support for Living Organ Donors Program provides financial assistance to living kidney donors, covering out‐of‐pocket expenses and lost income, thereby promoting living organ donation. In addition, DonateLife, Australia's organ donation agency (https://www.donatelife.gov.au/), drives national strategies to improve organ donation rates, including public awareness campaigns and hospital‐based initiatives to optimise donation processes. Programs led by peak patient organization Kidney Health Australia (https://kidney.org.au/) provide patient education and advocacy; in addition, they deliver a comprehensive national primary care education program focused on early detection and management of CKD with a focus on vulnerable at‐risk groups. Australia has a range of initiatives to support Indigenous health care, including community‐controlled health services, and The National Indigenous Kidney Transplant Taskforce (https://www.niktt.com.au/) addressing inequitable transplant rates.

3.5. New Zealand

Hospital and specialist healthcare is free for all citizens, residents and eligible visa holders in New Zealand. Patients not eligible for free health care either utilise private health care or pay for use of publicly funded services. Primary care is part funded with a co‐payment being required to see a family physician.

This funding structure leads to inequity in provision of care for patients with early CKD who do not meet the referral criteria to access specialist nephrology services. CKD has a higher incidence in Indigenous Māori and Pacific nations peoples (some of whom are not eligible for public healthcare). Māori and Pacific people have greater disadvantage with respect to socio‐economic determinants of health thus a co‐payment model for primary care unequally affects access for these groups. Māori are also more likely to live in rural and remote communities, which further exacerbates the ease of access to primary care. The incidence of kidney failure for Māori is 3 times greater than for Non Māori, Non Pacific and the incidence for Pacific people is five times that of Non Māori/Non Pacific patients [28].

New Zealand has a national drug buying organization Pharmac. Pharmac has a fixed budget determined by the central government so there are often delays in access to new medications compared with other Organisation for Economic Co‐operation and Development (OECD) countries. At present, there is no access to ns‐MRA's. The SGLT‐2 inhibitors are funded only for diabetic kidney disease.

Dialysis is available through the public health system. There is wide variation in practice patterns between dialysis units with high rates overall of home‐HD and PD. Due to the size of New Zealand and the low population density, patients may have to travel long distances or move to an urban centre to receive facility‐based HD. Kidney transplantation is available to patients who meet eligibility criteria for deceased donor transplantation using the New Zealand formal scoring system. Māori and Pacific people have lower rates of transplantation [29]. Efforts to reduce this disparity are required to provide culturally appropriate transplant work‐up pathways for recipients and live kidney donors.

3.6. Hong Kong

Healthcare in Hong Kong is a dual structure comprising of the public and private sectors. Public healthcare service is the cornerstone of Hong Kong's healthcare system, acting as a safety net for the community. The private healthcare sector provide personalised choices and more convenient services to those who are willing to pay more for private healthcare service [30]. The private sector is the chief provider of primary healthcare service, accounting for about 68% of the out‐patient doctor consultation market in Hong Kong. Secondary and tertiary care is dominated by the public sector [30].

Public healthcare services finance by the government are mainly delivered through the Department of Health (DH) and Hospital Authority (HA), under the governance of the Health Bureau [31]. DH takes care of matters related to public health, and HA manages public hospitals. The public healthcare system is accessible to all Hong Kong residents. Patients are able to receive appropriate medical care regardless of their ethnicity, gender and socio‐economic status. Hong Kong does not have a mandatory healthcare insurance program. The public healthcare system is heavily subsidised by the government, covering around 95% of the overall cost. The actual level of subsidisation varies across different services, with the highest level of subsidisation for in‐patient services at around 97% [32]. Further subsidy programs are available for the low income population.

Hong Kong's public healthcare system is comprehensive and ensures access to treatment. Challenges for public healthcare include waiting time for medical investigations, procedures and treatment, especially for chronic disease, and short doctor‐patient contact time during inpatient stays and consultations. Patients who are able to afford private medical care may have more options in this regard. Language barrier is another concern when one considers the readiness of minority groups to receive healthcare. Chinese and English are the main languages of use in the public sector. Ethnic groups with language barrier may be disadvantaged in terms of receiving healthcare information.

The Hong Kong Health Bureaus shifted the healthcare focus from curative treatment to the prevention of diseases to address the new challenges in the healthcare system brought about by an ageing population and increasing chronic disease prevalence [30]. Initiatives such as the ‘Chronic disease Co‐Care Scheme’ has been rolled out in 2023 to promote early detection and timely treatment of chronic diseases, such as hypertension and diabetes mellitus in primary care, with a vision to reduce the burden of cardiovascular disease and CKD [30].

More than 90% of renal replacement services for kidney failure patients in Hong Kong is provided by the Hospital Authority [33]. In 1985, the ‘PD‐First Policy’ was introduced by the Central Renal Committee of the Medical and Health Department in Hong Kong. The policy has been promoted by the Hospital Authority (HA) in the past 40 years as PD was found to be a more cost‐effective form of kidney replacement therapy. In 2021, there were 6909 patients on dialysis in HA with 73.6% on PD and 26.3% on HD [34]. To meet the increasing demand for kidney replacement therapy, the government engages the private sector in ‘HD Public Private Partnership Program’ (HD PPP). In addition, resources have also been placed to develop home‐HD to facilitate home‐based therapy for patients who are contraindicated for PD or when PD becomes inadequate.

Last but not least, the HA Renal Registry, an online computerised registry system, was established in 1995 by the HA Central Renal Committee. It captures data regarding all kidney failure patient under replacement therapy treated by the HA and aims to guide planning of renal service provision in Hong Kong [35].

3.7. Malaysia

Only 6% of kidney failure expenditure was spent on kidney transplantation, and the remaining 94% was spent on dialysis [36]. The Malaysian nephrology fraternity has had several national programmes since 2018, including the National Action Plan for Healthy Kidneys (ACT‐KID), launching of CKD roadshow and beyond in order to create public awareness to halt the increasing prevalence of chronic kidney disease in Malaysia [37].

The healthcare system in Malaysia can be generally divided into the public and private healthcare systems. The public system is fully funded by the Malaysian government, is open to all Malaysian citizens and consists of health clinics, primary hospitals, secondary hospitals and tertiary hospitals including university hospitals. The public healthcare system provides a wide array of services, from treatment of simple ailments to the management of complex cases requiring multidisciplinary care to all Malaysian citizens at a very minimal cost. It aims to provide healthcare services to every Malaysian citizen.

The private healthcare system in Malaysia consists of private general practitioner clinics and private hospitals. The private healthcare system is meant to provide services to everyone, including Malaysians and foreigners at own expenses or under private medical insurance schemes coverage. The various services provided in public and private healthcare systems include those nephrology‐related services.

The prevalence of CKD has increased from 9.07% to 15.48%, from in 2011 to 2018. As a result, the expenditure on kidney failure was reported to double within 6 years, from 572 million ringgit to 1.12 billion ringgit, from 2010 to 2016 [36]. Therefore, the Malaysian nephrology fraternity has several national programmes, including the National Action Plan for Healthy Kidneys (ACT‐KID), in order to create public awareness to halt the increasing prevalence of CKD in Malaysia [37].

Besides, Malaysian nephrology fraternity also intends to promote ‘PD‐Preferred’ policy to increase the uptake of PD among kidney failure patients because the low total operational cost compared to HD and better penetration rate into rural areas.

In addition, a new Malaysian Kidney Allocation System has been introduced to optimise the transplant outcomes of deceased‐donor kidney transplantation. It was designed using a mathematical scoring system to manage the waiting list for deceased donor kidney transplants instead of the use of dialysis vintage‐ based criteria.

3.8. Singapore

Singapore's healthcare system is structured around the twin philosophy of that emphasises an individual responsibility and affordable healthcare to all citizens [38]. Singapore's healthcare system offers citizens a co‐payment universal healthcare coverage system with multiple layers of financing protection. Its ‘3Ms’ healthcare financing framework of ‘Medisave’ (compulsory medical savings account), ‘Medishield Life’ (a national health insurance) and ‘Medifund’ (a national endowment fund acting as safety net) is supported by government subsidies, private insurance and non‐profit organization [39]. The ‘3Ms’ can be used to offset the cost of outpatient dialysis treatment (both HD and PD), kidney transplant, outpatient renal consultations and investigations related to CKD, and the purchases of renal‐related medications, such as erythropoiesis stimulating agents (ESAs). The Ministry of Health (MOH) offers means‐tested subsidies for community‐based dialysis for eligible citizens and permanent residents with subsidy levels based on the Monthly Per Capita Household Income (PCHI) or the Annual Value of the residential properties (if PCHI is not available). Citizens, who have bought Integrated Shield Plan from private insurance companies may receive increased coverage for dialysis treatment on top of the ‘Medishield Life’ coverage. There are several non‐profit organisations in Singapore, such as National Kidney Foundation (NKF), Kidney Dialysis Foundation, MTFA Ihsan Kidney Care and Tzu Chi Foundation, who provide further subsidies to lower co‐payment amounts for dialysis for low‐income patients, based on MOH means‐testing.

The Holistic Approach to Lowering and Tracking CKD (HALT‐CKD) is a nationwide program, which covers all public healthcare clusters at primary and tertiary care in Singapore. It was introduced and supported by the MOH in 2017. It aims to slow down CKD progression and prevent kidney failure development by systematically recruiting and tracking patients with risk factor control at the primary care level [40]. In addition, a shared care protocol for advanced CKD patients is also being established to improve collaboration between primary and nephrology services in the care of advanced CKD patients at primary healthcare [40]. Apart from these initiatives from MOH, non‐profit organisations, such as NKF, offer multiple outreach programs, such as mass media campaigns, school‐based programs, community health screenings, road shows and educational talks to educate the public on the topic of CKD [41].

3.9. Mongolia

In Mongolia, the NIH provides comprehensive coverage for kidney care, including dialysis and kidney transplantation. Specifically, the insurance fully covers healthcare costs for children, elderly individuals, and patients with disability due to chronic diseases. Notably, the costs associated with dialysis therapies, including HD and PD, as well as kidney transplantation, are entirely covered by the health insurance system, representing a significant advantage within the country's healthcare framework [42]. In the last decade, the rapid increase in patients who require kidney replacement therapy has raised the costs of healthcare services, creating a significant burden on individuals and the society's economy.

Due to the shortage of specialised nephrologists and medical professionals in rural areas, the services provided to patients with CKD or newly diagnosed kidney disorders are not appropriate, leading to delayed diagnoses and progression of the disease. The CKD is often not diagnosed at an early stage, but at a time requiring kidney replacement therapy. Additionally, insufficient education about the disease among the population contributes to a lack of awareness, prevention, and exacerbation of the disease. In recent years, the government has started to support and implement screening programs, which gives hope for future positive consequences [43].

The urgent need to increase the accessibility and capacity of medical professionals in rural areas, early diagnosis and treatment of CKD, preventive care, and improving the quality of kidney replacement therapy are the key issues facing kidney care in Mongolia.

3.10. Thailand

All Thai citizens are covered by one of three public schemes: the Civil Servant Medical Benefit Scheme (CSMBS) for government employees and dependents, the Social Security Scheme (SSS) for private‐sector employees, and the tax‐funded Universal Coverage Scheme (UCS) for everyone else. Coverage of medicines under UCS/SSS is anchored to the National List of Essential Medicines (NLEM), whereas CSMBS is generally more permissive, this design keeps access broad but can constrain some high‐cost drugs outside the NELM [44, 45]. Although Thailand has made significant progress through its universal health coverage system, disparities in access to care remain, particularly between the urban and rural areas of the country. Many patients are diagnosed with advanced‐stage CKD when therapeutic options are limited and the risk of complications is high. The primary care system is often under‐resourced and lacks structured referral pathways to nephrologists and multidisciplinary teams, resulting in fragmented care.

Thailand is at a kidney health tipping point, with CKD affecting 17%–18% of adults [46]. Thailand's kidney health promotion framework combines population‐level prevention with early detection and integrated primary care. The Ministry of Public Health's SALTS strategy (2016–2025) targets sodium reduction through food reformulation, labelling, public awareness and surveillance, reflecting WHO ‘best buys’ [47]. In 2025, the Department of Disease Control, working with the Kidney Foundation of Thailand and partners, launched a national collaborative CKD screening initiative to expand risk‐based case‐finding across health regions. Primary‐ and community‐care models such as CKDNET (Khon Kaen University with public‐health partners) leverage village health volunteers and multidisciplinary teams; trials and evaluations (ESCORT‐1/2) show integrated care can delay CKD progression in rural settings [48, 49].

Thailand has emerged as a regional leader in dialysis policy and the kidney replacement therapy policy has evolved substantially. Thailand launched PD‐First in 2008 under UCS to ensure equitable dialysis access and protect households from catastrophic costs. In 2022, rules were updated so UCS beneficiaries could choose HD or PD without out‐of‐pocket payment (‘free‐choice’ dialysis). Since then, the Thailand Kidney replacement therapy Registry Data subsequently show a sharp modality shift into HD versus PD, alongside the continued growth in dialysis infrastructure and striking rise in the number of HD centers [50]. To safeguard care standards amid this growth, nationally defined key performance indicators are used to monitor and benchmark HD‐unit quality. After further considerations, the authorities re‐emphasised a PD‐prioritised approach in 2025 emphasising the pre‐authorization and shared decision‐making, clarified it is not mandatory, and invested in automated PD capacity. Importantly, insurance coverage directly shapes the choice of modality. Beneficiaries of the Civil Servant Medical Benefit and Social Security Schemes may begin treatment with either PD or HD, whereas UCS beneficiaries require preauthorization and are expected to start with PD unless contraindicated. By guaranteeing dialysis under the National Health Security Scheme, this framework closes access gaps and ensures the clinical effectiveness and financial sustainability of ESRD care in Thailand. Prioritising PD over HD within universal health coverage promotes equity, maintains affordability, and provides a robust and cost‐effective model of care. Despite near‐universal coverage, some scheme differences still drive anaemia‐of‐CKD inequities. ESAs are fully covered for dialysis across all schemes, but pre‐dialysis ESA is reimbursed under CSMBS only (not under UCS/SSS), contributing to gaps in upstream anaemia control for non‐dialysis CKD.

Kidney transplantation began to be reimbursable under UCS since 2008, covering surgery, post‐operative care, rejection management, and long‐term immunosuppression. A fixed‐rate provider payment model was introduced to promote equitable access. Although activity has grown, supply remains constrained; the waiting list continues to outpace organ availability, underscoring a persistent pressure point for the kidney transplantation program [51].

3.11. Indonesia

Healthcare access in Indonesia has significantly improved following the introduction of the Indonesian NHI System in 2014, which had enrolled over 95% of the population by 2023 and is aiming for universal health coverage [52]. Despite this progress, access remains uneven across the archipelago due to geographical barriers, limited nephrology workforce (only 0.57 nephrologists per million population), and scarcity of dialysis centers in remote areas, forcing many patients to travel long distances for treatment and workforce limitations [53]. The Indonesian Renal Registry 2023 reported 18 210 dialysis machines serving 127 900 active HD patients versus only 2129 continuous ambulatory peritoneal dialysis (CAPD) patients (1.1%), illustrating the overwhelming dominance of HD over CAPD. Most dialysis units were privately owned (63%), followed by public hospitals (33%), military facilities (3%) and others (1%) [54].

Healthcare financing for HD in 2022 was primarily through the Indonesian NHI System, with 78% non‐subsidised, 20% government‐subsidised premiums for poor people, and only 2% out‐of‐pocket [54]. Despite near‐universal insurance coverage, vulnerable groups—including rural and eastern Indonesian populations, paediatric kidney failure patients, and socioeconomically disadvantaged communities—continue to experience delayed referrals, limited access to kidney transplantation, and inadequate local dialysis infrastructure [53, 55]. To address these gaps, the MOH launched the Uro‐Nephrology Priority Program as part of the national health system transformation agenda, aiming to strengthen early CKD detection, improve distribution of dialysis access and treatment, enhance workforce training, and improve distribution of nephrology services across underserved regions [56].

3.12. Myanmar

In Myanmar, access to healthcare is open to everyone without discrimination based on socioeconomic status, ethnicity, gender, or literacy level. Additional efforts are directed towards providing healthcare for mobile and migrant populations, such as migrant workers. National programs addressing non‐communicable diseases, including hypertension and diabetes mellitus, have contributed to combating the burden of kidney failure.

The national healthcare program covers the entire country, including kidney health initiatives [57, 58]. The healthcare system comprises primary healthcare at the village and township levels, as well as tertiary healthcare in major hospitals located in large cities. Kidney health is integrated into general healthcare services, emphasising early detection and treatment of hypertension and diabetes mellitus. Preventive measures, such as health education, are also implemented. Due to the limited number of nephrologists, kidney care is primarily delivered by general physicians, diabetologists, and nephrologists. Patients requiring specialised kidney care, including management of acute kidney injury and late‐stage kidney failure, are referred to tertiary hospitals where kidney replacement therapy is available.

Sustaining CAPD remains challenging, as dialysis solutions must be imported from neighbouring countries such as Thailand, India, China and Bangladesh. Conversely, the number of HD centers has expanded in both the public and private sectors, although these are mainly located in large cities, resulting in longer travel times for patients [59]. Consequently, individuals residing in hilly or remote areas face accessibility issues, and kidney replacement therapy remains difficult for mobile and migrant populations.

Kidney transplantation using living donors has been performed successfully in Myanmar for several decades, with more than 500 transplant pairs completed to date [60]. Efforts are currently underway to establish a deceased donor transplantation program.

3.13. Nepal

Nepal has an estimated population of 29.49 million [61]. Healthcare delivery in Nepal follows a mixed model involving public, private, and nongovernmental sectors. However, out‐of‐pocket expenditure remains the predominant means of financing medical care. In pursuit of universal health coverage by 2030, Nepal enacted the NHI Bill in 2017 [62, 63]. Under the NHI scheme, insured families pay an annual premium of approximately US $29 to receive up to US $1400 in coverage for services at government‐accredited hospitals. The government also provides financial assistance through the Disadvantaged Citizens Medical Treatment Fund, which subsidises care for eight chronic diseases, including CKD [63].

Since 2011, the government has progressively expanded financial support for dialysis and transplantation, leading to a rapid increase in service availability. Between 2011 and 2016, the number of HD centers increased by 223% to 42 [64], reaching 60 centers by 2021 [65]. The free HD program, launched in 2014, initially provided 1 year of coverage and was later extended to lifelong support in 2016 [64]. Haemodialysis is currently free at public hospitals and at contracted private centers reimbursed by the Ministry of Health. In 2015–2016, the government introduced support for kidney transplantation, providing approximately US $4580 per recipient for surgical expenses and a monthly subsidy of US $40 for post‐transplant medications [63]. Additional subsidies include government‐supplied CAPD fluid bags for peritoneal dialysis and local municipal assistance of about US $35 per month for patients receiving dialysis [63, 65].

The country currently has 81 trained nephrologists, including paediatric specialists, of whom approximately 75 are in active practice nationwide. Most nephrologists serve in major cities. Now, Nepal has 145 HD centers, 48 of which are located in the Kathmandu Valley, and 12 renal transplant centers, nearly all situated in Kathmandu. The Nepal Society of Nephrology has recently initiated a pilot kidney replacement therapy registry, with a comprehensive national renal registry under development.

Geographic, socioeconomic, and educational disparities contribute to pronounced inequities in access to kidney care. Dialysis services and human resources are heavily concentrated in urban centers, leaving rural and remote populations with limited access to CKD diagnosis and treatment. Individuals from lower socioeconomic or educational backgrounds exhibit lower health awareness and reduced healthcare utilisation.

Although Nepal has adopted a national policy promoting gender and ethnic equity in healthcare access, cultural and social barriers persist. Women often face obstacles that limit their use of medical services, and certain ethnic groups experience poorer health outcomes due to social determinants. A study by Singh et al. highlighted disparities in kidney transplantation, showing that women, rural residents and specific ethnic or caste groups encounter barriers to transplantation. Notably, 70% of organ donors were female, whereas only 20% of recipients were women [66].

Nepal has formally recognised CKD as a public‐health priority and is developing strategies for early detection and management. National health‐education initiatives emphasise prevention through control of hypertension and diabetes, and efforts are underway to integrate CKD screening into primary‐care services.

Despite these commendable advances, substantial challenges remain in achieving equitable, sustainable, and geographically balanced access to comprehensive kidney care across Nepal.

4. Conclusion

The key health system characteristics, barriers of kidney care and efforts in promoting kidney health of different AP countries are summarised in Table 3. Despite resource gaps and local needs specific to particular countries, the AP region plays a critical role in nephrology, both in terms of disease burden and its contributions to care model innovation. However, achieving equity in kidney care remains to be reinforced in certain sectors. Use of modern technologies, such as telemedicine, represents a novel approach to overcome geographic barriers of care. The potential strengths, weaknesses, opportunities, and threats identified from this APSN‐DEC Regional Summary Reports are described in Table 4. In parallel, the World Health Organization's formal adoption of a global resolution on kidney disease in 2025 marks a historic milestone for a paradigm shift in nephrology care worldwide. For the first time, kidney disease is explicitly prioritised at a global policy level. This opens the door for national governments to align kidney health strategies with global noncommunicable disease frameworks, shaping future implementation of equitable, data‐driven, and preventive kidney care systems. Collaborative actions that require collective efforts in advocating effective public policy, affordable health care delivery, sustainable workforce capacity, unwavering education, and research enthusiasm are central to attracting the attention of stakeholders to push kidney care forward for regional kidney health.

TABLE 3.

Examples of healthcare disparities and countrywide efforts in promoting kidney health across the AP regions.

Items	Australia and New Zealand	Hong Kong	Japan	Korea	Indonesia	Myanmar	Mongolia	Malaysia	Nepal	Singapore	Taiwan	Thailand
Healthcare system	Single payer, Medicare	Public and Private sectors	Single payer, National Insurance System	Single payer, National Insurance System (except for foreigners)	Single payer, National Insurance System	Public and private sectors	Single payer, National Insurance System	Public and Private sectors	Mixture of public, private sector and non‐government organisations	Co‐payment from national medical saving scheme, medical insurance, out‐of‐pocket, and government subsidies	Single payer, National Insurance System	Civil Servant Medical Benefit Scheme, Social Security Scheme, Universal Coverage Scheme
Barries of healthcare	Disparities of care by geographic and cultural in indigenous and remote population Linguistic barriers	Disparities on waiting time for medical services geographical area, influenced by geographic factors Linguistic barriers •Low transplant donor	Geographic disparities on specialty service Linguistic barriers Low transplant donor	Geographic disparities on specialty service Disparities of care on minority population (LGBTQ people, HIV)	Geographic disparities on specialty service. Limited nephrology workforce Delayed referrals, Limited access to kidney transplantation •Inadequate local dialysis infrastructure	Geographic disparities on specialty service. Limited number of nephrologists PD solutions must be imported Barriers of care for mobile and migrant populations	Geographic disparities on specialty service Delay in early diagnosis Low health literacy and awareness of entire population	Urban–rural and state disparities, Shortage of staff Long waiting times Low transplantation rates and facilities High financial burden	Efforts to expanding equitable access to advanced kidney care, especially for women, rural, remote populations and low SES/education patients. Shortage of staff	Care burden due to non‐communicable disease	Short consultation time Poor gatekeeping of medical services	Geographic disparities on specialty service Shortage of staff Low transplant donor
Key kidney health promotion actions	Kidney Health Australia DonateLife National Indigenous Kidney Transplant Taskforce	PD‐first policy CKD prevention program to DM and hypertension patients	CKD prevention program	HD quality assessment and accreditation program Homecare Pilot Project KHP‐2033	Uro‐Nephrology Priority Program	Kidney health is integrated into general healthcare services, delivered by general physicians, diabetologists, and nephrologists	National CKD screening program	National Action Plan for Kidney Health (ACT‐KID)	Pilot program for national registry Health education campaigns focusing on control of CKD risk factors Integration of CKD screening into primary healthcare services.	HALT‐CKD	Pre‐ESRD program (CKD stage 3–5) Early CKD program (CKD stage 1–2) DKD program	CKD prevention programs PD‐prioritised policy HD quality assessment program

Abbreviations: CKD, chronic kidney disease; ESRD, end‐stage renal disease; HD, haemodialysis; LGBTQ, Lesbian, Gay, Bisexual, Transgender, and Queer (or Questioning); PD, peritoneal dialysis; SES, socio‐economic status.

TABLE 4.

SWOT analysis of kidney disease burden and care systems in the Asia‐Pacific Region: Insights from the APSN diversity and equity committee review.

Dimension	Key insights to achieve regional kidney health
Strengths	Strong regional leadership through APSN networks; successful model of universal health system coverage; national kidney initiatives; robust registries; multidisciplinary models; PD initiatives
Weaknesses	Intra‐regional heterogeneity; rural service gaps; low donor rates; limited resources to under‐represented population; workforce shortages; insufficient early detection and CKD prevention programs in some countries; gaps and inconsistent registry coverage across countries
Opportunities	Regional collaboration; telehealth and digital transformation; scalable prevention; NGO/industry partnerships; workforce development; increasing global attention to kidney health as an NCD priority endorsed by WHO
Threats	Ageing population and rising CKD burden; economic constraints; environmental CKD; disaster vulnerability; ongoing minority inequities

Abbreviations: APSN, Asian Pacific Society of Nephrology; CKD, chronic kidney disease; NCD, non‐communicable disease; NGO, non‐governmental organisations; PD, peritoneal dialysis; WHO, World Health Organization.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.