Expanding Home-Based Renal Care: Policy Recommendations for Peritoneal Dialysis in India

India faces a substantial treatment gap in end-stage renal disease (ESRD), with over 90% of patients lacking access to renal replacement therapy (RRT). The national reliance on in-center haemodialysis (HD) creates a resource-intensive, urban-centered model that limits equity for rural and pediatric populations, necessitating a shift toward home-based Peritoneal Dialysis (PD).

This policy paper sought to develop practical, evidence-based recommendations to increase PD access in India. The methodology comprised two stages: first, a comprehensive desk review was conducted, involving a systematic search of academic databases and government publications for policies, clinical studies, and economic analyses relevant to PD in the Indian context. Second, these findings were meticulously triangulated with expert insights derived from a semi-structured stakeholder consultation. This consultation brought together 23 nephrology experts and practitioners from nine different states for a focused discussion on predefined themes, specifically targeting systemic barriers in financing, infrastructure, workforce training, and quality assurance. This approach ensured the final recommendations were both clinically supported by evidence and practically grounded in real-world implementation challenges across diverse regional healthcare settings, allowing for the formulation of a comprehensive policy roadmap.

The stakeholder review identified three deeply interconnected systemic barriers contributing to the PD utilization rate remaining below 6%: 1) Policy and Financial Obstacles: A lack of harmonization between PD’s continuous, home-based nature and existing fragmented government schemes and private insurance models. This is exacerbated by high out-of-pocket monthly costs, which can reach $570–$700 USD, and economic disincentives for providers who favor revenue generated from facility-based HD sessions. 2) Workforce and Training Deficits: A significant gap was noted across the entire healthcare spectrum, starting with minimal PD training in MBBS and MD curricula. This deficit extends to specialist training, where postgraduate DM and DNB programs often lack mandatory procedural competence for PD catheter insertion, leaving new nephrologists unprepared or reluctant to offer the modality in practice. 3) Logistical and Quality Challenges: The absence of a mandatory National PD Registry prevents the collection of transparent, local data on peritonitis rates and technique survival, which consequently allows the widespread and persistent misconception that “peritonitis is inevitable” to remain unchallenged, further depressing patient choice and adoption.

Addressing the challenges of access and sustainability requires a decisive, coordinated national response. We recommend five integrated policy actions, supported by global PD-first models: 1) Reform financing by integrating a comprehensive, bundled monthly payment package under PM-JAY. 2) Mandate PD training and national certification for all relevant medical and nursing personnel. 3) Optimize logistics by promoting decentralized supply chains and telemonitoring-supported hub-and-spoke models. 4) Establish a mandatory National PD Registry linked to quality reporting. 5) Mandate structured, unbiased pre-dialysis options counselling and launch peer-support campaigns to counter stigma. These actions are vital to improving equity and resilience in Indian kidney care.