For research to have a positive impact on people and planet and drive progress toward the Sustainable Development Goals (SDGs), it must be channelled into effective policies and implementation strategies. Analyses show that research is widely cited in SDG-relevant policy documents, but most of this research is from the global north — and this needs to change. The World Health Organization has emphasized its commitment to strengthening evidence uptake into health policies with its Global Research Agenda, launched in 2025. For our part, the Nature Portfolio is committed to publishing policy-ready research that reflects the needs of global populations.

The Nature Portfolio Commissions represent a science-driven approach to some of the world’s most urgent problems. The goal is to produce transformational change, by providing evidence-based recommendations and paths to policy implementation. The breadth of subject-matter coverage across the portfolio, from engineering to natural sciences and social sciences, puts us in a unique position to facilitate truly multidisciplinary commissions.

Thailand: a case study for dialysis policy

Our first Commission Report, published in this issue of Nature Medicine, originates from Thailand. Since introducing its Universal Health Coverage (UHC) scheme in 2001, Thailand has increased access to essential health services and reduced health-related out-of-pocket spending for its inhabitants, performing well on UHC-related SDG indicators. It is also one of the minority of low- and middle-income countries (LMICs) that have integrated dialysis policy into their UHC program.

Since 2008, Thailand has operated a policy whereby most patients are covered for home-based peritoneal dialysis (PD), and only those medically ineligible for PD are offered free clinic-based hemodialysis (HD), which is more costly. Despite some criticism for limiting patient choice, the ‘PD-first’ approach was held up as an example of sustainable dialysis policymaking. But in 2022, an abrupt change to allow patients to choose either dialysis modality led to serious unintended consequences. The number of new patients receiving HD increased far beyond expectations, as did costs and mortality rates in patients initiating HD.

The purpose of the current commission — comprising Thai and international experts — was to resolve the ongoing dialysis policy challenges in Thailand and offer lessons for other countries working to expand access to dialysis within UHC frameworks.

Dialysis policy is a global challenge

HD is among the most expensive healthcare treatments, with 2–4% of the healthcare budget typically spent on just 0.1–0.2% of the population1. This illustrates a fundamental challenge to UHC: how to ensure access to essential but high-cost treatments in resource-constrained settings. Chronic kidney disease is on the rise, and most patients with this condition are in LMICs, where access to dialysis is often limited.

In many countries, dialysis expansion outpaces the development of transplant pathways and home-based care systems, causing an over-reliance on HD and under-use of PD. Persistent misconceptions about PD safety also limit uptake. These challenges are reflected in the findings of the commission, which recommends interventions to achieve 50% PD uptake in new dialysis patients in Thailand, alongside other policy goals related to dialysis expenditure and patient education. High-income countries such as the USA and UK also struggle to increase uptake of home-based dialysis. Therefore, the findings of the commission reflect a global need for sustainable kidney care solutions — but one that is most urgent in LMICs.

The importance of integrated research-to-policy infrastructure

Thailand has embedded both health technology assessment (HTA) and evidence-based decision making within its national infrastructure. This culture of science–policy engagement has enabled the commission to tease apart the complex interactions driving the negative consequences of the current policy and to generate evidence-based recommendations to address these.

Thailand’s Health Intervention and Technology Assessment Program Foundation (HITAP) — which organized and coordinated the work of the commission — has long championed the importance of HTA in policymaking. HITAP has supported HTA development in more than 20 LMICs2 and, together with the UK National Institute for Care Excellence, co-founded the International Decision Support Initiative, to increase the value and impact of health spending.

Many middle-income countries are now investing in HTA infrastructure, recognizing that HTA and priority-setting are crucial to sustainable UHC. For example, India, Indonesia, Malaysia and Brazil have dedicated HTA bodies within their ministries of health. South Africa recently launched their Evidence to Decision initiative to build capacity for timely, responsive evidence production to support health policy-making, while Kenya has introduced regulations requiring an evidence-informed and systematic process to develop health benefit packages.

Follow the evidence

Rigorous scientific research holds the solution to many of the world’s problems, but inadequate evidence-to-policy translation is a global challenge3. Clear pathways for evidence uptake will enable health systems to navigate the challenges of shifting demographics, climate and geopolitical crises, and political agendas. The first Nature Portfolio Commission provides a roadmap for dialysis policymaking but also for systematic, future-focused evidence generation to inform healthcare decisions.