The Cost of Dialysis in Malaysia: Haemodialysis and Continuous Ambulatory Peritoneal Dialysis

Background and Context

End-stage renal disease (ESRD) represents one of the most significant and growing healthcare burdens in Malaysia and globally. As the final stage of chronic kidney disease, ESRD requires renal replacement therapy — either dialysis or kidney transplantation — to sustain life. In Malaysia, where the prevalence of chronic kidney disease has been estimated at 15.48% of the adult population, the number of patients requiring dialysis has increased dramatically over the past two decades. The Malaysian Dialysis and Transplant Registry (MDTR) has documented a steady rise in both the incidence and prevalence of dialysis-treated ESRD, driven primarily by the escalating burden of diabetes mellitus and hypertension in the population.

Two principal dialysis modalities are available: haemodialysis (HD), in which blood is filtered through an external machine typically three times per week; and continuous ambulatory peritoneal dialysis (CAPD), a home-based therapy in which dialysis solution is infused into the peritoneal cavity through a permanent catheter. Each modality has distinct clinical advantages and disadvantages, and the choice between them is influenced by medical factors, patient preference, available infrastructure, and cost considerations.

Understanding the costs associated with each dialysis modality is essential for rational resource allocation and health policy planning. In a publicly funded healthcare system such as Malaysia’s Ministry of Health (MOH) programme, where dialysis services are provided at no direct charge to eligible patients, accurate cost data enable policymakers to project future expenditure, optimise service delivery models, and assess the relative cost-effectiveness of different treatment strategies.

Study Design and Methods

This was a one-year prospective multicentre study conducted from October 2016 to September 2017 across five large MOH dialysis centres in Malaysia. The study assessed the direct medical costs of 90 HD patients and 73 CAPD patients. A mixed method combining activity-based costing (ABC) and step-down allocation was employed to ensure comprehensive and accurate cost estimation.

Capital costs comprised expenditure on land, buildings, medical equipment, and furnishings, annuitised over their expected useful life. Recurrent costs included staff emoluments, facility utilities (electricity, water, maintenance), patients’ medical costs (medications, laboratory investigations, hospitalisations), and dialysis consumables (dialysers, blood tubing, dialysis solutions, and associated supplies). One-way sensitivity analysis was performed to investigate variability in the cost estimates across different centres and scenarios.

Cost Findings: Haemodialysis

The mean annual cost per HD patient was RM 46,628 (at the 2017 exchange rate of approximately USD 1 = RM 4.30, this equated to roughly USD 10,844). Cost components varied substantially across centres, reflecting differences in patient volumes, staffing levels, facility age, and geographic location. Staff emoluments represented the single largest cost category for HD services, followed by dialysis consumables and facility overheads.

The economies of scale were evident: larger HD centres with higher annual procedure volumes achieved lower per-treatment costs. This finding has important implications for facility planning and resource allocation, suggesting that consolidation of HD services into larger, well-equipped centres may achieve greater cost efficiency than distribution across numerous smaller facilities. However, this must be balanced against considerations of patient access, travel burden, and the need for geographically distributed services in a country as geographically diverse as Malaysia.

Cost Findings: Continuous Ambulatory Peritoneal Dialysis

The mean annual cost per CAPD patient was RM 50,208 (approximately USD 11,676). While the capital cost component was lower for CAPD — reflecting reduced requirements for facility space, specialised equipment, and staffing compared to centre-based HD — the consumables cost was substantially higher. CAPD is inherently consumables-intensive, requiring daily supplies of dialysis solution bags (typically using the twin-bag system in Malaysia), transfer sets, and associated disposables. Hospitalisation costs were also higher for CAPD patients, primarily related to peritonitis episodes and catheter-related complications.

Policy Implications

The findings of this study carry significant implications for Malaysian health policy. ESRD expenditure in Malaysia has been estimated to constitute approximately 4.2% of total public sector health expenditure — a disproportionate share for a condition affecting a relatively small fraction of the population. As the number of dialysis patients continues to grow (driven by the rising prevalence of diabetes and hypertension), this proportion is expected to increase, placing additional strain on the public healthcare budget.

Previous cost-effectiveness analyses (including the landmark 2005 study by Hooi and colleagues) concluded that both HD and CAPD are economically viable, with nearly equal cost-effectiveness ratios when measured in terms of cost per life year saved. The current study provides updated cost data that reflect contemporary clinical practice, exchange rates, and resource utilisation patterns. These data can inform Markov modelling and other health economic analyses to evaluate different scenarios for expanding dialysis services — for example, increasing the proportion of incident patients initiated on CAPD versus HD.

From a systems perspective, promoting CAPD as an initial dialysis modality offers several advantages: reduced demand for centre-based infrastructure, lower staffing requirements, and greater patient autonomy. However, successful CAPD programmes require robust patient training, ongoing support, timely management of complications (particularly peritonitis), and reliable supply chains for consumables. Investment in these support systems is essential for any strategy that seeks to expand CAPD utilisation in Malaysia.

Limitations

This study assessed only direct medical costs from the MOH provider perspective. Indirect costs — including patient transportation, lost productivity, caregiver burden, and out-of-pocket expenses — were not captured. The study was limited to five MOH centres and may not fully represent costs in private sector facilities, NGO-operated centres, or smaller public hospitals. Additionally, cost comparisons between modalities should be interpreted alongside quality-of-life and clinical outcome data, which were reported in companion publications from this research programme.

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