Dialysis deserts in the Philippines: a national geospatial modeling study of dialysis services

BACKGROUND: In the Philippines, dialysis facilities are clustered in urban centers, leaving patients with Kidney Failure (KF) in rural and geographically isolated regions severely underserved. Despite a national peritoneal dialysis (PD)-first policy since 2014, a decade of implementation has not closed this gap, and no national analysis has examined whether the existing organization of dialysis services drives geographic inequities or how integrating PD could reduce them. OBJECTIVE: To assess the geographic accessibility of dialysis services and estimate potential coverage gains from integrating PD into existing hemodialysis (HD) facilities. METHODS: Facility data from government registries were combined with population and terrain inputs. Geospatial analysis used least-cost path modeling with walking speeds adjusted for KF-related functional limitations. RESULTS: In 2023, the median regional coverage within one hour of an HD facility was 67.9% (IQR: 62.4-82.6%) and within two hours of a PD facility was 51.3% (IQR: 43.2-67.6%). Coverage was lowest (36%) in Mimaropa region. Full PD integration would extend coverage to an additional 11 million people, with the largest relative gains in regions currently without any dual-modality facilities. CONCLUSIONS: Geographic inequity in KF care persists in the Philippines despite a decade of PD-first policy, exposing a gap between national financing commitments and local service reach. In settings where health insurance expansion outpaces infrastructure development, spatial inequity becomes the next frontier for reform. Integrating PD within existing HD networks offers a potential pathway to reduce travel burdens, narrow access gaps, and strengthen Universal Health Care delivery.