OBJECTIVE: To investigate policy options for the introduction of access to renal replacement therapy (RRT) under universal coverage (UC) in Thailand. METHODS: Literature reviews, secondary data analysis, in-depth interviews with stakeholders and the analysis of policy options based on the WHO manual on ethical dimensions of health resource allocation. RESULTS: The incidence rate of end-stage renal diseases (ESRD) patients requiring RRT ranges from 100 to 300 per million populations. Forecasting indicates demand for RRT would exceed 50,000 cases in year five, and 100,000 cases in year ten, if universal access to RRT is adopted. The program requires 5.5% and 24% of total UC budget in year 1 and 15, respectively. By year 15, RRT would cost 7.7% of total national health expenditure, if neither strategy to reduce the costs for RRT nor case selection is in place. This huge forecast outlay is not affordable by the country. Analysis indicates neither hemodialysis nor peritoneal dialysis was cost-effective, as their cost per life year saved were greater than 5.2 times of GNI per capita. Though not cost-effective, protecting households against financial catastrophe justifies public funding; and to be financially feasible, rationing is unavoidable. This study advocates prevention of ESRD and providing RRT to every patient, up to an age cut-off, or to every patient with a fix number of RRT years by providing more years to the younger patients is financially feasible (due to discontinuation of RRT beyond the cut off point) while observes ethical principles of providing equal chance to all patients. CONCLUSIONS:The proposed options will go through a process of national consensus in 2006, with a series of public hearing, in order to solicit public opinion on rationing through dis-continuation in view of financial constraints.