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Received: 25 November 2020    Revised: 1 February 2021    Accepted: 10 February 2021

DOI: 10.1111/ajt.16537

PERSONAL VIEWPOINT
AJT

Bold policy changes are needed to meet the need for organ
transplantation in India

Sunil Shroff1 | John S. Gill2

1
Urology and Transplantation, Madras
Medical Mission Hospital, Chennai, India
2
University of British Columbia Faculty of
Medicine, Vancouver, BC, Canada
Correspondence
John S. Gill, University of British Columbia
Faculty of Medicine, Vancouver, BC,
Canada.
Email: jgill@providencehealth.bc.ca
Twenty-­five years after India passed legislation to legalize brain death, deceased
donor transplantation remains underdeveloped while the country has established
formidable capacity for living donor transplantation. Because of a large number of po-
tential deceased donors, there is hope that deceased donation could help meet India's
enormous need for organ transplantation. However, significant policy and practical
barriers limit progress. The vast majority of potential deceased donors are poor motor
vehicle accident victims who present for care in hospitals without the necessary in-
frastructure or expertise to support deceased donation. In contrast, transplant infra-
structure and expertise are concentrated in private hospitals and are only accessible
to those with the ability to pay. Given these realities, the potential of deceased donor
transplantation can only be recognized if Indians who are likely to donate organs are
also provided access to transplantation. In this viewpoint, we review the current status
of organ transplantation in India and propose new policies to establish a national or-
ganization to oversee deceased donor services in all states, to fund resources needed
to support deceased donation, to leverage the existing living donor infrastructure to
advance deceased donor transplantation, and call for establishment of government
policy on funding for posttransplant care and immunosuppression.

1  |  I NTRO D U C TI O N only a small number of deceased donor transplants. In 2019, 88%

In 1994 Indians with end-­stage heart, lung, and liver disease were
doomed to die and only a few wealthy patients with kidney failure
could obtain a living donor transplant. In response to embarrassing
revelations about the black market in kidney transplants and the ab-
sence of extra-­renal transplantation, the Indian government passed
the Transplantation of Human Organs (THO) Act.1-­4 The THO Act
legalized brain death and made the sale of organs a punishable of-
fense. However, the passage of the THO Act was not accompanied by
government-­funded initiatives to advance development of deceased
donor programs. Unsurprisingly, transplantation in India is predom-
inantly based on living donation. Today, India performs the highest
number of living donor kidney and liver transplants in the world but
Abbreviations: NOTTO, National Organ and Tissue Organization; THO, Transplantation
of Human Organs; USD, US Dollars.
of 9751 kidney transplants and 77% of the 2590 liver transplants
performed in India were from living donors.5 In comparison, in 2018
only 36% of kidney and 19% of liver transplants performed glob-
ally were from living donors. 6 A quarter century after the THO Act,
transplantation remains inaccessible for most Indians with end organ
failure. An estimated 220,000 persons die of chronic kidney disease
in India annually.7 The burden of extra-­renal end organ failure is
also undoubtedly large. It is estimated that between 200,000 and
300,000 persons die of liver failure annually with about 25,000 of
the deaths among patients who could have been transplant candi-
dates.8 In this perspective we review the current status and propose
national policies to advance deceased organ donor transplantation
in India. As the delivery of health-­care services in India is complex,
this viewpoint does not directly address implementation issues
which will vary between individual states in the country.

© 2021 The American Society of Transplantation and the American Society of Transplant Surgeons

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2  |  CU R R E NT S TAT U S O F
TR A N S PL A NTATI O N I N I N D I A
There is a dramatic geographic variation in deceased organ donation
and transplantation that is related to the state-­based organization
9
of health-­care services in India. The deceased donations that take
place are largely due to the efforts of a few state governments, non-
government organizations, and hospitals that are highly committed
to transplantation.10 The provision of health care in India is the re-
sponsibility of individual state governments. India's universal public-­
funded health-­care model aims to provide basic access to health
care for its citizens free of charge. In reality this system is viewed
as inadequate and inferior to the parallel private system which
provides the majority of health-­care services. With regard to the
public system, the national government is responsible for broadly
applicable issues such as prevention of major diseases, while state
governments oversee hospitals and health-­care delivery. Interaction
between the national and state governments occurs for issues that
require large-­scale resources or are determined to be of national
significance. In 2019, the Indian government committed US $21
million to the National Organ and Tissue Organization (NOTTO).1
Launched in 2014, NOTTO aims to work with existing regional-­and
state-­level organizations to co-­ordinate interstate transplants. In ad-
dition, NOTTO’s mandate includes establishment and implementa-
tion of protocols and guidelines, monitoring of transplant activity,
maintenance of a national organ and transplant registry, promotion
of organ donation, and training of organ donation staff.
Ironically, states that perform the largest numbers of living donor
transplants are not necessarily leaders in deceased donor transplan-
tation. For example, the Union Territory of Delhi performed a total
of 21,471 organ transplants between 1995 and 2019; however, 97%
(20757) were living donor transplants.1 This disconnect between
living and deceased donor activity is because transplant infrastruc-
ture and expertise is concentrated in private hospitals that oper-
ate revenue—­generating living donor transplant programs. Private
hospitals perform 90% of all organ transplants and 98% of all liver
transplants at a cost that is relatively low, approximately $ 7,500 US
dollars (USD) for a kidney transplant and $50,000 for a liver trans-
plant, but still well beyond the reach of most Indians who have an
average annual income of less than $2000 USD.11,12
The advanced living donor infrastructure in India is increasingly
accessed by foreigners, and private Indian hospitals are now the pre-
ferred destination for transplantation among foreign patients with
a living donor but without timely or affordable access to transplant
services in their own country of residence. It has been estimated
that in some private centers 25–­30% of all living donor kidney and
13,14
liver transplants involve foreigners. We estimate the national
proportion to be in the range of 15–­20%. Foreigners must pro-
vide their own living donors (usually from their home country) and
there is a review process to reduce the risk of donor exploitation
and transplant tourism. Although this activity may be justified be-
cause it provides lifesaving transplantation to people without access
in their home countries, the revenue, infrastructure, and expertise
SHROFF and GILL
generated has been limited to the private sector and has not been
leveraged to meet India's vast transplantation needs.
The available literature indicates strong public support for organ
donation in India.15,16 The paucity of deceased donations is because
the vast majority of potential donors are indigent motor vehicle ac-
cident victims who are primarily treated in hospitals that lack the
necessary infrastructure to support deceased donation. The con-
centration of transplant services and expertise in for profit private
hospitals focused on living donor kidney and liver transplantation
also indirectly limits the development of thoracic organ transplant
services. As a result, those who cannot pay are likely never referred
for transplantation nor waitlisted resulting in instances where de-
ceased donor hearts and lungs cannot be utilized because there is
no identified waitlist candidate. Indian law permits foreigners to re-
ceived deceased donor transplants when there is no Indian waitlist
candidate, and a number of cases in the past of foreigners receiving
transplants in India have been reported in the lay press. The claim
that no Indian patient could be identified has fueled public distrust
that the system favors wealthy foreigners over Indians.
The lack of deceased donor services is particularly troubling
because of the large potential number of deceased donors. There
were over 150,000 fatalities due to road traffic accidents in India in
2018 with the majority being young men who presumably would be
suitable organ donors.17 Not surprisingly even small investments in
deceased donor services have had significant impact. For example,
in the state of Tamil Nadu, a dramatic increase in deceased dona-
tion and organ transplantations was achieved by establishment of
deceased donation procedures, a central waiting list, education and
engagement of health professionals, and establishment of the so-­
called green corridors to facilitate efficient transport of organs. With
these simple state government investments, Tamil Nadu had 1338
deceased donors, and performed 4712 lifesaving deceased donor
transplants from 2008 to 2019.9
3  |  W H AT C H A N G E S A R E N E E D E D?
The current system limits the health benefits of donated organs
to patients with the ability to pay and allows private hospitals to
profit without contributing much to the system. Poor Indians who
donate organs have little or no hope of ever receiving lifesaving
transplants, and there is little investment in developing the neces-
sary infrastructure and expertise to support deceased donation
in government hospitals where most potential donors present for
care. Although the available literature indicates strong public sup-
port for deceased donation,15,16 there is growing discontent with
the disparity in access to transplantation between the rich and
poor and with foreigners receiving deceased donor heart and lung
transplants. If poor Indians are to donate organs, they must have
equal access to organ transplantation. It is not sufficient that do-
nated organs are equally allocated to waitlisted patients in public
and private hospitals, if only wealthy individuals are ever wait-
listed. The income-­related disparities in access to transplantation
SHROFF and GILL
undermine public trust in the organ donation and transplantation
system and jeopardize the advancement of deceased donor trans-
plantation throughout the country. Therefore, it is imperative that
policies to address the financial barriers to deceased donation and
transplantation are undertaken.
Given the reality of a limited government health-­care budget,
creative solutions are needed to fund the resources and infrastruc-
ture necessary to support deceased donation. It is apparent that
some Indian patients are able to pay for transplantation in private
hospitals. These patients overwhelmingly obtain living donor trans-
plants but could receive deceased donor transplants instead. It is
short-­sighted to allow for profit hospitals to obtain deceased donor
organs to perform transplants while contributing little to the cost of
deceased donor services. Currently private hospitals pay a nominal
organ maintenance fee to the donor hospital that is not standardized
between states. The implementation of a standardized organ acqui-
sition fee similar to that in the United States would generate nec-
essary funds to help advance the development of deceased organ
donation services in the so-­
called nontransplant organ retrieval
centers. In parallel, safeguards would be needed to ensure patients
without the ability to pay received equitable access to transplanta-
tion. This could be accomplished by implementing policies to ensure
that every deceased donor transplant performed in a paying patient
would be matched by a transplant in a patient without the ability
to pay. To ensure capacity to perform deceased donor transplants
in poor patients, the government could incentivize private hospitals
by waiving the organ acquisition fee for these transplants and by
linking the number of organs allocated to private hospitals for paying
patients to the number of transplants performed in poor patients by
the hospital.
It is anticipated that private hospitals will decry a tithe on de-
ceased donor organs and argue that transplants will be too costly
for patients. Private hospitals could likely afford to pay a significant
organ acquisition fee without sustaining a financial loss from de-
ceased donor transplantation because these transplants do not incur
the costs of living donor evaluation, surgery, and post-­donation care.
For example, state-­funded public transplant programs (i.e., Gujarat
University of Transplantation Sciences, Ahmedabad) report patients
costs of $5000 for deceased donor kidney transplantation and
$10,000–­$15,000 for deceased donor liver transplantation.18 These
costs are substantially lower than the amounts charged for living
donor transplantation in private hospitals (i.e., $7500 to $10,000
for a living donor kidney and $50,000 for a living donor liver trans-
plant).11,12 It is also likely that paying Indian patients would be able to
afford a somewhat higher cost for a deceased donor transplant as an
alternative to having a family member serve as a living organ donor.
The proposed policy changes would encourage private hospitals to
expand their current business model that is narrowly focused on liv-
ing donor transplantation for the wealthy to include deceased donor
transplantation for the benefit of all Indians.
The funds generated would be used to operate a national orga-
nization for deceased donation. The vast socioeconomic differences
between Indian states make it unrealistic that NOTTO, which has
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only a limited mandate to facilitate interstate transplants, can ad-
dress the existing geographic disparities in deceased donor services.
The national organization would work with individual states to fund
strategic regional infrastructure needs and to accredit hospitals to
perform deceased donations. This national entity would work with
existing state organizations and transplant programs to train and
employ a multidisciplinary team of health professional to ensure
culturally sensitive end of life care to all potential donors and their
families and to ensure deceased donor service was provided in all
states according to international standards. Importantly the organi-
zation would be responsible for allocation of deceased donor organs
according to transparent allocation rules to ensure equitable access
to patients in need irrespective their place of residence, sex, religion,
socioeconomic or social status.
As India is now the preferred destination for foreigners with
their own living donors in need of transplantation, it is imperative
to implement policies to ensure this activity does not detract from
efforts to provide transplant services for Indians. Requiring private
hospitals to pay a portion of the proceeds from such transplants into
the national system would accomplish this objective. A portion of
these funds might even be targeted to enhance living donor services
for Indian patients such as advancement of kidney-­paired donation
programs or to ensure living donors have access to long-­term post-­
donation health care.19 Although deceased donor organs should be
prioritized for transplantation in Indian patients, a limited number
of deceased donor organs may reasonably be allocated to foreign
patients for humanitarian purposes with proceeds reinvested to ad-
vance the Indian transplant system.
Facilitating more transplants in poor patients will also require
a government commitment to provide funding for long-­term post-
transplant care and immunosuppression. The availability of generic
immunosuppressant drugs in India has reduced the average annual
cost of posttransplant care including laboratory tests and physician
care to between $1000 and $2000 USD. A policy decision on long-­
term government support for transplant care and immunosuppres-
sion is long overdue considering the Indian government announced
payment for chronic dialysis treatment in 2016 which will cost ap-
proximately $6000 USD per patient per year. 20
The solutions proposed in this viewpoint may not be acceptable
by those who are well-­served by the status quo. The current sys-
tem is a by-­product of the fact that donation and transplant services
were virtually nonexistent only 25 years ago, and it was inevitable
that innovation would be restricted to the privileged few. The Indian
transplant community has achieved remarkable progress in the past
25 years; however, the resulting expertise and infrastructure must
now be leveraged for the benefit all Indians. The choice is clear, the
government of India must now take steps to provide equitable ac-
cess to transplantation for all Indians, or risk losing the critical sup-
port of its citizens who are essential to advance the system.
AC K N OW L E D G M E N T
John Gill is funded by a Foundation Grant from the Canadian
Institutes of Health Research
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SHROFF and GILL

10. Abraham G, Reddy Y, Shroff S, et al. Evolution of deceased

D I S C LO S U R E
The authors of this manuscript have no conflicts of interest to dis-
close as described by the American Journal of Transplantation.
DATA AVA I L A B I L I T Y S TAT E M E N T
12. Narasimhan G. Living donor liver transplantation in India.
No data will be made available
13. Nagral S, Nanavati A, Nagral A. Liver Transplantation in India: at the
ORCID
14. Foreigners seeking transplant must get family tree attested by high
John S. Gill  https://orcid.org/0000-0002-8837-6875
15. Poreddi V, Sunitha TS, Gandhi S, et al. Knowledge, attitude and
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How to cite this article: Shroff S, Gill JS. Bold policy changes
are needed to meet the need for organ transplantation in India.
Am J Transplant. 2021;21:2933–2936. https://doi.org/10.1111/
ajt.16537