NEW DELHI: Despite India making impressive progress in organ transplantation, and being a much sought-after transplant tourism destination for patients from abroad, the country still faces challenges in achieving equitable access for all its citizens, especially those living in remote areas, said a latest Lancet study. 

The study stressed that India needs stronger government investment, better data collection, improved public sector capacity, and policies to reduce financial and geographic barriers. 

India, which is placed in Category 4 along with South Africa, witnesses most transplants in private hospitals concentrated in urban areas. Despite free dialysis being available in many states, it said there is no comprehensive national policy covering transplantation costs.

Speaking with this paper, Dr Vivekanand Jha, co-author and Executive Director, The George Institute for Global Health India, said, many Indians, especially people experiencing poverty and those outside major cities, will continue to lack access to life-saving transplants if India does not provide equitable access for underserved and marginalised populations.

He said, however, there are some states like Tamil Nadu, which has emerged as a leader amongst all Indian states in deceased donor programs and also in providing public funding to support transplantation through government hospitals.

“Most transplants are performed in private hospitals, mainly in cities, making them unaffordable and inaccessible for many people, especially those in rural areas,” he said.

India faces a critical shortage of donated organs, especially from deceased donors.

“Most transplants rely on living donors, which limits the number of available organs. Public hospitals are underfunded and have limited capacity for transplantation due to the demand,” Dr Jha said.

There is also a risk of unethical practices, with continued reporting of instances of organ trafficking and commercialisation. 

Even though India is one of the top two or three in terms of the total number of transplants in the world, when adjusted for population size, it sits very low in the table, he added.

Notably, the level of development of transplant services varies across states in India, with certain states such as Tamil Nadu, Andhra Pradesh, Telangana, Kerala, and Gujarat doing better than others. In contrast, states like Odisha and some north-eastern states are bereft.

Moreover, states like Bihar, Jharkhand, Chhattisgarh, and large parts of Uttar Pradesh and Assam are just starting.

Dr Jha said while recipients from over 35 countries – mainly from Africa, South East Asia, and Central Asia - came to India to get a transplant last year, with almost all coming with their donors, many Indians, especially people with low incomes and those outside major cities, continued to lack access to life-saving transplants.

The Lancet paper examined disparities in organ transplantation systems, especially in low and middle-income countries, and called for policy reform to ensure global equity in organ transplantation.

The researchers categorised the transplant system globally into five groups. 

While Category 1 included many low-income and middle-income countries such as Zimbabwe, Chad, and Niger, which lack transplant centres, forcing patients to seek transplants abroad, Category 2 included countries like Cameroon, Uganda, and Mongolia that have limited centres developed through partnerships, primarily focusing on kidney transplants, but face urgent needs that often exceed capacity. 

In category 3, countries like Egypt and Vietnam were slotted as they perform living donor transplants, yet struggle with multi-organ transplants due to insufficient infrastructure. 

Category 4 included India and South Africa, which have multiple transplant centres but face challenges with funding and prioritisation. Finally, category 5 included countries like the US and Spain, which have regulated transplant systems and robust frameworks to enhance equity in access to transplant services.

What India needs is increased public investment, a comprehensive national registry, and oversight.

It also needs recipients and donors to be provided with financial risk protection through national insurance or reimbursement programs; standardization and simplification of eligibility allocation criteria; enhanced ongoing public awareness and education to address myths and encourage organ donation, and to encourage partnerships to leverage resources and expertise while ensuring access for people experiencing poverty, promoting quality monitoring and enhanced care delivery through the use of technology, such as telemedicine, sporting training and retention of skilled health workers in public sector.

The authors, including researchers from Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia; School of Public Health, Imperial College, London, UK; Department of Surgery and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, US; University of Stellenbosch, Faculty of Medicine and Health Sciences, Cape Town, South Africa; and Department of Epidemiology and Department of Surgery, Johns Hopkins University, Baltimore, US, pointed out persistent disparities in access to transplantation across, and within, certain countries, especially in low-income and middle-income countries, due to less access to new technologies, mainly due to limited infrastructure and resources.

While high-income countries, such as the US, Spain, and South Korea, report over 100 transplants per million annually, many regions in Africa, Asia, and South America remain below 20 per million.

Additionally, they said, marginalised groups, especially racially and ethnically minority people and individuals from low socioeconomic backgrounds, might be most susceptible to these inequities worldwide.