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| COMMENTARY |
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| Year : 2017 | Volume
: 61
| Issue : 4 | Page : 299-301 |
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Organ donation in India: Scarcity in abundance
Sandeep Sachdeva
Professor, Department of Community Medicine, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India
| Date of Web Publication | 6-Dec-2017 |
Correspondence Address:
Sandeep Sachdeva
Department of Community Medicine, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.IJPH_230_16
 Abstract | | |
In modern era, India witnessed its first successful corneal, kidney and cardiac transplant in the year 1960, 1967 and 1994 though the reverberations for organ donation and transplantation (ODT) existed since time-memorial with roots existing in Hindu mythology along with vivid example of Guru Dadheech and lord Ganesha. No country in the world is able to meets its organ requirement. Government of India promulgated Transplantation of Human Organ and Tissues Act in 1994 and with the view to enlarge its scope and promote organ donation government has brought new amendments as of year 2014 and 2017. In the background of this journey many new developmental milestones have been achieved in the country however organ donation which has assumed public health significance has been consistently lower than expectations. This manuscript highlights the current status of ODT in the country; legislative environment, limitations, challenges, health education activities, and newer initiatives.
Keywords: Behavior change, cadaver, cornea, eye, health education, heart, kidney, legislation, national program, organ donation, organ transplant, public health
How to cite this article:
Sachdeva S. Organ donation in India: Scarcity in abundance. Indian J Public Health 2017;61:299-301 |
The mention for organ donation and transplantation (ODT) existed since time-memorial with roots existing in Hindu mythology along with vivid example of Guru Dadheech and lord Ganesha. However the consequences of rising burden of noncommunicable diseases, living geriatric population, other risk exposures and behavior are propelling the graph of end stage organ failure across the globe including India. For last couple of decades, it has assumed public health significance due to ever increasing gap of need and supply of human organs. Atleast twenty-five different organs/tissues can be donated by humans either through living or deceased donation under certain contraindications, psychiatric, and medical fitness.[1] Young death due to road traffic accident or cardiovascular event provides a best option for organ donation.
No country in the world till date collects sufficient organs to meet the needs of their citizens. It is estimated that currently organ transplantation covers <10% of the global need. Spain, Austria, Croatia, USA, Norway, Portugal, Belgium, and France stand out as countries with high rates of deceased organ donors. Kidneys are the most commonly transplanted solid organs, followed by liver and then heart across the globe while cornea and musculoskeletal grafts are the most commonly transplanted tissues.[2],[3],[4]
Unfortunately, India with a 1.2 billion population is lagging behind in OD with a national deceased donation rate of <1/million population (pmp); however, Tamil Nadu has shown exemplary performance in OD with 1.3 donor pmp.[5] The Tamil Nadu model is helping poor and rich people not only from India but foreigners also. Although India falls in the second position with numbers of live donor transplants undertaken in the world after the USA, but stand nowhere in the list of deceased donor transplant.[6],[7],[8],[9] Country needs 260,000 organs every year, i.e., 180,000 kidneys; 30,000 livers and 50,000 hearts, whereas only 6000 kidneys, 1200 livers and 15 hearts are transplanted annually (National Organ Transplant Program). India has a fairly well-developed corneal donation, and transplant program however donation after brain death has been relatively slow to take off. In the backdrop of annual requirement of 100,000 corneas around 40,000 were collected during the past few years yet <25% could be transplanted due to quality issues (personal communication).
Solid organ transplant activities are largely driven by the private sector in the country. The cost of solid organ transplantation in private sector in India may vary from rupees fifty thousand to fifteen lakhs depending on organ involved, and there are some definitive charges at selected government institution also (personal communication). There is no direct cost implication on the deceased organ donor's family while live donor has definitive cost implications. India is acknowledged as favorite destination for foreign nationals seeking high quality low-cost medical care in the world with well-established accredited health system capacity, adoption of global best practices, English speaking work-force, courteous support team, availability of air-ambulance, provision of health visa, utilization of high end health/communication tool/techniques/technology, etc.[10] leading to the popularity of medical, reproductive and transplant tourism.
There have been instances of organ trafficking in India as in other parts of world leading to resistance/negative publicity, but since then many corrective interventions have been taken to eliminate this menaces. In spite of all efforts commercial activities involving poor donors are still being reported that arouses cautious, suspicious approach and further checks leading to critical delays. Financial and other policy initiatives including cleanliness drive, interventions, activities, and steps taken by the new central government is not only uplifting general sentiments in the society but also improving behavior, work ethics, discipline, and system transparency. This will in-turn lead to the elimination of black money and corruption-free environment but would also influence all aspect of the health sector positively.
The government of India promulgated Transplantation of Human Organ and Tissues Act in 1994 and with the view to enlarge its scope and promote cadaver organ donation has brought amendment into legislation (2011) and notification of rules (2014). Some of the broad areas included in recent amendments are:[11],[12],[13]
- Provision of registration and renewal of retrieval and transplant centers
- Definition of term “near relatives” to include grandparents and grandchildren in addition to parents, children, brother, sister, and spouse
- Removal of eyes/corneas permitted by a trained technician
- Brain death certification board has been simplified to enable a surgeon/physician and an anesthetist/intensivist to be included in the medical board in the event of nonavailability of a neurosurgeon/neurologist for certification of brain death
- Authorization committee to be hospital based if number of transplants undertaken is twenty-five or more in a year at the respective transplantation centers, and if the number are <25 in a year, then the state or district level authorization committee would grant approval(s)
- Medical practitioner involved in transplantation team will not be a member of authorization committee
- It is mandatory for the Intensive Care Unit/treating medical staff to request relatives of brain-dead patients for organ donation
- Swap donations of organs between near relatives allowed
- Procedures for foreign nationals notified if they happen to be donor or recipient
- Detail procedures notified to prevent commercial activities and exploitation of minors
- Establishment of a National Organ Retrieval, Banking, and Transplantation Network
- Maintenance of registry of donors and recipients waiting for organ transplants
- Mandatory position of a “Transplant Coordinator” in all hospitals registered for ODT
- Every authorized transplantation center should have its own website. The identity of the people in the database shall not be in public domain
- The authorization committee is required to take a final decision within 24 h of holding the meeting for grant of permission or rejection for transplant. The website of transplantation center shall be linked to state/regional/national networks through the online system for organ procurement, sharing, and transplantation
- The cost for maintenance of the cadaver (brain-stem dead declared person), retrieval of organs or tissues, their transportation and preservation, shall not be borne by the donor family and may be borne by the recipient or institution or government or nongovernment organization or society as decided by the respective state government or union territory administration
- Detailed procedures regarding quality assurance, donor screening, qualification and experience of doctor/transplant coordinator, laboratory investigations, equipment, documentation, and other requirements notified.
With other demanding and pressing public health issues being faced by the country government of India has not committed substantial funds into ODT in the 12th 5-year plan since it is a very cost-intensive activity. At the same time, government has not shunned from its role and responsibility. Many diverse and collateral activities have been established under favorable legislative environment with the involvement of stakeholders. National Organ and Tissue Transplant Organization (NOTTO) situated at Safdarjung Hospital, New Delhi has been commissioned and has two divisions [1] National Human Organ and Tissue Removal and Storage Network [2] National Biomaterial Centre (National Tissue Bank). Regional/State level organ and tissue transplant institutions would be established in a phase manner at Kolkata, Chennai, Mumbai, Chandigarh and Guwahati in-addition to six cities were AIIMS are established. The NOTTO website http://notto.nic.in has become functional and various operational guidelines of National Organ Transplantation Program have been released in public domain.[14]
Organ retrieval and banking organization and national eye bank established in AIIMS, New Delhi are acting as mentor, research center and coordinating unit in the national capital region with other public sector and private hospitals. A call centre is being set up which will set up contact between established centers, donors and people in the waiting list on a real-time basis. Technical, administrative and sensitization training of doctors, paramedics and transplant coordinators is underway. Registry and surveillance activity has been established. Memorandum of understanding has been linked with other countries and international organization for learning and sharing of best practices. Phase development of 100 medical college/hospitals in country has been planned to act as transplant center or organ/tissue retrieval center. Provision of financial assistance has been ear-marked for salary of transplant coordinator and office maintenance for both public and private centers.
There is limited understanding of the concept of brain-death amongst health personnel and society at large. Knowledge, attitude, and practice surveys undertaken on various stakeholders with regard to organ/tissue donation in the country indicate diverse but high positive knowledge with poor practices. It is also noticed that large number of willing people/family members of deceased individuals are unable to donate organs due to lack of system preparedness and poor inter-institutional linkages. Recently police in Delhi, Mumbai, Bangalore, and Chennai have been forth-coming in establishing air and road linkage with different centers by providing dedicated congestion-free roads (green corridor) for efficient organ transfer. Annual organ donation awareness day is being observed in the country since 2010 in addition to eye donation awareness fortnight (25th August to 8th September).[15] Active online and print media awareness has been underway since the last couple of years, and successful transplant stories are also highlighted. Various registered nongovernmental organization are involved in health education, training, and community mobilization activities through the signing of pledge cards. Mobilization of faith healers, sect, spiritual, and religious leaders may inspire society for the altruistic act of OD.
To conclude, there is a definitive gap between need, demand and availability yet differential strategy including concentrated health education and counseling activities, especially in metropolitan/larger cities along with functional brain stem death committee, real-time institutional linkage, flexible bureaucratic procedures, and logistics can make a big difference in organ donation movement. The debate on accountability, ethics, equity, cost-effectiveness, safety, surveillance, standardization, unscrupulous activity, incentives, and competing priorities will continue to dominate organ donation and transplant platform in current and future socio-political environment.
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| 14. | National Organ and Tissue Transplant Organization. Available Available from: http://www.notto.nic.in. [Last accessed on 2016 Aug 15]. |
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