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Commentary

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

Summary
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.

Key words: Behavior change, cadaver, cornea, eye, health education, heart, kidney, legislation, national program, organ donation, organ
transplant, public health

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.[2‑4]
Unfortunately, India with a 1.2 billion population is lagging
behind in OD with a national deceased donation rate
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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.[6‑9] 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
Address for correspondence: Prof. Sandeep Sachdeva,
Department of Community Medicine, North Delhi Municipal Corporation
Medical College and Hindu Rao Hospital, New Delhi, India.
E‑mail: sachdevadr@yahoo.in
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the
new creations are licensed under the identical terms.

DOI:
10.4103/ijph.IJPH_230_16 How to cite this article: Sachdeva S. Organ donation in India: Scarcity in
abundance. Indian J Public Health 2017;61:299-301.

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Sachdeva: Organ donation and transplantation

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:[11‑13]
1. Provision of registration and renewal of retrieval and
transplant centers
2. Definition of term “near relatives” to include grandparents
and grandchildren in addition to parents, children,
brother, sister, and spouse
3. Removal of eyes/corneas permitted by a trained
technician
4. 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
5. 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)
6. Medical practitioner involved in transplantation team will
not be a member of authorization committee
7. It is mandatory for the Intensive Care Unit/treating
medical staff to request relatives of brain‑dead patients
for organ donation
8. Swap donations of organs between near relatives allowed
9. Procedures for foreign nationals notified if they happen
to be donor or recipient
10. Detail procedures notified to prevent commercial
activities and exploitation of minors
11. Establishment of a National Organ Retrieval, Banking,
and Transplantation Network
12. Maintenance of registry of donors and recipients waiting
for organ transplants
13. Mandatory position of a “Transplant Coordinator” in all
hospitals registered for ODT
14. Every authorized transplantation center should have its
own website. The identity of the people in the database
shall not be in public domain
15. 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
16. 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
17. 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

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Sachdeva: Organ donation and transplantation
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
Indian Journal of Public Health  ¦  Volume 61 ¦  Issue 4  ¦  October-December 2017
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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