Introduction
Deceased donor transplantation (DDT) is a crucial strategy for addressing the growing global burden of ESKD, with over 1.2 million individuals affected annually.1 Despite increase in the number of transplantation, organ availability remains critically insufficient. DDT offers a life-saving solution, especially in regions with limited live donor pools, by improving survival rates and enhancing the quality of life for patients with organ failure. High-income countries such as Spain and the United States with donation rate exceeding 49.9 per million population (pmp) and 42 pmp, respectively, have established advanced frameworks for DDT, characterized by strong public engagement, policy enforcement, and health care infrastructure, serving as models for other nations.2,3
Challenges in Low- to Middle-Income Countries and India
Low- to middle-income countries face several barriers in scaling DDT programs, including inadequate health care infrastructure, low public awareness, and cultural or religious resistance. A major challenge is the limited acceptance of brain death, which hampers donor identification and consent. In addition, low- to middle-income countries struggle with insufficient training for health care professionals, lack of financial resources, and limited access to advanced medical facilities. India faces similar challenges. Data from the National Organ and Tissue Transplant Organization from 2013 to 2023 indicate that out of a total of 115,942 solid organ transplants, 95,470 (82.34%) were from living donors, while only 20,472 (17.68%) were from brain dead donors (BDDs). Notably, there were no recorded cases of organ donation after cardiac death.4
Despite these challenges, few states in India such as Telangana, Tamil Nadu, Gujarat, and Maharashtra have made considerable progress by establishing structured programs through active government involvement and robust public engagement.5,6
Telangana's Jeevandan Model: A Success Story
Telangana, a southern state in India with a population of 40 million, has built a strong health care infrastructure that supports both primary care and advanced medical treatments, particularly in urban areas. The state's proactive approach to health care, including investment in advanced medical equipment, specialized training for health care professionals, and public awareness initiatives, has been instrumental in the success of its DDT program. Recognizing the need for an organized and efficient transplant system, Telangana state established its DDT program in 2010 through a government order known as Jeevandan, meaning “donating life.” This initiative has streamlined organ allocation, strengthened donor identification processes, and promoted a culture of organ donation, positioning Telangana as a leader in deceased organ transplantation in India.7
Government Support, Funding, and Long-Term Commitment
The success of Jeevandan is closely linked to sustained government support. Early initiatives included identifying leaders in brain death management, ensuring adequate funding, and forming dedicated teams for program implementation. Public and private participation have played a pivotal role, with private hospitals providing advanced infrastructure, expertise, and the donor pool, and government providing the policies and regulations. Currently, over 40 private and public hospitals are actively participating in the program. In addition, efforts were made to establish dedicated organ procurement centers.
Legislation
India's organ transplantation framework is governed by the Transplantation of Human Organs and Tissues Act, enacted in 1994 and amended in 2011.8 Jeevandan aligns with Transplantation of Human Organs and Tissues Act by providing clear protocols for organ donation, brain death declaration, and organ allocation, ensuring compliance through regulatory oversight. Coordination with the national body, National Organ and Tissue Transplant Organization and the Regional Organ and Tissue Transplant Organization, has further ensured effective interstate organ sharing and contributed to maintaining national registries.4
Building and Maintaining Public Support and Trust
The success of the Jeevandan model can largely be attributed to policies that prioritize trust and transparency, along with the round-the-clock availability and accessibility of experts for consultation and decision making. These policies include transparent organ allocation systems and training programs for health care professionals, including donor counselors, with a strong emphasis on communication skills, family consultation, and consent processes. In addition, dedicated educational initiatives for journalists and practices centered on the needs of donor families have played a crucial role in dispelling myths and misconceptions about organ donation. Furthermore, special programs that honor donor families, along with government-led condolence visits to donor families' homes, have significantly enhanced public perception and trust in the organ donation system.
Accessibility to Transplantation
To ensure financial accessibility, government insurance schemes, particularly Aarogyasri (public insurance program in Telangana), cover most transplant costs, including lifelong immunosuppressive therapy. Approximately 25% of all deceased donor transplants in Telangana are fully covered by government insurance, providing access to economically disadvantaged patients.
Policies for Brain Death Declaration and Donor Optimization
Jeevandan has established standardized protocols for brain death declaration and donor optimization. Regular training programs for intensivists, neurologists, and anesthetists ensure adherence to these protocols, maximizing organ viability. In addition, maintaining donor hemodynamic stability has improved organ retrieval outcomes.
Online Transparent Allocation System
A key feature of Jeevandan is its online organ allocation platform, which ensures transparency, equity, and fairness (jeevandan.gov.in). The system prioritizes recipients based on medical urgency, organ compatibility, and waiting time. This approach is comparable with international best practices and serves as a model for other Indian states.
Training and Capacity Building
Jeevandan emphasizes continuous training and capacity building. Certified transplant coordinators play a critical role in facilitating the donation process. Specialized training programs focus on brain death declaration, donor management, and ethical considerations. During the coronavirus disease 2019 pandemic, Jeevandan adapted by conducting virtual training sessions and webinars in collaboration with international experts, further enhancing health care providers' skills.
Public Awareness Initiatives
Extensive public awareness initiatives have been a cornerstone of Jeevandan program. The integration of organ donation education into school curricula, coupled with community outreach programs and media campaigns, has helped cultivate a culture of organ donation.
Efforts to engage religious leaders and journalists have addressed cultural concerns, while events honoring donor families on National Organ Donation Day and during their ritual days have further sensitized the public. These initiatives have significantly contributed to increasing donor numbers.
Deceased Donation and Transplantation Data
There has been steady increase in BDD from 41 donors in the year 2013 escalating to maximum of 200 BDD in year 2023, totaling 1550 BDD donors from January 2013 to December 2024 facilitating 4314 solid organ transplants during that period.9 This growth mirrors a national trend in India (Table 1). Telangana has played a significant role in the national organ donation pool, contributing an average of 17.87% of the nations's brain dead donations between year 2013 and 2023. The state's contribution of BDD to national pool peaked at 29.34% in the year 2021. Remarkably, Telangana achieved a maximum organ donation rate of 5.54 pmp in the year 2023, compared with a national rate of <1 pmp, highlighting its strong commitment to promoting deceased organ donation.10
Table 1.
Brain dead donations and transplantations: National Organ and Tissue Transplant Organization versus Telangana state Jeevandan program
| Year | National NOTTO BDDs | Telangana State | ||||||
|---|---|---|---|---|---|---|---|---|
| Telangana State BDDs and Percentage to National NOTTO BDD, n (%) | Kidney Transplants from BDD | Liver Transplants from BDD | Heart Transplants from BDD | Lung Transplants from BDD | Pancreas Transplants from BDD | Total Solid Organ Transplants from BDD | ||
| 2013 | 340 | 41 (12.01) | 76 | 36 | 2 | 3 | 2 | 119 |
| 2014 | 408 | 51 (13.23) | 90 | 52 | 1 | 0 | 1 | 144 |
| 2015 | 666 | 89 (13.36) | 151 | 90 | 10 | 1 | 0 | 251 |
| 2016 | 930 | 106 (11.39) | 182 | 101 | 14 | 2 | 4 | 303 |
| 2017 | 773 | 150 (19.30) | 220 | 138 | 32 | 2 | 1 | 394 |
| 2018 | 875 | 160 (18.28) | 243 | 151 | 22 | 6 | 1 | 423 |
| 2019 | 715 | 134 (18.74 | 193 | 125 | 17 | 9 | 1 | 345 |
| 2020 | 351 | 75 (21.13) | 97 | 70 | 14 | 20 | 0 | 201 |
| 2021 | 552 | 162 (29.34) | 228 | 139 | 26 | 83 | 2 | 478 |
| 2022 | 941 | 194 (20.61) | 263 | 171 | 30 | 66 | 0 | 530 |
| 2023 | 1099 | 200 (18.19) | 287 | 173 | 15 | 76 | 2 | 441 |
| 2024 | — | 188 | 297 | 175 | 26 | 75 | 0 | 573 |
| Total | 7650 | 1550 (17.87) | 2327 | 1421 | 210 | 342 | 14 | 4314 |
BDD, brain dead donor; NOTTO, National Organ and Tissue Transplant Organization.
Challenges in Jeevandan Program
Despite the success of Jeevandan, cultural and religious reservations, along with persistent myths, continue to challenge organ donation. India is a secular country with diverse religions, and each faith has its own beliefs and reservations about organ donation. Approximately 15% of families refuse organ donation because of religious reasons, highlighting the need for a sensitive and inclusive approach that respects different faiths while increasing awareness about the life-saving effect of organ donation. In addition, infrastructure limitations in rural areas restrict outreach and donor identification. Policy fragmentation and disparities in health care access further complicate the program's expansion.
Although brain death donation is well-regulated, the adoption of donation after cardiac death remains low, limiting the potential to increase organ availability. Addressing these challenges is crucial for sustaining and expanding Jeevandan.
Conclusion
Jeevandan exemplifies how visionary leadership, structured policies, and collaborative efforts can transform DDT in a developing region. By addressing existing challenges, Jeevandan can continue to lead India's efforts in bridging the gap between organ demand and supply, ultimately saving countless lives.
Supplementary Material
Acknowledgments
The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or Kidney360. Responsibility for the information and views expressed herein lies entirely with the authors. Author acknowledge the Government of Telangana for the opportunity to serve as Nodal Officer of the Jeevandan Programme and for its consistent support in building a successful deceased donor organ transplantation program in the state.
Disclosures
Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/B58.
Funding
None.
Author Contributions
Conceptualization: Urmila Anandh, Swarnalatha Guditi.
Data curation: Swarnalatha Guditi.
Supervision: Urmila Anandh.
Writing – original draft: Swarnalatha Guditi.
Writing – review & editing: Urmila Anandh.
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