Why Are So Few Liver Transplants Done in the Public Sector in India and How Can We Improve the Numbers?

More than 30 years ago, when some of us launched a campaign to introduce liver transplantation in India, we envisaged that the procedure would mainly be done by obtaining whole organs from deceased brain-dead donors in large government hospitals which dominated the health sector at that time. The situation now is far from what we envisaged for the country, with more than 95% of the liver transplants being performed in the private sector and approximately 80% of these are from parts of the liver obtained from living donors. Of the total of 2592 liver transplants done in 2019 (before COVID), > 95% were done in 175 private sector hospitals and only <5% were done in 5 hospitals in the public sector.^{1, 2} Private hospitals perform 90% of all solid organ transplants and 98% of all liver transplants at a cost that is relatively low by international standards, approximately $ 7,500 US dollars for a kidney transplant and $25–30,000 for a liver transplant, but still well beyond the reach of most Indians who have an average annual income of less than $2000 US dollars.²

Why is this so and what can be done about it? In this editorial, we will try and analyse the reasons why the public sector is unable to cope with the demand for equitable, subsidized, and accessible transplantation based on an altruistic organ donation registry. Why do our public hospitals perform so few procedures and what are the limitations of health infrastructure in India? We offer our suggestions on how the situation might be improved.

But first, we must remember some ground realities. Liver transplantation is a very expensive procedure and requires major investments in trained manpower as well as infrastructure in the form of supportive technology. The cost of a living donor partial liver transplant varies from 16 to 40 lakh rupees in Indian private centres.

The second major problem is that although the Transplantation of Human Organs Act was passed in 1994,³ which legalised brain stem death as a form of death, there has been a general reluctance in India of both doctors and the relatives of brain-dead individuals to ask for and agree to organ donation.^{4, 5} This has forced most transplant centres to concentrate on living donor liver transplants usually using the right or the left lobe—a more difficult procedure than whole organ transplants and a technique which exposes a healthy donor to the risk of major postoperative complications and (extremely rarely) even death.⁵ However, its advantages are that the donor organ is readily available and is healthy and the procedure is done conveniently electively rather than in an emergency. This success of the living donor liver transplant procedures may inadvertently have further pushed the deceased donor programme to the periphery! The main reason for the paucity of public sector transplants is that when the Indian economy was liberalised in the early 1990s (nearly coincident with the passage of the Transplant Act), it allowed private players to enter the health field. Thus major hospital chains with huge investments, both Indian and foreign, entered the health ‘business’ and with their available funds were able to establish transplant units and lure away surgeons and other personnel from the public sector by offering huge sums of money. It is rumoured that the star liver transplant surgeons in corporate hospitals are now earning up to 1 crore rupees a month which is nearly 50 times the take-home salary of a government professor.

Offering liver transplantation in a private hospital is a major booster to its reputation, especially if it has been able to recruit one of the star surgeons. Not only does it bring in the large sums of money that the patients pay but also it establishes itself as a place where these and other complex procedures are possible. The competition between the present large centres to attract patients from both within India and abroad has also led to some unethical practices like providing kickbacks or ‘facilitation charges’ to referring physicians, stretching the limits on which donor livers (both living and brain-dead) are used for transplantation and ‘inappropriately’ recording the complication rates and even hiding incidences of donor mortality. It has been written that “availability of 25 lakh rupees and a donor is the main indication for liver transplantation”.⁶ All this contravenes the rules laid down in the Transplant Act which requires all registered centres to report all their results in detail to the Central Government's Appropriate Authority. This raises issues about the inadequate regulatory oversight mechanisms and suboptimal implementation of centralized registries by the state-mandated organisations. Nevertheless, the one-year recipient survival data of about 90% obtained in the best centres in this country are now as good as anywhere else in the world and it will be difficult to persuade patients dying from liver failure or cancer not to sell all their worldly belongings and get transplantation done in these elite hospitals.

Public hospitals are beset with difficulties. There is no incentive given to surgeons and anaesthetists to spend long hours performing a liver transplant and then deal with the possible complications, and the news of any problems associated with the procedure in the case of live donor transplants cannot be kept under wraps in an open system and will result in the programme being criticised or closed. Finally, although it has been estimated that there are at least four brain-dead donors (mainly after road accidents) in intensive care units every month the treating doctors are reluctant to ask for organ donation as it is seen to be a failure of their care. A dedicated system of grief counsellors, transplant procurement managers and coordinators is difficult to come by. The poor relatives also do not agree as they see organ harvesting as a further mutilating procedure on a dead body and because of the need for family consent for organ donation often one of them who has had little recent contact with the patient will refuse permission for organ harvesting. The law in India requires four doctors, the treating physician, a neurosurgeon as well as representatives of the hospital and government, to certify brain death at two intervals 6 h apart and this is difficult to implement in a public hospital where there is no incentive for these individuals to spend time doing this. Furthermore, presumed consent is not mandated in Indian law and the declaration of brain death has remained linked to the act of organ donation, an anomaly which contributes to hesitation on the part of treating/critical care teams to request a donation.

What is to be done? Unfortunately, because of the success of the procedure in the private sector, a so called ‘learning curve’ will not be tolerated by the public at large. It will want acceptable results from the beginning.

Our suggestions are

• 1.We first need to identify patients who will be suitable for liver transplantation. They must be ‘valued’ lives e.g. young mothers and sole wage earners and should be in a position, educationally and financially to sustain the transplant in the long term.
• 2.The initial procedures should be carefully chosen to be the easier ones e.g. thin patients with reasonably preserved liver function and unresectable hepatocellular carcinomas
• 3.Strong tie-ups with private hospitals which have successful ongoing liver transplant programmes (public-private partnerships) should be encouraged. This has already happened in a few instances and we are sure many of the expert surgeons will only be too pleased to help e.g. at least their alma maters!
• 4.There must be a major drive to promote deceased organ donation. We should follow Tamil Nadu's example and issue Government Orders to make the declaration of brain death and request for organ donation compulsory in ICUs.⁴ There should be a mandatory audit of brain deaths and required requests in all ICUs of transplant hospitals and NTORCs.
• 5.The donor family should be recognised publicly for their generosity and the recipient's family receive a government subsidy (Umbrella Rashtriya Arogya Nidhi scheme, PM JAY insurance, state/ESI insurance) towards their treatment costs.^{2, 4} In addition, the next of kin of the donors should be incentivized by government health insurance cover. Those who pledge donations may also be rewarded by allocation priority in case they themselves end up with organ failure (a model which has been implemented in Israel).⁷ Strengthening deceased organ donation can have a ripple effect on the entire transplantation scenario in the country.
• 6.The government based transplant teams should be provided financial and academic incentives to perform the procedures. Although this will meet with opposition from other faculty, we should, as there are Institutes of National Importance, liver transplantation should be designated to be a Procedure of Institutional Importance.



Unless some radical steps are taken, we are afraid things will remain as they are and have been for the last 30 years, where rich Indians and foreigners get liver transplants and the middle class and poor die from liver failure.