Organ Donation in India: An Overview

Context:

The Hindu reported that National Organ and Tissue Transplant Organization (NOTTO) give priority to foreign patients over Indian patients waiting for a donor heart transplant.

What is organ donation?

• Organ donation is the donation of biological tissue or an organ of the human body, from a living or dead person to a living recipient in need of a transplantation.
• Transplant: A transplant is a medical procedure where one person’s dysfunctional organ or tissue is replaced by that of a healthy person, thus restoring its function.

Different types of organ donation:

Living Donation:

• Living donation takes place when a living person donates an organ (or part of an organ) for transplantation to another person.

Deceased Cadaver Donation:

• An organ or part of an organ given at the time of donor’s death. (Cadaver means corpse)
• Donated after the donor is declared brain dead.
• Brain death is the total and irreversible loss of all brain functions.
• Brain dead persons are kept on ventilators (artificial support) to ensure all organs remain oxygenated and healthy until they are harvested.

What organs can be donated and when?

Status of Organ Donation in India:

Poor Organ donation Rate:

• 26 Per million in India as compared to 36 per million in Spain, 32 per million in Croatia and 26 per million in USA

Demand and supply gap (Annual)

Regional Variation:

• Tamil Nadu(155 donors in 2015) has the highest number of organ donations followed by Maharashtra, Kerala, Karnataka, Telangana and Gujarat

Deceased Organs Donation (as of 2013):

1. Kidney: 548
2. Liver: 257
3. Heart: 25

Policy Initiatives:

Transplantation of Human Organs Act (THOA), 1994

Objective:

• To regulate the removal, storage and transplantation of human organs for therapeutic purposes
• To prevent commercial dealings in human organs

Key features:

• Scope: Organs only
• Legalized the concept of brain death- Brainstem death. Brain death certification to be given by Medical Board
• Imprisonment of up to 10 years and fine up to Rs. 20 lakh for removal of organs without authority

Transplantation of Human Organs (Amendment) Act, 2011 

Key features:

• Scope widened: Both organs and tissues
• Brain death certification Board simplified, more experts permitted
• Mandatory transplant coordinator- for coordinating all matters relating to removal or transplantation of human organs
• National Human Organs and Tissues Removal and Storage Network at one or more places and regional network
• National Registry of Donors and Recipients
• Provision of SWAP Donation included- A Swap transplant involves an exchange of organs between two families, who cannot donate the organ to their own family member because of blood group mismatch.

Transplantation of Human Organs and Tissues Rules (THOT), 2014

• Authorised transplantation centre must have its own website
• Apex national networking organization at the centre; regional and state level organizations
• State units to be linked to hospitals, Organ/Tissue matching Labs and Tissue Banks within area and also regional and national networking organisations
• National Registry on Donors and recipients of Human Organ and Tissue to be accessible online

Organizations:

1. National Organ and Tissue Transplant Organization (NOTTO) set up under Directorate of Directorate General of Health Services, Ministry of Health and Family Welfare
2. National Human Organ and Tissue Removal storage Network
3. National Biomaterial Centre

National Organ Transplant Programme (NOTP)

• Objective:
• To promote organ donation in India
• To organize a system of organ and Tissue procurement & distribution for transplantation.
• To promote deceased organ and Tissue donation.
• To train required manpower.
• To protect vulnerable poor from organ trafficking.
• To monitor organ and tissue transplant services and bring about policy and programme corrections/ changes whenever needed.
• Financial support to States to set up Regional Organ and Tissue Transplant Organizations/State Organ and Tissue Transplant Organizations. (Note: Health is a State subject)

Issues and Challenges:

Demand and Supply Gap:

• Huge gap between demand and supply of organs.

Socio-cultural beliefs:

• Religious beliefs hinder deceased organ donation. Superstitions prevalent such as being born (rebirth) with a missing organ (that has been donated), being tangled in the life-death-rebirth cycle

Lack of awareness:

• The concept of ‘brain death’ and its legal implications unfamiliar to majority of Indian population

Infrastructural issue:

• Limited facilities for transport of donated organs; no air ambulance facilities
• Lack of training for intensive-care unit personnel to maintain brain dead person
• Lack of awareness among doctors
• Lack of effective transplant coordinators
• Not all hospitals in India are equipped to carry out the process of organ transplantation and retrieval.
• Out of 301 hospitals equipped to handle the process, only 250 are registered with National Organ and Tissue Transplant Organisation (NOTTO)

Wastage of organs:

• Organs (especially hearts and lungs) not used due to lack of suitable recipient. This leads to wastage of organs.

High Cost of transplant surgeries:

• Unregulated cost of transplant surgeries; cost out of reach of poor people

Regional Variation:

• All states in India do not have active organ donation programmes. Organ donation rates in North India abysmally poor.
• Further, since health is a state subject, there are issues with implementation of THOA
• There are only 5 Regional Organ and Tissue Transplant Organisation (ROTTO)

Negative propaganda by media:

• False proclamation of “scandals”; organ rackets
• News of improper practices of organ collection breaks public trust and is impediment to the entire process of organ donation

Best Practice:  Spain

• Spain has the highest organ donation rate in the world
• Creation of National Transplant Organization (ONT)- Coordinates transplant policies across Spain
• It has an opt-out system- organ donation is automatic unless refused
• Circulatory death (when circulation, heartbeat and breathing stop, as opposed to brain death) is also a circumstance in which donation is considered
• Designation of appropriate professionals (intensive care doctors) to ensure organ donations are fast and efficient
• More emphasis on organ donation in patients older than 65 years of age- In Spain 10% of donors are 80+

Way Forward:

Public awareness:

• Reducing the shortage of organs by promoting deceased organ donation
• Public awareness is the most important step that can lead to improved rates of deceased organ donation
• Example: In 2017, Andhra Pradesh government had initiated the screening of “Punarjanam” (one -minute short film on organ donation) before starting of each show for one week.

Infrastructure:

• Increasing the number of transplantation centres
• Training transplant coordinators
• Training doctors, paramedical personnel
• Improving transport of organs; developing air ambulance services
• Proper storage facilities; setting up tissue banks

Finance:

• Reducing the problem of finances; reduction in cost of transplants
• Financial support for poor

Organizational:

• Strengthening the role of NOTTO for coordinating the organ distribution system
• Effective centralised organ donation registry

Legislation:

• Declaring brain-death should be made mandatory in all hospitals
• The Centre proposed to amend the law on motor vehicles to include a choice for voluntary organ donation in new or renewed driving licenses. The draft to amend the Central Motor Vehicles Rules, 1989 should be implemented

Ensuring zonalization of organ sharing:

• To ensure more effective sharing of organs a zonalization should be done (USA has such a provision). This would help in transporting and transplantation of organs which can be preserved only for shorter durations e.g. hearts.

Process of allocation to be more transparent:

• The process of allocation of organs should be made more transparent. It should be made monitored and tracked; made accessible to public.
• Further, outcome of transplantation should be properly monitored.

Responsible media:

• The media should be more responsible before proclaiming scandals, rackets. Information should be properly investigated before being published.