New Delhi: India sees 17,000-18,000 solid organ transplants every year — the most in the world after the US and China — but three-quarters of these are done by the country’s private healthcare sector, say experts.
The reasons for the gap, according to surgeons, include heavy patient flow in government hospitals, the economic profile of patients in government hospitals, lack of dedicated teams, and social and cultural barriers that have prevented cadaver transplant programmes from taking off.
India’s first successful heart transplant was conducted at the All India Institute of Medical Sciences (AIIMS), New Delhi, in 1994 by Dr. P. Venugopal, who went on to become the director of the institute. But after that, the baton was passed almost entirely to the private sector. Currently, MGM Healthcare in Chennai is the leader in heart and lung transplants.
The heart, lung and pancreas are among the least transplanted organs because this can only be done when a viable cadaver donor is available. But even for the more commonly transplanted organs such as the liver and the kidney, over 90 per cent and over 80 per cent, respectively, of surgeries happen in the private sector.
Many government hospitals such as King George’s Medical University in Lucknow and Seth Sukhlal Karnani Memorial Hospital (SSKM) in Kolkata have now started reaching out to private hospital surgeons for organ transplants, but even these are few and far between.
The largest kidney transplant centre in the public sector is Chandigarh’s Postgraduate Institute of Medical Education and Research (PGIMER), which does about 200 surgeries per year — a third of the annual output of Delhi’s Indraprastha Apollo Hospital alone. For liver transplants, of the 20-2200 surgeries that take place in the country every year, about 250-300 happen at just one private centre in Delhi — Max Superspeciality, Saket.
Dr Harsha Jauhari is advisor (organ transplantation) at the National Organ Transplantation and Tissue Organisation (NOTTO) under the health ministry, and senior consultant, renal transplantation at Sir Ganga Ram Hospital, Delhi. According to him, of the estimated 17,000-18,000 solid organ transplants (heart, kidney, liver, pancreas etc) that are conducted in India annually, over 75 per cent happen in the private sector.
“The expertise is largely there. Surgeons and physicians are equally competent. But the problem is, transplant programmes need intensive infrastructure. There is a lot of cost involved. Government hospitals are typically short of staff and resources, so those are much better utilised for other ailments — both for critical and non-critical care,” Dr. Jauhari told ThePrint.
He added, “For the private sector, it works because these are centres of excellence and these are high-end surgeries — low volume and high revenue. They are also good for the image of the institution. In the government sector, the infrastructure is not very inviting, so patients who can afford to pay prefer to come to the private sector.”
He added that while governments both at the Centre and in states are now trying to popularise transplant surgeries, the cost is often prohibitive.
Organ recipients also have to be on immunosuppressive drugs for the rest of their lives, and that can cost anything between Rs 10,00 and Rs 15,000.
However, the Pradhan Mantri Jan Arogya Yojana covers kidney transplants. In addition, many state government insurance schemes also include transplant packages.
Missing out on transplants
Organ transplants in India date back to the 1980s when a bunch of talented, foreign-trained surgeons returned home to set up centres to train more people like themselves. India’s National Organ Transplant Program was first conceived in 2011-2012.
Despite this, however, experts say there’s a significant gap between the number of Indians who need a transplant and those that actually end up getting one. According to an estimate made by the Directorate General of Health Services, around 1.8 lakh people suffer from renal failure every year but only 6,000 renal transplants are done each year.
“An estimated 2 lac (sic) patients die of liver failure or liver cancer annually in India, about 10-15 per cent of which can be saved with a timely liver transplant. Hence about 25-30 thousand liver transplants are needed annually in India but only about 1,500 are being performed,” the DGHS says.
“Similarly about 50,000 persons suffer from heart failures annually but only about 10 to 15 heart transplants are performed every year in India. In case of cornea, about 25,000 transplants are done every year against a requirement of 1 lakh.”
Organ transplants are among the most regulated medical procedures in the country thanks to multiple reports in the past of organ trafficking and even sale. However, according to Dr Jauhari, there’s often a lack of data transmission from the states to the Centre, making it difficult to assess the actual distribution of the surgeries, although some states are better than others.
The gap is in part the due to the lack of easy availability of organs and in part due to cadaver transplants still not being popular in India. And despite the promise of financial aid from the Prime Minister’s National Relief Fund, the lack of dedicated transplant centres in the public sector is also a hurdle.
Help from the Prime Minister’s National Relief Fund is available to people from economically weaker sections, usually with the proviso that the patient or family would arrange part of the funds.
Dr Ashish Sharma, head of the department of renal transplant surgery at Chandigarh’s PGIMER, said that of the 8,000-odd kidney transplants conducted in India annually, about 80 per cent take place in the private sector. One of the reasons for this, he said, is that the public sector does not have dedicated transplant departments.
“There are not enough training facilities. Except for the kidney, no major public sector hospital has a dedicated transplant department,” he said. “Usually, surgeons do it as an add-on — gastro surgeons do liver, and urology surgeons do kidney transplants. In the entire public sector, there have been only two lung transplants to date — one at AIIMS and one at PGIMER Chandigarh.”
PGIMER’s renal transplant surgery department, he said, is one of the only centres in the public sector with a dedicated training programme.
“We do kidney and pancreas, of which we have done about 34 so far. But my graduates do not get work in the public sector,” he told ThePrint.
Many of the top surgeons in the private sector, though, have trained in the public sector. Most go abroad after that before helming their own programmes.
Surgeons talk about logistical hiccups in running a transplant programme in the public sector. Dr Subhash Gupta, chairman of the centre for liver and biliary sciences at Max Superspeciality Hospital, Saket, who worked at AIIMS for many years, said, ”Living donor liver transplantation is very difficult work and needs a lot of teamwork. It’s a long-drawn operation”.
“In the government sector, very few people work in cohesion with each other. On an average day, the operation theatre starts at 7.30 am and gets over around 6-6.30 pm. It’s a very resource-intensive programme”.
The best way to push cadaver donations, he said, is to incentivise them.
“Most cadaver donations happen in government hospitals, so my firm belief is that, should the public sector start doing more transplants and should we start incentivising donations from braindead patients — such as a CGHS card, say — cadaver donations would go up,” he said.
Dr Jauhari also spoke about incentives for all those involved, including the doctors and paramedical staff, to encourage transplant programmes in the government sector and to tide over the problem of shift timings.
Meanwhile, others pointed out that in the public sector, one of the limitations is that they cannot build their own teams. Hiring happens at the level of the government, and there are provisions such as reservation to be adhered to, limiting choices.
Dr Sandeep Guleria, who worked for many years at AIIMS before moving to Apollo as a consultant transplant surgeon, said, “The aim of the public sector is three-pronged — teaching, patient care and research. In the private sector, it is just profit. But in government you cannot hire your own team, it is often not a meritocracy. AIIMS does a lot of transplants — about 100-150 per year. But there is a 6-8 month waiting list for live-donor kidney transplants. These hospitals have a huge patient load. Just the 37-40 tests that need to be done before a transplant often take very long”.
However, a senior transplant surgeon at AIIMS, speaking to ThePrint on condition of anonymity, dismissed these concerns.
“What would I do with a permanent team? The idea is to train people so that they can open new centres. People trained by me are working in the private sector; some of them are now opening a transplant centre at AIIMS Rae Bareli. Here, it is not about making money, unlike in the private sector where they will do surgeries even at 2 am. We are not a dedicated centre because my residents need to be trained in other surgeries too, not just transplants”.
“We have limited capacity, limited resources,” the consultant said, adding, “The private sector doesn’t have responsibilities such as training and research.”
‘Need one dedicated hospital per state’
The largest heart and lung transplant programme in the country is run by MGM Healthcare in Chennai. Dr K. R. Balakrishnan, director of the Institute of Heart and Lung Transplant and Mechanical Circulatory Support, said that running a transplant programme is easier in the private sector because it is more “nimble”.
“If there is a call in the middle of the night about a cadaver that’s available, say, in Chandigarh, decisions such as how to expedite the transfer, etc. have to be taken instantly without hierarchy,” he said.
His prescription to increase transplants in India is that every state should have a dedicated hospital for transplants.
“For the tests, there can be a designated laboratory so that the delays can be minimised,” he told ThePrint.
“One needs to understand that the cost of a surgery and the charges of a surgery are two different things. The costs are what they are but governments need to step in to reduce the charges. In Tamil Nadu, for example, the state government covers heart and lung transplant under its health plan. They pay a fixed price of Rs 16-20 lakh per surgery. Beyond that, the patient needs to pay.”
All surgeons agree on the need to promote cadaver donations, and one way of doing that, said Dr Jauhari, is to build public awareness of the concept of brain death.
“People understand cardiorespiratory death but cannot always understand the concept of a man with a beating heart not being alive. In the government sector, they are so overburdened that they have no reason to pursue a transplant programme. That is why we need to incentivise it for all. Incentives are not inducements — we need to make that distinction,” he says.
(Edited by Uttara Ramaswamy)