Organ donation is highly skewed in India with the poor too often being donors and the rich too often being recipients. Some transplant professionals suggest more money should be spent on transplant programmes to address this inequity. However, transplantation is an expensive proposition and public funds can be better spent on other preventive health and cost-effective measures to ensure the greater good of a larger number of people.
In a 2010 resolution, the World Health Assembly urged member states to promote “equitable access to transplantation services in accordance with national capacities, which provides the foundation for public support of voluntary donation”. This foundation of equity is missing in India and public support for transplantation is starting to wane.
Of the more than 2 lakh Indians getting into kidney failure each year, 90% die because they cannot afford to start dialysis, which is needed three times a week. Of those who start treatment, 60% stop soon because of financial constraints. Public dialysis centres are few and far between and one study shows that in a central government funded institution, a patient getting supposedly free dialysis had to spend on average Rs 2,800 for each session, which often results in catastrophic health expenditure, tipping the family into poverty. A study of over 13,000 patients covered by public insurance for dialysis in Andhra Pradesh showed that patients spent an average of only six months on dialysis. Only 3.5% of patients who dropped off dialysis got kidney transplants. The rest faced death.
More than 95% organ transplantations in India, like most other tertiary care interventions, take place in private hospitals. Kidney transplants cost the least among transplant surgeries, at Rs 5 lakh, with other organ transplants costing three to six times as much. Then there are the recurring annual costs of around Rs 1.5 lakh for medication after any transplant surgery. The expense associated with transplantation is the main reason why more than half the hearts and lungs donated do not find recipients. Government insurance schemes coverage for transplant surgeries is very small and much of that goes towards procedures performed in public hospitals with a small quantity going for procedures done in private transplant facilities.
Should governments spend more on transplants?
Here is the dilemma of the state level policy maker. Faced with a finite health budget, she has to draw up a list of items on which money can be spent and then add weightage to each after assessing cost-to-benefit in achieving a certain goal. What is, or ought to be, this goal?
The Union health ministry has declared universal health coverage with equity as a goal. The achievement of universal health coverage is an objective of the National Health Policy of India, 2017. The World Health Organisation in its report, Making fair choices on the path to universal health coverage, 2014, recommends that healthy life years saved can be a measure to determine priorities for expenditure. For example, it points out that $1,000 spent on fortifying food with vitamin A and zinc can save 60 healthy life years and if spent on dialysis will save only 0.02 healthy life years.
The report says that one “unacceptable trade-off” in trying to achieve universal health coverage is to give priority to very costly services whose societal health benefits are very small compared to alternative, less costly services. As an example, it cites a Thailand study that finds that money spent on dialysis can save 300 times more healthy life years if spent on tuberculosis control instead.
Kanchan Mukherjee, who specialises in health policy and health economics, has critiqued the government’s decision to open renal dialysis centres in all districts in India as “being made without supporting evidence or evaluations of cost effectiveness”. He cites an analysis that shows that if all patients with renal failure are to be treated, the cost of the programme could exceed the cost of the entire National Health Mission by 1.6 times.
Only if the current stagnant public spend of 1.2% of gross domestic product on health doubles in the near term and trebles in the medium term, can transplantation services at least inch into the low priority category for public funds in India. This is one of many reasons for the central and state governments to substantially increase their health budgets and keep moving towards 5%, the share that WHO recommends.
Meanwhile, the government should ensure preventive care that is far more cost effective than treatment. A doorstep program to control blood pressure and blood sugar has established that such interventions can possibly prevent 61% of kidney failures, 69% of heart attacks and 82% of strokes. Another such doorstep screening has shown that two-thirds of people identified as diabetic or hypertensive were unaware of their condition. Civil society can get more involved in organ failure prevention, supplementing government efforts in these doorstep programmes.
The government can also consider mandating that private hospitals should perform 25% of all their transplant surgeries on poor patients – referred to them from government hospitals – free of cost. This will be similar to mandating that private schools allot 25% free seats to disadvantaged children under the Right to Education Act. This will amount to cross subsidisation, where affluent organ recipients will enable the less affluent to access the same service of the same quality. This is a partial solution to the equitable access problem and is far more practicable than public subsidisation.
Equity in organ transplantation is difficult to address in a country that has high and increasing levels of inequality. It is not practicable to expect the government to help finance transplantation when there are other low-cost high-priority health initiatives possible. Instead, we need to push the government to quadruple its health spend, focusing on organ failure prevention and working on cross subsidisation for transplantation.
Dr J Amalorpavanathan is a former member secretary of the Transplant Authority of Tamil Nadu, Chennai. CE Karunakaran is a Trustee of the NNOS Foundation, Chennai.