Economics of Organ Transplantation in India A. Shrivastava, P. Singh, M. Bhandari, and A. Kumar T RANSPLANTATION has emerged as a definitive therapeutic modality, and a focus on economic con- straints has become increasingly essential. 1 In India, mainly owing to economic reasons, only 2.5% of patients with end-stage renal disease are able to afford renal transplan- tation. 2 In the absence of effective health insurance, social security systems, and overriding priorities of preventive and promotive medicine in the health sector, the onus of funding transplantation falls on the patient and his family. Kidney transplantation from living donors was the only form of transplantation done in India until 1996. Enactment of the Transplantation of Human Organ Act 1994 on February 4, 1995, has paved the way for transplantation of solid organs obtained through cadaver sources. Transplan- tation of cadaver organs is on the rise, but the numbers are grossly inadequate to match the needs. Therefore, where there is nonavailability of a suitable and willing donor in the family, paid unrelated donors are resorted to in some private centers. This adds to the cost of transplantation, and it has spawned a US$20 million annual unrelated kidney donor market. 3 The purpose of this study was to analyze cost and financing of renal transplantation in India so as to identify possible areas of cost containment and to identify possible avenues of financing. MATERIALS AND METHODS Information on economic status, modality of funding for trans- plant, direct medical costs (hospital, drugs, and investigation charges) and nonmedical costs (loss of wages, transportation, accommodation and food) was collected through exhaustive pro forma and personal interviews from 111 transplanted patients reporting to our follow-up transplant clinic. Of these, 93 patients, including 14 spousal grafts, were transplanted at Sanjay Gandhi Postgraduate Institute of Medical Sciences, (SGPGI, a publicly funded institute) and 18 patients were transplanted in different private hospitals. The patients transplanted at our center received triple drug immunosuppression (Aza + Pred + CyA). Patients with spousal donor received ATG induction followed by triple drug immunosuppression. All patients were 2 weeks’ posttransplant; 75 and 33 patients were 3 and 12 months’ posttransplant, respectively. RESULTS Ninety-four percent of recipients were literate, 72% were employed, and 41% were the breadwinner for their family. Seventy percent of patients had to pool in more than one source of funding. Governmental support in the form of donation or reimbursement (60%), savings (60%), loan (40%), assets mobilization (20%), and support from family or friends (20%) provided sources for funding. None of the patients were supported by nongovernmental organizations (NGO). Average duration of maintenance dialysis was 17.0 weeks, with an average expenditure of US$1140 (INR41,025). There was no statistically significant differ- ence between duration of maintenance dialysis in various economic groups and level of education. Time lost in mobilizing resources was the major cause of postponement of transplant in 38% of cases, and finaliza- tion of donor delayed 36% of cases. In 10% of cases, patient transplant was delayed (8 weeks on dialysis) due to hospital waiting list, and another 12% of patients took time to decide about the transplant center. Medical fitness of donor (11%) and recipient (12%), ignorance of conse- quences of disease (9%), and social factors (5%) were other causes for prolonged dialysis. Mean direct medical cost of transplant and 2 weeks postoperation at SGPGI was US$2016 (INR72,570), SD US$420 (INR15,124). Trans- plants done in private hospitals were 217% costlier. Direct medical expense at 1-year posttransplant was US$4781 (INR171,122), again, 66% cheaper than a private hospital. CONCLUSIONS In India, more than the organs, financial affordability is a major constraint in providing efficient renal replacement therapy to the patients with ESRD. By decreasing the waiting period, expenses incurred on dialysis can be mini- mized. Cost of a transplanted kidney at a publicly funded hospital in India is the least expensive. This is in sharp contrast to the cost of transplant: $70,000 in the U.S., 1 $52,431 in the Netherlands, 4 $16,176 in Costa Rica, 5 and $35,000 in Spain. 6 Indian private hospitals are much more From Sanjay Gandhi Postgraduate Institute of Medical Sci- ences, Lucknow, India. Address reprint requests to Dr Mahendra Bhandari, Director, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014 India. © 1998 by Elsevier Science Inc. 0041-1345/98/$19.00 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(98)00961-0 Transplantation Proceedings, 30, 3121–3122 (1998) 3121