Current Challenges And Future Directions For Liver Transplantation
Over the past 20 years, liver transplantation, especially living donor liver transplant has increased manifold in India and successfully saved thousands of patients across India and from countries in the Indian sub-continent, middle-east and Africa. However, several challenges remain.
Currently, about 2500 liver transplants are performed annually at approximately 200 liver transplant centres, out of which around 30 may be very active. However, the estimated need is for about 20,000 transplants annually, therefore, there is an urgent need for more transplant centres in India. However, there are few surgeons and hepatologists trained in liver transplantation. Most initial programs were started by doctors trained abroad after returning to India. However, recently, doctors have been able to train well and qualification in India itself and start new programs.
The prohibitive cost of a liver transplant (approximately 15-30 lakh) is unaffordable for about 80 per cent of India’s population, although it may be about a fifth of its costs in the west. Indigenisation of drugs and consumables used in liver transplant may significantly reduce the cost. Several avenues to fund transplants such as insurance, medical trusts and croudfunding are used by patients. While overall health insurance coverage is poor in India, even those who do often have inadequate cover for a liver transplant. Most policies now cover not only the recipient, but also the donor for transplants. It is important to buy large enough insurance to cover transplants. Several trusts such as Transplant Help the Poor Foundation and Praveen Agarwal Foundation are dedicated for transplant funding whereas other private trusts fund transplants too. Crowdfunding is also a common way of raising funds and is remarkably effective for children.
Cost and accessibility could also be facilitated by developing liver transplant units at government hospitals. A Public-Private-Partnership (PPP) model between experienced private hospitals and government hospitals has been successful in few cases. Several state governments such as Tamil Nadu and Karnataka have schemes to fund transplants for economically weaker patients in any public or private hospital, with Rajasthan recently announcing coverage for all transplant under the Chiranjeevi Health Insurance scheme. On the other hand Gujarat and Delhi governments have developed successful liver transplant units where it is subsidised.
Another big challenge is low number of deceased organ donations in India (less than 1 per million population). This can be increased using a mass awareness campaign by the government on organ donation and transplant, similar to campaigns like Beti Bachao and Make In India. Donation after Cardio-circulatory Death (DCD) may be another avenue to increase organ donations, as has been successful in many countries in the last decade as out of all deaths, only about 2 per cent are brain-death. This could be facilitated by legislation and rules to positively and explicitly allow DCD. New technologies such as ex-vivo organ perfusion that have improved the results of DCD transplants in the West are expensive and could be made cheaper by indigenisation.
Most problems discussed may be resolved by the efforts of all stakeholders and patients desperately waiting for liver transplants can finally see the light at the end of the tunnel.
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