A Lancet study flags how transplant systems in India are growing— but still leave behind the rural poor, the uninsured, and those without influence.
Published Jul 13, 2025 | 7:00 AM ⚊ Updated Jul 13, 2025 | 7:00 AM
Organ Donors. (Representative Image)
Synopsis: A Lancet study highlights stark inequities in India’s organ transplant system, where rural and low-income patients struggle for access, despite global acclaim. Dominated by private urban hospitals and lacking national funding, most Indians face out-of-pocket costs. Experts urge reforms: national registries, public investment, fair organ allocation, better coordination, and insurance coverage to ensure equitable, inclusive transplant care.
India is one of the busiest countries in the world when it comes to organ transplants. With a flourishing network of private hospitals and highly trained surgeons, it has even become a magnet for international patients seeking lifesaving procedures.
But a new study in The Lancet, published in July 2025, paints a sobering picture of what lies beneath that success story: A deeply unequal system where ordinary Indians—especially those from rural or low-income backgrounds—struggle to access the very care their country is known for.
“Access to solid organ transplantation and specialty care after transplantation varies widely within and across countries. Individuals in low-income and middle-income countries, as well as marginalised populations within all countries, face substantial barriers to transplantation due to limitations in infrastructure, financing, specialist workforce, and regulatory support,” the paper states bluntly.
Dr Vivekanand Jha, co-author and Executive Director at The George Institute for Global Health India, calling for an urgent need for policy reform to ensure global equity in Organ Transplantation told South First, “As we strive to advance global health, we must prioritise public investment and accountability, ensuring that innovative treatments are accessible to all, regardless of social-economic status.”
The study classifies global transplant systems into five categories.
“Minimal national registry data; insufficient government investment and oversight; variable access to specialty care; inadequate coordination between referring clinicians and transplant programmes; and variable insurance coverage and funding requirements for patients,” the paper lists as India’s key challenges, which lacks fundamental building blocks.
This lancet paper defines equity in organ transplantation as “every person with end-stage organ disease who could benefit from transplantation having a fair and just opportunity to receive a transplants, as well as the care needed to thrive afterwards.”
And yet, disparities are stark. Africa, which holds 17 percent of the world’s population, accounts for just one percent of transplant procedures.
In the USA, which has the world’s highest transplant rate, patients who are Black or from low-income groups are significantly less likely to be referred for a transplant or placed on waiting lists–even when their medical need is the same.
“Without intentional policy action, emerging innovations in the field of solid organ transplantation could deepen existing health disparities rather than bridging them,” authors warn.
While India provides dialysis free at point of care in many states, transplant procedures and follow-up care are mostly out-of-pocket expenses—putting them far beyond the reach of most Indians.
“In India where most transplantations occurs in private hospitals, which are concentrated in major cities, access is restricted for rural populations, and there is no national policy to cover transplantation costs, although dialysis is free at the point of care,” the paper argues.
One Indian case study in the paper offers a powerful anecdote to illustrate what this inequity means in real life.
“A 23-year-old tailor (monthly income $65) was diagnosed with [end-stage renal disease]… post-transplant, he was inducted into a drug trial, which enabled him to get immunosuppressive drugs for 6 months. Subsequently, tacrolimus and azathioprine were provided free of cost by a generic pharma company.”— Clinician, India.
This young man’s survival depended not on public policy or systematic access, but on luck, a drug trial, and charity. And he is not alone.
A growing concern flagged in the report is “transplant tourism”. They caution that this “Could divert attention from the development of local expertise.”
“Access to solid organ transplantation and speciality care after transplantation varies widely within and across countries,” the authors write.
India’s transplant ecosystem has become a preferred destination for patients abroad. According to the study: “Data presented during the 2024 Congress of the Indian Society of Organ Transplantation showed that patients from 39 different countries travelled to India for a transplant in 2024.”
But this booming medical tourism comes within a dark underside. “Specific hospitals in Indian report that over 90 percent of their transplant activity involves patients who are foreign, usually with accompanying living donors,” says one of the authors.
But this system creates inequity, the authors warn: “Only well connected or individuals with a high income can gain access to transplantation, and creating risk of organ trafficking and commercialisation.”
India’s top transplant centres are concentrated in urban hubs–Delhi, Mumbai, Chennai, Bengaluru, Hyderabad–leaving vast swathes of rural India underserved.
The Lancet paper doesn’t name Indian states specifically but warns that in countries like India, “Access is restricted for rural populations, and there is no national policy to cover transplantation costs, although dialysis is free at the point of care.”
They warn that dominance of private sector further tilts access away from the poor. Public hospitals capable of performing transplants are few and often overwhelmed.
“Many transplant programmes in category 3 and 4 countries operate predominantly in the private sector, limiting accessibility for the general public,” the authors note.
From non-invasive tools that can detect early signs of rejection, to genetically enhanced pig organs and perfusion pumps that repair donor organs before surgery–the future of transplantation is bright. But these breakthroughs could worsen disparities if access remains unequal.
The authors call for international policy action to prevent cutting-edge technology from becoming just another tool of inequality.
“Without intentional policy action, emerging innovations in the field of solid organ transplantation could deepen existing health disparities rather than bridging them.”
They recommend:
The authors argue that “National strategies must build public trust and tailor solutions to local contexts. Crucial interventions include ensuring financial neutrality for living donors, embedding equity metrics transplant registries and expanding telemedicine and other tools to bring coordination to underserved regions.
Nephrologists not connected with the study commended it. Speaking to South First Dr Sundar Sankaran, Program Director at Aster Institute of Renal Transplantation in Bengaluru said, “As a transplant nephrologist, I commend the document for it’s focus on addressing the critical shortage of transplantable organs and improving access to care. It’s emphasis on telemedicine as a tool to reduce travel burdens is a promising and innovative approach to enhance equity, particularly for patients in underserved or remote areas.”
He says by prioritising solutions that improve access to transplantation and follow up care, the study takes a meaningful step toward addressing disparities in the field, aligning with the goal of making organ transplantation more inclusive and accessible to all.
According to nephrologists, a lot of patients do come along with their living donors to Bengaluru from Africa, Middle East, Bangladesh. These transplants have to be legally cleared by the authorisation committee for transplants and only after the clearance the transplants are done at private hospitals.
As transplant nephrologist Dr Sundar suggests:
(Edited by Sumavarsha.)
