Published Jul 31, 2026 | 10:19 AM ⚊ Updated Jul 31, 2026 | 10:19 AM
Organ transplant
Synopsis: A new Lancet Regional Health–Southeast Asia study estimates that India meets only a fraction of its organ transplant need despite performing the world’s third-highest number of solid organ transplants. Using NOTTO and parliamentary data, the story explores why South India leads transplantation, the barriers patients face, and the widening gap between demand and access.
A patient with kidney failure searches for a transplant slot. A patient with liver disease does the same. Most never find one.
India performs more organ transplants than nearly every country in the world. Only the United States and China rank above it. Yet a new study in The Lancet Regional Health, Southeast Asia, finds that this volume conceals a shortfall affecting hundreds of thousands of patients each year.
Researchers built the first national estimate of India’s unmet transplant need. They combined disease incidence data from the Global Burden of Disease project with transplant registry records and population projections through 2040. The result challenges the assumption that transplant volume equals transplant access.
“India stands third in the world in terms of olid Organ Transplantation (SOT) crude numbers,” the authors write. “However, this figure does not truly reflect the SOT requirements.”
Yet India’s transplant story does not spread evenly across the country. The study found that a small group of states accounted for between 80% and 96% of India’s transplant activity, despite holding only 29.3% of the country’s population.
Although Maharashtra and Delhi NCR remain major transplant centres, three of the five leading regions the study identifies, Tamil Nadu, Telangana, and Kerala, sit in South India, with Karnataka also emerging as a leading state for several transplant programmes.
Government data from the National Organ and Tissue Transplant Organisation (NOTTO) show Tamil Nadu is one of India’s busiest transplant states, Telangana recorded the highest number of lung transplants among states, Kerala ranks among the leading states for kidney transplantation, and Karnataka is a major heart transplant centre.
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Researchers built the first national estimate of India’s unmet transplant need. Unlike previous studies that relied largely on transplant registry data, the researchers estimated need by combining disease incidence with evidence-based transplant eligibility criteria, allowing them to measure how many medically eligible patients never receive a transplant. They drew on disease incidence data from the Global Burden of Disease project, transplant registry records from NOTTO, and population projections through 2040.
In 2021, India needed an estimated 1,25,894 kidney transplants, 1,84,542 liver transplants, 83,841 heart transplants, and 11,253 lung transplants, the researchers found.
Actual transplant numbers covered only 7.2% of kidney need, 1.5% of liver need, 0.2% of heart need, and 1.2% of lung need.
In absolute terms, roughly 1,16,800 patients who needed a kidney went without one that year. Liver need went unmet for about 1,81,700 patients. Heart need went unmet for 83,700. Lung need went unmet for 11,100.
The paper projects this gap will widen. By 2040, annual need will climb to 1,43,722 kidney transplants, 2,10,649 liver transplants, 95,711 heart transplants, and 12,846 lung transplants, the analysis estimates.
Even under the study’s moderate reform scenario, annual growth of 8 to 10%, kidney coverage reaches only 32.6% by 2040. Liver, heart, and lung coverage stay below 7%. The researchers call this the most realistic path for India, benchmarked against reform in Turkey, Brazil, and Argentina.
Their most optimistic scenario, 15% annual growth modelled on Spain’s donation system, still leaves India meeting only 19.2% of liver need, 2.2% of heart need, and 14.7% of lung need by 2040.
“Even this scenario achieves only 32.6% kidney coverage and 6.9% liver coverage by 2040,” the authors note, calling this evidence of “the magnitude of system transformation required.”
The paper adds a point often missed in transplant policy discussions. Population growth and an ageing population will continue to increase transplant demand even if disease rates themselves hold steady. India’s demographic shift alone guarantees rising need for decades, regardless of any success in disease prevention.
The researchers describe their estimates as conservative. Diabetes and metabolic disease keep spreading across India. The authors note that advances in diagnostics and expanding transplant eligibility could push demand even higher than their projections.
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Researchers estimate nearly 3.9 lakh Indians needed a transplant in 2021. Yet only 82,285 patients sat on India’s official transplant waiting list as of 8 December 2025, according to a Rajya Sabha reply tabled that month.
The two figures are not directly comparable. The Lancet study estimate measures total medical need. The registry counts only patients evaluated and accepted onto a waiting list. Together, the two numbers suggest that many eligible patients never enter the transplant system at all.
Kidney patients made up 60,590 of the registered waiting list. Liver patients numbered 18,724. Heart patients numbered 1,695. Lung patients numbered 970.
Between 2020 and 2024, 2,805 patients died while on a transplant waiting list, according to the same government data. Delhi recorded the highest count at 1,425 deaths. Maharashtra followed at 297. Tamil Nadu recorded 233. Haryana recorded 215.
India’s transplant system still depends overwhelmingly on living donors. This route supplies around 80% of all transplants nationally, the study finds.
Deceased donation stood at 0.65 donors per million population in 2021. Spain recorded 46 donors per million that year. The United States recorded 38.
“This is 70-fold lower than Spain and 58-fold lower than the United States,” the authors write.
Living donation has inherent limits that hospital expansion alone cannot overcome. A living donor can give only a kidney or part of a liver. Hearts and lungs require a deceased donor. This limit explains why heart and lung transplant coverage lags so far behind kidney coverage nationally, in every region of the country.
The study argues that closing India’s transplant gap requires a shift toward deceased donation at scale. “The aspirational scenario implicitly demands a fundamental compositional shift toward deceased donation,” the paper states, adding that this shift needs investment in intensive care unit based donor identification, organ transport systems, and a much larger transplant coordinator workforce.
Government reimbursement rates illustrate one of the financial barriers patients may face, particularly for heart and lung transplantation, where treatment concentrates in a limited number of specialised centres.
Central Government Health Scheme rates set kidney transplant costs at 200,000 to 345,000 rupees, depending on whether the donor is a relative and whether the hospital holds accreditation. Heart transplant costs run to 1.5 million rupees under the same scheme. Lung transplants cost 2.5 million rupees. A combined heart and lung transplant reaches 3.5 million rupees.
Private hospital costs run well above these government reference rates in most cases, and vary by facility, city, and post-transplant care requirements.
The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana scheme covers renal transplantation through empanelled hospitals, and central government hospitals typically provide transplants free or at a subsidised rate. Coverage for heart and lung transplants remains far thinner across public insurance schemes than coverage for kidney transplants.
The Lancet model assumes medical eligibility, not financial access. Affordability is likely to be an important barrier separating eligible patients from transplantation, particularly for heart and lung procedures concentrated in a small number of centres. The authors make a related point in their conclusion, warning that continued transplant growth driven mainly by private, urban hospitals is unlikely to close the gap, and may deepen the inequities the study documents.
Most countries with established transplant registries report kidney transplantation as the largest source of demand. India runs against this pattern.
The study finds liver transplant need exceeded kidney transplant need throughout the study period, despite the researchers applying a stricter eligibility threshold to liver disease than to kidney disease, 2% against 5%.
“This differs from patterns reported in high-income and upper-middle-income countries, where kidney transplantation dominates waitlist registries,” the paper notes.
Chronic liver disease affects roughly four times as many people in India as kidney disease does, based on Global Burden of Disease incidence data. Even a smaller share of eligible patients within that larger pool produces higher total demand than kidney disease generates.
The researchers expect this gap to widen further. Metabolic dysfunction associated steatotic liver disease keeps spreading across urban India alongside rising diabetes and obesity rates. The study names this condition as a likely driver of future liver transplant demand, replacing the hepatitis infections that once dominated India’s liver disease burden.
Disease rates between men and women stayed close for kidney and lung conditions, according to the data. Men showed somewhat higher rates for liver and heart disease, at ratios of 1.18 and 1.52 respectively.
Transplant recipient numbers tell a sharply different story. NOTTO’s 2023 sex-disaggregated data show women accounted for only 36.8% of kidney recipients, 30.4% of liver recipients, 23.5% of heart recipients, and 47.2% of lung recipients.
Based on disease incidence alone, the researchers calculated women should represent closer to 49% of kidney recipients, 46% of liver recipients, and 40% of heart recipients.
The gap holds across every organ except lung transplantation, where recipient numbers land close to what disease incidence would predict.
Published research from India points to delayed referral, financial dependency within families, and cultural patterns around caregiving as contributing factors. The study’s authors add a caution against reading this gap as proof of access discrimination alone. Differences in disease progression, competing causes of death, and disease phenotype between men and women may also shape the numbers. Time series data broken down by sex do not exist in India’s transplant registries, so researchers cannot say whether this gap has widened or narrowed over time.
The persistence of a wide gap between need and access reflects constraints that extend beyond organ availability alone, the Discussion states.
The paper points to an uneven spread of specialised transplant centres, shortages of trained workforce, limited intensive care capacity, and gaps in long-term follow-up care across most of the country. These four factors, more than anything else, explain why a handful of states perform so far ahead of the rest.
Tamil Nadu, Telangana, Kerala, Maharashtra, and Delhi NCR together performed 79.6% of kidney transplants, 87.4% of liver transplants, 87% of heart transplants, and 96.1% of lung transplants, despite holding only 29.3% of India’s population. The authors call this concentration one of the starkest findings in their subnational analysis.
“Successful state-level programmes, such as Tamil Nadu’s deceased donor network and Telangana’s Jeevandan initiative, demonstrate that high performance is achievable when supported by political will, infrastructure, and public engagement,” the paper states.
Tamil Nadu built its deceased donor network over more than a decade, coordinating hospitals, police, and transport agencies to move organs quickly across the state. Telangana’s Jeevandan programme grew out of similar coordination and recorded the highest number of lung transplants among states in the latest NOTTO annual report. Kerala took a different route, building a kidney transplant ecosystem centred on living donation and dense private hospital infrastructure, one that keeps waiting times short.
The December 2025 Rajya Sabha reply reported no waiting list deaths from Kerala during 2020 to 2024, unlike most other major transplant states. These figures come from deaths reported through the national registry and may not capture every patient with end-stage organ disease who never reached a transplant centre at all.
But concentration cuts both ways. Patients in states without strong transplant infrastructure often travel long distances to reach a centre, adding cost and delay to an already difficult process. NOTTO’s state-wise counts, the authors caution, record where a hospital performs a transplant rather than where a patient lives, meaning the true regional access gap may run even deeper than the raw numbers suggest.
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The Ministry of Health and Family Welfare has acknowledged the pattern researchers describe. In a parliamentary reply tabled in March 2026, the ministry confirmed it has reviewed inequities in access, gaps in awareness, and capacity limits across regions.
Current measures include infrastructure grants to states, training programmes for transplant coordinators and surgeons, and a national registry portal tracking waiting lists and donor pledges. More than 4.8 lakh citizens had registered organ donation pledges through the national portal as of March 2026.
These measures already existed when the researchers modelled their reform scenarios. The study’s own projections suggest that sustained growth under current policy settings still leaves most organs short of meaningful coverage by 2040.
(Edited by Fayisa CA)
