🎗Financial sustainability of Transplant Programs in low middle-income countries. A snapshot of models providing “free of cost” transplant services

Introduction: There is a paucity of transplantation activity in Low Middle-Income countries (LMIC) due to economic constraints, inadequate health infrastructure, and government expenditure on health <6% of the GDP.  Of the total global transplants, 11% are performed in LMIC.  In this backdrop of economic constraints, countries in LMIC have developed free-of-cost funding models for transplant programs.  The objective of this paper is to identify transplant models that have achieved financial sustainability in LMIC.  
Methods: Data sources were taken from the period 2020-2025.  This includes the United Nations Development Report 2025. Global Observatory on Organ Donation and Transplantation (GODT) report of 2023.  Transplant activity for International Registry on Organ Donation and Transplantation (IRODaT) report of 2025, World Population Review 2023.  International Nephrology Society Publications of 2023. Specific country data were sought by a search of PubMed, Google Scholar, and Science Hub for studies published in the period 2020-2025.  This paper was approved by the Institutional Review Board, IRB No: 704.    
Results: Several countries have included transplantation in Universal health coverage, e.g., Sri Lanka, Iran, Kazakhstan, Thailand, Argentina, and Brazil, where transplantation is performed from both living and deceased donors.  Majority of these countries mainly perform Kidney and Liver transplants with small numbers of Heart, Lung, Pancreas, and Small Bowel Transplants.  Overall, 5-year graft survival rates are >85% for the kidney and liver.  A number of countries have developed Public-Private Partnership (PPP) to provide free-of-cost transplantation, including Pakistan, South Africa, Egypt, Philippines, Kenya, and Nigeria, while others have mixed funding models where 30-40% are performed by public funds, <5% private out-of-pocket expense, and the rest by PPP, e.g., India, Turkey.  These mixed models are prevalent in the majority of LMICs.  Similar to public-funded models, other countries with PPP or mixed models mainly performed kidney and liver transplants, followed by heart, lung, pancreas, and small bowel.  Graft survival rates for liver and kidney at 5 years are >85%.
Conclusion: Funding for organ transplantation is a challenge in LMIC, mainly due to economic constraints and inadequate infrastructure for transplantation.  To support the transplantation, governments in a number of countries have included transplantation under universal healthcare, where 50-70% of patients get free transplantation, and others have developed PPPs and mixed funding models.  These programs have led to the development of transplant infrastructure and deceased donation, resulting in heart, lung, pancreas, and small bowel transplants.