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Anwar Naqvi Pakistan - Monday 28 - Management and organization models for donation and transplantation A challenge for healthcare systems

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  • 1. Management and organization models for donation and transplantation: A challenge for healthcare systems Eastern Mediterranean Sindh Institute of Urology and Transplantation Karachi, Pakistan
  • 2. EMRO / MESOT Region
    • Origin of major religions: Islam, Christianity
    • Kuwait Statement – 2006
    • Istanbul Declaration - 2008
    Human Development Report 2010 Algeria Cyprus Egypt Iran Jordan KSA Kuwait Lebanon Libya Oman Pakistan Qatar Syria Tunisia Turkey UAE
    • Population = 597 million
    • GNI: $2,387 - $79,426
    • Produces 30% of oil output
  • 3. Kidney Transplantation Liver Transplantation Global Observatory on Donation and Transplantation Global Transplant Activity in 2010 (pmp)
  • 4. Comparisons of Kidney and Liver Transplantation with Human Development Index
    • Indication
    • Life Expectancy
    • Schooling years
    • GNI
    • Dimensions
    • Health
    • Education
    • Living standard
    Human Development Report 2010
  • 5. Transplant Activity (pmp) and Governance
    • Country Pop LK Tx DK Tx LL Tx DL Tx Total
    • Republic
    • Algeria 34.4 3.3 - 0.1 - 3
    • Cyprus 0.7 48.6 34.3 - - 49
    • Egypt 76.8 15.6 - 1.0 - 17
    • Iran 72.2 21.4 5.3 0.5 2.0 30
    • Lebanon 4.1 19.5 6.8 - - 26
    • Pakistan 167 4.6 - - - 5
    • Syria 20.4 12.7 - - - 13
    • Tunisia 10.4 9.5 2.7 - 0.4 12
    • Turkey 71.5 17.4 5.8 5.4 3.0 32
    • Monarchy
    • Jordan 6.1 31.1 - 3.3 - 34
    • Kuwait 2.9 17.2 8.9 - 0.3 26
    • KSA 25.3 9.0 6.5 1.5 2.3 20
    • Libya 6.3 8.7 - 0.3 - 9
    • Oman 2.7 5.5 - - - 5
    Heart: Iran (0.72), KSA (0.75), Turkey (0.71) Lung: KSA (0.04), Turkey (0.01) Global Observatory on Donation and Transplantation, 2010
  • 6. Public Health Expenditure (% GDP) and Transplant Activity (pmp) Health Exp (% GDP) 26 13 17 30 5 20 5 32 34 26 49 9 12 3 Tx (pmp) Human Development Report 2010 Global Observatory on Donation and Transplantation, 2010
  • 7. Literacy Rate and Transplant Activity (pmp) Literacy rate (%) Human Development Report 2010 Tx (pmp) Global Observatory on Donation and Transplantation, 2010
  • 8. Religious influences on Organ Donation and Transplantation All religions have sanctioned deceased organ donation
    • Factors operational in Islamic Societies
    • Body belongs to God vs saving a life is like saving all of humanity in the Quran
    • Disfigurement and mutilation of body
    • Delay in burial in deceased donation
    • The Local Imam. No hierarchical structure in Islam. This gives considerable autonomy to individual religious leaders to issue rulings (Fatwa) on organ donation and transplantation
    Al-Khader et al. Exp Clin Transplant. 2003, Oliver M, et al. NDT 2011, Alkhawari FS et al. AJT 2005
  • 9.
    • Tribal and feudal societies where the family patriarch decides on life and death issues
    • Reverence for the dead: Mutilation / intact body concept
    • Mistrust of the medical profession including “brain death”
    • Moral calculations weighing benefits against harms about treatment options in the face of life-threatening illness.
    Cultural influences on Organ Donation and Transplantation Oliver M, et al. NDT 2011, Wong LP Transplant Proc 2010 Hamdy S Revue Internationale Interdisciplinaire 2010
  • 10.
    • Attitudes toward transplantation in UK. Muslim Indo-Asians in
    • West London 1 .
    • Unwilling to donate 89%
    • Buy organs from native country 42%
    • Mistrust of the healthcare system
    • Percent of deceased donors in UK and USA (UNOS) 2 .
    • UK USA
    • White 96% 74%
    • Black 1.9% 12%
    • Asian (subcontinent) 1.7% (Chinese) 1.8%
    • Hispanics - 10.7%
    • Chinese 0.2% -
    • Others 0.7% 0.8%
    Minorities and ethnics groups in high income countries 1. Alkhawari FS et al. AJT 2005 2. Oniscu GC. Ann Acad Med Singapore 2009
  • 11.
    • Organ donation and transplantation
    • Knowledge 50-90%
    • Supportive attitude 50-70%
    • Willing to donate 35-89%
    • Commercialization of medicine and organ trade
    • High costs of renal replacement disfranchises the poor and the vulnerable
    • Commercialism encourages exploitation of vulnerable groups and erodes the trust of the public in the medical profession
    Social Influences on Organ Donation and Transplantation Ashraf O et al. Artificial Organs 2005, Wong LP. Clin Transplant 2011 Bapat U et al. SJKT 2009
  • 12. Saudi / Kuwait
    • Governmental agency (National organ procurement center) to supervise organ donation and transplantation (encourage all types of donation, statistics, allocation of organs, ethics)
    • It also coordinates the process of organ donation between the donating hospitals and transplant centers (coordinators, consents, harvesting teams)
    • Applies strategies to increase the awareness of the medical community and public at large to the importance of organ donation and transplantation (training, media, publications)
    Saudi Centre of Organ Transplantation (SCOT)
  • 13. Living & Deceased Transplantation (SCOT Data) Deceased (n=2227) Living (n=4395) Deceased (n=571) Living (n=358) Kidney Liver
  • 14. Iran
    • Unrelated Iranian living kidney donors receive “a gift from the government” as a reward - supervised by Dialysis & Transplant Patient Association
    • The majority further receive supplemental compensation, equivalent to US $1,550 from the recipients.
    • The Iranians call their model a “regulated market” and it has been seen as a solution to the increasing demand for organs.
    • Transplants are carried out at University hospitals
    • Transplants are not done for foreigners
    • This compensation system has resulted in a reduction in the rate of related living donation and limits expansion of cadaveric kidney transplantation
    Alex He Jingwei AH etal. Global Health Governance, 2010
  • 15. Renal Transplantation in Iran Living related = 15.2% Living unrelated = 79.6% Deceased = 5.2% - 16% Socioeconomic class Donor Recipient Poor 84% 51% Middle 16% 36% Rich - 13% Ghods A, Clin, JASN 2006 Einollahi B, Ann Transplant, 2008
  • 16. Pakistan: SIUT’s Initiative A programme for disfranchised Doctor Community Government Patient * 25 years, 2.5 million patients * 60,000 patients dialysed * 3,300 kidney transplants with life long follow-up and immunosuppression Concept of free with dignity Pakistan: Health expenditure = 0.8% Literacy rate = 54% Poverty ($2/day) = 74% Exorbitant cost of RRT in private sector Community government partnership
  • 17. Pakistan: the largest bazaar for cheap organs (2003-07) The Grim Set Back
  • 18. Impact of Commercialism in Transplantation
    • Affects growth of local transplant programme High refusal of intrafamilial donors
    • Encourages physicians & surgeons to operate in private centres Transplant activity shifted from government to private centres
    • Commercialism injures the trust in medical sector Exploitation of vendors negatively affects donation
    • Delays promulgation of transplant legislation Pakistan took 18 long years to promulgate the law
    • Negatively affects deceased donor transplantation e.g. Pakistan, Egypt
  • 19. Shoring up transplantation activity after legislation: SIUT’s effort Pre legislation Post legislation Local Foreigners HOTA Data (2007-2009): 29 transplant centres performed 1721 renal transplants SIUT’s contribution – 1022 (59%) SIUT Transplant Activity ??
  • 20. National imperatives
    • Each country must develop a legal framework and national self-sufficiency in organ donation and transplantation
    • Each country must have a transparency of transplantation practice that is accountable to national legislation
    • Countries in which the buying and selling of organs is outlawed must not permit their citizens to travel to destination countries and return for insured health care in the client country
    • Insurance companies should not support illegal practices preferentially in some countries
  • 21. The Way Forward
    • Public awareness through non governmental organizations
    • Involvement of media, articles, serials, talk shows, social media
    • Civil society engagements (religious scholars, college and university students)
    • Training of Coordinators (METCO)
    • Sharing regional experiences (e.g. AST/MESOT/ASNT)
    • Registry and Organ sharing network (public sector)
    • Involving recipients for promotion of transplantation and honouring donors
  • 22.  
  • 23. Poverty and Transplant Activity (pmp) People live on $2/day (%) 26 20 30 5 12 9 13 5 17 3 49 34 32 Tx (pmp) Human Development Report 2010 Global Observatory on Donation and Transplantation, 2010