Introduction
Solid organ and tissue donations, although closely linked, have disparate histories. Tissue donations, especially skin grafts, date back millennia, with the Ebers Papyrus describing them in 1,500 BCE.[1] In India, skin grafting and nose reconstruction were recorded 2,500-3,000 years ago[2] and would eventually become more sophisticated; the surgeon Sushruta wrote a treatise on these subjects in the 6th-century BCE.[3] Today, a range of tissues, including the cornea, heart valves, bone/tendon/muscle grafts and even the amnion[a] and pancreatic islets,[b] are transplanted.
In contrast, solid organ transplantations can be described as a more “modern” phenomenon. The first recorded instance was a kidney transplant conducted in 1954 by American surgeon, Joseph Murray, who later received the Nobel Prize in 1990.[4] Today, medical advancements allow for the transplantation of organs as complex as the liver, heart, lungs, small bowel, and even composite structures like the hands.
Many countries, including India, face severe shortages of organs and tissues.[5] India’s challenge, however, is particularly acute due to social, religious, and legal barriers, as well as limited capacity. As a result, India’s deceased organ donation rate remains below 1 per million population (PMP), compared with global leaders like Spain where the rate is at 49 PMP.[6]
In 2015, the Indian government estimated a shortfall of 75,000 corneas (75 percent of the requirement), 144,000 kidneys (96 percent), 28,800 livers (96 percent), and 49,983 hearts (99.97 percent).[7] In 2021, researchers estimated a 99.99-percent shortfall for the pancreas.[8] These are considerable numbers, with the cost measured in lives. However, greater government focus over the past decade has brought improvements. In particular, the creation of the National Organ and Tissue Transplant Organisation (NOTTO) in 2014 led to the deceased organ donation rate rising from 0.27 PMP in 2013 to 0.81 PMP in 2024—a 300-percent increase in just 11 years. Moreover, India has conducted 80 hand transplants till date, making it likely the world leader by a fair margin in this cutting-edge procedure.[9] The Amrita Hospital in Kochi and Gleneagles Hospital in Mumbai have conducted more hand transplants than any other country, barring the United States (US).[10] Yet, much more needs to be done to fill the gaps.
A primary challenge in understanding the shortfall is the lack of data. While still imperfect, NOTTO’s new Annual Reports, combined with recent qualitative and quantitative data, provide greater granularity, allowing a higher-quality assessment of the trends and dynamics of India’s organ and tissue donation landscape. This report describes the current organ and tissue donation landscape in the country; examines global trends; and highlights patterns in the data for India.
Organ and Tissue Transplants: An Overview
Solid organ transplants commonly include the kidneys, liver, heart, lungs, pancreas, and small bowel. Composite tissue allografts, such as the hands and face, have also emerged in select transplant centres. While kidneys and portions of the liver can be donated by living donors, most other solid organs are retrieved from deceased donors.
Although advances have made living lung lobar transplants and small bowel transplants more feasible, they remain uncommon, with some exceptions. For example, in Japan, living lung lobar transplants accounted for 39 percent of lung transplants from 1998-2015, helping narrow the supply-demand gap, ease scheduling, and provide more options for severely ill children.[11]
Preservation is a critical challenge in solid organ transplantation. Most grafts must be transplanted within hours of retrieval, necessitating swift coordination between retrieval and surgical teams. Figure 1 shows the elements that may influence the outcome of a transplantation, including feasibility, optimal transplant windows, and cold-chain resources.
Figure 1: Components of a Solid Organ and Composite Structure Transplant Facility
Source: Author’s own – multiple sources[12],[13],[14],[15],[16],[17],[18],[19],[20] and standard practice; Graphics – iStock (Liver, Small Bowel), Paint (Pancreas).
Static Cold Storage (0-4℃) is the most common form of storage as it is cheaper while offering a reasonably large transplant window. While dynamic methods of organ preservation such as hypothermic machine perfusion (HMP) for kidneys, normothermic machine perfusion (NMP) for the heart, and ex vivo lung perfusion (EVLP) for the lungs may offer better transplant outcomes or graft preservation, they are more expensive, limiting uptake. Figure 2 presents emerging clinical and research evidence on common and experimental transplants.
Figure 2: Notes on Common and Experimental Solid Organ and Composite Structure Transplants
Source: Author’s own – multiple sources;[21],[22],[23],[24] Graphics – iStock (Small Bowel), Paint (Pancreas).
In contrast, tissue grafts can be stored much longer, from weeks to years, using long-term preservation methods. In general, tissue transplants are also substantially more common than solid organ transplants and include the cornea, musculoskeletal grafts (tendons, bones), skin, heart valves, blood vessels (e.g., for cardiac shunts). More rarely, amniotic membrane grafts, stored post-delivery, are particularly useful for ophthalmological, dermatological, plastic, and gynaecological surgeries due to their anti-scarring, anti-inflammatory, anti-microbial and non-immunogenic properties.[25],[26],[27],[28] Figure 3 summarises important details for tissue grafts and transplantation practices.
Figure 3: Components of a Tissue and Composite Structure Transplant Facility
Source: Author’s own –multiple sources;[29],[30],[31],[32],[33],[34],[35],[36] Graphics – iStock (Heart Valves), Shutterstock (Blood Vessels).
Cryopreservation allows tissues to be stored for extremely long periods.[37] However, cost considerations and medical needs often necessitate storage at higher temperatures or alternative conditions, which shortens preservation time. Figure 4 also presents recent findings from clinical trials and research on preservation methods and graft performance.
Figure 4: Notes on Tissue and Composite Structure Transplants
Source: Author’s own, from multiple sources[38],[39],[40]
Current Global Trends
Donations from Deceased Donors: Income and Regional Distributions
Contrary to common perceptions, average annual income shows only a moderate positive correlation with deceased organ donation rates (Figure 5). The megaphone pattern—i.e., greater dispersion of data points as the X and Y variables increase (Average Annual Income and Deceased Donation Rates, respectively)—could suggest that beyond a minimum income level that makes deceased transplants feasible, income levels may become less of an influencing factor. Further statistical analysis is required, however, to make conclusive interpretations. A positive correlation could reflect factors like deceased organ donation requiring a minimum maturity of the hospital ecosystem, including affordability of preservation and transplant equipment, training of surgeons and staff for organ retrieval and transplant, and cooperation with other medical institutions and authorities to ensure donated organs reach recipients in time.
Figure 5: Deceased Donation Rates and Average Annual Incomes (Global, 2023)
Source: Author’s own; Data – IRODaT 2023;[41] WorldData.info;[42] Software –STATA
Global Observatory on Donation and Transplantation (GODT) charts linking HDI and deceased donation rates show that donations remain essentially negligible until an HDI of 0.7 (classified as high HDI). After this level is crossed, donation rates tend to increase with HDI but in a megaphone pattern, suggesting that objective measures of per capita income, education, and lifespan might be less relevant than other factors like donation-specific awareness, access to medical facilities, and adequate training opportunities for staff. India currently has an HDI of 0.644.[43]
Figure 6: Deceased Donation Rates and HDI (Global)
Source: GODT 2023[44]
Figure 7 shows that while North America and Europe (darker green) record the highest rates of organ donations by deceased donors, South America and Iran outperform wealthier regions such as Oceania and East Asia. Consequently, strategies to boost deceased organ donation by Brazil and Argentina may be more applicable to the Global South and deserve serious evaluation.
Figure 7: Deceased Donation Rates (Global)
Source: Author’s own; Data – IRODaT 2023;[45] Software – Datawrapper, Paint
Donations from Living Donors: Income and Regional Distributions
Rates of organ donation from living donors vary widely across regions, with large outliers and no clear income-linked patterns. As a result, no conclusive inference can be drawn between living donation rates and average annual income at this stage and further statistical analysis is required to make conclusive interpretations (Figure 8). It is possible that there may be countervailing factors such as black-marketing (dependent on income and law enforcement activity) as well as transplant tourism,[c] which offset the income-driven factors.[46]
Figure 8: Living Donation Rates and Average Annual Incomes (Global, 2023)
Source: Author’s own; Data–IRODaT,[47] WorldData.info;[48] Software–STATA
The choropleth chart highlights different hubs of living transplant activity, with the Middle East (particularly Türkiye and Saudi Arabia), Mongolia, and South Korea showing the highest rates despite low deceased donation levels. Overall, living donor transplants are more common in the Middle East, Asia, North America, and Oceania.
Figure 9: Living Organ Donation Rates (Global)
Source: Author’s own; Data – IRODaT 2023;[49] Software – Datawrapper, Paint
Organ and Tissue Trafficking and Illicit Trading
Organ trafficking and illicit transplants comprise a large proportion of living donor organ donations. Unethical transplants can take many forms, including the trafficking of people for forced organ removal, transplant tourism, and commercial trade in organs or tissues. The Declaration of Istanbul[d] distinguishes between benign travel for transplants and harmful transplant tourism—the latter defined as situations where “[transplant] resources (organs, professionals, transplant centres) devoted to providing transplants to non-resident patients undermine the country’s ability to provide transplant services for its own population.”[50] Transplant tourism is noted to “violate the principles of equity, justice, and respect for human dignity and should be prohibited.”[51] Given the long waiting lists and specialist shortages, it is likely that virtually all foreign transplant activity in developing countries like India is transplant tourism.
Inadequate data and the illegal nature of these activities make their scale difficult to ascertain, though dated estimates suggest that black-marketing accounts for 5-10 percent of global transplant activity,[52] and transplant tourism at 10 percent.[53] The 2024 UNODC Report on Trafficking in Persons noted that trafficked victims are generally in “desperate economic and humanitarian need,”[54] which also drives transplant tourism and organ trading.[55],[56] There is real-world evidence of this, in the sharp rise in such activities in Nepal following the devastating 2015 earthquake[57] and in Myanmar[58] following the 2021 coup.
The trafficking of persons for organ removal is the most serious form of unethical transplants, comprising 0.14 percent of all detected trafficking victims and 1 percent of convictions in 2022.[59] It is most common in the MENA (Middle East & North Africa) region and Central Asia and Eastern Europe, followed by East Asia and then South Asia (Figure 11). These statistics are derived from nationally reported data, meaning they are likely underestimates due to poor law enforcement in many countries.
Figure 10: Detected Victims of Trafficking by Intent (%)
Source: UNODC elaboration of national data (2022 or most recent)[60]
Within MENA, the UNODC’s sub-regional classification of “Other countries of the Middle East” (Iraq, Israel, Jordan, Lebanon, Syria, Yemen) recorded the highest share of trafficking for organ removal at 7 percent of detected victims, followed by North Africa[e] and then the GCC countries[f] (Figure 11). Victims were generally adult males.
Figure 11: Detected Victims of Trafficking in MENA Sub-Regions (%)
Source: UNODC elaboration of national data (2022 or most recent)[61]
Meanwhile, the leading destination countries for transplant tourism have been China, India, Pakistan, and the Philippines.[62],[63] Other countries with high levels of such activities include Brazil, Egypt, Moldova, Romania, Russia, South Africa, and Türkiye.[64] Transplant tourists come largely from wealthier countries like Australia, Canada, Israel, Japan, Oman, Saudi Arabia, and the US.[65] Reliable and recent estimates remain scarce and are heavily reliant on national reporting and law enforcement. However, reported evidence of large-scale trafficking in entire regions of Nepal, Mexico, and the Philippines suggests that organ trafficking and trading continue to pose a massive challenge at both the national and international levels,[66] despite efforts such as the Declaration of Istanbul and national crackdowns.
Tissue Transplants
There is little information available on tissue transplants at the global level, as most countries do not formally collect such data. For instance, a 2023 project by the Global Alliance of Eye Bank Associations to gather global data from the year 2019[67] onwards for corneal donation and transplants remains incomplete. At the national level, however, a few countries collect such data, largely for cornea.[68] For instance, in the UK, NHS Blood and Transplant (NHS BT) publishes detailed data on corneal transplant activity,[69] while the European Cornea and Cell Transplantation Registry (ECCTR) maintains an online database covering procedures from 15 EU nations,[g] the UK, and Switzerland.[70],[71],[72],[73] In other countries, such as the US, data is reported by private organisations like the Eye Bank Association of America (EBAA).[74]
Comprehensive registries for other tissues are rarer but do exist, like the SWEDEHEART database, which records all coronary or valvular interventions (including heart valve transplants) across Sweden.[75],[76] It may also be possible to use proxies like hospital billing codes and reimbursement data,[77] but these are generally inferior to a dedicated database.
The Context in India
Current Organ and Tissue Donation Landscape
Health is on the State List of India’s Constitution. In practice, however, the Central government has increasingly overseen organ and tissue transplants due to the clear need for national standardisation and oversight. This is primarily done through the Transplantation of Human Organs and Tissues Act (THOTA), 1994, which regulates the removal, storage, and transplantation of organs and tissues and contains some of the strongest and most detailed provisions globally against illicit organ and tissue dealing.[78] It was amended in 2011 to close loopholes being exploited for commercial dealings. While credited with some success, the persistent challenge of organ trafficking and trading remains
This amendment defines the legal basis for NOTTO, which is the apex body for organ and tissue donation in India, with feeder bodies at the Regional (ROTTO) and State (SOTTO) level. Sustained efforts by NOTTO have resulted in a near-threefold increase in the organ donation rates from deceased donors from a very low base, albeit still much below the global average and less than one-fourth that of neighbour Sri Lanka.
Nevertheless, states retain flexibility in shaping organ and tissue donation policy. They may enact State-specific legislation, although this is generally harmonised with national law.[79] The impact of state policies and demographics should not be underestimated. According to these author’s estimates, calculated using data from NOTTO, Chandigarh records a deceased donation rate of ~16.1 PMP (+1,997 percent of the national level), comparable to the best performers globally; Telangana has 4.9 (+610 percent) and Tamil Nadu has 3.5 PMP (+431 percent).[80],[81] These states have implemented comprehensive policies to boost organ donation rates. Chandigarh benefits from the presence of the Institute of National Importance (INI) PGIMER, which carries out complex organ transplants[82] and records some of the country’s highest donation rates.[83] As a public hospital, it also provides more affordable transplants[84],[85] and was recognised with a ‘National Award for Best ROTTO’ for its sustained efforts to facilitate organ and tissue donation in North India.[86]
Additional measures, such as ‘green corridors’ to expedite organ transfer, have also contributed. Telangana’s Jeevandan system provides a common platform for organ donation, allocation and transplantation across the system based on ethical guidelines,[87] while also reducing allocation-information-mismatch frictions. Tamil Nadu also uses ‘green corridors’[88],[89] and provides full State Honours at the funerals of deceased organ donors, leading to a significant increase in donation interest.[90],[91],[92]
At the time of writing, national reforms are underway. The National Health Authority (NHA) has announced a two-part plan to digitise organ and tissue donation data.[93] The first phase—a portal that allows individuals to formally pledge their organs or tissues—has already been operationalised, improving public awareness and assisting medical institutions with checking donor status. The second phase, as part of the Ayushman Bharat Digital Mission, will establish national donor and recipient registries and enable matching based on medical prioritisation guidelines in a transparent manner.[94],[95] This has the potential to eliminate non-transparent or unfair prioritisation/allocations and informal/commercial transactions that are present in the ecosystem.[96],[97],[98] The Ayushman Bharat Digital Mission Strategy Overview also mentions the possibility of using the Health ID system to facilitate data sharing or delegated consent for organ donation.[99]
Data Deficiencies
India’s diversity in economic, social, and religious parameters makes localised approaches essential. However, two crucial data deficiencies restrict effective policy analysis and evaluation.
First, NOTTO’s published statistics on organ donation are incomplete, as it does not receive updated information from many states.[100],[101] Further, for tissue transplants, there is no government data available. While some private organisations collect tissue transplant data, such as corneal collection and utilisation rates compiled by the Eye Bank Association of India, the published data is not suitable for state- and district-wise analysis.
Second, data on solid organ transplants is irregular and not granular enough. For instance, the NOTTO Annual Report 2023-24 contains a state-wise breakdown of liver transplants from both living and deceased donors.[102] However, for kidney transplants, only total numbers are available. Similarly, there is no district-wise breakdown provided, nor a comparison of metro and non-metro regions or between Tier-1, -2, and -3 cities. This restricts the development of targeted policy approaches to raise donation rates.
Data Analysis: India
This section uses the most recent data sets from NOTTO for macro-level analysis.
Domestic and Foreign Transplants
According to government data, 10 of every 100 transplants in India involve foreign nationals (see Figure 12). Given the gaps in data for both total and foreigner transplants, this is likely an underestimate. The MOHAN Foundation estimates that 15-20 percent of living transplants in India go to foreigners—as mentioned earlier in this report, a notable proportion of this number would comprise “transplant tourism”.[103] Indeed, cases have been reported of foreign recipients being prioritised over Indian nationals, including due to the economic interests of transplant centres, which clearly violates the Istanbul Declaration and India’s commitments to the World Health Assembly.[104],[105]
Figure 12: Transplants by Citizenship
Source: Author’s own; Data – NOTTO Annual Report 2023-24[106]
Adding to the concern, both NOTTO communications and media reports suggest that there has been a recent surge in foreign transplants, including black-market transactions.[107],[108] Although the THOTA has been credited with reducing the prevalence of commercial dealings and black-marketing, this remains an ongoing challenge, with India continuing to be described as a “centre”[109] for such activities.[110],[111],[112]
There are three types of commercial dealings that are locally relevant. First, the trafficking of people for the forced removal of organs, of which 17 cases were detected by the Ministry of Home Affairs, India (MHA) in 2022.[113] Second, commercial dealings in unlicensed facilities involve a mixture of local or foreign donors and recipients, which is unlikely to be reflected in official statistics. Third, illicit organ dealings masquerading as legitimate donations at licensed hospitals or facilities, which can—and likely does—show up in official figures.[114]
Currently, India mandates that foreigners must bring a donor from their home country, with certification from their Embassy vouching for a non-commercial relationship.[115] These documents are assessed and verified by the hospital’s Authorisation Committee (AC) before approval. Alternatively, Indian-origin foreign citizens can rely on Indian relatives, with ACs empowered to conduct DNA tests to verify their relationship if needed.[116]
There remain, however, lacunae in this process that are open to exploitation. First, the system places the burden of investigation on Transplant Coordinators and ACs within medical institutions, a task further exacerbated by the under-hiring of Transplant Coordinators to curtail costs. [117] However, ACs often lack the ability to verify foreign documents and often rely on Embassy certifications, which may be fraudulent or inaccurate.[118],[119] For example, media reports say there are cases of recipients from Myanmar bringing with them to India commercial donors who are not their relative.[120] With most foreign transplants conducted in private hospitals, there is the possibility of institutional complicity for economic gain.[121]
Second, the inclusion of a spouse as a near-relative donor, even in marriages of short duration,[122] raises the risk of ‘sham’ marriages undertaken for the purpose of organ donation.[123] This risk intersects with the gender gap in Indian organ donation activity, to be discussed further in this report.
Third, under Section 9(3) of the THOTA, Indian residents can receive donations from unrelated Indian citizens “by reason of affection or attachment.”[124] This provision, along with the exception allowing near-related donations to foreigners, creates space for abuse. It enables Indian residents to receive donations from commercial donors or citizens of neighbouring countries such as Nepal, Bangladesh, and Myanmar who can reasonably pass off as Indian relatives if their citizenship is not adequately investigated. Research has been done on this matter by the MOHAN Foundation[125] and other researchers,[126],[127],[128] and the media has reported on it as well.[129],[130],[131]
Thus, the high proportion of foreign transplants in India raises concerns of both illicit dealings and harmful transplant tourism, which disproportionately affects the low-income and inhibits the development of a proper ecosystem for organ donations from deceased donors.[132] This is exacerbated by the fact that over 99.5 percent of foreign transplants are living donor transplants (Figures 12, 13), most likely kidney and liver, which are susceptible to such commercialisation and exploitation. The geographic distribution for such transplants is also a matter of concern (see Figure 13), as states like Rajasthan, West Bengal, and Uttar Pradesh record more activity than Telangana, Maharashtra, Karnataka, Gujarat and Tamil Nadu, despite being poorer and having less transplant activity (Figures 22, 23, 24). Living donor transplants in states like Manipur[133] also require further investigation.
Figure 13: Foreign Transplants by State/UT (2023)
Source: NOTTO Annual Report 2023-24[134]
Living and Deceased Organ Transplants
Following global patterns, in India, living organ donations comprise more than 80 percent of total transplants (Figure 14). This has remained fairly stable and is driven by many factors. For instance, living organ donations are more profitable and involve less administrative work, particularly incentivising private hospitals, which conduct most transplants in the country.[135] They can also be easier to manage, as there is greater flexibility in timing, and organ preservation is less costly and rigorous compared to donations from deceased donors, where organ preservation poses unique challenges.[136] Moreover, public hospitals face funding challenges and extremely high patient loads.[137],[138],[139] This particularly affects deceased organ donations, since the lack of facilities and high demand for beds means that doctors rarely have an incentive to reserve ICU beds for critically ill Brain Stem Dead (BSD) patients to facilitate organ retrieval post-death.[140],[141],[142],[143] Other factors include illicit commercial dealings for living organ transplants in India, which likely partially show up in official data as well.
Figure 14: Total Transplants by Donor Type
Source: Author’s own; Data – NOTTO Annual Report 2024-25[144]
Organ donations from deceased donors are conducted for many organs in India, mostly the kidney and the liver (Figure 15). Each deceased donor enables, on average, more than three transplants (Figure 16), a multiplier effect that has increased over time (over +15 percent from 2023 to 2024).
Figure 15: Deceased Donor Transplants by Organ
Source: Author’s own; Data – NOTTO Annual Report 2024-25[145]
Figure 16: Transplant Multiplier Effect
Source: NOTTO Organ Donation and Transplantation Data (2013-2024)[146]
Living organ donations in India are conducted only for the kidney, liver, and small bowel, although other organs could also be suitable. As shown in Figure 17, living donor transplants account for over 85 percent of kidney transplants and over 80 percent of liver transplants. For the small bowel, which comprises a minority of living organ transplants, the trend is reversed with ~89 percent being deceased donor transplants.
Figure 17: Living Organ Donations by Donor Type
Source: Author’s own; Data – NOTTO Annual Report 2024-25[147]
Gender Distribution
Women comprise the majority of living (and thus, total) organ donors, and the gender gap is a matter of concern. While long-term data shows that 80 percent of donors are women and 80 percent of recipients are men,[148] this has narrowed over time. In 2023, 63 percent of living donors were women (Figure 18). This is due to gender imbalances in near-related donations (~77.9 percent of all living donations),[149] where 90 percent of spousal donations are from the wife to the husband.[150]
Figure 18: Living Donors by Gender (2023)
Source: Author’s own; Data – NOTTO Annual Report 2023-24[151]
Note: As transgender donors comprised a very small percentage of the total, their share does not appear clearly on this chart.
The causes are multiple. In many cases, women choose to donate out of a benign sense of affection or familial responsibility,[152] which is allowed under THOTA[153] and should not be problematised. However, the imbalance does reflect harmful influences, including family pressure and patriarchal expectations of caregiving and sacrifice.[154],[155]
While men comprise the vast majority of deceased organ donations, these are still a minority. A five-year data chart (Figure 19) provides insight into gender dynamics in living versus deceased organ donation, highlighting that males predominate as organ recipients regardless of donor type.
Figure 19: Gender Ratio for All Transplants (2019-2023)
Source: The BMJ[156]
Note* The sizes of the circles correspond to donation and transplant activity. The inner circle in the Donors series reflects the gender breakup for deceased organ donation; the outer does this for living organ donation. In the Recipients series, the inner circle reflects the gender breakup for recipients who have received organs from a deceased donor; the outer circle reflects the gender breakup for recipients who have received organs from a living donor.
Types of Transplants, and Overview by States and Incomes
There is workable data on solid organ transplants in India. The vast majority of solid organ transplants in the country are covered by just the kidney and liver (Figure 20). Most hospital transplant units lack the physical infrastructure and human resources to conduct other types of transplants.
Figure 20: Total Transplants by Organ (India, 2024)
Source: Author’s own; Data – NOTTO Annual Report 2024-25[157]
State-wise distributions reveal a broader trend of higher transplant activity in the higher-income Southern and Western regions, while poorer Northern, Eastern, and North-Eastern regions lag behind (Figure 21). Telangana, Tamil Nadu, Maharashtra, and Karnataka appear especially strong on this front, regardless of organ type (Figures 21, 22). This may be reflective of many factors including stronger medical systems, greater ability to afford transplants, and higher medical literacy levels.
Figure 21: Geographic and Income Distribution of Common Transplants
Source: Author’s own; Data – NOTTO 2024 Organ Transplantation Data,[158] Statista,[159] Software – Datawrapper
Transplant activity for the heart, lungs, pancreas, and small bowel is substantially lower. This may propagate health inequities, as patients from many regions may face limited access if they cannot afford travel, or, if they can, may encounter higher barriers to treatment based on their place of residence, privileging those from higher socio-economic strata.
Figure 22: Transplant ‘Dead Zones’
Source: Author’s own, Data – NOTTO Annual Report 2024-25,[160] Software – Datawrapper
However, for living donor kidney and liver transplants, this regional trend is less strong (Figure 23). This reflects factors including long-standing and mature living donor kidney/liver programmes, higher revenue for private providers who dominate transplants, high foreign transplant rates, and large excess demand due to the prevalence of diabetes, hypertension, and Hepatitis B and C in India.[161],[162],[163],[164],[165]
Figure 23: Living Donor Transplants
Source: Author’s own; Data –NOTTO 2024 Organ Transplantation Data,[166] Software – Datawrapper
These patterns may change over time due to efforts to raise awareness of the benefits of organ and tissue donation through State schemes like Jeevandan as well as Central initiatives to digitise and simplify the transplants system, such as NOTTO’s online portal, which allows individuals to quickly and verifiably pledge/register their consent for organ/tissue donation after death. Indeed, pledges PMP data show no clear geographic distribution, with states from the North (Rajasthan, Himachal Pradesh, Uttarakhand), South (Karnataka, Telangana) and West (Gujarat, Maharashtra) performing well—although the Eastern and North-Eastern regions fare poorly (Figure 24). Some smaller UTs (Chandigarh, Dadra and Nagar Haveli and Daman and Diu, and Puducherry) also have steep pledge rates, reasons for which require further research.
Figure 24: Organ/Tissue Pledges (PMP) by State/UT
Source: Author’s own; Data – RGI/UIDAI 2024 State/UT Population Projections,[167] NOTTO ABDM Dashboard on 10/07/2025 at 2025H IST,[168] Software – Datawrapper
These pledges demonstrate a better gender balance. Moreover, younger and middle-aged pledgers (ages 18-45) dominate, reflecting increased interest in organ donation and the potential success of awareness-building measures (Figure 25).
Figure 25: Pledges Broadening Awareness and Acceptability
Source: NOTTO ABDM Dashboard on 15/02/2025 at 1838H IST[169]
Policy Recommendations
This report makes the following recommendations.
- Mandatory requirements should be implemented for all medical institutions to provide direct real-time data on all transplants via the Ayushman Bharat Digital Health Mission. To ensure compliance, the American model of including transplant regulations and the timely reporting of deaths (and imminent deaths) to the Organ Procurement Organisation through the Conditions of Participation for the federal Medicare and Medicaid programmes[170],[171] can be adapted to the popular Ayushman Bharat PMJAY Scheme. Initially, this should aim for complete coverage of all organ transplants, before expanding to cover tissue transplants in a graded process.
- All non-identifiable data pools should be made available for analysis, in line with the National Digital Health Blueprint framework.[172] In the short term, this can be modelled on the Annual Data Reports of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (OPTN/SRTR Annual Data Reports).[173],[174] This would ensure standardised, publicly available reporting of key transplant details, including organ type, donor status, and one- and five-year patient survival. Over the longer-term, a more detailed online database should be made available for researchers, similar to those maintained by NHS BT,[175] the ECCTR, and SWEDEHEART. These collect a variety of data, which allow for stratification and analysis by patient demographics, patient history, medical history, transplant and patient survival. In India, these should also include the ability to conduct State/district-wise analysis due to massive local diversity. This can offer valuable insights to guide policy formulation.
- A high-powered committee with representatives from NOTTO, medical institutions, MHA, Ministry of External Affairs, and the Ministry of Health and Family Welfare should be tasked with strengthening regulations on foreign transplant activities within a one-year period. The following measures should be evaluated:
-
Mandatory generation of a provisional NOTTO ID prior to applying for a visa or prior to the operation (if already a resident in India) instead of the current practice of generating NOTTO IDs up to 48 hours after the procedure.[176] If already a resident in India and not an OCI/medical visa holder, further scrutiny by the MEA should be undertaken to assess if there were visa rule violations. If overseas, designated Ports of Entry should be stipulated.
-
Cancellation of visas/OCI cards with permanent bars on entering or transiting through India for transplant regulation violations. Mandatory notification to the MHA/MEA by medical or enforcement staff.
-
Revenue-based financial penalties for hospitals and staff that facilitate such activity or fail to conduct due diligence, debarment from medical work, removal from the Ayushman Bharat scheme, and shutdown orders.
-
No provision of monetary assistance or charitable aid from Indian entities to non-OCI foreigners seeking transplant in India to prevent assistance being redirected from vulnerable Indians.
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Compulsory DNA testing for near-related transplants involving foreigners.
- Having adequate permanent Transplant Coordinators should be a requirement to maintain status as a transplant facility, and the role should be augmented with a compensation floor to improve its attractiveness for staff. In rural regions or those with vulnerable populations, some vacancies should be reserved for female TCs for gender-sensitised counselling to prevent coercion.
- Areas with the largest disparity between pledge registrations and transplant activity, e.g., DNH & DD should be identified and given targeted assistance to develop the transplant ecosystem.
Conclusion
Recent and forthcoming policy changes offer the potential to meaningfully raise long-stagnant organ and tissue donation rates in India. Although India still has a relatively low per-capita income and HDI<0.7, it has historically outperformed on critical healthcare challenges, such as polio eradication, demonstrating an ability to mobilise capacity and build public awareness that could be transferable to the transplantation ecosystem. In conjunction with the quality of domestic medical professionals and a world-leading low-cost pharmaceutical industry, there is potential to raise donation rates remarkably—as States and UTs like Chandigarh and Telangana have done.
Even so, comprehensive and granular data systems are still the foundation of effective assessment and policymaking. Narrowing the gaps currently present in achieving disaggregated, timely, and organ- and tissue-specific transplant databases is an imperative for national and state health authorities.
While advances have been made, particularly in gender equality between donors, as well as in building awareness, there remain serious concerns. Transplant service delivery continues to be beyond the reach of large populations in the country, contributing to health inequity. Future research should explore how these constraints can be resolved, with evidence from local and global best practices—including policy models, incentive frameworks, and regulatory enhancements that can bridge gaps in equity, ethics, and access.
Pulkit Athavle is an Economics undergraduate at the University of Sydney, New South Wales, Australia.
All views expressed in this publication are solely those of the author, and do not represent the Observer Research Foundation, either in its entirety or its officials and personnel.
Endnotes
[a] The amnion is a layer of the placenta, which is an organ that develops during pregnancy. It is usually discarded with the rest of the placenta post-delivery.
[b] Pancreatic islets are small clusters of endocrine cells in the pancreas, that produce insulin and glucagon, amongst other hormones. They are destroyed by autoimmune responses in Type I Diabetes.
[c] ‘Transplant tourism’ is when individuals travel from one country to another for the sole purpose of receiving a transplant. It is often linked to illicit dealing or exploitation, especially involving those from the Global North travelling to the Global South. The Declaration of Istanbul affirms that transplant tourism should be prohibited.
[d] The Declaration of Istanbul on Organ Trafficking and Transplant Tourism (original 2008, updated 2018) brought together key medical experts, government officials and ethicists from 78 countries including Australia, Brazil, China, India, Saudi Arabia, Singapore and the US to document key principles for ethical organ/tissue transplants and prohibitions against trafficking and transplant tourism.
[e] North Africa countries: Algeria, Egypt, Libya, Morocco, Tunisia
[f] GCC countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, UAE
[g] Austria, Belgium, Czech Republic, Finland, France, Germany, Ireland, Italy, Norway, Portugal, Spain, Latvia, The Netherlands, Sweden, Denmark
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