Challenges to establishing and maintaining kidney transplantation programs in developing countries: What are the coping strategies?

Table 2 Distribution of the challenges to the establishment and maintenance of kidney transplantation programs in different regions of the World Health Organization

Regions	Challenges ordered relative to significance in each region	Proposed coping strategies
Regions	Challenges ordered relative to significance in each region	Proposed coping strategies
AFR	Financial challenges: Lacking human and material resources[5,17,32], delayed program establishment, and absent DDKT[5,17]	To recruit external resources: Training and qualification of KT physicians and surgeons[18,32], out-of-pocket payment[17,31]
	Sociocultural challenges: Religious and traditional beliefs[17,123]	Insignificant workups[17,123]
AMR	Lacking health workforce: Low number of nephrologists[16]	To recruit external resources: Collaboration with expert centers for training[2]
	Financial challenges: Delayed program establishment[16]	To recruit external resources: Financial support by charitable foundations and public-private partnerships[16], the model of the Integrated Healthcare program[20], and reduction of consumption[20,114]
SEAR & WPR	Lacking legislations: Commercial KT and transplant tourism[125]	Activation of local legislation and Istanbul Declaration[125,126]
	Lacking medical personnel[125]	Overseas KT under governmental supervision[125,126]
	Financial challenges[125]	National insurance coverage programs[125]
	Sociocultural challenges: Lacking DDKT[125]	Increasing governmental services and education programs[125,126]
EUR	Financial issues: Delayed establishment of LDKT program[36]	To recruit external resources: Training and qualification of KT physicians and surgeons[36]
	Political policies and consequences[36]	Establishing a national program[36]
EMR	Commercial and organ selling practices [33,34,66,67]	Establishing effective legislation[20,98], governmental reimbursement[117,118], and creation of novel models: Private-public partnership[7] and Iranian Model[119]
	Sociocultural challenges: Religious and traditional beliefs[122]	Anthropologic studies[47-51], education programs
	Organizational and administrative insufficiencies: Delayed or incomplete establishment of the national KT program[30,35]	National and intercontinental registries[96,97]. Establishing effective legislation[20]
	Financial challenges: Lacking human and material resources[24,31]	To recruit external resources: Training and qualification of KT physicians and surgeons[31]. Reduction of consumption[20,14]

AFR: African region; AMR: Region of the Americas; DDKT: Deceased donor kidney transplantation; KT: Kidney transplantation; LDKT: Living donor kidney transplantation; SEAR: South-East Asian Region; EUR: European region; EMR: Eastern Mediterranean Region; WPR: Western pacific region.