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

Table 1 Examples of challenges and shortages in the establishment or maintenance of kidney transplantation programs in studies from developing countries

Ref.	Country	Shortage
Budiani-Saberi and Mostafa[33], 2011	Egypt	Commercial living donors care
Haddiya et al[24], 2012	Morocco	Lacking human and material resources
Okafor[17], 2016	Nigeria	Absent DDKT
		Lacking human and material resources
Mekdim et al[32], 2017	Ethiopia	Delayed program establishment
		In September 2015, the first Ethiopian KT program was launched in Addis Ababa, in collaboration with the University of Michigan
Davidson et al[5], 2015	South Africa	Materials for immunological tests: HLA and cross-matches
Ahmed et al[31], 2018	Sudan	Materials for immunological tests
		Delayed program establishment: In 2000, it was established with the assistance of visiting teams from England
Naqvi and Rizvi[34], 2018	Pakistan	Organ selling
Guy-Frank et al[16], 2019	Guyana	Unavailability of RRT: HD and KT. Only HD before 2007 with limited sessions (high costs)
		Delayed program establishment; started in 2008 with the assistance of volunteer teams from the United States
Bakr et al[35], 2020	Egypt	Absent DDKT program
Babloyan et al[36], 2021	Armenia	Financial issues for immunosuppressive and antiviral agents
		Irregular deceased KT program; Delayed establishment of LDKT program; launched in 2002, assisted by Belgium, Switzerland, and International Society of Nephrology and Guy’s Hospital (London)
Gadelkareem et al[30], 2023	Egypt	Delayed program establishment
		Incomplete national KT program

DDKT: Deceased donor kidney transplantation; HD: Hemodialysis; HLA: Human leucocytic antigen; KT: Kidney transplantation; LDKT: Living donor kidney transplantation; RRT: Renal replacement therapy.

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.