Central America, as constituted by the Republics of Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, and Panama, is characterized by highly diverse social and economic levels reflected by the Human Development Index, ranging from 0.614% for Nicaragua to 0.765 for Costa Rica, and by the percent of Gross Domestic Product dedicated to Public Health Services (ranging from 1.2% in Guatemala to 6.6 in Costa Rica). This has a direct impact on access to transplantation services for the population and on the advancement of deceased donation programs. It is therefore not surprising that only Costa Rica and Panama (and recently El Salvador) have national transplant organizations as part of, and dependent of, and financed by their Ministries of Health. A trend that correlates the Human Development Index with the total number of kidney transplants per year, particularly in developing countries,1–4 is also found in Central America (Figure 1).
Fragmented Health systems, like the ones in Central America, split delivery of services into different providers, such as the always precarious public health systems, financially more solid social security programs, and private services usually only accessible to a minority of the population.
All 6 Central American countries have legislations ruling over brain death and the use of organs from deceased donors for transplantation, with the latest law issued by Nicaragua as recently as 2013. Nevertheless, because of the fragmented health systems, each health care provider manages their own waitlist for its affiliates. Countries, such as Panama and Costa Rica, with 85% to 99% of the population being covered by the social security system, have an almost universal, nationwide waiting list. However, countries, such as El Salvador, Guatemala with only a limited access to Social Security (18%–21%), respectively, do not have a structured waiting list. The same restriction applies for posttransplant immunosuppression that covered lifelong for Social Security affiliates, but only for 2 years (or for children until age 18 years) for recipients that are covered by the public health sector.
Typically, transplant programs in each Central American country started small and isolated. Living related renal transplant programs by pioneering physicians in the 1970s and 1980s grew into more institutionalized programs with the initiation of government-funded dialysis programs. Problematic have been the step toward full coverage by the public health sector as for any other health services. Intense lobbying from dialysis providers and the growing incidence of ESRD due to poorly controlled hypertension, diabetes, and the recently described “Mesoamerican nephropathy” have dramatically increased numbers of patients entering hemo- or peritoneal dialysis.5 Funding for access to dialysis is now almost universal for both Public Health and Social Security systems in all 6 countries, but only a small percentage of patients on renal replacement therapy has access to transplantation. Posttransplant immunosuppression, although representing less of a financial burden compared to maintenance dialysis, is far from being universally covered in all countries, at least for patients not covered by the Social Security system.
Over the last 10 years, with the guidance of the RCIDT (The Iberoamerican Network for Donation and Transplantation, under the patronage of Spain’s Organización Nacional de Trasplantes and Pan American Health Organization), great efforts have been made to support centralized national transplant coordination, supervised, and financed by health authorities. Regional guidelines have been developed on audited recovery of organs from deceased donors and management of waitlists. Moreover, structures have been put in place in Costa Rica and Panama, with transplant coordinators based in hospitals to routinely identity and follow potential donors and screening for transmissible diseases, thus assuring quality and security of the process. In Guatemala, this structure is in place in 2 hospitals only, through initiatives of the transplant teams albeit with little support form health authorities. In addition, tissue banks and registries are being established, but ultimately each country has implemented their transplant program based on country-specific resources. As a result, the region has differing, country-specific transplant activities and donation rates.6,7 Unfortunately, the transplantation activity does not meet the increasing demand of patients with end-stage organ failure, particularly ESRD, considering prevalence rates of 338 pmp to 517 pmp, and incidence rates of 128 pmp to 197 pmp.8,9 Regional transplant activity and donation rates are shown in Figure 2.6,7
Donation in the region is based on opt-in legislations. Only Costa Rica had an opt-out system that has been transitioned to a system based on informed consent in the recently issued law of February 2014, mainly based on recently publicized concerns with organ trade. Subsequent to transplant tourism incidents in the region in recent years, a motion has been set in place banning transplantation of foreigners while limiting living nonrelated donations by tight regulations. There are no incentives in place for living donation, but unfortunately many disincentives exist. Living donors in the public health sector enjoy no specific protection for future negative consequences of their donation, and no support for lost wages or employment guarantees are in place. Economic rewards for the donation itself or payment for an organ are illegal in all 6 countries, with variable penalties. Strong supportive actions from RCIDT and Declaration of Istanbul Custodian Group, as well as The Transplantation Society and The Latin American Transplant Society), have helped transplant professionals to develop clear and ethical guidelines for donation and transplantation in the region.
Low incomes and socioeconomic levels make the general population in Central America vulnerable to organ traffic and transplant tourism. Those aspects have received a sufficient amount of attention, and efforts to keep the region safe are under way. Recent news reports on organ trafficking in Nicaragua and Costa Rica have resulted in positive reactions of national health authorities with prosecution of involved parties and revision (or creation) of specific regulations, although the events initially negatively impacted organ donation activities. Financial, logistic, and political support from health authorities for deceased donation programs exists in Costa Rica and Panama only. Guatemala reports some deceased donation, but with scarce and sporadic governmental support. The remaining countries still have to develop deceased donation. Low-volume liver transplant programs have been established in Costa Rica and Panama with 3 pmp and 1.8 pmp, respectively. To date, only Costa Rica has an active heart transplant program (1.3 pmp).
In summary, it is evident that the goal of establishing formal programs for organ donation and transplantation still has to gain priority on the agendas of health authorities in several countries of Central America. Unfortunately, transplant activities are competing for budget and implementation with other health priorities although rates of ESRD are on an alarming rise.
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2. 2011 Human Development Reports: United Nation´s UNDP.
3. Global Observatory on Donation and Transplantation http://www.transplant-observatory.org/pages/home.aspx
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6. Newsletter Trasplante Iberoamérica. 2011; V (1) 27–29.
7. Newsletter Trasplante Iberoamérica. 2012; Vl (1) 37–39.
8. Pan American Health Organization Directive Council CD 52/8 2013 (original Spanish).
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