In April 2018, the Council of Europe Committee on Organ Transplantation (CD-P-TO) adopted a statement rejecting the concept of Global Kidney Exchange (GKE) and advising its State members, hospitals and medical professionals not to engage with GKE programs. The committee argued that GKE raises important ethical concerns and perverse financial incentives, and echoed criticisms emphasized by the World Health Organization (WHO), The Transplantation Society (TTS), the Red Consejo Iberoamericano de Donación y Trasplante, and the Declaration of Istanbul Custodian Group. With these precedents, how should countries in the Global South deal with GKE programs?

GKE is both a concept and its implementation. As a concept, GKE is the application to kidney transplantation of Alvin Roth’s economic model based on Lloyd Shapley’ algorithm, and for which they received the 2012 Nobel Prize in Economic Sciences. Their model addresses the difficulties inherent to “matching markets”, or markets where one has to choose and also be chosen, like loan allocation to entrepreneurs and school placement of students in the U.S. GKE’s implementation is being promoted by groups in the United States and Europe, with the aim of facilitating trans-national kidney donation. The GKE program currently being implemented between the U.S., Mexico and the Philippines aims at reducing the unmet demand of kidneys in the U.S. through the trans-nationalization of kidney exchange programs. Such kidney exchange programs facilitate donation when a donor is incompatible with a loved recipient, through a chain of donations that ultimately help each recipient get a transplant. In the U.S., this organ exchange is ultimately funded by the individuals’ health insurance, be it private, public or mixed. GKE would also be funded through US-based individuals’ health insurance, which would cover the immediate costs for the foreign, uninsured donor and recipient, and the financial incentive for insurance companies is that over the years, the costs of such transplants are cheaper than replacement therapy through dialysis.

Critics of GKE programs argue that it would offer financial and symbolic incentives that have the potential of promoting organ trafficking, that it wrongly assumes that low- or middle-income countries (LMICs) do not offer organ transplantation to those who need it, and would add barriers to the efforts that LMICs countries are already doing to improve their responses to end-stage renal failure and organ trafficking. For GKE to be implemented, it would need to be allowed to operate in at least some LMICs.  So, the capacity of GKE “to ensure that targeted donors in “underdeveloped” countries will be emotionally related, free of coercion, and fully informed of risk is not feasible when the culture is so experienced with organ sales”.

What should Global South countries do about GKE programs?

First of all, countries need to acknowledge that GKE programs have the potential of both increasing health inequities and promoting human trafficking with the purpose of organ donation. In consequence, countries should decide between prohibiting such programs to operate and allowing their operation under strict regulation. In other words, just letting GKE programs operate freely should not be an option.

Secondly, countries should understand that some issues of concern are beyond the level of influence of local authorities. For instance, there is an unmet demand of kidneys in high-income countries that incentivizes organ trade and transplant tourism, an important problem that needs solutions. Similarly, transnational organ trafficking as well as human trafficking with the purpose of organ donation are problems that need more visibility if solutions are ever going to be found. Global health governance currently lacks effective mechanisms for supranational institutions to harmonize national legislation and regulating the imbalances in counties’ wealth and regulatory power.

Finally, countries should asses the local realities affecting chronic kidney disease and human trafficking. It is necessary to analyze the countries’ needs and response to kidney transplant, organ trafficking, transplant tourism and black markets for organs, as well as the local legal, ethical and sociocultural dimensions of organ donation. In other words, the response needs to be rooted in the local situation, even if a transnational response is clearly also required.

In sum, countries in the Global South should not let GKE programs operate freely, but an effective response should be both local and transnational. The GKE programs and the global epidemic of chronic kidney disease highlight the need for global solutions that should be based on a system of global health governance that promotes health equity. The latter can only be achieved through participatory and democratic processes that involve civil society organizations, health professionals and authorities.