Kidney transplant reform: Building trust and equity in care

I recently sat with a patient who had traveled from a distant province to reach our transplant center. She was exhausted and hopeful. I’ve seen far too many patients make such pilgrimages. In the Philippines, kidney transplants remain confined to a few major hospitals in cities. This centralization forces patients to uproot their lives for a chance at a new kidney. It shouldn’t be this hard: where you live shouldn’t determine if you live.

Even for those who reach a transplant center, financial barriers can be equally daunting. A kidney transplant here can cost over a million pesos — an impossible sum for most families. Our national insurance’s “Z Benefit” transplant package helps by covering a large portion of this cost. From an initial P600,000 a decade ago, it now shoulders up to around P2.1 million (depending on the case), including surgery and initial immunosuppressants. Still, gaps remain. Many patients struggle to afford the pre-transplant tests or the lifelong medications and follow-up care that aren’t fully covered. I’ve seen patients postpone getting on the transplant list to scrape together funds, even with insurance support. No one should have to choose between debt and a kidney, yet that’s the dilemma many families face.

Workforce shortages threaten to undermine progress. Kidney transplantation is specialized, and only so many surgeons, nephrologists, and nurses can do it. Most are clustered in Metro Manila and a few other cities. Outside those hubs, some hospitals have the will and infrastructure, but not the people — some regions don’t have a transplant surgeon at all. Meanwhile, many specialists leave for jobs abroad or simply burn out. Even with more funding and new facilities, we might still lack the hands to perform the surgeries or care for patients afterward. We need to train more transplant professionals and give them reasons to practice in underserved areas.

Another under-addressed issue is the opacity of data. Basic questions like how many Filipinos get a kidney transplant, or how long patients wait, have no easy answers. Centers keep their own records, but there’s no unified public reporting of outcomes or waiting lists. That makes it hard for patients and policymakers alike to see the big picture. And lack of data means a lack of accountability — problems can easily hide in the shadows. For patients, not knowing where they stand in line or their odds of getting a deceased-donor kidney is deeply unsettling.

There’s an uncomfortable truth I’ve seen first-hand: Inconsistency among doctors. Even in one hospital, two equally qualified transplant doctors might make different calls on similar patients. I’ve seen one patient get approved for transplant while another with a similar profile was told to wait by a different team. These subtle differences in judgment — born of personal experience or varying interpretations of criteria — can lead to unfair outcomes. To patients, it can feel arbitrary and erode their trust. We, transplant professionals, must recognize this problem and push for more standardized criteria and team-based decision-making. Patients deserve to know that no matter which doctor they consult, they’ll get the same fair assessment.

The most glaring weakness is our deceased donor program. Our deceased organ donation rate is among the lowest in the region. Organ donation still isn’t routine here — culturally or logistically — so most kidney transplants come from living donors (usually a relative or friend). Yet thousands die whose kidneys could have saved lives. Brain death is legally recognized and laws encourage organ donation, but implementation still lags. Many hospitals lack staff trained to discuss donation with families, and public awareness campaigns are sporadic. The result: patients can languish on dialysis for years with only a slim hope of a deceased donor, unless a loved one steps up to give a kidney. We need to foster a culture and system that truly supports deceased donation through education and a coordinated organ procurement network, so that transplants aren’t limited to those lucky enough to have a willing relative.

Despite these challenges, I remain hopeful because each has a clear solution. We can decentralize kidney transplant services by empowering regional centers and training more specialists to staff them, so patients outside Metro Manila won’t have to travel for care. We can improve financial support — raise insurance coverage for transplant costs and ensure post-transplant medications are affordable or provided. We can demand transparency by creating a national transplant registry for public monitoring, to track outcomes and address shortcomings. And we must reinvigorate the deceased donor system — establish organ donation units in hospitals, fund awareness programs and make organ donation the norm rather than the exception.

All these reforms are achievable. They will take resources and political will, but also the collective voice of doctors, patients and advocates. I’m highlighting these issues because I’ve seen too many people die waiting for a kidney that never came. The status quo is not good enough. If we fix these gaps — make transplants accessible regardless of geography or wealth, ensure fair and consistent decisions, and fully tap both living and deceased donation — we can give many more Filipinos a second chance at life. As a doctor, I owe it to my patients to push for change. And as a society, we will be judged by how we care for our most vulnerable. It’s time to make our kidney transplant system more equitable, transparent and worthy of the trust patients place in it.