Why Are Wealthy Indian Patients Registering with Government Hospitals for Organ Allocation?

Organ transplantation is a life-saving intervention that demands fairness, ethical integrity, and strict adherence to the law. In India, the path to receiving an organ transplant is deeply influenced by how organs are allocated.

Unfortunately, many states have, both before and after 2014, relied on policies like creating intra-state ‘zones’ and favoring public (government) hospital patients over those in private hospitals under SOTTO. While some state health authorities defend these measures as a state prerogative, each has agreed—via legislative resolution—to a national “One Nation, One Policy” standard, ceding the power to deploy divergent, local allocation rules.

Why Are Wealthy Patients Registering with Government Hospitals?

Some state policies and hospital guidelines still prioritize patients listed at public hospitals for organ allocation. As a result, wealthy patients—who could afford private care—are registering themselves with government hospitals to improve their position on the waiting list and increase their chances of getting an organ.

This circumvention is a direct response to a system that, rather than being need-based and equitable, artificially restricts access by drawing institutional distinctions. Consequently, valuable government hospital resources—intended to serve the disadvantaged—are commandeered by patients with means, undermining the social justice goals of public healthcare.

The Legal Backbone: What Does Indian Law Require?

The Transplantation of Human Organs and Tissues Act (THOTA), 1994, is crystal clear:

• Equitable and transparent organ allocation is a must.
• All decisions must be based on State (SOTTO) – Regional (ROTTO) – National (NOTTO) List—not on geographical zones or the hospital’s status as public or private.

Both national (NOTTO) and state (SOTTO) authorities administer the process, but every action must adhere to THOTA and the Constitution.

How States Perpetuate Discrimination

Many states continue to:

• Carve the state into ‘zones’: Organs from donors in one region are first offered to recipients from the same zone, only then being made available more widely, which unfairly restricts access for others in need.
• Favor public hospital patients: Guidelines in many states explicitly or implicitly prioritize government hospital patients, irrespective of urgency or eligibility.

The Gujarat High Court Judgment: A Key Ruling

The Gujarat High Court in November 2021 unequivocally struck down state-level policies that:

• Prioritized local residence (state resident) over other state resident
• Required domicile/ residency certificates.

The Court ruled these measures:

• Unconstitutional (violating Articles 14 and 21—equality and right to health/life).
• Not permitted by THOTA, which does not authorize non-medical preference.
• Arbitrary, unreasonable, and unfair.

Organs are a national resource. Allocation cannot be skewed for reasons of geography or institutional affiliation.

Central Directive: Centralized, Equal Access

To close loopholes for local bias:

• The Union Ministry of Health requires all organ allocation to flow through a centralized NOTTO ID, ensuring equal consideration for all eligible patients and accountability in the system.
• Any discrimination—such as priority for zones, institutional types, or locals—can be directly challenged and is subject to action.

Why These Policies Are Discriminatory and Illegal

• Zones Preferences violate equality, unfairly prioritizing some based on arbitrary geographic boundaries, in direct breach of constitutional values.
• Distinctions Between Public and Private Hospitals are a form of unjust discrimination. THOTA and judicial precedent require decisions to be based solely on medical criteria—not whether a patient is in a government or private hospital.
• Right to Health is fundamental for every individual, regardless of address or institutional affiliation. Barriers or delays created by these policies are clear legal violations.

Section 31(4)(e) of the THOTA 2014 Rules requires SOTTO to maintain one consolidated waiting list by organ category—Sate, Regional, National, and Foreign. Any separate intra-state zone list is illegal.

Why the Current Situation Is Especially Harmful

Not only do these discriminatory rules encourage wealthy individuals to register at government hospitals, crowding out the needy, but they also damage public trust in the organ transplant system. Scarce public resources designed for the poor and vulnerable are diverted to those with means, defeating the very purpose of public healthcare.

The Path Forward

• State Policies creating zones or making public-private distinctions in allocation are illegal and unconstitutional.
• Both the courts and central government have condemned and are monitoring to end such practices.
• Only legitimate grounds for organ allocation are medical urgency, compatibility, and equity—not geography or institutional type.
• Patients who are denied fair allocation or witness discrimination are empowered to challenge these illegal practices in court.
• Upholding the law and the Constitution is vital to protect fairness and save lives.

India must ensure that the organ allocation process honors the values of justice, equality, and the welfare of all its citizens. Any deviation from these standards is unconstitutional, discriminatory, and legally challengeable. Patients and family must come forward if they believe that they are discriminated.

This blog is by Advocate Prashant Ajmera, who co-founded OneIneiOneLaw.org — a site all about organ donation laws in India.