Can the World Learn From Spain When it Comes to Organ Donation?

Clarinha Glock

December 08, 2021

In 2010, when the World Health Organization's 63rd World Health Assembly adopted a resolution (WHA 63.22) urging member states to put measures in place to maximize organ donation from deceased donors and protect living donors, Spain had already begun to implement changes that would make it the world leader in organ, tissue, and cell donation and transplantation.

"The key to our model's success is in reforms to the management system and in the organizational approach to the process," explained Beatriz Domínguez-Gil, MD, PhD, director general of the National Transplant Organization (Organización Nacional de Trasplantes, ONT), an agency of Spain's Ministry of Health created in 1989 to spearhead the reorganization of the country's donation and transplantation system.

The creation of ONT was one step in the process, said Domínguez-Gil. Ten years prior, in 1979, the Spanish Transplantation Law had been enacted, guaranteeing universal coverage through a public healthcare system and providing a "presumed consent" policy for organ donation. Presumed consent is a legal framework whereby citizens must place their name on a national "opt-out" register, otherwise consent for organ donation is presumed.

But she points out the Transplantation Law was not what really made the difference.

Rather, it was the agreement made by Spain's 17 autonomous regions to implement what is now known as the "Spanish Model of Organ Donation and Transplantation."

The country has gone from 14 donors per million population before the ONT was created, to 49 donors per million population in 2019. While other regions in the world — such as Santa Catarina and Paraná in Brazil — have come close to reaching these rates, Spain continues to be the global leader in organ donation.

A number of Latin American countries have since learned from Spain, sending physicians to follow the procedures there. Others could still benefit, as could nations all over the world.

One of the keys to the collaboration with Latin America was the establishment of the Ibero-American Network/Council of Donation and Transplantation (RCIDT), of which Domínguez-Gil is president.

How Did Spain Do It?

Originally, the Spanish system was based on the management of a very complex process of deceased donation. "To carry out the process, there needs to be a system of qualified professionals who are able to identify cases, make a diagnosis of brain death, conduct interviews with the family, and ensure that the organs are adequately preserved," Domínguez-Gil emphasized.

The ONT invests €1 million annually in ongoing training for professionals who participate directly or indirectly in this process, she said. 

"In Spain, we have a reimbursement system adapted to the donation and transplantation program's characteristics. This system guarantees coverage of expenses related to the human and material resources needed for the development of these activities," she noted.

In hospitals able to conduct transplants, units have specific coordinators — almost all of whom are intensive care physicians. Through the Quality Assurance Program in the Deceased Donation Process, the ONT performs an audit of all deaths occurring in critical care units (CCUs), identifying who is eligible to be a donor and gathering indicators on a national level.  

Another important aspect is engaging with the public, said Domínguez-Gil. "We do this through the media. We're always available for interviews to address questions and to educate people about organ donation and transplantation." 

Sharing Spain's Experiences With Latin America

In partnership with the Pan American Health Organization (PAHO), the ONT and RCIDT developed courses and training programs to share Spain's experiences, as well as those of other regions in the world that have adapted the Spanish model.

Through the ONT's Máster Alianza Program, professionals from Latin America and other regions spend 2 months in Spain participating in training sessions and, under the guidance of a senior transplant coordinator, experiencing the day-to-day activities of a local hospital. What they learn will then be incorporated into practices back home.

Formed in 2005, the RCIDT's mission is to encourage national systems to organize, regulate, and train professionals with respect to the donation and transplantation of organs, tissues, and cells.

"Through the RCIDT, Spain and Latin America have been able to collaborate in developing legislation, structuring systems of coordination in these countries, and increasing donation activity in the region by 100%," reported Domínguez-Gil.

"The effects of adapting the Spanish model in Brazil have translated into a very positive experience in Santa Catarina," confirmed the state's transplant center coordinator, Joel de Andrade, MD, who participated in the 2008 Máster Alianza Program and now organizes RCIDT and PAHO courses.

Even throughout the COVID-19 pandemic, two states in Brazil were able to maintain a high level of donation and transplantation. At the end of 2020, Paraná had the best rate in the country — 41.5 donors per million population — followed by Santa Catarina with 39.4 donors per million population. In recent years, the two states have been taking turns at claiming the top spot.

Basic Minimum of Healthcare Needed to Maximize Organ Donation

José Luis Bustos, MD, is the vice-chair of Argentina's National Central Institute Single Ablation and Implant Coordinator (INCUCAI), the agency responsible for regulating, coordinating, and supervising the country's organ, tissue, and cell donation and transplantation activities.

He believes that for some Latin American countries, such as Paraguay, Dominican Republic, and Bolivia, shortcomings in terms of numbers of donors reflect shortcomings in other areas: hospital structure, human resources, and even political policies. "There are a number of factors," said Bustos.

He points out that the organization of the healthcare system including monitoring, training professionals, and communicating are the basic pillars needed to ensure that the donation and transplantation process functions well.

The States Parties of the Southern Common Market (MERCOSUR) Agreement also created the Donation and Transplantation Registry (DONASUR), a tool to record their donation and transplantation activities. Over the years, the registry has expanded and now includes 17 countries in the region. "By outlining the relationship between donations and transplantations, DONASUR made the system transparent," Bustos said.

Bustos has partnered with the PAHO to create an online course to share best practices and increase the number of donations and transplantations in the region. Comprised of modules and touching on all pillars of the process, the course is scheduled to run for 5 years, starting in early 2022. The first stage is geared towards healthcare managers and decision-makers.

Where Does Spain Go From Here?

Having established a successful model that others can replicate, Spain is now proceeding to the next stage — one with three lines of action. The first is the transplantation of organs within the elderly population — donors and recipients alike — called "old for old".

"More than 50% of our donors are age 60 or older; 28% are over age 70, and 5% are over age 80. These are individuals who die of cerebrovascular accident. We're making progress and getting good results in organ transplants between older people. These types of transplants happen frequently in Europe, given its aging population; however, we still don't see them being done very often in Latin America," Domínguez-Gil explained. 

The second line of action is the development of techniques for organ donation after circulatory death. After cardiac arrest, blood stops flowing and organs quickly deteriorate, so they cannot be transplanted; however, in Spain there was an increase in this type of donor thanks to the use of extracorporeal membrane oxygenation (ECMO) machines for preserving organs inside the body before they are retrieved, as well as ex vivo machines to preserve the organ after it has been removed.

"These techniques allow us to keep the organs viable and assess them before they reach the recipient," said Domínguez-Gil, who also represents Spain in the European Commission's Competent Authorities for organ, tissue, and cell transplantation, and is a member of the WHO transplantation task force.

The third line of action involves introducing more locations for donations. They primarily occur in CCUs, but the goal is to bring emergency rooms (ERs) into the picture as well.

"We've established a collaborative effort so that the transplant coordinator will be notified if there's a patient in end-of-life care or a patient who has died in an ER," Domínguez-Gil said.

It is essential for ER physicians to participate in ongoing training so they can gain knowledge about the required protocols and documents as well as the skills for assessing results. Recording these measures will help facilitate development of a series of recommendations for the donation and transplantation of organs that can be replicated in other countries.

This story originally appeared on Medscape em Português, available here.

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Spanish experience as a leading country: what kind of measures were taken? Available here. Accessed December 8, 2021.

Red/Consejo Iberoamericano de Donación y Trasplante – RCIDT. Available here. Accessed December 8, 2021.

Donation after circulatory death and its expansion in Spain. Available here. Accessed December 8, 2021.

Summary of Spanish recommendations on intensive care to facilitate organ donation. Available at here. Accessed December 8, 2021.

About Máster Alianza. Available here. Accessed December 8, 2021.

[The challenge of keeping up organ donations and transplantations during the pandemic.] Available here.

Registro Mercosur de Donación y Trasplante – DONASUR. Available here. Accessed December 8, 2021.


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