Pan Daxiang (left), who donated part of her liver and a kidney to her son Chen Kai, holds Chen's hand on May 8 after successful transplant operations in Zhengzhou, Henan Province. Photo: CFP

After 6-year-old girl Shanshan from Hunan Province was confirmed to be brain dead in a Guangzhou hospital earlier this year, her parents allowed for her organs to be harvested and successfully transplanted into three patients. Her two kidneys went to two patients in Guangzhou and her liver went to a patient in Chongqing.

The girl's organs were allocated through a national computerized system for organ donation and transplant - China Organ Transplant Response System (COTRS), which was launched in April 2011.

China's public organ donations are operated by the Red Cross and donated organs are allocated within the hospitals that harvest them. 

The practice of allocating donated organs through a computerized system is expected to address lingering issues of unfairness and raise people's awareness about organ donation. However, there is still a long way to go before the national allocation system becomes fully accepted and mandatory. 

Where do organs come from?

"Organ transplants in China are facing a problem since (people don't know) where these organs come from and where they go," said Wang Haibo, director of the COTRS Research Center, a non-profit organization attached to Hong Kong University and headquartered in Shenzhen, Guangdong Province. 

The top health authorities entrusted the Li Ka Shing Faculty of Medicine at Hong Kong University to develop the computerized system to tackle the problems of organ scarcity and unfairness in allocation in 2009. The system has allocated 770 transplant organs in Chinese mainland since its launch, or around one-third of the donated organs nationwide.

Donated organs remain highly scarce in China. An estimated 1.5 million ailing people in China are in need of organ transplants annually, including 1 million patients with kidney diseases and 300,000 patients with liver diseases, but less than 1 percent of them receive them, according to government statistics.

China started a voluntary organ donation program in 19 provinces and municipalities in 2010. The program has seen in a measure of success, resulting in the donation of 1,804 major organs from 659 donors by this March, Xinhua reported. 

However, as around 10,000 people undergo organ transplants annually in recent years, China is still the second-largest nation in terms of the number of organ transplants conducted, following the United States.

The contrast between supply and demand has caused waiting times for the general public to rise to years, giving rise to an illegal trade in organs and has left the country heavily dependent on organs from executed prisoners.  

Allocation troubles

Faced with these growing worries, COTRS is expected to address issues of fairness and efficiency in China's transplant organ allocation and gradually replace the current hospital-led organ transplant system. 

Until the allocation system is fully rolled out, the Red Cross-led efforts mean that when a dying patient is found suitable for donation, hospitals notify an organ donation coordinator from the local Red Cross society.

The coordinator then seeks to persuade the family members of the dying patient to have the organs donated. The donated organs are then procured by an organ procurement organization (OPO) in hospitals. The country now has 169 OPOs accredited by the top health authority. They also have transplant qualifications and can allocate the organs within the hospitals.  

The allocation of donated organs within hospitals can be based on money, power and connections, as hospitals also need to make profits, said one doctor belonging to an OPO in Guangzhou, who declined to reveal his name.

The Beijing News also reported on Monday that local Red Cross Societies usually demand hospitals donate a large sum of money to organ donors via the Red Cross but never publicize the detailed use of the money. If hospitals refuse to pay, they are not given donated organs, the report said.

In contrast, the new system doesn't collect any data on patients' social or wealth status. "These are absolutely not considered in our system," said Jiang Wenshi, statistical analysis director of COTRS, adding that "the most amazing thing about the system is no one knows the background of the patients so that it can prevent the privileged from obtaining organs through unfair means." 

Built into the complicated calculation are medical factors including seriousness of the illness, distance from donors, compatibility of the organ to the recipient, and many other objective elements. The system automatically calculates rankings for all waiting patients and their condition is updated frequently to ensure continued accuracy.

Once a doctor identifies donated organs and inputs their information into the system, the system, which functions 24 hours a day, is able to make a match in less than a minute.

Doctors in charge of the five candidates that best match the donor's organ needs are then informed via text message by the system and requested to reply within an hour as to whether they will accept the organ if not. Once one candidate accepts the organ, the allocation automatically informs the others.

Wang said the organ allocation was designed to be carried out with the least human intervention. "All the data is stored on cloud computing, and human intervention is reduced to the lowest," he said.

The center also swears to indicate its sources cleanly. All the registered organs are provided by OPOs and so far 149 OPOs have already used the system.

"The new system will dissipate the reliance on organs from executed convicts," said Wang in his interview with World Health Organization last year.

Wang Jiefu, former Vice Minister of the Ministry of Health stated publicly in 2009 that more than 65 percent of transplanted organs came from the executed prisoners. In comparison, all 770 organs COTRS has allocated to date came from volunteers, said Wang.

Still a long way to go

The system is monitored by provincial and central health authorities, who are entitled to cancel allocations should illegal acts be detected.

"The traceability of the system makes it possible to hold individuals to account," said Wang.

The top health authorities will send experts to the hospitals without prior notice to check whether the illness severity of the registered waiting patients is authentic. The qualification for organ transplant will be abolished should fraud be identified, he said.  

The center has drawn heavily on international experience in order to bring China's existing organ transplant situation to a better level.

"We based our system on the American system United Network for Organ Sharing (UNOS) after we researched the organ transplant policies of 15 countries and found that the transplant situation and geographical conditions in China were similar to those in the US," said Wang. 

In May the center cooperated with Italy and Spain to start a long-term collaboration on system construction and maintenance, personnel training as well as the way to apply for donations in China.

However, statistics show only about one-third of the nation's publicly donated organs were allocated through this system since 2011. The remaining organ transplants were still conducted by hospitals, leaving room for human manipulation.

Even those involved in the automated system may be in dereliction of duty. One CCTV reporter said he once saw a doctor ignoring messages about potential organ transplants as he was "too busy."

Although the top health authority announced the issue of a draft regulation in October 2013, ordering the mandatory use of the computerized organ allocation system by hospitals, the draft has never been published.

The need for more transparency in the system has been raised by families of patients who are eager to know how long their loved ones will have to wait.

Liao Xinbo, vice director of Guangdong Health Department, who runs a popular blog, suggested that patients themselves should be informed about their waiting status so as to monitor the system as well as media and government watchdogs. 

How hospitals are prioritized for organ allocation is also a controversial issue in the system. Under the current system, only when hospitals that harvest organs do not need specific organs for transplant can these be allocated within the province where the hospitals are located, and then nationwide.

That means hospital location overrides severity of condition in the system.

"We still have to take the interests of hospitals into consideration and let those which procure organs have priority in using them," said Wang, explaining that otherwise the hospitals will lack the initiative to procure organs. 

However, a compromise should be met wherein a patient in critical condition doesn't lose their chance.

"The organ allocation mode is an innovation in China. It will have a big impact on the original practice between hospitals and individuals. The key is fairness," said Liao.

"The biggest challenge is we still need to gain public confidence and support," concluded Wang.