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Organ donation and transplantation in Central America.

Central America, as constituted by the Republics of Guatemala, El Salvador, Honduras, Nicaragua, Costa Rica, and Panama, is characterized by highly diverse social and economic levels reflected by the Human Development Index, ranging from 0.614% for Nicaragua to 0.765 for Costa Rica, and by the percent of Gross Domestic Product dedicated to Public Health Services (ranging from 1.2% in Guatemala to 6.6 in Costa Rica). This has a direct impact on access to transplantation services for the population and on the advancement of deceased donation programs. It is therefore not surprising that only Costa Rica and Panama (and recently El Salvador) have national transplant organizations as part of, and dependent of, and financed by theirMinistries of Health. A trend that correlates the Human Development Index with the total number of kidney transplants per year, particularly in developing countries, is also found in Central America (Figure 1). Fragmented Health systems, like the ones in Central America, split delivery of services into different providers, such as the always precarious public health systems, financially more solid social security programs, and private services usually only accessible to a minority of the population. All 6 Central American countries have legislations ruling over brain death and the use of organs from deceased donors for transplantation, with the latest law issued by Nicaragua as recently as 2013. Nevertheless, because of the fragmented health systems, each health care provider manages their own waitlist for its affiliates. Countries, such as Panama and Costa Rica, with 85% to 99% of the population being covered by the social security system, have an almost universal, nationwide waiting list. However, countries, such as El Salvador, Guatemala with only a limited access to Social Security (18%–21%), respectively, do not have a structured waiting list. The same restriction applies for posttransplant immunosuppression that covered lifelong for Social Security affiliates, but only for 2 years (or for children until age 18 years) for recipients that are covered by the public health sector. Typically, transplant programs in each Central American country started small and isolated. Living related renal transplant programs by pioneering physicians in the 1970s and 1980s grew into more institutionalized programs with the