The kidney distribution system for transplantation in Chile explained according to Game Theory: How theoretical generosity is transformed into real selfishness

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Context: There is a huge mismatch between demand and supply of organs for transplantation, particularly kidneys. Their allocation system in Chile delivers one kidney to the procuring institution and the second to another national institution; policy designed seeking to stimulate procurement in transplant institutions. Objectives: Evaluate whether this policy has been effective for increasing nationwide organ donation and procurement rates in procuring centers, whether their behavior is aligned with the local / pool kidney allocation system, and whether the policy has contributed to increasing equity in access to kidney transplantation. Methods: We obtained the origin of all organ donors between 2010-2020 from public records, separating them by private or public institutions, and matched those organs with the corresponding information from the centers that implanted them, and used descriptive statistics, t-student tests, and linear regressions over time for analysis. We performed an economic analysis of the costs of procuring a kidney for transplantation, for which we gathered the public static prices, and a sample of the 5 largest private transplantation facilities’ prices. Results: We found no significant increase in the total number of organ donors in the country during the studied period, and the mild increase observed was due to the addition of new public centers to the system. We observed that private institutions are increasing their participation in the transplant market and they do so at the expense of public institutions and without increasing their contribution of organs to the system, because of the high cost of procuring compared to the cost of transferring a kidney. Conclusions: This behavior can be framed within the Game Theory, specifically the Tragedy of the Commons, describing that the players maximize their benefit at the expense of the rest without considering the subsequent consequences, which leads to an imbalance between demand and supply of organs for transplantation that worsens over time and lengthens waiting lists.