**1. Introduction and overview**

#### **1.1 Background**

Many diseases especially non-communicable diseases (NCDs) culminate in end-stage organ failures; the preferred treatment for most end-stage organ diseases is transplantation. Transplantation programme is a complex healthcare service

which entails huge costs and requires highly skilled health professionals, complex infrastructure and equipment, and well-articulated legal frameworks to enable its operationalization [1]. The need for appropriate interventions for organ failures in sub-Saharan Africa (SSA) is underscored by the high prevalence of end-organ diseases such as chronic kidney disease (CKD), chronic liver disease (CLD), chronic lung and heart diseases (interstitial lung disease, cystic fibrosis, cardiomyopathies and chronic rheumatic heart diseases) which cause increased morbidity and mortality. For example, Kaze *et al* [2] in a systematic review of prevalence studies on CKD in SSA documented the highest prevalence in West Africa 19.8%, Central Africa 16%, East Africa 14.4%, and Southern Africa 10.4%.

Globally, beside organs, tissues and cells (bone marrow cornea, etc.) are also transplanted. However, in SSA, apart from South Africa which also does liver and heart transplantation, the common organ transplanted is the kidney [3]. Though outcomes for transplantation have improved over the years due to better surgical techniques including minimal access surgeries, newer and better immunosuppressive medications, innovations in organ donation; improvement in transplant services is not apparent in SSA. Organ transplantation remains largely inaccessible and unaffordable to this population.

Sub-Saharan Africa has a disproportionate burden of communicable diseases (CDs) and NCDs compared to other world regions [4]. Currently, NCDs are responsible for a large and increasing burden of death and disability in the region. World Health Organization (WHO) in 2018, documented that NCDs killed 41 million people per year accounting for 71% of the global deaths [5]. The ages most affected were 30 to 69 years age-group, belonging to the productive workforce of any population. People from low income countries (LICs) and lower-middle income countries (LMICs) accounted for most of these deaths approximating over 85%. Four of the five commonly quoted diseases i.e. the "Big Five" (cardiovascular diseases, cancers, respiratory diseases, diabetes mellitus (DM) and mental illness) that account for most NCD deaths are drivers of CKD. Several risk factors with multiplier effect on NCDs are tobacco use, physical inactivity, harmful use of alcohol and unhealthy diets. Communicable diseases, though less common in high income countries (HICs) and upper-middle income countries (UMICs) are still prevalent in LICs and LMICs prompting WHO to highlight the double burden of diseases in these regions [6]. Both CDs and NCDs culminate in end-organ disease underscoring the high prevalence of end-organ failures, disabilities and deaths in SSA (see **Figure 1**). Unfortunately, most countries in this region lack resources to cope.
