The protocols - Germany and India

Both Germany and India are known to be bureaucratic. Things usually take as much time to get done in either countries, except, the German bureaucracy tends to be reliable, in India it isn't always the case. The medical protocols to be followed before and after a Kidney transplant with respect to the tests involved for the recipient and donor are largely the same.
The doctors in Germany were rather impressed with the thorough tests done for my mother and me before the transplant. They confirmed they would not have done anything more or different.

India unfortunately happens to be popular for low cost kidney transplants also due to the rampant illegal organ trade prevalent in the country :(. Call it our foolishness or immense sense of lawfulness, that we decided ONLY to follow the legal approach.
The protocol below describes the legal approach to undergo a Kidney transplant in a renowned, world class hospital in Bangalore, India. Yes, we managed to follow the entire legal procedure without paying any bribes or feeding other forms of corruption. It tested our patience but it was worth it and eventually we were grateful for a couple of officials who were extremely helpful to us.

Germany

• The German protocol states, no 'open' issue of a patient can be kept open before beginning a new procedure. With a positive Quantiferon test 4 years back, this meant I would need to first get investigated upon and perhaps treated for Tuberculosis - something I did not have (proven to be latent). Every other person from India would have TB cells in their body but it does not mean they have active TB - a fact that was not taken seriously enough in Heidelberg.
   
  (We were quite convinced that the Indian doctors will be able to give a better diagnosis for this given the sheer number of REAL TB cases they deal with. On day one without any tests, just physical examination and case history, the doctor in Bangalore ruled out TB. He said, "you would not be sitting here feeling the way you are if you had TB for the last 4 years." He laughed at how seriously a Quantiferon test was taken in the west and the paranoia associated with it. This proved to be a big contributing factor for our decision to proceed with the transplant in India)
   
• In Germany the standard value to begin dialysis is when the Creatinine goes beyond 5. Which did not leave me much time. They follow the 'early dialysis' approach.
   
  (Second big contributing factor for our decision in favour of India. I was able to skip the dialysis phase completely with a 'pre-emptive' transplant. At the time of the surgery, my Creatinine was 7.)
   
• As we explored the health insurance coverage scenario we learnt that the German public health system will not cover any expenses incurred for procedures done outside of Europe. However, they would fund the expenses for the recipient and the donor if the procedure was done in Germany. They would even cover the flight tickets and accommodation (if required) for the donor. We still decided to skip this option because too many of our family members wished to be physically with us during this difficult phase and logistics would have been difficult to manage.
   
  (Third contributing factor in favour of India - support of family and friends. This is a BIG deal. One does need a lot of 'manpower' especially post transplant)
   
• There are also many restrictions on how the public insurance system will deal with the daily allowance to be paid for a valid employment contract beyond the 6 weeks time frame when the employer is liable to pay.

India

• Due to costs involved and lack of a public health insurance scheme, India follows the approach of late dialysis. This has been practiced here for years and this approach is widely being discussed in the developed world as a cost effective alternative given the crunch on health insurance schemes. In the Indian approach, as long as the patient is not having adverse symptoms, dialysis is delayed.
  
  This gave me enough time to get into a maintenance mode to keep my original kidneys to continue functioning and skip the entire phase of dialysis - a very big plus. I walked in, ready for a transplant with almost no symptoms, looking and feeling almost normal.
• Like every other situation, the attempt to curb illegal activities results in the legal approach becoming more difficult and stringent. The most painful part was the sheer amount of paper work and often the relevance of some of documents required. Nevertheless, we choose to go down this path so we did a deep dive. The following is what's involved, given both the recipient and donor are residents of the same city and same state of India. (Things can get more complex if there are multiple states/cities involved).
• Police verification of the case.
• This involved, receiving clearance from the entire hierarchy of the Police department of the city of Bangalore. Needless to say, to save time, we became the in-house mail people for them - carrying the relevant documents from one office to another...so they did not lie on the desk of some officials endlessly.
1. Commissioner of Police Bangalore
2. Deputy Commissioner of Police
3. Assistant Commissioner of Police.
4. Inspector of local police station
• This process started with the Commissioner of Police and had to complete the loop and end back at the Commissioner of Police. Needless to say, the maximum pain and trouble was caused to us by the officials lowest in the pecking order - the Inspector of the local police station.
• Creation of Family tree from local village revenue office. (One of those things we do not understand the relevance of)
• For someone who has lived all our life in a city, we had no clue who a village revenue officer is. Our first task was to find out where our local revenue office was and who would do this job for us.
• It took us 3 days visiting several government offices to finally locate the right office to go to and the person to meet.
• We found ourselves staring at a big lock for the first 2 visits to this office but we managed to get the mobile number of the officer from the vegetable vendor below this office :)
• On our 3rd visit, we met an officer - the assistant to the Revenue Officer. With his broken Tamil, my broken Kannada (local language) a bit of English and Hindi words thrown in, we managed to understand what our tasks were:
• Go to the local corporation office
• Get our family tree typed out on a stamp paper with an affidavit
• Come back to this office
• Get the family tree translated to Kannada (to be done by this assistant)
• Get a stamp and signature from the Revenue officer on the original
• Submit this original to the local police station
• It took us 3 daily trips based on promises of the Revenue Officer to finally meet him and get him to sign and stamp our documents.
• With all the documents (proof of address, identity, no objection certificate from spouse, medical records from the hospital, family tree...) for the Police ready, we now had to begin the reverse process of clearance up the hierarchy. It took us several trips along with my aged parents to meet the Inspector and Sub-Inspector of the local police station for them to seem to acknowledge our case and look at our papers. Despite medical tests that prove my relationship with my mother (DNA, HLA etc.), I had to answer questions to the Inspector to prove that I was indeed the daughter of my mother.
• Finally, after a gruelling 3 weeks we were done with all the paper work involved with the Police. Now began the wait to get a date to meet the Government Transplant Committee. Given the stature of the hospital, they organized this meeting within the hospital. This committee comprises of top government officials and lawyers therefore it takes a long time to get everyone's calendar in synch and schedule a date that works for them all and also have a minimum of 4-5 patient cases that they can look at.
• After 2 weeks of waiting we finally had a date for this committee meeting. This went quite smoothly. The recipient and donor are individually called in to meet this group to answer questions on preparedness etc. We got the clearance from the committee  to proceed with the transplant.