Saudi Journal of Kidney Diseases and Transplantation

: 2021  |  Volume : 32  |  Issue : 5  |  Page : 1319--1329

Public survey of financial incentives for kidney donation in Bahrain

Amgad E El-Agroudy1, Adel A Alalwan2, Mohamed R Rajab2, Asma M Alqahtani3,  
1 Department of Medicine, College of Medicine and Medical Sciences, Arabian Gulf University; King Abdulla University Medical Center, Manama, Bahrain
2 Department of Nephrology, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain
3 Department of Pediatrics, Children Hospital, Aljouf, Saudi Arabia

Correspondence Address:
Amgad E El-Agroudy
Department of Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama


With the increasing prevalence of end-stage kidney disease in Bahrain, kidney donation is of vital importance. In this study, we want to assess how financial incentives will influence peoples’ views and decisions regarding kidney donation. The aim is to establish strategies to increase the number of kidneys for transplantation in Bahrain. We adapted a previously established questionnaire on financial incentives for living kidney donations. The questionnaire assessed the public opinion in Bahrain on how kidney donation can be influenced by two different financial incentives, namely 10,000 Bahraini Dinars and life-long health insurance. We collected a convenient sample of 446 participants by distributing an electronic version of the questionnaire. IBM SPSS Statistics version 23 software was used for data entry and analysis. Of the total participants, 39% were male and 61% were female. Eighty percent of the participants believed that their chances for kidney donation will not increase in turn of receiving a financial compensation, while 20% of them believed that it will increase. Our study found that generally married participants (70%) find it a preferable development for health insurance companies to offer financial compensation for kidney donation, while nonmarried participants (30%) found it not a preferable but also not an adverse development (P = 0.038). Furthermore, there is a positive correlation between age and preferable views toward financial incentives to increase kidney donation (P <0.001). Although financial incentives for kidney donation might encourage a minority of the population, the majority will not be influenced by implanting a financial incentives’ system for kidney donation.

How to cite this article:
El-Agroudy AE, Alalwan AA, Rajab MR, Alqahtani AM. Public survey of financial incentives for kidney donation in Bahrain.Saudi J Kidney Dis Transpl 2021;32:1319-1329

How to cite this URL:
El-Agroudy AE, Alalwan AA, Rajab MR, Alqahtani AM. Public survey of financial incentives for kidney donation in Bahrain. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Aug 14 ];32:1319-1329
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Full Text


End-stage renal disease (ESRD) is a major cause of morbidity and mortality in Bahrain. In 2000, the annual incidence of ESRD was estimated at about 120 per million and the estimated mortality rate of hemodialysis patients was around 10% annually. Although kidney transplantation is the optimal form of renal replacement therapy, there is a lag in the annual numbers of kidney transplantations in Bahrain due to a shortage in kidney donors.[1],[2] Donation rates from living and deceased donors have remained relatively unchanged over the last 10 years, despite strategies to increase the pool of transplantable organs by using expanded criteria organs, unrelated living donation, ABO-incompatible transplants, and living donor paired exchange programs.[3],[4]

Although living donation programs, based on the idea of donation being a gift without a financial reward, have certainly resulted in more kidney transplantations, wait lists nevertheless, continue to grow.[5],[6] It has therefore been proposed to introduce financial incentives in an attempt to further increase the number of living kidney donors.[7] Arguments for and against financial incentives and regulated organ markets have been debated since the early 1990s.[4],[5],[6],[7],[8],[9]

In this study, we aim to assess the public awareness and acceptance of financial incentives for kidney donation in Bahrain.

 Materials and Methods

We adapted a previously developed Dutch questionnaire to investigate the public opinion on introducing incentives to increase the numbers of kidney donors.[10] Permission was obtained to adapt and translate the questionnaire from the authors. The questionnaire aimed to explore public opinion for two different kinds of fixed compensation, either life-long health insurance compensation or 10,000 Bahraini Dinars (BHD). In addition, we investigated public preferences for two different types of practice, either the patient seeks a donor or the donor registers for donation at an independent institute. The questionnaire consisted of eight questions with multiple-choice answers. Six of the eight questions had multiple choice answers in an ordinal fashion (questions 1–4, 6, 8) and two questions had multiple choice answers in a nominal fashion (questions 5 and 7). The questionnaire was translated to the Arabic language by a certified translator and then distributed electronically using Google Forms, which were in turn distributed to the public using WhatsApp mobile application, and we asked the study population to answer the questionnaire in 20 min and also to answer the questionnaire alone. The participants were only permitted to answer the questionnaire once; thus, they were required to log in using their Google accounts before answering the questionnaire. Our participants were selected using nonprobability snowball (chain) sampling. We used this sampling technique by initially sending the questionnaire to our co-workers, friends, and their families. Then, the existing participants started to recruit future subjects from among their acquaintances by sharing the electronic version of the questionnaire through the WhatsApp platform. Each participant was asked to give informed consent before taking part. Confidentiality was maintained, no personal identifying information was obtained from participants. Ethical approval for this study was obtained from the Ethical Committee of the Institutional Review Board at Salmaniya Medical Complex, Ministry of Health, before the start of the study. All participants signed a consent to use their data for research and publication.

 Statistical Analysis

The IBM SPSS Statistics version 23.0 (IBM Corp., Armonk, NY, USA) was used for data entry and analysis. Frequencies and percentages were computed for the categorical variable. Mean, standard deviation, median, minimum, and maximum were computed for the quantitative variable. Mann–Whitney test was used to determine whether there is a significant difference in the median of ordinal variable between two groups. Kruskal–Wallis test was used to determine whether there is a significant difference in median of ordinal variable between more than two groups. Chi-square test was used to determine whether there is a significant relationship between two nominal variables or between a nominal variable and ordinal variable. Spearman’s correlation coefficient was used to measure the correlation between two ordinal variables. In all statistical tests, P <0.05 was statistically considered significant.


A total of 446 participants filled out the questionnaire. The minimum age for filling out the questionnaire was 18 years. Respondent characteristics were male/female (M/F) 39%/61%, mean age was 39 years old, 97.8% were Bahraini citizens, 99.3% were Muslim, and 70% were married. In addition, 67.7% of participants were university graduates, around 60.1% held full-time jobs, and 11.2% get from 800 to 1000 BD per month. Furthermore, 74% did not have a private health insurance [Table 1].{Table 1}

Of all participants, 80.2% stated that their chances to donate a kidney will not increase in exchange for an attractive financial compensation. The responses were also similar to the proposed compensation system (life-long health insurance/10,000 BHD), where around 74.5% stated that their chances in donating a kidney were slim. There are, however, more desirable responses (40.4% of participants) to donate a kidney to a family member or friend even with no compensation [Table 2]. We present the response distributions for all items in [Table 2].{Table 2}

We observed that 58.8 % of participants thought that the situation in which health insurance companies would introduce financial incentives to increase the number of living kidney donors is preferable (39.8% preferable and 19% very preferable) [Table 2]. Married participants were statistically more in favor of this situation (P = 0.038). Moreover, we found that acceptance to receive an attractive financial compensation for kidney donation is not increased, and this was statistically significant among unmarried persons (P = 0.04) [Table 3].{Table 3}

In addition, 48.9% of participants believed that the donor should choose his preferred method of reimbursement. The choice where the donor registers at an independent institute to donate to a patient on the waiting list and receives life-long health insurance compensation selected as most favorable (49.1%) [Table 2]. We observed that students and retired persons were more likely to accept that kidney patients try to find themselves such donor in order to get transplanted as soon as possible if such compensation-based system that causes more persons to donate (P = 0.023) [Table 4], although this was not statistically significant among married people (P = 0.225) [Table 3]. We found that the chance that you would donate one of your kidneys to help someone you do not know is statistically significant among unemployed persons (P = 0.0001) [Table 4], while the marital status does not affect this item (P = 0.057) [Table 3].{Table 4}

We found that positive responses to the situation where kidney patients try to find themselves a donor in order to get transplanted as soon as possible was positively correlated with higher mean age (r = 0.123, P = 0.014) [Table 5]. There was also a positive correlation between favorable views on this situation in which health insurance companies would introduce financial incentives to increase the number of living kidney donors is preferable and higher mean age (r = 0.168, P = 0.001) as well as higher monthly income (r = 0.142, P = 0.005) [Table 5].{Table 5}

For all questions, there was no statistically significant difference between male and female subjects, religion as well as different educational levels (data not shown).


It can be argued that introducing financial incentives for kidney donors is the only effective strategy to generate sufficient kidneys to meet the growing gap between supply and demand for donor kidneys and where lives currently lost awaiting kidney transplantation could be saved. This is due to perceived inadequate response of altruistic organ donation programs, in which donors (or their families) do not materially gain from donation.[11],[12]

Several authors seem willing to consider a regulated system of paid living kidney donation, given that certain conditions are met. These conditions include an equal reimbursement for all donors which can be expressed in money or other valuables like health insurance benefits. There also should be a single mediating institute that is legalized for donor reimbursement as well as public awareness and acceptance which should be taken into consideration before implementing such compensation-based system.[4],[5],[6],[7],[8],[9],[11],[12],[13],[14],[15],[16]

The supply–demand gap between the number of waitlisted candidates and the number of kidney transplantations performed annually in Bahrain is reinforcing the claim that unmet needs for transplantation constitute a devastating drawback, costing numerous lives and requiring immediate intervention in the form of incentives for living kidney provision.[1]

Our study predominantly showed that the public willingness to donate a kidney in Bahrain will not increase with financial incentives. One explanation for this could stem from the fact that most of the Bahraini public are practicing Muslims and they might view receiving any form of payment for organ donation as immoral and unreligious, whether in the form of cash or as life-long health insurance. Furthermore, even though many Islamic councils have ruled in favor of organ donation, there are theological dilemmas that might interfere with Muslims decision to donate an organ, such as the believe that on the day of judgment their bodily parts and organs will testify before God and how can such testimony occur if an organ has been donated away in life or after death.[16],[17] Another explanation might include kidney-donation unawareness and fear of health-related complications and kidney failure post donation, and thus, they were not persuaded by the proposed financial incentives.

From our study, a considerable portion of the Bahraini public thought that the donor should pick his preferred method of reimbursement and register at an independent institute to donate to a patient on the waiting list and receive a life-long health insurance compensation, instead of a cash price. As noted in a 2008 Dutch study, the public’s reluctance towards reimbursement in cash is likely due to linking the notion of “money for organs” with the negative reports of exploitation of the poor and the awful activities of organ harvesting.[18],[19] These associations may induce fears that introducing money as incentive, even in a legalized, well-organized system, will result in similar practices. Therefore, symbolic incentives may be perceived as more appropriate. This is further supported by the fact that most participants favored financial incentives to be in the form of donor health insurance coverage.

Views on financial incentives for kidney donation have been studied in different populations. We compared our results to two similar published studies, a 2016 American study on US voters and a 2008 Dutch study.[10],[20] The American study involved 1011 voters and concluded that most US voters view living kidney donation positively, and most (59%) would be motivated toward donor nephrectomy if offered a payment of 50,000 dollars. In the Dutch study, in which 550 respondents took part, 46.6% of respondents opposed the situation where health insurance companies would introduce financial incentives for kidney donors. In both studies, younger people were more supportive of ideas on introducing incentives to increase the number of living kidney donors. Interestingly, we found the contrary in our study, where older age groups were more in favor of the introduction of financial incentives and donors receiving life-long health insurance from an independent institute. This might reflect that older age groups in Bahrain have more awareness about the kidney donor’s shortage and the suffering of patients on the waiting lists.

Furthermore, in our study, higher monthly income positively correlated with favorable responses to health insurance companies introducing financial incentives for kidney donors. This was in line with the Dutch study[10] where participants with lower incomes were not more likely to be acceptant about the idea of introducing financial incentives, the opposite was found in the American study,[20] in which respondents with low incomes favor donor compensation more than those of higher income levels. We think this suggests that awareness about the current crisis of supply–demand gap in kidney donation plays a larger role in driving the Bahraini public decisions rather than financial needs


Overall, more than half of participants were supportive toward introducing a system with fixed compensation to increase the number of living kidney donors. Most participants preferred a system where the donor would register at an independent institute to donate to a patient on the list and, in turn, receive lifelong health insurance compensation. Older age and higher income were positively related to approval of ideas on introducing incentives for kidney donation. Despite that, the public willingness to donate a kidney in Bahrain is not likely to increase with financial incentives.

Conflict of interest: None declared.


1El-Agroudy A, Ghareeb S, Alarrayed S, et al. Outcome of kidney transplantation in Bahrain. Transplantation 2014;98:614.
2Al Arrayed A, Al Tantawi M, Faree E, Haider F, Abouna G. Renal transplant is an established and successful treatment for end-stage renal failure in Bahrain. Bahrain Med Bull 2000;22:63-5.
3Barnieh L, Klarenbach S, Gill JS, Caulfield T, Manns B. Attitudes toward strategies to increase organ donation: Views of the general public and health professionals. Clin J Am Soc Nephrol 2012;7:1956-63.
4Rodrigue JR, Crist K, Roberts JP, Freeman RB Jr., Merion RM, Reed AI. Stimulus for organ donation: A survey of the American Society of Transplant Surgeons membership. Am J Transplant 2009;9:2172-6.
5van Buren MC, Massey EK, Maasdam L, et al. For love or money? Attitudes toward financial incentives among actual living kidney donors. Am J Transplant 2010;10:2488-92.
6Friedman AL. Payment for living organ donation should be legalised. BMJ 2006;333: 746-8.
7Altshuler JS, Evanisko MJ. Financial incentives for organ donation: The perspectives of health care professionals. JAMA 1992;267: 2037-8.
8Delmonico FL, Arnold R, Scheper-Hughes N, Siminoff LA, Kahn J, Youngner SJ. Ethical incentives – Not payment – For organ donation. N Engl J Med 2002;346:2002-5.
9World Health Organization (WHO). A Report on Developments under the Auspices of WHO (1987-1991). Geneva: WHO; 1992. p. 12-28.
10Kranenburg L, Schram A, Zuidema W, et al. Public survey of financial incentives for kidney donation. Nephrol Dial Transplant 2008;23:1039-42.
11Martin DE, White SL. Financial incentives for living kidney donors: Are they necessary? Am J Kidney Dis 2015;66:389-95
12World Health Organization. WHO guiding principles on human cell, tissue and organ transplantation. Transplantation 2010;90:229-33.
13Friedman EA, Friedman AL. Payment for donor kidneys: Pros and cons. Kidney Int 2006;69:960-2.
14Israni AK, Halpern SD, Zink S, Sidhwani SA, Caplan A. Incentive models to increase living kidney donation: Encouraging without coercing. Am J Transplant 2005;5:15-20.
15Harris J, Erin C. An ethically defensible market in organs. BMJ 2002;325:114-5.
16Alkhawari FS, Stimson GV, Warrens AN. Attitudes toward transplantation in U.K. Muslim Indo-Asians in West London. Am J Transplant 2005;5:1326-31.
17Sharif A. Organ donation and Islam-challenges and opportunities. Transplantation 2012;94: 442-6.
18Bakdash T, Scheper-Hughes N. Is it ethical for patients with renal disease to purchase kidneys from the world’s poor? PLoS Med 2006;3: e349.
19Held PJ, McCormick F, Chertow GM, Peters TG, Roberts JP. Would government compensation of living kidney donors exploit the poor? An empirical analysis. PLoS One 2018; 13:e0205655.
20Peters TG, Fisher JS, Gish RG, Howard RJ. Views of US voters on compensating living kidney donors. JAMA Surg 2016;151:710-6.