Is India Ready for “One India One Allocation Policy” in Deceased Donor Kidney Transplant?

India’s deceased donor kidney transplant landscape reflects wide disparities in donation rates, infrastructure, and allocation systems across states. While some regions have adopted robust, multiparameter allocation frameworks, others rely on basic “first-come, first-served” models due to administrative and logistical limitations. This variation raises ethical and operational concerns in a low-donation, resource-constrained setting. This paper presents the first detailed comparative analysis of state-level kidney allocation policies in India, evaluating their alignment with the principles of equality, equity, and utility. It proposes a pragmatic, phased roadmap toward a unified national allocation framework, “One India One Allocation” – balancing ethical imperatives with real-world feasibility. The Indian experience, particularly the coexistence of diverse regional systems within a federal structure, offers valuable lessons for other Asian countries facing similar challenges: low organ donation rates, uneven healthcare access, and the need for regionally adapted but ethically sound allocation models. Countries across South and South-East Asia may benefit from India’s incremental, consensus-driven approach to reform. This manuscript reflects insights from national and state-level transplant authorities and highlights the importance of harmonized policies, transparency, and public trust in building equitable organ allocation systems within emerging health ecosystems.