*Purpose: The research asks why global living and deceased donor rates of the past 15 years in advanced economies far exceed those occurring in Singapore, Hong Kong, and Taiwan, three economically-developed societies that favor kinship domination and spiritual norms to keep bodies intact after death, while these polities adopt regulations for living and deceased donor kidney transplantation that include the full range of possibilities.

*Methods: To explain these striking discrepancies, the researcher conducted literature reviews and on-site interviews (n=62) with national registries, medical professionals, and community members to understand why even the strongest incentives (i.e., presumed consent without family consultation and monetary compensation for the living donors in Singapore) only yield similar results with that of the most restricted donor pool (i.e., a kin-exclusive living donation system and an opt-in system requiring written consent from the relatives at the time of procurement in Taiwan).

*Results: In addition to the shared ethical norms that prevent many from becoming donors in the study sites, the research uncovered critical roles that institutional frameworks and organizational arrangements play in determining rates of donation. Even though Singapore adopted substantial incentives, having a single transplant program limited donation. In Hong Kong, with the addition of regional hospital coordinators, the results have been improving. Nonetheless, the lack of a central registry remains one indication of how a more integrated system is needed to match donors and recipients in time. Despite the restricted laws on donor eligibility, Taiwan has been able to demonstrate comparable results with the other two polities because of its national registry, multiple transplant units that foster competition, and the advocacy of the hospital-affiliated organ procurement organizations. Coordinators in the OPOs provide persuasive accounts in nudging donor families to agree to procurement.

*Conclusions: There have been ongoing debates about which efforts motivate more kidney donation worldwide. Comparing East Asian societies that embody different donation policies but similar struggles to shorten the waitlists and waiting time, the study highlights factors other than policies and ethical challenges that affect donation results. The findings not only underscore the importance of developing donation programs tailored to different ethnic groups but also show effective organizational designs can overcome the socio-cultural barriers against organ donation.

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