Health Policy 94 (2010) 255–265 Contents lists available at ScienceDirect Health Policy journal homepage: www.elsevier.com/locate/healthpol Kidney black markets and legal transplants: Are they opposite sides of the same coin? Roger Lee Mendoza Cherry Hill, NJ 08003, USA article info Keywords: Black market Brokerage Demonstration effects Legal transplantation Nephrology Nephrectomy Organ trafficking Regulation Related and unrelated donations Transaction costs Unintended consequences abstract Objectives: This study investigates why the illegal traffic of kidneys exists and remains resilient in the Philippines. It also evaluates the efficacy of the legal and regulatory frame- work for kidney (and organ) transplantation, and the corresponding implications for health policy. The experiences of comparable countries are noted. Methods: Three surveys were employed in this study: 1) a review of related literature on kidney black markets; 2) questionnaire-based interviews of a multi-stage probability sam- ple of 131 kidney vendors from the two largest supplier regions in the Philippines; and 3) a comparative content analysis of pertinent legal and regulatory measures to address the underground kidney trade. Results: Survey results, based on a 4.0 percent statistical margin of error, indicate that kidney vendors are typically males (98.4 percent) who belong to the lower income classes/groups D and E (88.5 percent). The vast majority of vendors (89.2 percent) were unrelated to kidney recipients, many of whom were of foreign descent (60.3 percent). The study finds that cer- tain key elements underpin the kidney black market in the Philippines: an open, brokered and compensation-based contractual system between unrelated donors and sellers. These elements are sustained and reinforced by a robust supply-and-demand interface anchored on brokerage pricing, government incapacity, policy contradictions and public tolerance or indifference. Conclusion: The study suggests that the relative ambiguity of, and continuity between, the legal and underground kidney transplant systems be carefully addressed prior to enacting more specific reforms. The study also calls attention to the unintended consequences of var- ious reform efforts, which are often neglected in formulating health policy and evaluating its costs and benefits. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction 1.1. Objectives and significance of the study Human organ trafficking is a public health concern worldwide, especially in many developing countries. Healthcare globalization and the growth of transplant tourism (patients traveling abroad to purchase donor organs and undergo organ transplantation) have outpaced E-mail address: profdrrlmendoza@gmail.com. the implementation of internationally accepted ethical standards for procuring transplantable organs. The World Health Organization (WHO) estimates that the illegal traffic of kidneys accounts for as much as 20 percent of all kidney transplants, and higher in developing countries [1–4]. This is the first study of the illegal kidney trade in the Philippines based on quantitative data. It is guided by the following questions: 1) Why and how does the under- ground trade in kidneys (and other organs) thrive in the Philippines despite the global donor shortage? 2) Why are Philippine legal, regulatory and health promotion initia- tives unsuccessful in curtailing such illicit trade? 3) What 0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2009.10.005