Every year, thousands of people die waiting for an organ transplant. The main constraint is not technology or medical expertise. In many low- and middle-income countries (LMICs), organ transplantation is technically feasible; however, the supply of donated organs remains far below the need. Why? In Tunisia, our scoping research found that people often lack basic knowledge about how organ donation works, mistrust the institutions in charge, and worry about religious prohibitions—concerns that are largely unfounded, as Islam strongly encourages organ donation.
Policy changes may not always be the right answer. In 1991, Tunisia introduced “presumed consent,” following the example of several European countries, which saw large increases in organ donation after making being a donor the default option. But presumed consent requires high institutional trust: in Tunisia, officials in practice always seek family consent when the deceased’s preferences are unclear because they anticipate public backlash. Unfortunately, family refusal rates remain high, leaving the country trapped in an inefficient equilibrium where the need for organ transplants far exceeds supply.
Given the low levels of awareness and trust, we hypothesized that local experts would be best placed to spread awareness of organ donation and foster trust in medical institutions. My job market paper therefore asks whether an expert-led informational intervention can change young adults’ minds about organ donation. More importantly, can it actually change behavior, leading to an increase in organ donor registrations?
Previous Work
Economists have proposed—and helped implement—a range of policies to increase organ supply. Kidney exchange markets match incompatible donor–recipient pairs. Priority rules reward registered donors. Presumed consent systems make donation the default option unless individuals actively choose to opt out.
These policies have saved lives. But they all rely on something that is often scarce outside high-income democracies: institutional trust and administrative capacity.
Presumed consent, for example, works best when people trust the state not to abuse its power. Kidney exchange markets require sophisticated coordination and enforcement. Priority rules depend on credible registries and belief in fair enforcement. In many LMICs, these conditions are not yet met.
In Tunisia, where my study takes place, organ donation faces particularly severe barriers. Deceased donor rates are extremely low. Survey evidence and qualitative interviews reveal widespread fear of organ trafficking, deep mistrust of public institutions, and persistent religious misperceptions—some worry that organ donation is at odds with Islam. None of these constraints are addressed by simply changing default rules or introducing new allocation mechanisms.
This creates a policy dilemma. The need is urgent, but the standard tools are ill-suited to the context.
Can Trusted Information Change Behavior?
Instead of changing laws or building new institutions, my research tests a simple idea: can expert-led information overcome misperceptions and increase organ donation?
Working in partnership with Tunisia’s National Center for the Promotion of Organ Transplantation, we designed an in-person informational intervention targeted at university students. The intervention had three key components.
First, participants were shown a short video featuring a heart transplant recipient from a rural area of Tunisia.
Second, medical professionals from the national transplant authority explained how organ donation actually works, covering relevant medical procedures, the legal safeguards, and the administrative process. They addressed common fears directly, including concerns about organ trafficking.
Third—and crucially—they discussed the Islamic perspective on organ donation. Contrary to widespread beliefs, religious scholars across the Muslim world agree that organ donation is not only permissible, but to be encouraged, as a way of saving lives.
After the presentation, students could ask questions in an open Q&A session.
Measuring Real Behavior
Figure 1: ID changes at the South Mediterranean University, 10 April 2025
To evaluate the impact of this intervention, we ran a randomized controlled trial with over 1,200 students at a Tunisian university.
Importantly, we did not rely solely on survey responses. In Tunisia, adults can officially declare their desire to become deceased organ donors by adding the word “donor” to their national ID. In collaboration with the Tunisian Technical and Scientific Police, we offered students access to on-the-spot ID changes on campus after the intervention.
This allowed us to measure a real, costly decision—rather than mere stated willingness.
We also collected detailed survey data before, immediately after, and six months following the intervention, allowing us to study changes in knowledge, beliefs, trust, and persistence over time.
Small Numbers, Big Effects
We find that students who attended the informational sessions were significantly more likely to register as organ donors than those in the control group. In absolute terms, the increase was about 3 percentage points. That may sound small—but when only 1.3% of control students registered, it represents a dramatic behavioral shift.
The intervention is cost-effective. In the long run, a one-year scale-up could plausibly generate several additional transplants at a cost lower than maintaining only one patient on long-term dialysis. The social network data further suggest that there are spillovers to the control group, making the intervention even more cost-effective.
Beyond registration itself, the intervention substantially increased medical and legal knowledge, corrected religious misperceptions, and raised trust in the national transplant authority. These effects seem to persist even six months later.
A Family Constraint?
One of the most important findings of the study concerns the role of families.
We find that the treatment effect on organ donor registration is entirely driven by male students: 76% of all registrations came from men. This is at odds with baseline intentions—female students reported higher interest in registering as organ donors and higher altruism. We can rule out that these gender differences in registrations are driven by differences in treatment effectiveness: female students learn as much as male students during the intervention and gain similarly high levels of institutional trust.
Instead, these gender differences are consistent with the existence of a family constraint. Using baseline data, we measured students’ expectations of their families’ approval of organ donation. The intervention increased knowledge and trust for everyone—but only students who expected family support were likely to act on that information and register as donors. This suggests that in Tunisia, organ donation is not viewed as an individual decision. It is likely that family attitudes are particularly constraining young women’s agency to act on their preferences.
The policy implication is clear: informational interventions work—but they may work even better if they reach older generations as well.
Why It Matters for Economics
So far, organ donation has rarely been studied in LMIC settings. Our study shows that information delivered by credible experts can be powerful in a context characterized by low awareness and low levels of institutional trust.
The broader policy lesson goes beyond organ donation. When markets are missing and institutional trust is low, understanding beliefs, misperceptions, and social constraints becomes essential for policy design. Sometimes, saving lives does not require new laws or massive investments in infrastructure, but the right messenger, in the right place, and at the right time.
About the Author
Christina Sarah Hauser is a Postdoctoral Researcher at Collegio Carlo Alberto in Turin, Italy. She received her PhD in Economics from the European University Institute in 2025.
Her research focuses on development, more specifically on issues related to health, gender, and education. To learn more about her work, visit: https://sites.google.com/view/christinasarahhauser/home
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This blog post is an updated version of the post published at the World Bank’s Development Impact Blog on 14 November 2025.
Acknowledgements: This research was only possible thanks to the intellectual and practical support of the Tunisian Center for the Promotion of Organ Transplantation (CNPTO). We would like to express our gratitude to the CNPTO and especially to Dr. Boutheina Zannad, Dr. Inès Jaafar, Khadouja Ben Nakissa and Mejda Chaouachi. We also thank Leila Triki, Sana Mami, Imen Bouhestine, Lamia Ben Fdhila, Emnaa Chahed, and the faculty of the South Mediterranean University.
