Person:
de Walque, Damien

Development Research Group

Fields of Specialization

Education, Macroeconomic and Structural Policies, Health

ORCID

0000-0003-1592-7602

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Development Research Group

Last updated: October 24, 2023

Biography

Damien de Walque is a Lead Economist in the Development Research Group (Human Development Team) at the World Bank. He received his Ph.D.in Economics from the University of Chicago in 2003. His research interests include health and education and the interactions between them. His current work is focused on evaluating the impact of financial incentives on health and education outcomes. He is currently evaluating the education and health outcomes of conditional cash transfers linked to school attendance and health center visits in Burkina Faso. He is also working on evaluating the impact of HIV/AIDS interventions and policies in several African countries. He is leading two evaluations of the impact of short-term financial incentives on the prevention of HIV/AIDS and other sexually transmitted infections (STIs): individuals who test negatively for a set of STIs receive regular cash payment in Tanzania, while in Lesotho they receive lottery tickets. On the supply side of health services, he is managing a large portfolio of impact evaluations of results-based financing in the health sector. He has also edited a book on risky behaviors for health (smoking, drugs, alcohol, obesity, risky sex) in the developing world.

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Publication Search Results

Now showing 1 - 10 of 69

Effects of a Lottery Incentive on Sexually Transmitted Infections and HIV Incidence among Female Sex Workers in Tanzania: Results from the RESPECT II Randomized Trial
(World Bank, Washington, DC, 2023-09-26) Balampama, Marianna; de Walque, Damien; Dow, William H.; Hémono, Rebecca
Female sex workers are a key population who experience a disproportionately high burden of HIV and sexually transmitted infections. A growing body of evidence suggests that financial incentives can reduce risky sexual behavior and the incidence of HIV and sexually transmitted infections; however, few studies have examined a lottery-based incentive mechanism or been conducted with female sex workers. This paper examines the effect of a lottery intervention on the combined incidence of HIV and herpes simplex virus 2 among female sex workers in Tanzania. The RESPECT II trial was an unmasked, two-arm, parallel group randomized controlled trial conducted in Dar es Salaam, Tanzania among 2,206 enrollees from 2018 to 2021. Participants were randomized in a one-to-one ratio to the basic test control group or to the lottery intervention group. The basic test group received testing and counseling for HIV and biweekly text messages with information on safe sex practices. The lottery group received the basic test group intervention plus entry into a weekly lottery with a 100,000 Tanzanian shilling (US$50) reward offered to 10 randomly selected participants, conditional on negative test results for syphilis and trichomonas. The primary outcome was combined HIV and herpes simplex virus 2 incidence after 36 months. The results showed no statistically significant effect on this primary outcome. Thus the study finds no evidence that the lottery-based incentives reduced the incidence of HIV and sexually transmitted infections among the female sex worker population. However, the results may have been affected by disruption from the COVID-19 pandemic, and unexpectedly high study attrition levels made it impossible to statistically rule out possible moderate-sized effects.
Early Education, Preferences, and Decision-Making Abilities
(World Bank, Washington, DC, 2022-09) Cardim, Joana; Carneiro, Pedro; Carvalho, Leandro S.; de Walque, Damien
One way to advance understanding of individual differences in decision making is to study the development of children’s decision making. This paper studies the causal effects of daycare attendance on children’s economic preferences and decision-making abilities, exploiting a lottery system that randomized admissions into oversubscribed daycare centers in Rio de Janeiro. Overall, daycare attendance had no effect on economic preferences or decision-making abilities. However, it did increase aversion to disadvantageous inequality (having less than one’s peer). This increase is driven mostly by girls, a result that reproduces in a different study that randomized admissions into preschool education.
Improving Effective Coverage in Health: Do Financial Incentives Work?
(Washington, DC: World Bank, 2022-05-11) de Walque, Damien; Kandpal, Eeshani; Wagstaff, Adam; Friedman, Jed; Neelsen, Sven; Piatti-Fünfkirchen, Moritz; Sautmann, Anja; Shapira, Gil; Van de Poel, Ellen
In many low- and middle-income countries, health coverage has improved dramatically in the last two decades, but health outcomes have not. As such, effective coverage -- a measure of service delivery that meets a minimum standard of quality -- remains unacceptably low. This Policy Research Report examines one specific policy approach to improving effective coverage: financial incentives in the form of performance-based financing (PBF) or financial incentives to health workers on the front lines. The report draws on a rich set of rigorous studies and new analysis. When compared to business-as-usual, in low-income settings with centralized health systems PBF can result in substantial gains in effective coverage. However, the relative benefits of PBF are less clear when it is compared to two alternative approaches, decentralized facility financing which provides operating budget to frontline health services with facility autonomy on allocation, and demand-side financial support for health services (i.e., conditional cash transfers and vouchers). While PBF often results in improvements on the margins, closing the substantial gaps in effective health coverage is not yet within reach for many countries. Nonetheless, there are important lessons learned and experiences from the roll-out of PBF over the last decade which can guide health policies into the future.
Invitations, Incentives, and Conditions: A Randomized Evaluation of Demand-Side Interventions for Health Screenings
(Elsevier, 2022-03) de Walque, Damien; Chukwuma, Adanna
This randomized controlled trial investigates the impact of four demand-side interventions on health screening for diabetes and hypertension among Armenian adults. The interventions are 1) personalized invitations from a physician, 2) personalized invitations with information about peer screening behavior, 3) personalized invitations with a labeled but unconditional financial incentive, and 4) personal invitations with a conditional financial incentive. Compared with the control group, interventions 1 to 3 led to a significant increase in the screening rate of about 15 percentage points for diabetes and hypertension. The highest impact was measured for intervention 4 leading to a 31.2 percentage point increase in both screenings.
Incentivizing Quantity and Quality of Care: Evidence from an Impact Evaluation of Performance-Based Financing in the Health Sector in Tajikistan
(University of Chicago Press, 2022-02) Ahmed, Tashrik; Arur, Aneesa; de Walque, Damien; Shapira, Gil
To improve utilization and quality of health services, a growing number of low- and middle-income countries have been experimenting with financial incentives tied to providers’ performance. Relying on a difference-in-differences approach, we estimate the impacts of the performance-based financing pilot in Tajikistan. Primary care facilities were given financial incentives conditional on the quality and quantity of selected services. Significant improvements are found on quality indicators, including elements of the content of care. While the communities in the pilot districts reported higher satisfaction with the local primary care facilities, and despite the improvements in quality, the impact on utilization was limited.
COVID-19 Age-Mortality Curves for 2020 Are Flatter in Developing Countries Using Both Official Death Counts and Excess Deaths
(World Bank, Washington, DC, 2021-10) Demombynes, Gabriel; de Walque, Damien; Gubbins, Paul; Urdinola, Beatriz Piedad; Veillard, Jeremy
Using official COVID-19 death counts for 64 countries and excess death estimates for 41 countries, this paper finds a higher share of pandemic-related deaths in 2020 were at younger ages in middle-income countries compared to high-income countries. People under age 65 constituted on average (1) 11 percent of both official deaths and excess deaths in high-income countries, (2) 40 percent of official deaths and 37 percent of excess deaths in upper-middle-income countries, and (3) 54 percent of official deaths in lower-middle-income countries. These contrasting profiles are due only in part to differences in population age structure. Both COVID-19 and excess death age-mortality curves are flatter in countries with lower incomes. This is a result of some combination of variation in age patterns of infection rates and infection fatality rates. In countries with very low death rates, excess mortality is substantially negative at older ages, suggesting that pandemic-related precautions have lowered non-COVID-19 deaths. Additionally, the United States has a younger distribution of deaths than countries with similar levels of income.
Financial Incentives to Increase Utilization of Reproductive, Maternal, and Child Health Services in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis
(World Bank, Washington, DC, 2021-10) Neelsen, Sven; de Walque, Damien; Friedman, Jed; Wagstaff, Adam
Financial incentives for health providers and households are increasingly used to improve reproductive, maternal, and child health service coverage in low- and middle-income countries. This study provides a quantitative synthesis of their effectiveness. A systematic review was conducted of the effects of performance-based financing, voucher, and conditional cash transfer programs on six reproductive, maternal, and child health service indicators, with eligible evidence coming from randomized controlled trials and studies using double-difference, instrumental variables, and regression discontinuity designs. Four literature searches were conducted between September 2016 and March 2021 using seven academic databases, Google Scholar, development agency and think tank websites, and previous systematic reviews. Random effects meta-analysis was used to obtain mean effect sizes. From 58 eligible references 212 impact estimates were extracted, which were synthesized into 130 program-specific effect sizes. Financial incentives increase coverage of all considered reproductive, maternal, and child health indicators, but mean effects sizes are of modest magnitude. Effect size heterogeneity is typically low to moderate, and there is no indication that study bias risk, baseline indicator levels, or a combination of provider- and household-level incentives impact effect sizes. There is, however, weak evidence that mean effect sizes are somewhat smaller for performance-based financing than for voucher and conditional cash transfer programs, and that the increase in income, rather than the incentive itself, drives coverage improvements. Financial incentives improve reproductive, maternal, and child health service coverage. If future research confirms the preliminary finding that performance-based financing has smaller effects, voucher and conditional cash transfer programs are the preferred policy option among incentive interventions to achieve higher reproductive, maternal, and child health service coverage. The relative effectiveness and efficiency of incentives compared with unconditional increases of provider and household incomes, however, need to be studied further.
How Many Infants May Have Died in Low-Income and Middle-Income Countries in 2020 Due to the Economic Contraction Accompanying the COVID-19 Pandemic? Mortality Projections Based on Forecasted Declines in Economic Growth
(BMJ Publishing Group, Ltd., 2021-08) Shapira, Gil; de Walque, Damien; Friedman, Jed
While COVID-19 has a relatively small direct impact on infant mortality, the pandemic is expected to indirectly increase mortality of this vulnerable group in low-income and middle-income countries through its effects on the economy and health system performance. Previous studies projected indirect mortality by modelling how hypothesized disruptions in health services will affect health outcomes. We provide alternative projections, relying on modelling the relationship between aggregate income shocks and mortality. The findings underscore the vulnerability of infants to the negative income shocks such as those imposed by the COVID-19 pandemic. While efforts towards prevention and treatment of COVID-19 remain paramount, the global community should also strengthen social safety nets and assure continuity of essential health services.
Looking into the performance-based financing black box: Evidence from an impact evaluation in the health sector in Cameroon
(Oxford University Press, 2021-07) de Walque, Damien; Saidou, Hamadou; Sorgho, Gaston; Steenland, Maria
Performance-based financing (PBF) is a complex health systems intervention aimed at improving the coverage and quality of care. Several studies have shown a positive impact of PBF on health service coverage, often coupled with improvements in quality, but relatively little is known about the mechanisms driving those results. This article presents results of a randomized impact evaluation in Cameroon designed to isolate the role of specific components of the PBF approach with four study groups: (i) PBF with explicit financial incentives linked to results, (ii) direct financing with additional resources available for health providers not linked to performance, (iii) enhanced supervision and monitoring without additional resources and (iv) a control group. Overall, results indicate that, when compared with the pure control group, PBF in Cameroon led to significant increases in utilization for several services (child and maternal vaccinations, use of modern family planning), but not for others like antenatal care visits and facility-based deliveries. In terms of quality, PBF increased the availability of inputs and equipment, qualified health workers, led to a reduction in formal and informal user fees but did not affect the content of care. However, for many positively impacted outcomes, the differences between the PBF group and the group receiving additional financing not linked to performance are not significant, suggesting that additional funding rather than the explicit incentives might be driving improvements. In contrast, the intervention group offering enhanced supervision, coaching and monitoring without additional funding did not experience significant impacts compared to the control group.
The Intergenerational Mortality Tradeoff of COVID-19 Lockdown Policies
(World Bank, Washington, DC, 2021-05) Ma, Lin; Shapira, Gil; de Walque, Damien; Do, Quy-Toan; Friedman, Jed; Levchenko, Andrei A.
In lower-income countries, the economic contractions that accompany lockdowns to contain the spread of COVID-19 can increase child mortality, counteracting the mortality reductions achieved by the lockdown. To formalize and quantify this effect, this paper builds a macro-susceptible-infected-recovered model that features heterogeneous agents and a country-group-specific relationship between economic downturns and child mortality, and calibrate it to data for 85 countries across all income levels. The findings show that in low-income countries, a lockdown can potentially lead to 1.76 children’s lives lost due to the economic contraction per COVID-19 fatality averted. The ratio stands at 0.59 and 0.06 in lower-middle and upper-middle income countries, respectively. As a result, in some countries lockdowns can actually produce net increases in mortality. In contrast, the optimal lockdown that maximizes the present value of aggregate social welfare is shorter and milder in poorer countries than in rich ones, and never produces a net mortality increase.