de Walque, Damien

Person:
de Walque, Damien

Development Research Group

Fields of Specialization

Education, Macroeconomic and Structural Policies, Health

ORCID

0000-0003-1592-7602

External Links

ResearcherID
RePEc
Blog: Africa Can ... End Poverty

Departments

Development Research Group

Last updated: March 11, 2025

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.

Full item page

Publication Search Results

Now showing 1 - 10 of 70

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.
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.
Risking Your Health : Causes, Consequences, and Interventions to Prevent Risky Behaviors
(Washington, DC: World Bank, 2014) de Walque, Damien; de Walque, Damien
Behaviors that pose risks for an individual’s health and that also represent important threats for public health, such as drug use, smoking, alcohol, unhealthy eating causing obesity, and unsafe sex, are highly prevalent in low income countries, even though they are traditionally associated with richer countries. Individual choices are an important part of the risky behaviors. Risking Your Health: Causes, Consequences, and Interventions to Prevent Risky Behaviors explore how those choices are formed and what are their consequences. Why do people engage in risky behaviors? Many different explanations have been proposed by psychology, sociology, economics or public health. One trait common to all these behaviors is that there is a disconnect – a function of both delay and uncertainty - between the pleasure or satisfaction provided by them and their consequences. Another characteristic of risky behaviors is that they rarely occur in isolation. Peer-pressure, parental influences, networks and social norms often play an important role in initiating, continuing, or quitting those behaviors. Even if they might often be the first to suffer, the consequences of risky behaviors are also rarely limited to the individuals engaging in them. In certain cases, such as second-hand smoking or HIV transmission, the link is direct. In other cases, the link is less direct but not necessarily less real: the long term health consequences of many of these behaviors are costly to treat and could stretch households’ finances and worsen poverty. Finally, these risky behaviors have consequences for society as a whole since they often trigger a non-trivial amount of public health expenditures and lead to declines in aggregate productivity through premature death and morbidity. Changing behaviors is tricky -- public health interventions via legislation with strong enforcement mechanisms can be more effective than simple communication campaigns informing consumers about the risks associated with certain behaviors, since translating knowledge into concrete changes in behavior seems to be hard to achieve. Economic mechanisms such as taxes (especially on alcohol and tobacco products), subsidies (such as free condoms), and conditional/unconditional cash transfers are also used to reduce risky behaviors (for example in HIV prevention). Of great interest to policy makers, academics and practitioners, this book assesses the efficiency of those interventions designed to reduce the prevalence of behaviors that endanger health.
Cash Transfers and Child Schooling : Evidence from a Randomized Evaluation of the Role of Conditionality
(World Bank, Washington, DC, 2013-01) Akresh, Richard; de Walque, Damien; Kazianga, Harounan
The authors conduct a randomized experiment in rural Burkina Faso to estimate the impact of alternative cash transfer delivery mechanisms on education. The two-year pilot program randomly distributed cash transfers that were either conditional or unconditional. Families under the conditional schemes were required to have their children ages 7-15 enrolled in school and attending classes regularly. There were no such requirements under the unconditional programs. The results indicate that unconditional and conditional cash transfer programs have a similar impact increasing the enrollment of children who are traditionally favored by parents for school participation, including boys, older children, and higher ability children. However, the conditional transfers are significantly more effective than the unconditional transfers in improving the enrollment of "marginal children" who are initially less likely to go to school, such as girls, younger children, and lower ability children. Thus, conditionality plays a critical role in benefiting children who are less likely to receive investments from their parents.
Mines, Migration and HIV/AIDS in Southern Africa
(2012-02-01) Corno, Lucia; de Walque, Damien
Swaziland and Lesotho have the highest HIV prevalence in the world. They also share another distinct feature: during the last century, they sent a large numbers of migrant workers to South African mines. This paper examines whether participation in mining in a bordering country affects HIV infection rate. A job in the mines means leaving for long periods away from their families and living in an area with an active sex industry. This creates potential incentives for multiple, concurrent partnerships. Using Demographic and Health Surveys, the analysis shows that migrant miners ages 30-44 are 15 percentage points more likely to be HIV positive, and women whose partner is a migrant miner are 8 percentage points more likely to become infected. The study also shows that miners are less likely to abstain or use condoms, and female partners of miners are more likely to engage in extramarital sex. The authors interpret these results as suggesting that miners' migration into South Africa has increased the spread of HIV/AIDS in their countries of origin. Consistent with this interpretation, the association between HIV infection and being a miner or a miner's wife are not statistically significant in Zimbabwe, a country where the mining industry is local and does not involve migrating to South Africa.
Sexual Behavior Change Intentions and Actions in the Context of a Randomized Trial of a Conditional Cash Transfer for HIV Prevention in Tanzania
(2012-03-01) Packel, Laura; Dow, William H.; de Walque, Damien; Isdahl, Zachary; Majura, Albert
Information, education, communication and interventions based on behavioral-change communication have had success in increasing the awareness of HIV. But these strategies alone have been less successful in changing risky sexual behavior. This paper addresses this issue by exploring the link between action and the intention to change behaviors. In Africa, uncertainty in the lives of those at risk for HIV may affect how intentions are formed. Characterize this uncertainty by understanding the reasons for discrepancies between intentions and actions may help improve the design of HIV-prevention interventions. Based on an incentives-based HIV prevention trial in Tanzania, the longitudinal dataset in this paper allows the exploration of intended strategies for changing sexual behaviors and their results. The authors find that gender, intervention groups and new positive diagnoses of sexually transmitted infections can significantly predict the link between intent and action. The paper examines potential mediators of these relationships.
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.
Evidence from a Randomized Evaluation of the Household Welfare Impacts of Conditional and Unconditional Cash Transfers Given to Mothers or Fathers
(World Bank, Washington, DC, 2016-06) Akresh, Richard; de Walque, Damien; Kazianga, Harounan
This study conducted a randomized control trial in rural Burkina Faso to estimate the impact of alternative cash transfer delivery mechanisms on education, health, and household welfare outcomes. The two-year pilot program randomly distributed cash transfers that were either conditional or unconditional and were given to either mothers or fathers. Conditionality was linked to older children enrolling in school and attending regularly and younger children receiving preventive health check-ups. Compared with the control group, cash transfers improve children's education and health and household socioeconomic conditions. For school enrollment and most child health outcomes, conditional cash transfers outperform unconditional cash transfers. Giving cash to mothers does not lead to significantly better child health or education outcomes, and there is evidence that money given to fathers improves young children's health, particularly during years of poor rainfall. Cash transfers to fathers also yield relatively more household investment in livestock, cash crops, and improved housing.
Female Sex Workers Use Power Over Their Day-to-Day Lives to Meet the Condition of a Conditional Cash Transfer Intervention to Incentivize Safe Sex
(Elsevier, 2017-05) Cooper, Jan E.; Dow, William H.; de Walque, Damien; Keller, Ann C.; McCoy, Sandra I.; Fernald, Lia C.H.; Balampama, Marianna P.; Kalolella, Admirabilis; Packel, Laura J.; Wechsberg, Wendee M.; Ozer, Emily J.
Female Sex Workers are a core population in the HIV epidemic, and interventions such as conditional cash transfers (CCTs), effective in other health domains, are a promising new approach to reduce the spread of HIV. Here we investigate how a population of Tanzanian female sex workers, though constrained in many ways, experience and use their power in the context of a CCT intervention that incentivizes safe sex. We analyzed 20 qualitative in-depth interviews with female sex workers enrolled in a randomized-controlled CCT program, the RESPECT II pilot, and found that while such women have limited choices, they do have substantial power over their work logistics that they leveraged to meet the conditions of the CCT and receive the cash award. It was through these decisions over work logistics, such as reducing the number of workdays and clients, that the CCT intervention had its greatest impact on modifying female sex workers’ behavior.
Socioeconomic Determinants of Stigmatization and HIV Testing in Lesotho
(Taylor and Francis, 2013-06-09) Corno, Lucia; de Walque, Damien
HIV/AIDS stigmatizing attitudes and their consequences on preventative behaviors are among the most poorly understood aspects of the AIDS epidemic. This paper analyzes the socioeconomic determinants of discriminating attitudes toward people living with HIV and their implications on the likelihood of HIV testing. These effects are tested using the 2004 and 2009 Demographic and Health Surveys conducted in Lesotho, where HIV/AIDS is a pervasive problem. We find that HIV/AIDS stigmatizing attitudes are negatively associated with education and wealth and positively correlated with Catholic religion for women and traditional circumcision for men. The analysis also shows a negative association between stigmatizing beliefs and the probability of being tested for HIV.