By Christina Sarah Hauser and Maleke Fourati
Every year, thousands of people in developing countries die waiting for an organ transplant that never comes, not because the surgery is too expensive or too complex, but because of the dearth of donors.
In 2023, only 17 people in Tunisia donated their organs after death, though they saved more than that number in lives (one organ donor can save up to eight people).
Tunisia is by no means unique - across much of the Middle East and Africa, rates of posthumous organ donation remain extremely low. This could be attributed to several factors, including a lack of awareness, religious doubts and distrust of public institutions.
Our research suggests that while these challenges are real, they are not insurmountable.
Working with Tunisia’s National Centre for the Promotion of Organ Transplantation, we ran a randomized controlled trial, enrolling more than 1,200 university students in Tunis in 2025. Half of them attended a 30-minute awareness workshop led by two medical experts from the CNPTO, opening with a short video of a rural Tunisian patient’s testimony about how a heart transplant saved her life.
The experts then explained how the organ-transplant system works from a legal, medical, and religious perspective. The latter is especially important because many people in the Muslim world do not know that leading Islamic scholars have endorsed organ donation for decades.
The results were striking. Students had the opportunity to add the word “donor” to their national identity cards - a legally binding decision - at an on-campus registration fair that we organized in collaboration with the CNPTO and the Tunisian Technical and Scientific Police.
Students who attended the workshop were more than twice as likely to register as organ donors as those who did not.
This behavioral change - striking because of the (often wide) gap between stated intentions and actions - has significant implications for health policy. Funding a small team of doctors to visit classrooms over the course of an academic year would cost less than keeping one patient on kidney dialysis for two years. And, because a successful transplant can dramatically improve both survival and quality of life while reducing long-term health-care costs, such information-sharing is even more cost-effective.
The intervention likely worked because the real barriers to organ donation are misinformation and fear, not ideology. Many people wrongly assume that organ donation conflicts with their religious beliefs, while others worry that their organs will go to the rich or, worse, end up in trafficking networks.
In Tunisia, and North Africa more broadly, concerns about illegal organ trafficking have undermined trust in medical institutions. A large share of the students we surveyed expressed the belief that this practice was common in their country.
Putting their concerns and questions to a medical professional changed that. Students left these face-to-face meetings better informed about how transplantation works and more trusting of the system. Six months later, we found that participants still displayed higher levels of knowledge and institutional trust.
But our study also revealed a more fundamental obstacle. Many students who wanted to register as organ donors did not do so because they feared their family’s disapproval. Young women, in particular, appeared constrained by this consideration, even when they personally held favorable views toward donation. Family attitudes turned out to be a pivotal predictor of whether someone signed up.
Policymakers must confront the reality that, in much of the developing world, organ donation is viewed as a family decision, not a personal choice. In Tunisia, nearly six out of ten families approached for organ donation refused consent in 2023, and our study suggests that young adults rarely register as organ donors against their family’s wishes.
This suggests that while awareness campaigns targeting students and young adults are valuable, they are unlikely to achieve their full potential unless the conversation moves beyond classrooms and into households to reach parents and older generations.
Countries facing organ shortages often search for complex solutions: opt-out systems, financial incentives, or other legal reforms. These policies could help, but they require strong institutions and high public trust - both of which are in short supply in many low- and middle-income countries.
Tunisia’s experience suggests that the first step need not be so complicated. Sending a doctor into a room to have an honest conversation about transplants and answer questions that people are normally too afraid to ask can go a long way toward enlarging the pool of prospective donors.
Christina Sarah Hauser is a postdoctoral researcher at the Collegio Carlo Alberto. Maleke Fourati is an associate professor at South Mediterranean University’s Mediterranean School of Business.
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