ICASA 5 December 2011 Addis Ababa Ethiopia SCHOOL-BASED

ICASA, 5 December 2011 Addis Ababa, Ethiopia SCHOOL-BASED SEXUALITY EDUCATION PROGRAMMES A Cost and Cost-Effectiveness Analysis in Six Countries Dhianaraj Chetty and Joanna Herat (UNESCO), Jari Kivela, Evert Ketting and Rob Baltussen (Radboud University, Netherlands)

Background n Little known on the economic aspects n To run present and future programmes more efficiently n To provide key stakeholders with evidence on costs and budget implications of SE n To use the data to advocate for greater support n Study commissioned by UNESCO n Costs of SE programmes in six countries n Cost-effectiveness of SE programmes in two countries

Study Programmes Long Live Love Human Studies

Study Questions n What are the costs of different phases of SE programmes n Development / adaptation n Implementation n Update n Scaling-up n What is the cost-effectiveness of SE programmes? n Cost per unintended pregnancy, STI, HIV infection averted n Study is not an evaluation of the programmes

Methods – Cost Analysis (i) n Methodology: WHO-CHOICE n Data Collection: School surveys; inspection of financial records; Interviews with personnel n Data Analysis: by phase / activity; Economic vs. Budgetary cost; n Focus on cost per learner reached n Scale-up Scenarios

Methods – cost analysis (ii) Which costs are included? Development or Adaptation phase Implementatio n phase Update phase Teacher materials Teacher salaries Training Teacher materials Operations Training Advocacy Operations Advocacy

Study Programmes Long Live Love Human Studies

Programme Characteristics n Intra-curricular, compulsory programme n Nigeria, India, Estonia, The Netherlands n Extra-curricular, voluntary n Indonesia, Kenya n Delivery modality: n Mo. E: Estonia, India n Private – Public: Nigeria, The Netherlands n External (NGO): Kenya, Indonesia n NOTE: all classes delivered by existing teachers

Programme Characteristics n National or State-level Coverage: n Nigeria, India, Estonia n Age-group: secondary n Builds on primary level programme: Estonia, The Netherlands n Duration n 3 year: Nigeria, India, Estonia n 1 year: The Netherlands (complements other subjects n 6 months: Kenya, Indonesia

Country Nigeria Kenya Indon esia India Estoni a The Netherla nds Huma n Studie s Long Live Love Name of SE programme Family Life and HIV Educati on World Starts With Me Daku! Adolesc ent Reprod. & Sex. Health curricul um Intra-/extracurricular Intra Extra Intra Programme duration yrs Total number of hours 3 43 1 46 1 47 3 34 3[1] 24 1 11 Schools covered in 2009 319 112 77 5, 560 382 174 Students covered in 2009 246, 000 7, 300 1, 805 780, 000 28, 000 25, 300 Total costs US$ 3. 4 mil 1. 2 mil 10. 8 mil 5. 6 mil 12. 2 mil Annual costs 2009 US$ 562, 000 364, 00 0 289, 00 0 3, 502, 0 00 311, 00 0 830, 000 6. 90 50. 00 159. 90 13. 50 32. 90 32. 80 Cost per learner in US$

Study Programme - Nigeria

Nigeria – Family Life and HIV Education n Fully scaled up in Lagos State n 246, 000 students in 2009 n Intra-curricular programme, mandatory uptake n Context: sexuality is a sensitive issue n Abstinence-focussed n Age group 11 -14 years n Duration 3 years / 27 lessons

Nigeria – Implementation Costs Cost per learner (per completed curriculum): $6. 90

Main Findings - Nigeria n Relatively low cost per learner: us$6. 90 Budgetary outlay: us$0. 60 n High coverage of schools n Teaching costs low n Large class size: 75 – 150 students Concerns about quality n Materials, advocacy, operations costs low

Study Programme - Kenya

Kenya – World Starts With Me n Extra-curricular programme n Computer-based, teacher assisted n Pilot by NGO, started in 2006 n Limited coverage n 112 schools, 7, 300 student in 2009 n 4 provinces, geographically spread out n Age group: 14 -20 years n Duration: 1 semester / 15 lessons n Context: sexuality is a sensitive issue

Kenya – Implementation Costs Cost across schools: in 2009 If scaled up in andper learner : $50 US$16

Main Findings - Kenya n High cost per learner in current form: us$ 50 n Budgetary outlay: us$37 n High operational costs (52%) n Low coverage (pilot programme): 112 schools n Geographically spread out n International technical assistance & NGO-led n Computer based – constrained uptake Cost if scaled up within and across schools: us$16

Impact Evaluation Human Studies

Methods – Impact analysis n Health-related outcomes: n Improved knowledge Improved attitudes Improved behaviours (Estonia and Kenya) Improved health outcomes (Estonia and Kenya) n Non-health outcomes not included in this study

Methods – Cost-effectiveness

Methods – Cost-effectiveness analysis Costs of SE programme Cost-effectiveness = ---------------Impact of SE programme

Methods – Cost-effectiveness analysis US $ 300, 000 Cost-effectiveness = ---------------1, 000 HIV infections averted = US $ 300 per infection averted

Impact Analysis - Estonia n Time series analysis based on surveys & national registries (births, abortions, HIV and STI) n 12 Studies / surveys 1994 – 2007 n Limitation: Impact of Sexuality Education cannot be fully distinguished from youth friendly services (developed simultaneously)

Trends in Outcome Indicators (i) Abortions per year 2001 - 2009

Trends in Outcome Indicators (ii) Diagnosed HIV infections per year 2001 - 2009

Cost-effectiveness analysis (exploratory) SE Programme costs (US$) us $5. 6 m Observed reduced number of HIV-infections in Estonia 2001 – 2009 1, 970 Life treatment costs per HIV infection us $ 67, 825 Break-even point : SE programme costs equal savings from averted HIV treatment costs 83 (4%)

Discussion n Costs of the SE programme are offset by the savings resulting from averted HIV infections n Lifetime treatment costs us$67, 825 n Cost of other health outcomes not analysed n Savings, or effectiveness, could be greater n Contribution of Sexuality Education programme not separable from youth-friendly service delivery

Impact Analysis - Kenya n Evaluation by implementing organisation n Changes in knowledge, attitude, behaviour n No statistically significant results n Methodological issues - No n Implementation issues - No n Social desirability bias? Possible n Further research required n Not possible to conduct the cost-effectiveness analysis

Observations 1. 2. 3. SE programmes are potentially highly effective, costeffective and even cost-saving Intra-curricular programmes with high coverage have low cost per student (Nigeria, India, Estonia) Teaching costs are most important cost driver n n 4. Materials, training, and advocacy much lower Operations costs can be high in certain models Certain characteristics lead to higher costs: n n n Extra-curricular Low uptake Geographically spread out

KEY CHARACTERISTICS – IMPROVED HEALTH OUTCOMES AND OPTIMAL COST-EFFECTIVENESS Building block pedagogical approach over several years Integrated into the curriculum COMPREHENSIVE SEXUALITY EDUCATION PROGRAMME Scaled-up in schools and rolled out nationally Youth-friendly SRH service provision Cost-savings and improvements in young people’s health outcomes, including reductions in unintended pregnancy, HIV infections and other STIs

Recommendations 1. 2. 3. 4. 5. Investing in SE programmes to improve sexual health should be seriously considered. For optimal resource-use, the following characteristics should be prioritised: 1. Compulsory & intra-curricular with full uptake 2. Scaled-up (national / state coverage) 3. Delivered in conjunction with youth-friendly SRH services Extra-curricula or voluntary programmes not cost-efficient n May be important stepping stones in sensitive contexts Take into account that comprehensive SE programmes also have large non-health benefits Advocacy and public education are necessary cost components of SE programmes and should be included in budget plans

Full report & Executive Summary available on our website www. unesco. org/aids@unesco. org THANK YOU!