A Cost and Cost-Effectiveness Analysis in Six Countries

IATT/YP Meeting, Paris

June 2011

SCHOOL-BASED SEXUALITY EDUCATION

PROGRAMMES

Background

Little known on the economic aspects To run present and future programmes

more efficiently To provide key stakeholders with evidence

on costs and budget implications of SE To use the data to advocate for greater

support Study commissioned by UNESCO

Costs of SE programmes in six countries Cost-effectiveness of SE programmes in

two countries

Study Programmes

Long Live Love

Human Studies

Study Questions

What are the costs of different phases of SE programmes Development / adaptation Implementation Update Scaling-up

What is the cost-effectiveness of SE programmes? Cost per unintended pregnancy, STI, HIV infection

averted

Study is not an evaluation of the programmes

Methods – Cost Analysis (i)

Methodology: WHO-CHOICE

Data Collection: School surveys; inspection of financial records; Interviews with personnel

Data Analysis: by phase / activity; Economic vs. Budgetary cost; Focus on cost per learner reached

Scale-up Scenarios

Methods – cost analysis (ii)

Development or Adaptation phase

Implementation phase

Update phase

Teacher materials Teacher salaries Teacher salaries

Training Teacher materials Teacher materials

Operations Training Training

Advocacy Operations Operations

Advocacy Advocacy

Which costs are included?

Study Programmes

Long Live Love

Human Studies

Nigeria – Family Life and HIV Education Fully scaled up in Lagos State

246,000 students in 2009 Intra-curricular programme, mandatory

uptake Context: sexuality is a sensitive issue Abstinence-focussed

Age group 11-14 years Duration 3 years / 27 lessons

Nigeria – Implementation Costs

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

2003 2004 2005 2006 2007 2008 2009

OperationsTrainingAdvocacyTeaching materialsTeaching salaries

Cost per learner (per completed curriculum): $6.90

Main Findings - Nigeria

Relatively low cost per learner: us$6.90 Budgetary outlay: us$0.60

High coverage of schools Teaching costs low

Large class size: 75 – 150 studentsConcerns about quality

Materials, advocacy, operations costs low

Kenya – World Starts With Me Extra-curricular programme

Computer-based, teacher assisted Pilot by NGO, started in 2006 Limited coverage

112 schools, 7,300 student in 2009 4 provinces, geographically spread out

Age group: 14-20 years Duration: 1 semester / 15 lessons Context: sexuality is a sensitive issue

Kenya – Implementation Costs

Cost per learner : $50 in 2009

$ 0

$ 50,000

$ 100,000

$ 150,000

$ 200,000

$ 250,000

$ 300,000

$ 350,000

$ 400,000

2006 2007 2008 2009

OperationsTrainingAdvocacyTeaching materialsTeaching salaries

If scaled up in and across schools: US$16

Main Findings - Kenya

High cost per learner in current form: us$ 50 Budgetary outlay: us$37

High operational costs (52%) Low coverage (pilot programme): 112 schools Geographically spread out International technical assistance & NGO-led

Computer based – constrained uptake

Cost if scaled up within and across schools: us$16

India - Adolescent Reproductive and Sexual Health Education Implementation plan 2010 onwards

Programme developed & piloted 1999 – 2002

Halted due to opposition Re-started in Orissa state 2007

Integrated intra-curricular programme Comprehensive Orissa state only

Study analysed programme plans (2010 – 2014)

India – Projected Implementation Costs 2010 - 2014

Cost per learner : Economic: $13.50

Budget cost: $2.50

$0.0

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

$3.5

$4.0

2010 2011 2012 2013 2014

Mill

ion

s

Operations

Training

Advocacy

Teaching materials

Teaching salaries

Methods – Cost-effectiveness

Impact Analysis - Estonia

Time series analysis based on surveys & national registries (births, abortions, HIV and STI)

12 Studies / surveys 1994 – 2007

Limitation: Impact of Sexuality Education cannot be fully distinguished from youth friendly services (developed simultaneously)

Trends in Outcome Indicators (ii)

0

100

200

300

400

500

600

2001 2002 2003 2004 2005 2006 2007 2008 2009

Dia

gnos

ed n

ew H

IV in

fecti

ons

20-24 years15-19 years

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

Costs of the SE programme are offset by the savings resulting from averted HIV infections Lifetime treatment costs us$67,825

Cost of other health outcomes not analysed Savings, or effectiveness, could be greater

Contribution of Sexuality Education programme not separable from youth-friendly service delivery

Observations

1. SE programmes are potentially highly effective, cost-effective and even cost-saving

2. Intra-curricular programmes with high coverage have low cost per student (Nigeria, India, Estonia)

3. Teaching costs are most important cost driver Materials, training, and advocacy much lower Operations costs can be high in certain models

4. Certain characteristics lead to higher costs: Extra-curricular Low uptake Geographically spread out

KEY CHARACTERISTICS – IMPROVED HEALTH OUTCOMES AND OPTIMAL COST-EFFECTIVENESS

COMPREHENSIVE SEXUALITY EDUCATION

PROGRAMME

Building block pedagogical

approach over several years

Integrated into the curriculum

Scaled-up in schools and rolled

out nationally

Cost-savings and improvements in

young people’s health outcomes, including reductions in unintended pregnancy, HIV

infections and other STIs

Youth-friendly SRH

service provision

Recommendations

1. Investing in SE programmes to improve sexual health should be seriously considered.

2. For optimal resource-use, the following characteristics should be prioritised:

1. Compulsory & intra-curricular with full uptake2. Scaled-up (national / state coverage)3. Delivered in conjunction with youth-friendly SRH services

3. Extra-curricula or voluntary programmes not cost-efficient May be important stepping stones in sensitive contexts

4. Take into account that comprehensive SE programmes also have large non-health benefits

5. Advocacy and public education are necessary cost components of SE programmes and should be included in budget plans

THANK YOU

Executive Summary available online

Full report also available shortly

www.unesco.org/aidsaids@unesco.org