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 materialsTeacher salaries TrainingTeacher materials OperationsTraining AdvocacyOperations 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 years Duration 3 years / 27 lessons

Nigeria – Implementation Costs 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 students Concerns 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 provinces, geographically spread out Age group: years Duration: 1 semester / 15 lessons Context: sexuality is a sensitive issue

Kenya – Implementation Costs Cost per learner : $50 in 2009 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 Cost per learner : Economic: $13.50 Budget cost: $2.50

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) Diagnosed HIV infections per year

Cost-effectiveness analysis (exploratory) SE Programme costs (US$) us $5.6 m Observed reduced number of HIV-infections in Estonia 2001 – ,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 peoples 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 uptake 2. 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