1. Sex and the Classroom: Can a Cash Transfer Program for Schooling decrease HIV infections? Sarah Baird, George Washington University Craig McIntosh, UCSD Berk Özler, World Bank

2. Outline Background & motivation  CCT Programs  Education, Sexual Behavior, and HIV Risk  Cash transfers, Sexual Behavior, and HIV Risk The Zomba Cash Transfer Program (ZCTP)  Malawi  Sampling and survey design  Research design and implementation Findings  Balance at baseline and attrition in panel data  One-year impacts on school attendance, sexual behavior, and risk of HIV and HSV-2 infection. Discussion and Conclusions

3. BACKGROUND AND MOTIVATION

4. Conditional Cash Transfer Programs As of 2007, 24 countries around the world had some type of a Conditional Cash Transfer program (CCT) in place, with many others planning or piloting one (WB PRR, 2009):  CCTs can be an important component of social protection policy,  There is considerable evidence that they improved the lives of poor people.  As UPE becomes common in Africa, next step in promotion of primary education is likely to be CCTs.

5. Conditional Cash Transfer Programs Four policy questions for our study in Malawi: 1. What is the impact of CCT programs on schooling in SSA? 2. How should we “tweak” their design for optimal effect?  Conditionality (‘income’ vs. ‘price’ effects).  Literature based on simulations (Bourguignon, Ferreira, and Leite, 2003; Todd and Wolpin, 2006) or on glitches in implementation (De Brauw and Hoddinot, 2007; Schady and Araujo, 2008).  Elasticity of outcomes to variation in transfer size  Filmer & Schady (2008) discontinuity design in Cambodia.  Identity of the recipient  Berry (2008) experiment from India randomizes benefit to parent or child. 3. Are non-beneficiaries effected by CCTs (spillovers)? 1. Angelucci & de Giorgi, 2008. 4. What other outcomes can schooling CCTs impact (sexual behavior, HIV, marriage)? 1. Duflo et al. (2006)

6. Conditional Cash Transfer Programs Four policy questions for the study 1. What is the impact of CCT programs on schooling in SSA? 2. How should we “tweak” their design for optimal effect?  Conditionality (‘income’ vs. ‘price’ effects).  Literature based on simulations (Bourguignon, Ferreira, and Leite, 2003; Todd and Wolpin, 2006) or on glitches in implementation (De Brauw and Hoddinot, 2007; Schady and Araujo, 2008).  Elasticity of outcomes to variation in transfer size  Filmer & Schady (2008) discontinuity design in Cambodia.  Identity of the recipient  Berry (2008) experiment from India randomizes benefit to parent or child. 3. Are non-beneficiaries effected by CCTs (spillovers)? 1. Angelucci & de Giorgi, 2008. 4. What other outcomes can schooling CCTs impact (sexual behavior, HIV, marriage)? 1. Duflo et al. (2006)

7. Education, Sexual Behavior, HIV risk There is a much evidence showing an association between school attendance, sexual behavior, and HIV prevalence (Jukes, 2008; Beegle & Özler, 2007). Possible pathways include: 1. Incentives to avoid pregnancy, and 2. Smaller sexual networks. However, this correlation could be driven by various factors: ‘ good kids’ valuation/expectations of the future quality of parenting There is only one study that points to a possible causal link between school attendance and sexual behavior (Duflo et. al., 2006).

8. Cash Transfers, Sexual Behavior, HIV risk There may also be an ‘income effect’ on the sexual behavior of young women associated with (conditional) cash transfer programs. Large literature on transactional sex, a lot of which focuses on young women: young women  Luke (2006); Dupas (2009); Poulin (2007), inter alia. In our data, at baseline, approximately 25% of the young women who are sexually active stated that they started their relationship because they “needed his assistance” or “wanted gifts/money”.  Second only to “love” (28%).

9. Income, Schooling, and HIV Risk Given that CCT programs are about to become more commonplace in SSA, where HIV is a problem among school- aged girls and young women, we decided to evaluate the impact of a CCT/UCT intervention on the sexual behavior of its young beneficiaries. Zomba Cash Transfer Program (ZCTP) is a two-year randomized intervention that provides cash transfers to current schoolgirls (and young women who have recently dropped out of school) to stay in (and return to) school. Through the use of a unique research design, we hope to contribute to the literature by filling the knowledge gap mentioned above – the understanding of all of which is critical to inform effective policy interventions.

10. Conclusions (preview) We see sizeable ONE-YEAR impacts of the program on:  school attendance.  onset of sexual activity and risky sexual behavior.  on the prevalence of HIV and HSV-2.  This is the first study to causally link a schooling CCT with detailed sexual behavior and Biomarker data for STIs. In this talk, I will discuss three main topics: 1. Conditional and unconditional cash transfer programs for young women reduce their subsequent risk of HIV and HSV-2 infection. 2. This reduction in HIV and HSV-2 infection risk is consistent with the program’s causal impact on the delayed onset of sexual activity, as well as the reduction in risky sexual behavior. 3. We cannot (yet) conclusively answer the more academic question of the causal relationship between increased school attendance and HIV risk.

11. ZOMBA CASH TRANSFER PROGRAM: SAMPLING AND SURVEY DESIGN

12. Sampling and Survey Design 3,805 young women were sampled from 176 enumeration areas (EAs) in Zomba, a district in Southern Malawi. EAs randomly drawn from three strata: urban, near rural, and far rural. All households in each sampled EA were listed using two forms, then the sample selected from the pool of eligible young women.

13. Sampling and Survey Design Eligibility into the program was defined as follows:  Eligible dropouts: unmarried girls and young women, aged 13-22, already out of school at baseline, ANDgirls  Eligible schoolgirls: unmarried girls and young women, aged 13-22, who can return to Standard 7-Form 4, enrolled in school at the time of their first interview. Otherwise, there was no targeting of any kind. The survey designed for the impact evaluation consists of two parts:

14. Sampling and Survey Design Part I is administered to the HH head, and collects information on the following:  household roster,  dwelling characteristics,  household assets and durables,  consumption (food and non-food),  household access to safety nets & credit, and  shocks (economic, health, and otherwise) experienced by the household  mortality

15. Sampling and Survey Design Part II is administered to the core respondent, who provides further information about her:  family background,  Education, labor market participation, time allocation  health and fertility,  dating patterns, detailed sexual behavior at the partnership level,  knowledge of HIV/AIDS,  social networks,  own consumption of girl-specific goods (soaps, mobile phone airtime, clothing, braids, handbags, etc.).

16. Additional data collection instruments School Census (2008); Biomarker data on HIV, HSV-2, and syphilis (2009 & 2010); Learning assessment in mathematics, reading comprehension, and life skills (2010). Biomarker data on malaria and nutrition (2010) HH time use and labor market modules (2010 & 2012) ECD outcomes for children (2012).

17. ZOMBA CASH TRANSFER PROGRAM: STUDY DESIGN

18. Zomba Cash Transfer Research Design

19. Zomba Cash Transfer Program Design Each transfer offer has two main components:  A transfer to the parents/guardians that varies across EAs,  A transfer to the girl that varies within each EA.  In addition, if the CCT recipient is attending secondary school, then a transfer equal to the school fee is made directly to the school each term. Transfer amounts for the parents range from $4 to $10 per month. Transfer amounts for the girls range from $1 to $5 per month.

20. Offer Letters Conditional Transfers The Zomba Cash Transfer Program (ZCTP) with funding from the World Bank would like to offer you, ________________, a cash transfer to help you and your family with the burdens of school attendance for the 2009 school year. By accepting this offer, in return for going to school you will be given: You are receiving this money in order to help you return to school or stay in school. In order to receive this money you MUST attend school at least 80% of the days for which your school is in session. Unconditonal transfers The Zomba Cash Transfer Program (ZCTP), with funding from the World Bank, would like to offer you, ________________, a cash transfer to help you and your family. By accepting this offer you will be given: This monthly transfer amounts specified above are given to you as a result of a lottery. You are not required to do anything more to receive this money. You will receive this money for 10 months between February and November, 2009.

21. Zomba Cash Transfer Program Implementation During December 2007 and January 2008, offers were made to the 1,193 randomly selected young women (only one refused to participate and 24 were not found). In February 2008, the first of 10 monthly cash transfers for the 2008 school year were made. The program continues in 2009.10 monthly cash transfers In its first year, the program disbursed US$120,000, of which more than US$100,000 were transferred directly to beneficiaries and their parents, with the rest of the funds going towards school fees.  The average total transfer of $10 is approximately 15% of monthly household expenditures. Our range is 8%-24%.  The range in the ROW is 2-3% (Cambodia) to 22% (Mexico).

22. Zomba Cash Transfer Program Implementation For CCT recipients, attendance is checked monthly at each program school using a combination of physical checks and phone calls (with random spot checks). Transfers for the first month are free. For CCT recipients, the payment for the next month is withheld if attendance is below 75%. However, the girl remains in the program. CT recipients receive their transfers by only showing up.

23. RESULTS: BALANCE AND ATTRITION

24. Baseline Means and Attrition Dropouts at baseline are very different than schoolgirls. They are…  older,  have lower school attainment,  much more likely to be sexually active and to have started childbearing,  from poorer families, etc.

25. Baseline Means

26. Attrition

27. RESULTS: SCHOOLING IMPACTS

28. One-year impact on self reported school enrolment

31. One-year impact on school attendance reported by teacher.

32. Summary of schooling impacts The program had large impacts on school enrolment and attendance for both baseline dropouts and baseline schoolgirls. The impact of the CCT program on schooling outcomes for baseline schoolgirls is indistinguishable than that for the UCT program after one year  “income effect” dominates the “price effect”.

33. ONE YEAR IMPACTS: SEXUAL BEHAVIOR

34. 34 One-year impact on sexual activity

35. One year impact on risky sexual activity

37. Summary of impacts on sexual behavior Program delayed the onset of sexual activity for both baseline dropouts and baseline schoolgirls, but at different margins. It also decreased the number of lifetime sexual partners for both groups. However, the reduction in risky sexual behaviors, such as frequency of sex and age of partner, was only observed among baseline schoolgirls.  This, despite large impacts on marriage and pregnancy among baseline dropouts Finally, gifts received from sexual partners declined significantly – consistent with the decline in the frequency of sexual activity and age of partner.

38. ONE YEAR IMPACTS: BIOMARKER DATA ON HIV AND HSV-2

39. Biomarker data for STIs Self-reported data on sexual behavior may be unreliable:  Understatement of sexual activity will cause attenuation bias,  If correlated with treatment status, misreporting will bias the impact estimates. Voluntary Counseling and Testing (VCT) teams visited a randomly selected 50% of the panel sample between June- September 2009. (Refusal rate: 3%, attrition rate: 1%) Voluntary Counseling and Testing (VCT) Rapid tests for HIV, HSV-2, and Syphilis. Prevalence among control (baseline dropout/baseline schoolgirl)  HIV prevalence rate: 3.8% (8.2% / 3.0%)  HSV-2 prevalence rate: 4.0% (9.2% / 3.1%)  Syphilis prevalence rate among controls: 0.8% (1.0% / 0.7%)

40. Program impacts on prevalence of HIV

41. Program impacts on prevalence of HSV-2

43. Summary of impacts on HIV and HSV-2 The program decreased the prevalence of each of HIV and HSV-2 by more than 60% among baseline schoolgirls.  The program seems to have stopped the progression of these STIs in their tracks. The impact of the transfers conditional on schooling is identical to that of unconditional transfers. Despite significant declines in sexual activity, marriage, and childbearing, the program did not affect the prevalence of HIV or HSV-2 among baseline dropouts.

44. Does an exogenous increase in schooling cause a decrease in risk of HIV infection? After one year, our findings do not allow us to answer this question:  Our initial assumption was that conditionality would be a good instrument for schooling.  We do not see any schooling differences between conditional and unconditional.  Nor do we see any HIV/HSV-2 etc. differences.  In our case, conditionality is not a good instrument, because it is not correlated with schooling outcomes.

45. HSV-2 prevalence by treatment and schooling status Schooling/marital status by treatment status HSV-2 prevalence

46. Transfers make a difference regardless of schooling status

49. Summary of pathways explaining program impacts We cannot conclusively state that keeping girls in school causes a decline in the risk of HIV/HSV-2 infections. An exogenous infusion of cash to the HH of a school-aged female causes risk of infection to decline among baseline schoolgirls – conditional on schooling status in follow-up. The impact is not due to improvements in:  HIV testing,  knowledge of HIV/AIDS, or  mental health.

50. Conclusions Are we just delaying the inevitable?inevitable  It remains to be seen whether the longer-term impacts of the program will be as strong as the short-term impacts described in this paper.

51. Conclusions This is the first study that causally links a schooling (conditional) cash transfer program to sexual biomarker data. The ZCTP has led to large increases in school attendance among young women after only one year. We also find declines in the onset of sexual activity among all program beneficiaries, and declines in risky sexual activity among baseline schoolgirls. We also find that the program led to significant declines in risk of HIV and HSV-2 infection. No evidence yet that keeping girls in school, as opposed to an exogenous income shock, is the reason for the decline in HIV risk. The program effect was similar regardless of schooling status in follow-up.

52. End of presentation

53. HIV Generally, an age mismatch exists between teenage girls and their partners. This generates HIV rates among teenage girls which are often substantially higher than their male age-mates, because they are partnering with older men.substantially higher  HIV prevalence among 15-24 old women is 9.1%, compared to 2.1% among males of the same age

54. Education and HIV

59. Time HIV prevalence T=0T=2 (end of CCT)T=4 0.05 0.08 0.10 Hypothetical HIV incidence by treatment status Treatment Control