Sex and the Classroom: Can a Cash Transfer Program for Schooling decrease HIV infections?

Transcription

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 Education as a Social Vaccine for HIV 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).

3 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: 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%).

4 Income, Schooling, and HIV Risk 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. A novel intervention specifically designed to identify causal links between schooling and HIV (as well as income and HIV). To our knowledge, this is the first study to causally link a schooling CCT with detailed sexual behavior and Biomarker data for STIs. In the process, we also ended up designing an experiment that also answers some important CCT design questions, not adequately studied to date: Conditionality Elasticity of outcomes to benefit level Identity of the recipient

5 ZOMBA CASH TRANSFER PROGRAM: SAMPLING AND SURVEY DESIGN

6 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.

7 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, AND 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:

8 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

9 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.).

10 Additional data collection instruments School Census (2008); Biomarker data on HIV, HSV-2, and syphilis (50% random sub-sample in 2009 & full sample in 2010); Learning assessment in mathematics, reading comprehension, and life skills (2010). HH time use and labor market modules (2010 & 2012) ECD outcomes for children of the study sample (2010 & 2012).

11 ZOMBA CASH TRANSFER PROGRAM: STUDY DESIGN

12 Zomba Cash Transfer Research Design Malawi Research Design: Baseline Dropouts (N=890) Conditional (N=46) T1 CCT Treatment EAs (N=88) T2 Unconditional (N=27) T1 CCT T2a S2 T2b S2 Baseline Schoolgirls Within- Uncon- Within- (N=2,915) CCT village ditional village control CT control T1 Only (N=15) T1 CCT S2 Withinvillage control Control EAs (N=88) C1 Pure control C2 Pure control Household transfer randomized at EA level EA treatment saturation randomized Individual transfer randomized at individual level

13 Zomba Cash Transfer Research Design Malawi Research Design: Baseline Dropouts (N=890) Conditional (N=46) T1 CCT Treatment EAs (N=88) T2 Unconditional (N=27) T1 CCT T2a S2 T2b S2 Baseline Schoolgirls Within- Uncon- Within- (N=2,915) CCT village ditional village control CT control T1 Only (N=15) T1 CCT S2 Withinvillage control Control EAs (N=88) C1 Pure control C2 Pure control Household transfer randomized at EA level EA treatment saturation randomized Individual transfer randomized at individual level

14 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.

15 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 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).

16 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. UCT recipients receive their transfers by only showing up.

17 RESULTS: BALANCE AND ATTRITION

18 Attrition SCHOOL Conditional Unconditional ALL No S2 T2a-T2b Dropouts GIRL SG SG =1 if Treatment Girl (0.009) (0.009) (0.011) (0.020) (0.013) (0.012) =1 if Conditional Schoolgirl (0.013) =1 if Unconditional Schoolgirl (0.015) control mean 0.932*** 0.931*** 0.941*** 0.941*** 0.899*** 0.941*** 0.931*** (0.005) (0.006) (0.007) (0.007) (0.013) (0.007) (0.006) Number of observations 3,805 3,176 2,286 2, ,003 2,893 * significant at 90%, **significant at 95%, *** significant at 99. EA-clustered standard errors in parentheses to reflect the design effect.

19 RESULTS: SCHOOLING IMPACTS

20 One-year impact on school enrolment (selfreported) ALL CCT UCT CCT vs. UCT Treatment 0.045*** 0.039** 0.055*** 0.055*** (0.015) (0.017) (0.019) (0.019) Conditional Treatment (0.020) Constant *** *** *** *** (0.011) (0.011) (0.011) (0.011) Number of observations 2,087 1,832 1,618 2,087 note: *** p<0.01, ** p<0.05, * p<0.1

21 One-year impact on school attendance (reported by teacher: attended regularly at least one term) ALL CCT UCT CCT vs. UCT Treatment 0.040*** 0.041** 0.040** 0.040** (0.014) (0.017) (0.017) (0.017) Conditional Treatment (0.019) Constant 0.893*** 0.893*** 0.893*** 0.893*** (0.010) (0.010) (0.010) (0.010) Number of observations 2,087 1,832 1,618 2,087

22 One-year impact on school attendance (reported by teacher: attended regularly every term) ALL CCT UCT CCT vs. UCT Treatment 0.059*** 0.066** 0.047* 0.047* (0.022) (0.027) (0.028) (0.028) Conditional Treatment (0.033) Constant 0.791*** 0.791*** 0.791*** 0.791*** (0.015) (0.015) (0.015) (0.015) Number of observations 2,087 1,832 1,618 2,087 note: *** p<0.01, ** p<0.05, * p<0.1

23 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. We cannot address the schooling/hiv causal link!

24 Marriage and schooling status by treatment status after one year Control CCT UCT Ever married Never married and NOT attending school regularly Never married and attending school regularly TOTAL * Each cell represents a (column) percentage. Not for citation without explicit permission from the authors. 24

25 Marriage and schooling status by treatment status after one year Control CCT UCT Ever married Never married and NOT attending school regularly Never married and attending school regularly TOTAL * Each cell represents a (column) percentage. Not for citation without explicit permission from the authors. 25

26 Treatment effects on marriage (and pregnancy) UCT practically eliminated marriage (and pregnancy) among adolescent girls, while CCT had no effect. The findings are consistent with the condition being costly for the adolescent girl. Mental health outcomes are significantly improved among UCT compared with CCT (Baird et al., 2010).

27 ONE YEAR IMPACTS: SEXUAL BEHAVIOR

28 One-year impact on sexual activity (extensive margin) Never had sex Number of partners ever treatment_year * * (0.083) (0.083) year *** 0.170*** (0.000) (0.000) constant (control mean) 0.791*** 0.269*** (0.000) (0.000) Number of observations 4,306 4,306 note: *** p<0.01, ** p<0.05, * p<0.1 28

29 One-year impact on sexual activity (intensive margin) treatment_year ** * * (0.435) (0.047) (0.066) (0.057) year *** *** (0.002) (0.110) (0.279) (0.002) control mean at baseline 0.322*** 0.154*** 0.818*** 3.097*** (0.000) (0.000) (0.000) (0.000) Number of observations note: *** p<0.01, ** p<0.05, * p<0.1 never used condoms weekly sex older partner gift from partner 29

30 Summary of impacts on sexual behavior Program delayed the onset of sexual activity for both and decreased the number of lifetime sexual partners. There was also a reduction in risky sexual behaviors among those sexually active in both rounds. Finally, gifts received from sexual partners declined significantly consistent with the decline in the frequency of sexual activity and age of partner.

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

32 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 (Refusal rate: 3%, attrition rate: 1%) Rapid tests for HIV, HSV-2, and Syphilis. Prevalence among control in Round 2: HIV prevalence rate: 3.0% HSV-2 prevalence rate: 3.1% Syphilis prevalence rate among controls: 0.7%

33 Program impacts on prevalence of HIV HIV HSV-2 HIV HSV-2 HIV HSV-2 Treatment * *** * *** * *** (0.010) (0.008) (0.011) (0.016) (0.017) (0.026) Control mean in Round *** 0.031*** 0.029*** 0.067*** 0.046*** 0.097*** note: *** p<0.01, ** p<0.05, * p<0.1 ALL 16 and above 16 and above and high propensity to dropout (0.008) (0.007) (0.009) (0.016) (0.013) (0.025)

34 HSV-2 Prevalence by age and treatment status 12% 10% 8% 6% 4% Control Treatment 2% 0% 15 and under and older TOTAL

35 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. Again, the impact of the transfers conditional on schooling is identical to that of unconditional transfers.

36 Program makes a difference in HSV-2 status regardless of schooling status at follow-up Control Treatment Total NOT regularly attend school 9.7% 0.0% 5.6% Regularly attend school 1.5% 1.3% 1.4% Total 3.1% 1.1% 2.1%

37 Program makes a difference in HSV-2 status regardless of schooling status at follow-up Control Treatment Total NOT regularly attend school 9.7% 0.0% 5.6% Regularly attend school 1.5% 1.3% 1.4% Total 3.1% 1.1% 2.1%

38 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 a HH with an adolescent girl causes her risk of STI infection to decline. The impact is not due to improvements in: HIV testing, or knowledge of HIV/AIDS.

39 Conclusions Are we just delaying the 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.

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

41 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 find declines in the onset of sexual activity among program beneficiaries, and declines in risky behavior among the sexually active. 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.