Sexual and reproductive health (SRH) programmes for young people have a high priority in many low- and middle-income countries (LMICs). However, little is known about the economic aspects of these programmes. More information is needed to support policymaking and to accelerate the implementation of these programmes. This multi-country PhD thesis provides new evidence on costs and cost-effectiveness of young people’s SRH programmes in resource-limited settings. The six research papers are intended for national healthcare policymakers and public health programme managers in LMICs, and personnel of international organizations supporting their work. The World Health Organization (WHO) recommends the simultaneous implementation of health promotion and healthcare services. This thesis focuses on economic evaluations of these two pillars in the context of young people’s SRH. It is organized in two thematic sections; first school-based sexuality education (SBSE) programmes, and second youth-friendly sexual and reproductive health (YFSRH) services.
PhD book of Dr Jari Kempers
This is a PhD thesis of Jari Kempers: Economic Analysis of Youth Sexual and Reproductive Health Programmes – a Multi-Country Study.
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Jari Kempers, health economist PhD
jari.kempers (a) Qalys.eu
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Kempers Jari. Economic Analysis of Youth Sexual and Reproductive Health Programmes – a Multi-Country Study. 2015. ISBN: 978-94-6259-771-6. http://www.Qalys.eu/PhD-Jari-Kempers
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School-based sexuality education programs
The first thematic section presents economic analyses of school-based sexuality education programmes. There are numerous SBSE implementation guidelines for policy makers and programme managers. However, they are often left in the dark on budget implications and efficient design of SBSE programmes. The thesis addresses this by providing cost analyses and -comparisons of six real-world SBSE programmes in India, Indonesia, Kenya, Nigeria, Estonia and the Netherlands, by identifying efficient SBSE programme types and conducting an exploratory cost-effectiveness analysis on one the programmes.
This thesis suggests that SBSE programmes are potentially cost-saving and cost-effective in their public health objective to reduce unintended pregnancies, STIs and HIV infections. However, these outcomes are dependent on programme characteristics and context. The thesis demonstrates that SBSE programmes can be produced at a low cost per student when implemented as large scale intra-curricular programmes. It recommends countries to invest in scalable comprehensive intra-curricular SBSE programme models, that have demonstrated their effectiveness in a similar context. Moreover, the thesis shows that a context where sexuality is a sensitive issue increases costs and reduces the potential impact of SBSE programmes. The opposition has consequences for how and the pace at which SBSE programmes can be introduced and scaled-up, and for the content of sexuality education, i.e. comprehensive versus abstinence-only. Advocacy plays a key role in the success of the implementation of SBSE programmes. Advocacy appears to be a significant cost component, throughout all implementation phases, in many SBSE programmes. Despite this, advocacy is often not budgeted. Therefore, the thesis advises policymakers and programme managers to consider advocacy as a necessary and continuous investment. Lastly, a combination of SBSE and YFSRH services appears to be particularly effective.
Youth-friendly sexual and reproductive health services
The second thematic section presents economic analyses of youth-friendly sexual and reproductive health services. Young people have different healthcare needs and preferences than adults or children. It is important that healthcare systems offer youth-friendly SRH services that are accessible, acceptable and appropriate for young people. However, there is no single YFSRH service package that suits every country. Each country has to define its own package according to epidemiological, social and economic circumstances. This thesis supports these efforts by providing new evidence on the costs of two YFSRH services programmes in Estonia and Moldova, and on the cost-effectiveness of the latter programme. These programmes were selected because former Soviet Union and Eastern European countries are one of the frontiers in developments in young people’s SRH.
The thesis demonstrates that YFSRH services can be produced at a relatively low cost per patient. However, there is no clear answer to whether or not the YFSRH services are cost-saving and cost-effective. This is highly dependable on epidemiological context, especially HIV, and quality of the services. Nevertheless, the thesis recommends countries to invest in YFSRH services, which are an essential part of efforts to improve young people’s SRH, and to implement them together with SBSE programmes. Four chapters of this thesis include young people’s SRH programmes in Estonia. The country has become an internationally recognized success story on scaling up and sustaining national young people’s SRH programmes, with simultaneously improved SRH outcomes. A policy analysis summarizes the factors that contributed to successful scale-up of Estonian youth clinic network (YCN). First, Estonia had a favourable social and political climate for offering YFSRH services. Second, there was a clearly demonstrated need for the services. Third, there is a national professional organization, Estonian Sexual Health Association (ESHA), coordinating and representing youth clinics (YCs). Fourth, personnel of ESHA and YC’s played an important active role in advocating YFSRH services to policymakers. Fifth, the YCs receive sustainable funding through the national health insurance system. Sixth, the recognition of the improvements would not have been possible without the development of national reporting and monitoring systems, and many studies and international publications.
Measurement and attribution of impacts of young people’s SRH programs
This thesis demonstrates challenges with and provides recommendations for, measurement and attribution of impacts of the young people’s SRH programmes. It identifies the following main challenges with assessing the impacts of SBSE programmes: First, the long duration of SBSE programmes makes the use of pre- and post-measurements difficult and lengthy. Second, comparable control groups do not exist. Especially with integrated SBSE programmes, which are usually implemented country- or state-wide. Third, reliable SRH outcome data is not available, or even if data is available the challenge with attribution remains. Fourth, there is a delay between sexuality education (SE) and start of sexual intercourse. At the beginning of the SE programme pupils are usually quite young and not sexually active. They become sexually active several years later, and only then the impact can be assessed. Impact of YFSRH services is a combined result of healthcare services and health promotion. The challenges with assessing of impacts of YCs’ health promotion activities are similar to SBSE programmes. Comparable control groups and reliable SRH impact data do not exist, and there may also be a delay between health promotion and sexual behaviour. Measuring and attributing impacts of YCs’ healthcare services is easier. YCs usually have records on provided SRH services, which can be used for quantifying primary impacts of the healthcare services.
Despite these challenges, the thesis argues that assessing the impact and cost-effectiveness of young people’s SRH programmes is possible. It makes the following recommendations: First, impact- and economic evaluations of young people’s SRH programmes should be combined and planned together in advance. Second, a case-control design is a recommended approach. This requires identification of a comparable control group, or dividing sites randomly into intervention and control groups. Third, base-line measurements should be collected in both groups before the intervention begins. Fourth, special attention should be paid to that data collection captures the information needed for cost-effectiveness analysis. Priority should be given to health outcomes, and if these are not available then behaviour change outcomes should be collected. Fifth, a follow-up period should be for several years. It is important that individuals can be tracked and followed up over time.
Comparability of economic evaluations of young people’s SRH programs
The literature review for this thesis shows that economic evaluations of young people’s SRH programmes are scarce. The results of identified studies are largely incomparable, because the programmes and their contexts, research objectives and used evaluation methods are different, and due to a lack of transparency in documentation as well. The literature review process revealed that there are numerous publications on the impact and effectiveness of young people’s SRH programmes. Yet, very few had any cost- or cost-effectiveness components. This is surprising, especially because financial constraints are one of the main bottlenecks of implementation of young people’s SRH programmes. Most of the impact-only studies measure behaviour intentions (knowledge, skills, attitude) or behaviour changes (abstinence, condom use, number of sex partners), which are much easier to obtain and less suitable for cost-effectiveness analyses than health outcomes (pregnancies, abortions, STIs and HIV infections). Most of the identified economic analyses are limited to only HIV infections (cost per averted HIV infection and/or cost per DALY). The choice is understandable because averted HIV infections create the highest cost savings.
The thesis makes the following suggestions for building an evidence base and improving comparability of economic evaluations of young people’s SRH programmes. First, efforts should be made to combine impact studies with economic evaluations. Second, more attention should be paid to the use of comparable methods and indicators in economic evaluations of SRH programmes. Third, the results of economic evaluations should be compared. Fourth, documentation of methods, data and sources of economic evaluations of SRH programmes should be improved. Transparent reporting will improve the comparability of economic evaluations in the future.
Finally, the thesis makes the following general recommendations for economic evaluations of young people’s SRH programmes. Economic analyses should always aim to support decision making. These should be designed to answer questions that decision-makers are dealing with, and analyses should focus only on issues that are relevant for policymaking. Especially with young people’s SRH programmes health economists need to balance urgency for action (programme implementation) with the long time required for the collection of better data (impact and cost). In the low- and middle-income country context, affordability is the primary and often the only economic criterion included in the decision making process. Therefore the sequence of questions that economic evaluations address should be: How much the programme cost? Does it create cost savings somewhere else? Is it cost-effective? Lastly, complex research results should be simplified and communicated to decision-makers in their language.