Sensitivity of sexuality education and its effect on costs
The sexuality education programs in Nigeria, Kenya, Indonesia and India have been implemented in contexts where sexuality, and therefore sexuality education, is a sensitive issue. In contrast, sexuality education is not a sensitive issue in Estonia or the Netherlands. The sensitivity of the topic has important consequences for how and the pace at which sexuality education programs can be introduced, their character (comprehensive versus abstinence-only), and the scale at which they can be carried out. This has an effect on costs and potential impact. In Nigeria and India, sexuality education programs initially came to a halt because of socio-cultural opposition, thereby causing years of delay and related loss of investments. In Nigeria, the initial comprehensive program had to be reduced: all elements related to actual sexual and preventive behavior, including contraception and condoms were removed. The programs in Orissa State, India (as planned) and Estonia are good examples of comprehensive, integrated and fully scaled up sexuality education programs, and these hold important lessons for other countries that wish to achieve similar scales and related impact. The programs in Kenya and Indonesia are NGO-initiated, also in response to the sensitivity of sexuality education and the relative hesitance of national governments to address the topic. These programs are extra-curricular, voluntary and seem to be constrained in the coverage they can achieve. However, they can be an important stepping stone toward the development of national sexuality education programs. All sexuality education programs in all countries require careful planning and a wide variety of advocacy and public education activities to achieve their implementation.
Costs of sexuality education in relation to program design
The programs in Nigeria, India, Estonia and the Netherlands appear to be relatively inexpensive in terms of cost per student reached, costing approximately US$7, US$14, US$33 and US$33, respectively. These programs are all intra-curricular and implemented on a large scale (annually reaching 25,000 to 250,000 students), which reduces costs per student of national and state-level activities, such as program development, management and advocacy. Also important is the mandatory student enrolment in these programs, resulting in an almost comprehensive coverage of enrolled students per school. This reduces school-level costs per student, such as teachers’ salaries (in all programs, teacher salaries are a major cost component). On this basis, we conclude that intra-curricular sexuality education programs are most efficient, and we refer to the program in Estonia and the planned program in India as best examples in this respect. The sexuality education program in the Netherlands is difficult to interpret in this context, because the program is relatively short, and functions as an addition to a more elaborate sexuality education at primary school, and in biology lessons in secondary school.
The sexuality education programs in Kenya and Indonesia appear to be relatively costly, at US$50 and US$160 per student reached, respectively. These programs are currently in the pilot phase, geographically spread out, and initiated by international and national NGOs. At this stage, these programs have limited coverage – annually reaching between 1,800 and 7,300 students respectively – and carry high operations (salary and travel) costs. Cost per student would diminish considerably if the programs were scaled up beyond the pilot phase. However, both programs are also extra-curricular and thus voluntary, so the potential of such programs to achieve widespread coverage is questionable. Integration of the program in the regular curriculum would be a possible strategy to meet that concern. However, such programs may sometimes be the only available option in a country where sexuality education is a sensitive issue, and this could be a reason to accept their relatively high cost during a period of transition.
In addition, the sexuality education programs in Kenya and Indonesia are both computer-based, and this also makes them relatively costly because it necessarily reduces class size (schools have a limited number of computers). Uptake in schools – between 42 students per class in Indonesia and 44 students in Kenya – is constrained as a result. This hinders the scale-up of a program across and within schools, and its integration into the regular curriculum.
Teacher salaries are a major cost component in all programs, and class size strongly influences cost per student reached. In Nigeria, classes for the sexuality education lessons usually have 75 to 150 students, while classes are much smaller in, for example, India (around 40 students) and Estonia (around 18 students). While large classes are thus favorable for cost purposes, the quality of implementation in such classes will likely be compromised. Even when specific strategies are developed in sexuality education to cope with large classes, as in Nigeria, sexuality education typically requires interactive teaching methods with high levels of student involvement, which can hardly be realized in overcrowded classes.
Advocacy costs are a significant cost component in all countries, ranging between 4 per cent of total costs in Kenya to 13 per cent of total costs in Indonesia. The only exception was the Netherlands, where advocacy costs were 0.1 per cent. Therefore, advocacy costs seem to be highest where there is most resistance towards sexuality education. Advocacy costs are incurred not only in the development phase of the program but also throughout its implementation, and reflect the sensitive nature of sexuality education curricula in a country. Advocacy includes a broad scope of activities including political lobbying, media activities, stakeholder meetings, working groups, sensitization meetings for school staff, parents, and health care providers, and exhibitions.
Programs examined in this study differ in the way they were developed and/or adapted. Development costs in Estonia were low because of low salary levels during the first years of independence, and programs did not require intensive advocacy activities. Programs in Kenya and Indonesia were adapted from a similar program in Uganda and had important savings in the development costs of the original software. However, the adaptation process was still relatively costly as these computer-based programs required expensive software adaptation activities. Moreover, the adaptation was supported by an international organization, which added extra costs. The adaptation costs in these countries constituted between 15 per cent and 24 per cent of total costs. Development and updating costs ranged between 1 per cent and 11 per cent of total costs in the other study countries. Finally, the proportion of development or adaptation costs is also dependent on the number of years a program has been implemented in a country.
The duration of the programs varies. The number of learning hours per student over the duration of the curriculum varies between 11 hours in the Netherlands (which is additional to an extensive foundation established at the primary level and to biology classes), to some 40 hours in most other countries. Obviously, this is closely related to the cost per student reached. The number of learning hours also determines the impact of a program – international standards recommend at least 12 to 20 lessons (typically lasting 45 minutes to an hour) over several years.
Budget impact of sexuality education programs
The budget impact of implementing sexuality education programs is not equal to the economic costs as presented in this study. Teacher salaries are included as economic costs in this study but are a regular expense of the Ministry of Education, irrespective of the implementation of sexuality education programs. In the implementation of a sexuality education program, these salaries would therefore not incur additional budgetary outlays. This study shows that budgetary outlays are less than 25 per cent of the economic costs of sexuality education programs (with the exception of Kenya and Indonesia) and, as estimated in this study, range from US$0.60 in Nigeria to US$10 in the Netherlands. However, it should be noted that the introduction of a sexuality education program in the curriculum could come at the expense of not teaching other courses, which is an opportunity cost.
Efficient pathways to scaling up programs
In order to assess the cost implications of scaling up sexuality education programs, we defined several different scenarios and, based on these, we recommend the most efficient pathways to greater sexuality education coverage. The most efficient strategy appears to be to start first expanding program uptake in schools where the program is currently being implemented, for example, by making the curriculum mandatory, before introducing the program to new schools or districts. Again, this is because teacher salaries constitute a major cost component and are reduced by covering more students per class or school. The ideal strategy from the efficiency point of view is to maximize uptake in schools and the coverage of schools in a country.
Limitations
A number of limitations were faced in conducting the study. First, information on the actual number of learners reached was not always available, especially in the larger intra-curricular programs. In those instances, program coverage was calculated on the basis of secondary sources, e.g. student materials used or teachers trained. Second, it is not always clear where sexuality education programs begin and end. Sexuality education programs are sometimes part of wider life-skills programs, as in Estonia. Since general life skills, such as decision-making competence, serve more purposes than only promoting healthy sexual behavior, it is then somewhat arbitrary to determine which part of the program should be labeled sexuality education. Third, it was not always possible to make detailed assessments of costs. Some programs, such as curricula in Estonia and the Netherlands, have existed for a long time, and financial records were not always available. In those instances, the analysis was based on gross estimates from program personnel.
This study only focuses on the costs of sexuality education programs. It does not answer several other very important questions, such as variation in the quality of different types of programs, nor does it address the important question of how to develop a sexuality education program and integrate it into existing curricula. This requires additional efforts beyond the scope of this study, which could result in a strategic document that outlines pathways, under different conditions, for successfully developing and integrating sexuality education in school curricula.