The economics of school-based sexual and reproductive health education interventions

Bango, Funeka

The economics of school-based sexual and reproductive health education interventions

Thesis / Dissertation

2025

Publisher

University of Cape Town

Department

Department of Public Health and Family Medicine

Faculty

Faculty of Health Sciences

Abstract

Background: Promoting the sexual and reproductive health (SRH) of adolescent girls remains central to enabling their health, education, and economic prospects. Comprehensive school-based sexual and reproductive health education (SBSHE) has been recognised as a key strategy for promoting adolescent SRH. However, there is little evidence on the cost and cost- effectiveness of such programmes, limiting investment and priority-setting decisions. Methods: The thesis aimed to understand the economic costs of adolescent sexual and reproductive health services and to evaluate the potential value of a school-based sexual and reproductive health education intervention targeted at adolescent girls in South Africa. A critical review was conducted to understand the methods for conducting community-based health promotion interventions similar to SBSHE interventions. The economic data was collected within a cluster randomised trial. The Goals for Girls trial assessed a sports-based comprehensive SBSHE intervention targeting adolescent girls aged 14 to 17 compared to usual practice. Intervention costs were estimated from a Department of Education provider perspective, using a mixed-method costing approach. The costs of averted basic and emergency intrapartum care were estimated at two levels of care from a Department of Health provider perspective. Subsequently, the economic burden of adolescent girl SRH services was described from a Department of Health provider perspective. In addition, the value of the intervention was assessed via a modelled cost-consequence analysis from a multi-sector perspective across a range of intermediate (% time in school, % pregnant, and % giving birth by five years) and final outcomes (life years and quality-adjusted life years) Results: The results of the critical review showed that the methodological quality of the included studies was good overall. However, the methods applied did not adequately address the methodological issues of conducting economic evaluation in community-based health promotion. The costs of a sports-based SBSHE intervention were $ 9.9 per learner per session and $69.43 per learner graduating (seven of ten sessions). Sensitivity analysis indicated that these costs were sensitive to learner participation rates. The mean cost per patient for vaginal delivery at a maternity obstetric unit and obstetric hospital was US$142.47 and US$557.49, respectively, compared to US$943.33 for a c-section. Clinical costs, including personnel, were the leading drivers of costs in both facilities. The estimated undiscounted cost of SRH services per learner over a five-year period was $289.66, with contraceptives and obstetric services accounting for 48% and 47%, respectively. The total societal costs of the comprehensive SBSHE intervention were $447.07, while life years and quality-adjusted life years were estimated at 4.9 and 4.4, respectively. In scenario analysis, increasing levels of abstinence or contraceptives both improved biological outcomes, although the latter generated significantly higher contraceptive costs. One-way sensitivity analyses revealed that changes in the discount rate and the utilisation of the intervention had the most impact on societal costs. Conclusion: The findings from this thesis are significant for promoting ASRH in South Africa. The findings can contribute to decision-making for comprehensive SBSHE interventions. Including a multisector perspective supports transparency and can foster collaboration across sectors.