Malawi: The Zomba Cash Experiment - Does Paying Girls’ School Fees Reduce Their Risk of HIV Infection?

How to slow the spread of HIV infection and other sexually transmittable infections is something that countries in sub-Saharan Africa, in particular, have struggled with. The study took place in Malawi, a small, poor country in southern Africa with a population of almost 14 million in 2007, when the study was launched. Teenage pregnancy in Malawi was (and still is) common, with the adolescent fertility rate at 133 per 1,000 women aged 15-19, according to World Bank 2010 figures, and girls often cite pregnancy as the main reason for dropping out of school and getting married at an early age. This study sought to measure the impact of providing cash transfers to school girls on staying in school, early marriage, having children and the likelihood of getting infected with HIV or other sexually transmitted infections.

 

Research area:

Health- HIV/AIDS

Country:

Zomba District, Malawi

Evaluation Sample:

 3,796 girls at baseline -- 2,907 girls in school and 889  dropouts

Intervention Timeline:

2008-2009 (Completed)

Intervention:

Cash payments

Researchers:

Sarah Baird, George Washington University; 
Ephraim Chirwa, University of Malawi; 
Craig McIntosh, University of California at San Diego;  
Berk Ozler, the World Bank

Partners:

Bill & Melinda Gates Foundation,

 

Challenge
This study took place in the country’s southern Zomba district, which has high levels of poverty, low school enrollment, and high HIV prevalence, even in comparison to the rest of the country. In 2007, the prevalence of HIV infection among young women was 9.1 percent, compared with 2.1 percent in young men.

Intervention
The program provided two types of cash transfers -- conditional or unconditional -- to girls in school and recent dropouts over two years.  Participants in both intervention groups were randomly assigned by a lottery to receive monthly payments ranging from the equivalent of US$1 to US$5, while their parents were independently assigned to receive between US$4 and US$10. Those in the conditional cash transfer group received the money if they were in school at least 80 percent of the time; those in the unconditional cash transfer group received the money regardless. Secondary school fees for girls in the conditional cash transfer group were paid directly to the school. Girls were eligible if they were between the ages of 13 and 22 and unmarried.

Evaluation
There were 1,225 school-aged girls, and their parents, in the cash transfer groups, and 2,571 girls in the control group.

Results
The cash transfers had effects on a broad range of important outcomes related to girls schooling and health.  The cash transfers, whether conditional or unconditional, decreased the prevalence of HIV and Herpes Simplex Virus (HSV-2) infection 18 months after the program’s start by 64 percent and 76 percent, respectively. This reduction, however, was only among girls who were enrolled in school when the baseline survey was carried out around the end of 2007, before the program was launched. The effects are supported by changes in self-reported sexual behavior: individuals in the intervention groups chose younger partners, and sexual activity was less frequent with those partners. The impact did not vary by the size of the transfer. The findings suggest that financially empowering school-age girls and their families can have substantial effects on their sexual and reproductive health. There was no impact on girls were reported that they were no longer at school when surveyed at baseline. Girls in both cash transfer groups also were less likely to drop out of school than in the control group.

For girls who had dropped out at baseline, the cash transfers did however reduce their rate of early marriage and pregnancy, when compared with girls who were in school at the start of the study. It also increased the likelihood they would return to school, when compared with the control group. The results underscore that when targeting teengers, setting up a school-based program would end up excluding more vulnerable groups that could otherwise benefit. Follow-up work continues to be done to assess the long-term impacts.