- Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
Free primary and secondary school education policies in Kenya.
Free primary school was first introduced in Kenya in the 1970’s and was abolished in 1988 with the advent of the World bank structural adjustment plan to ease financial burden on the public education system. With the SAP – it meant that while the government provided the teachers and classrooms, the parents had to take up the burden on paying the fees, buying the books and uniform. This cost of education was associated with low enrolment, high dropouts, grade repetition, low completion and poor transition rates to high school. In 2003, the government reinstituted the FPE. The thrust of the FPE was ‘equity and socio economic agenda’ essentially aimed at narrowing the gaps of inequality in the country. While this resulted in increased enrolment and completion, the transition rate from primary to secondary schools has remained low, with only less than 50% of primary school graduates entering secondary school. As a consequence, the government is in the process of instituting a free secondary school education policy (2013)(albeit with great resistance). This has not picked up uniformly and provides a good opportunity to conduct a natural experiment.
I think that this free secondary school education policy has strong health implications particularly within my area of interest, which is adolescent sexual reproductive health and psychosocial wellbeing. Education is itself a social determinant of health. Higher educational attainment can play a significant role in shaping employment opportunities, it can also increase the capacity for better decision making regarding one’s health, and provide scope for increasing social and personal resources that are vital for physical and mental health.
In Sub-Saharan Africa, women account for over two-thirds of the HIV infection. Educating adolescent girls reduces the risk of HIV infection by empowering them to assert their sexual and reproductive rights. They are more likely to know how HIV is transmitted and that using condoms can reduce the risk of transmission. It is estimated that educating girls could also have prevented the 260,000 new HIV infections among children, as the vast majority of these children contract the virus during pregnancy or delivery, or when breastfed by HIV-positive mothers.
- Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
Adolescent girls are especially vulnerable to dropping out of school and also not transitioning from primary to secondary school. Providing free education is an effective intervention for keeping girls in school. There is evidence to support that in most settings, higher levels of education are associated with lower HIV risk and higher HIV testing acceptance. Education also has countless other positive effects in the lives of girls, young women, and their communities as a whole.
- Specify the outcomes and populations you think most affected or least affected by the policy.
Adolescent girls are most affected. The health related outcomes I would look at are
a) Teenage pregnancy rates
b) Psychosocial functioning
c) Uptake of sexual reproductive preventive health services such as family planning, condoms, HIV testing
d) Changes in sexual risk taking
- Propose a study design to evaluate the policy.
Owing to the current resistance in implementing the free secondary school education policy and the implausibility of doing a randomized control trial, I could conduct a natural experiment. The different counties that are not implementing the policy would serve as the control group and the rest, which are implementing would be the “intervention group” and then do a difference in difference analysis.
Alternatively, I could potentially consider the implementation of the free secondary school education as an instrumental variable and conduct analysis around the time it was implemented in the counties that have implemented.
5. Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
The biggest challenge in drawing inferences is that there are other factors that affect school attendance that are not linked directly to waiving of the school fees, things like purchase of uniform and books and issues around access.
The free secondary education is most likely to benefit those from the lower wealth quartiles which is not representative of the general population and as such it may be difficult to extrapolate across the socio-economic gradient