This presentation provides information about The Transfer Project and describes findings from a recent evaluation of the Kenya Cash Transfer Program for Orphans and Vulnerable Children.

1. Tia Palermo, Ph.D. & Amber Peterman, Ph.D.
UNICEF Office of Research—Innocenti
Research Seminar, Universita degli studi Firenze (DISEI)
May 2015

2. • Adolescence = critical juncture in life
 Transitions have implications for later education, health, poverty, autonomy,
intimate partner violence, HIV risk (among others).
• Early transitions in Africa
 In Africa, 41% women ages 20 to 24 were first married (or in union) before 18
(UNICEF 2011)
 Globally, 14 million children are born to girls aged 15 to 19 annually, > 91% in
low and middle income countries (Kennedy et al. 2011).
• Reviews of “What works” to prevent adolescent childbearing and & HIV in
low-middle income countries: social cash transfers (SCTs) are promising
interventions (McQueston et al. 2013; Pettifor et al. 2012)
 However, evidence is drawn from few, geographically and programmatically
diverse studies.
Motivation

3. • Who we are: Community of research, donor and implementing
partners
UNICEF, FAO, UNC-Chapel Hill, AIR, National Governments
• What we do: Provide rigorous evidence on of government-run
large-scale (unconditional) SCTs
• Why SCTs: Our work is premised on the knowledge that
Income poverty has highly damaging impacts on human
development
Cash empowers people living in poverty to make their own
decisions on how to improve their lives
• Where: Ghana, Kenya, Lesotho, Malawi, South Africa, Zambia and
Zimbabwe (Tanzania?)
Transfer Project: Overview

4. • Experimental and quasi-experimental study designs
• Longitudinal, mixed methods data collection to understand
impacts and pathways
• Focus on adolescents: How do cash transfers affect
structural determinants of safe transition to adulthood?
One-on-one interviews (up to 3 adolescents per
household) with same sex enumerators in Kenya,
Malawi, Zambia and Zimbabwe
Transfer Project: Research

5. Country Households
Sample Size
Adolescent
Age Range
Adolescent
Sample Size
Survey Years Design
Zambia MCTG 3078 13-17 2098 2011, 13,14 RCT
Zimbabwe HSCT 3063 13-20 1170 2013, 15, 16 District Matched
Case Control
Malawi SCT 3200 13-19 2109 2013, 14, 15 RCT
Kenya CT-OVC 1913 15-25 2223 2007, 09, 11 RCT
Tanzania PSSN TBD TBD TBD 2015, 17 RCT
Transfer project: Data collection (ongoing)

6. 1. Explore whether the Government of Kenya’s Cash Transfer for
Orphans and Vulnerable Children (CT-OVC) has impacts on:
 Early pregnancy and marriage among sample of girls aged 12 to 24:
Handa, Peterman et al. 2015.
 Sexual debut and risky sex among sample of boys and girls aged 15 to
24. Handa, Halpern et al. 2014 and Handa, Palermo et al. 2015.
2. Examine pathways through which the Kenyan CT-OVC may affect
outcomes, including increased education and through mobility of
adolescents.
3. Draw parallels with other Transfer Project countries to inform
government policy.
Kenya case study: Aims

7. Conceptual Model: Cash transfers and HIV Risk
Figure Source: UNICEF et al. (2015). “Social Protection Programs Contribute to HIV Prevention.”
http://strive.lshtm.ac.uk/system/files/attachments/Social%20protection%20programmes%20contribut
e%20to%20HIV%20prevention%20brief.pdf

8. Conceptual framework: SCTs and safe transitions?
• Reducing economic insecurity and negative coping strategies
 Buffer against short-term shocks, decreasing likelihood of need to marry
off girls, reduce household size and obtain brideprice payments
 Girls less likely to engage in intergenerational sex/ sexual exploitation
• Increase investment in girls education
 Schooling could reduce exposure to risky environments
 Increase health knowledge
 Perception that marriage and fertility come after education is finished
 Delay sexual debut or risky sexual activities
 Increase aspirations, positive future outlook
• Improving access to health case
 Increase in uptake of HIV treatment and care; reducing the vulnerability
to infections to those exposed or affected by virus

9. • Mexico, Honduras and Nicaragua, government CCTs: Among women aged <20,
programs had negative but insignificant effects on fertility (Stecklov et al. 2006).
However, data from urban expansion in Mexico (2002-2004) showed significant
impacts on delayed marriage and pregnancies (Gulematova 2009).
• Pakistan Female School Stipend Program, CCT: Targeted girls 6th to 8th grade over
six years, increased age at marriage by 1.2 to 1.5 years using a quasi-experimental
case-control design. No impact on fertility outcomes (Alam et al. 2010).
• Malawi Zomba, UCT/CCT: Reduced pregnancy in last year and early marriage
among girls aged 13 to 22 at baseline over a 14-month period. Impacts driven by
girls who were either out of school at baseline or recent dropouts (Baird et al.
2010).
• South Africa Child Support Grant, UCT: Reduction in pregnancy found in analysis
using eligibility and enrollment criteria and propensity score matching (Heinrich et
al. 2012)
Evidence: SCTs, early marriage and pregnancy

10. • Malawi Zomba, UCT/CCT: Transfers reduced prevalence of HIV
and Herpes Simplex 2, but results sensitive to weighting (Baird et al.
2012); reduced frequency of sexual activity & probability of partner
>1 year older (Baird et al. 2010)
• South Africa Child Support Grant, UCT: Transfers reduced
incidence and prevalence of transactional sex & age-disparate sex
among adolescents 10-18 years - PSM (Cluver et al. 2013); reduced
sexual debut (females only) and number of partners (males and
females) among adolescents aged 15-17
• Mexico Oportunidades, CCT: IV approach no impacts on sexual
debut & condom use among urban youth aged 12-24 (Galarraga &
Gertler 2009)
Evidence: SCTs and HIV risk

11. • Government’s flagship social protection program started in mid-
2007 after small pre-pilot in 2004-2006.
• Reaches >135,000 households and over 280,000 OVC (aged <18
years).
• Targets households who are ultra-poor and contain an OVC.
• Flat monthly transfer of ~21 USD (Ksh 1500).
• Transfer given to caregiver, 80% of which are female: Care and
protection of the resident OVC is household’s responsibility for
receiving the cash payment.
• Currently no punitive sanctions for noncompliance.
Kenya Cash Transfer Program for Orphans and Vulnerable
Children (CT-OVC)

12. 7 pilot districts,
4 Locations per
district
1. Kisumu
2. Migori
3. Homa Bay
4. Suba
5. Nairobi
6. Garissa
7. Kwale

13. • Cluster randomized longitudinal design – 2 Locations per district
randomized to delayed-entry control group:
 Baseline (2007): 1,542 (T) and 755 (C) households (a ratio of 2:1).
 Wave 2 (2009): 1,325 (T) and 583 (C) households
 Wave 3 (2011): 1,280 (T) and 531 (C) households
• Household level attrition high between 2007 – 2009 coinciding with post-
election violence. Attrition tests confirm few differential attrition between
treatment and control with respect to covariates.
Sample Design and Data

14. • Wave 3 only contained fertility module administered to females
aged 15 to 49.
• Sample restricted to girls aged 12 to 24 at wave 3, who had never
given birth previous to the baseline survey (N = 1,547).
• Probit regression, standard errors clustered at the household level.
Model 1: Pr(Yij )= β0 + βij(Treatj)+ βij(Xij)+ βj(Xj)+ εij
Model 2: Pr(Yij )= β0 + βij(Treatj) + βij(Zij)+ + βij(Xij)+ βj(Xj)+ εij
• Vector of X controls (baseline): Individual level [age (2011), gender,
child/grandchild of household head), and household level (age of
head, schooling attainment of head, living in Nairobi district].
Methodology

15. Descriptive statistics at baseline

16. Pregnancy and marriage outcomes
Lowess plot of ever been
pregnant, girls (N = 1,547)
Means: All (0.15), T (0.13), C (0.19)***
Lowess plot of ever been married
or co-habited, girls (N = 1,547)
Means: All (0.07), T (0.06), C (0.08)
Pregnancy and marriage outcomes

17. Impact estimates
Probit models with marginal effects. Robust t-statistics in parentheses clustered at the household level.
* p<0.1; ** p<0.05; ** p<0.05. All control variables from 2011 round with the exception of household head characteristics.

18. Kenya CT-OVC: Sexual debut
• Adolescent module introduced in 2011 (Wave 3)
• N=2210 youth aged 15 to 25 years interviewed
• Excluded youth new to the household since 2007 or sexually
debuted before baseline survey (N=1429 final analysis
sample)
• Mediators
 Education =1 if currently enrolled or completed at least grade 12
(reported in 2009)
 Not depressed = 1 if CES-D scale ≤10 (reported in 2011)
 Hope = 1 if Hope score ≥median of 22 (reported in 2011)
 Economic well-being = total household per capita consumption
expenditures on food and non-food items (reported in 2009)

19. Outcome by study arm in analytic sample, Kenyan adolescents,
Ages 15-25 years, 2011 (N=1429)
Full Sample
(N=1429)
Intervention
(N=1001)
Control
(N=428)
p-
value*
Mean Mean Mean
Sexual debut 0.383 0.357 0.444 0.002
Kenya CT-OVC: Sexual debut

20. Impacts on Sexual debut Youth, 15-25 (N=1429)
(1) (2) (3) (4) (5) (6)
Treatment -0.084*** -0.081*** -0.082*** -0.083*** -0.087*** -0.084***
(-2.779) (-2.660) (-2.702) (-2.731) (-2.872) (-2.760)
Currently
enrolled/completed
Standard 12 -0.190*** -0.189***
(-5.287) (-5.206)
Score 10 or below on
CESD -0.052* -0.037
(-1.746) (-1.163)
Hope>median -0.025 -0.003
(-0.958) (-0.124)
Log per capita
expenditures 0.021 0.033
(0.782) (1.237)
Probit models with marginal effects. Robust t-statistics in parentheses clustered at the household level.
* p<0.1; ** p<0.05; ** p<0.05. All control variables from 2011 round with the exception of household head characteristics.

21. (1) (2) (3) (4) (5) (6)
Treatment -0.121** -0.140*** -0.120** -0.122** -0.122**
-
0.143***
(-2.488) (-2.836) (-2.457) (-2.503) (-2.501) (-2.889)
Currently
enrolled/completed
Standard 12 -0.310***
-
0.300***
(-4.812) (-4.647)
Score 10 or below on
CESD -0.096* -0.054
(-1.947) (-1.031)
Hope>median -0.085** -0.055
(-1.975) (-1.248)
Log per capita
expenditures 0.009 0.035
(0.196) (0.725)
Sexual debut: Females, 15-25 (N=552)
Probit models with marginal effects. Robust t-statistics in parentheses clustered at the household level.
* p<0.1; ** p<0.05; ** p<0.05. All control variables from 2011 round with the exception of household head characteristics.

22. Sexual debut: Males, 15-25 (N=877)
(7) (8) (9) (10) (11) (12)
Treatment -0.072* -0.064 -0.070* -0.073* -0.078* -0.070*
(-1.813) (-1.604) (-1.754) (-1.826) (-1.954) (-1.775)
Currently
enrolled/completed
Standard 12 -0.122*** -0.125***
(-2.664) (-2.682)
Score 10 or below on
CESD -0.033 -0.031
(-0.863) (-0.764)
Hope>median 0.005 0.020
(0.133) (0.553)
Log per capita
expenditures 0.034 0.039
(1.018) (1.194)
Probit models with marginal effects. Robust t-statistics in parentheses clustered at the household level.
* p<0.1; ** p<0.05; ** p<0.05. All control variables from 2011 round with the exception of household head characteristics.

23. • Reduce HIV risk factors
 Delay sexual debut among adolescents 15 - 25 years (8 pp)
 Delay first pregnancy among females 12 - 25 years (5 pp)
 Lower risk of depressive symptoms, especially among adolescent males (5 pp)
• Impacts on behavioral risk
 No significant impact on early marriage, sexual partner characteristics or other
risky behaviors (condom use).
• Pathways
 Remain unclear - Program impacts on mental health and education in this
sample limited to males
 Education protective males and females; mental health protective for females
Summary of Findings: Kenya CT-OVC

24. • Evidence that addressing upstream structural factors can have
impacts on HIV-risk related behaviors
• Less conclusive evidence on conditional transfers and short-
term motivations
• Causal pathways still unclear
• Promise of investing in national integrated and
comprehensive programs - HIV prevention as an important
resulting dividend
• Similar large scale national ‘unconditional’ or ‘social’ transfer
programs exist in Zambia, Zimbabwe, Malawi, South Africa,
Mozambique
Currently examining impacts
Program and policy implications

25. Emails: tmpalermo@unicef.org, apeterman@unicef.org
• Download briefs at:
http://www.cpc.unc.edu/projects/transfer/publications/briefs
• New (as of Feb 2015):
 Methodological brief on adolescent modules
 Methodological brief violence
 Brief on education impacts
The authors are grateful to members of the OVC-CT Evaluation Team, in particular to
the Technical Working Group of the Children’s Department, Ministry of Gender,
Children and Social Development, Government of Kenya, and to Daniel Musembi, for
support to the follow-up study.
• This study received funding from the U.S. National Institute of Mental Health
through Grant Number 1R01MH093241 and by Eunice Kennedy Shriver National
Institute of Child Health and Development R24 HD050924 and was approved by
the Kenya Medical Research Institute Ethics Review Committee (Protocol #265)
and the Institutional Review Board of the University of North Carolina.
Acknowledgements and more information

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economics, 19(S1), 55-68
Cluver L, Boyes M, Orkin M, Pantelic M, Molwena T, & Sherr L. (2013). Child-focused
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