This study investigated the outcomes, the cost, and the cost-effectiveness of the ALS intervention in Bagong Silang. The outcome of the intervention could be measured in terms of the success rate of learners passing the A&E examination at both elementary as well as secondary level. The national average of ALS learners passing the A&E exam was 30% and in this respect, this particular ALS intervention at Bagong Silang was found to be 11 percentage points more effective (7).
Besides the short-term outcome of the success rate in the A&E examination, another outcome measure of ALS was the job status of 115 learners who were followed up after their completion of ALS. Approximately 60% reported that they were employed in the informal sector and 40% in the formal sector. A significant unadjusted association was found between passing the exam and getting formal jobs which suggest that a learner who passes the A&E exam is more likely to get a formal job. A 2018 report by the World Bank states that, in the Philippines, an individual who has enrolled at ALS and passed an A&E is twice as likely to get a formal job as someone who has not passed the exam (7). Since job status is a long-term outcome, and information is not yet available for 50% of the learners, who finished the course only recently, we have not yet drawn conclusions about the effectiveness of ALS for job outcome in this report. The staff of BRC are at present trying to collect more follow-up data. We will reevaluate the intervention when this follow-up data is available.
The benefits of education for work prospects have been shown in other settings. For example, Kienzl et al found that finishing high school in the USA is associated with a reduced risk of unemployment compared to non-completers (19). However, this relation is time dependent; a person who completes high school with a shorter drop out period (less than four years) is more likely to have a positive economic outcome than a person who takes longer (19). Since the age of most learners in the ALS programme was 16–19 years of age, suggesting a short drop out period, we expect that the intervention will have a positive effect on future employment rates and further improve the cost-effectiveness of the ALS intervention and thus “the social return of investment”.
An aspect of the success of the ALS intervention that is harder to measure is whether it can reduce the exposure of the participants to experiences of violence. The available data concerning violence before and after the intervention did not show any striking change. However, the data on experience of violence are difficult to evaluate. Experience of violence is likely to have been under-reported among the enrollees (25% of those who had pre-intervention violence experience passed the A&E while 42% those who did not reported such experiences passed A&E (Table 2)). UNICEF has reported that 80% of youths aged 13–24 years in the Philippines had experienced some form of violence in their lifetime, whether in the home, school, workplace, community or during dating (20). To address the challenge for young people in Manila in terms of exposure to violent, BRC’s ALS intervention has a psychosocial component designed to enhance the physical and mental welling of young people at risk, which we see as a strength of this intervention. The impact of violence goes beyond physical consequences. Toxic stress from experiencing violence can negatively impact the wellbeing and intellectual development of young people (21).
It is known that high prevalence of violence has a negative impact on the people living in slums like Bagong Silang in terms of perceived and actual safety, school attendance, and businesses opportunities. Therefore, an ALS intervention with an effective psychosocial component is likely to result in more self-esteem, self-mastery, and self-control for the participants, and also diminished behavioral/emotional problems and violence (7). In addition to addressing violence prevention the psychosocial interventions in this program were designed with an intention to address risk factors that were the reasons behind low attendance of learners and prevent them from dropping out.
ALS interventions are an important way of helping young people to become better qualified for coping with adult life. However, such interventions must be financed, and in discussions about finance it is important to have an evaluation of what they might cost. Until now, cost analysis has not been routinely undertaken for evaluation of such interventions. The cost of the ALS intervention discussed here was found to be $1,550 per enrolled learner, with an ICER of $3,830. The overhead costs accounted for a huge portion of the total cost, which means that a high proportion of money is not spent directly in project but rather in administration. For many donors, the overhead ratio is an important indicator for the efficiency of a non-governmental organization. However, a high overhead does not mean that an intervention is not cost-effective. We believe that the high overhead cost reflects on the need of higher investment for initial organizational development in resource limited settings. The proportion for overhead can be expected to decrease in long run, especially if a higher number of learners can be enrolled.
The ICER for ALS was found to be $3830/passed A&E Exam. As there is no internationally accepted value of improved education, or of social interventions targeting out-of-school youths, it is difficult to establish whether the intervention studied was cost-effective. Comparing our PPP results with those of similar interventions from similar contexts could indicate whether this was an efficient intervention. Unfortunately, all reports of comparable studies found in the literature were performed in high income countries, which poses a challenge for comparison. Kendall et al conducted an economic evaluation of an alternative learning initiatives for out of school youths in United Kingdom and found that the average cost per learner enrolled was $7,860 and the ICER for high school certificates obtained was $ 12,500 (22). Another study undertaking a cost-effectiveness analysis done by Hollands et al in the USA evaluated four different education programs targeting youths who had already dropped out of school. The average cost for learners enrolled in this study ranged from $ 15,750 to $ 20,890 and the ICER for extra high school completer ranged from $ 83,680 to $ 228,200 (23). Based on the PPP results of the comparative studies, the ALS intervention in Bagong Silang was found to be more cost-effective than the other informal education programs.
Since the published studies are of doubtful relevance to the situation in Manila, a more useful way of determining the worth of the investment is to compare it with the cost of school education in the Philippines. There is no tuition fee for primary and secondary education in government run public schools in Philippines. Budgets for maintenance and operating expenses are prepared at school level which pose a challenge to calculate cost per student enrolled. Therefore, yearly tuition fee for private schools were referred. At elementary level (1–6 years) and secondary level (7–12 years) combined, the cost ranges from $ 54,160 - $ 111,500 in 2019, which is around $ 4,510-9,220 per student per year (24). The average cost of ALS per student per year in Bagong Silang was estimated to be $1,550, which is 1/3 to 1/6 of the cost of attending a private school.
This study includes some parameters with uncertainties that may affect the estimated ICER. We performed two “one-way sensitivity analysis” and one “multi-way sensitivity analysis” and although this tended to increase the ICER, it remained in the lower range of prior studies and the cost of attending private schools in the Philippines. We therefore consider that the ALS intervention is cost-effective from a service provider’s perspective in achieving a higher level of education, which is a crucial step for youth empowerment, compared to a ‘do nothing approach’. However, this should not be an argument for students for dropping out of formal education and participating in non-formal education instead. As education in a formal setting offer more opportunity of engagement in the learning process, it plays an important role in developing non-cognitive skills in young people. Such skills are crucial for realising desirable life outcomes thus offering a sustainable solution to poverty alleviation (9, 25). Dropping out from schools is very common for at-risk youths living in Bagong Silang. These young people often need to work to earn money, and even though public schools are free, the learners are unlikely to follow the regular curriculum successfully as they may miss many classes or fall asleep in class due to fatigue from jobs. In addition, the public schools in the slums in the Philippines are not always a safe haven for the students and are often burdened by youth gangs. It is hard to keep the good teachers in violence-prone neighborhoods. This touches on the issues of inequality, as poverty itself forces children and young adults to work and thereby forgo formal education, resulting in them being less able to compete in the future labor market. Therefore, we consider ALS a reasonable investment on behalf of at-risk young people living in slums in Manila if they are dismissed/drop out from the public schools, as other educational options are scarce.
Strengths and limitations
A strength of this study was that this youth empowerment program followed the guidelines and curriculum set by the government, which facilitated a comparison with the national data. A limitation is that we did not have a control group with which we could make a direct comparison. However, we considered that the results could be reliably compared with a ‘do nothing alternative’ for young people who did not attended BRC’s ALS intervention, as none of them would be able to get a pass in the examination, and there would be no cost associated with that outcome. We acknowledge that a similar outcome could be obtained if an out- of- school youth benefits from the intervention in another non-formal program or returns to a formal school. However, based on our contextual research we consider this to be unlikely. In any case, the results would still indicate the value of ALS interventions although not necessarily indicating the cost-effectiveness of the ALS intervention under study.
In this study our emphasis for the analysis was on the immediate/short-term outcome of attaining higher level of education. Occupation is another determinant of socioeconomic status, and knowledge and skills are important factors determining job opportunities. Skills for a job can be gained through informal means as well. However, we assume that in the long run, completing secondary education would have better outcomes.
The intervention is also expected to have wider societal benefits beyond the learner’s better employment/income status and violence prevention. Taking a societal perspective in the economic evaluation could potentially have unmasked some interesting results and could have guided decision makers within the government for future investments. An important step involved when considering a societal perspective is to include opportunity costs of the participants, i.e., the individual cost for attending ALS (e.g., reduced work income). It is suggested that taking an ingredient approach for cost analysis would have facilitated a study from a broader perspective (23).