Do Health Investments Improve Education Outcomes? Evidence on the Intergenerational Effects of HIV/AIDS Treatment

Sub-Saharan Africa has both the heaviest disease burdens and the lowest levels of education in the world. While the specific diseases vary by country, the HIV/AIDs epidemic has been particularly acute in the southern cone of sub-Saharan Africa where more than 10 percent of prime aged adults are afflicted with the disease. These countries additionally face challenges in the education sector. Despite the institution of free primary education programs by 17 countries in sub-Saharan Africa since 1994, primary school enrollment and completion is far from universal. In this study, we focus on the effect of adult health on children’s schooling.

Previous studies have shown that children’s educational access and attainment can be impeded by their own health and nutrition as well as the health of others in the household through caregiving duties, labor substitution, and money available for nutrition and school expenses. This study contributes to the literature by estimating the effect of the at-scale provision of adult antiretroviral therapy (ART) on the schooling of children of infected adults. Even though the national and international response to HIV/AIDS has been to provide free or subsidized ART, the rigorous empirical estimation of the effect of adult ART (and corresponding improvement in adult health) on children’s schooling has been hampered by both a lack of data and compelling sources of exogenous variation in exposure to treatments. This study will provide the first estimates of the effect of a large scale subsidized adult ART program on children’s schooling.

We identify the effect of the availability of adult ART on children’s schooling through the interaction of temporal, spatial, and HIV status variation, a triple difference specification, in Zambia. Zambia has one of the highest HIV/AIDS prevalence in the world and one of the most successful antiretroviral distribution campaigns in sub-Saharan Africa. Prior to the availability of ART in Zambia, one in seven adults aged 15-49 was HIV positive and one in five children of primary school age was living with a mother, father, or household head who was HIV positive (DHS 2002). Between 2003 and 2007 the coverage of subsidized ART in Zambia increased from approximately zero to 70 percent of households. We combine unique data on the dates and GPS coordinates of the expansion of ART availability and two nationally representative household surveys that include HIV testing modules in a triple difference specification to identify the effect of adult ARV availability on children's educational outcomes in households with HIV positive adults.

We find that expanded ART availability increased the likelihood of children who lived with HIV positive individuals being the correct grade for age, a proxy for timely progression. We do not find any evidence that ART availability differentially increased the likelihood of children being enrolled in school or enrolling in school on time. Our evidence suggests that the effect of ART is stronger for children with fathers who are HIV positive than those whose mothers are HIV positive. Further research will disentangle the mechanisms as well as better understand this heterogeneity.