A review of Michelle Adato and Lucy Bassett’s "What is the Potential of Cash Transfers to Strengthen Families affected by HIV and AIDS?" 

Report presented at the International AIDS Conference in Mexico City,  August 3-8, 2008 (Please see original report here: http://www.jlica.org/protected/pdf/renewal-brieff-10.pdf?PHPSESSID=1b21075ecede06cbde5a872ed9c67df6 )

What are cash transfers?

The urgency of the HIV/AIDS crisis and the exponential effects it has had on poverty levels and livelihoods has pushed the notion of "cash transfers" into to the spotlight.  Interest in social protection programming, such as cash transfers to support the purchase of food, transportation, health care and education is increasingly recognized as an important component to an effective AIDS response.  According to Adato and Bassett, "social protection enables individuals, families, and communities to reduce risk and vulnerability, mitigate the impacts of stresses and shocks and to support people who suffer from chronic incapacities to secure basic livelihoods...Social protection can enable people to move structurally out of poverty by building assets and by altering social relations."

Many variations of cash transfers exist.  They can be given to a household unit or individuals or families who care for orphans or families with children, for example.  Cash transfers may be conditional, such as tied to participation in health or training programs or they can be linked to voluntary participation in such programs or may be entirely unconditional.  Cash transfers may be used for the purchase of food and clothing and, at the same time, can contribute to development, poverty reduction and increasing women’s level of autonomy.   

The report acknowledges the recent realization that HIV/AIDS shares a close relationship with both malnutrition and food insecurity further underscoring the moral and economic importance of cash transfers.  With 25 million people living with HIV/AIDS in sub-Saharan Africa alone, social protection is an important piece of a comprehensive AIDS strategy.  Of the millions of people affected by AIDS, most are children and, "as of 2006, an estimated 15.2 million children under age 18 had lost at least one parent to AIDS, about 80 percent of whom live in sub-Saharan Africa."  Cash transfers can help defray the cost of the family and community members who have stepped in to the role of caretaker for the growing number of orphans and children who have been made vulnerable by the epidemic.  Costs of caring for ill family members erodes livelihood systems, and can often lead to destitution of the entire household, impacting the health, education and nutrition of children.

Conceptual framework

The report details an asset-based social protection conceptual framework, explaining varying types of interventions and objectives:

OBJECTIVES:

1. Securing a basic level of consumption needs.
2. Reducing fluctuations in consumption in order to avert the reduction of assets.
3. Enabling people to save, invest in and accumulate assets through reduction in risk and income variation.
4. Building, diversifying, and enhancing use of assets, by reducing access constraints, directly providing or loaning assets, or building links with institutions.
5. Transforming institutions and economic, social or political relationships. 

OUTCOMES:

1. Securing basic subsistence for families where illness prevents them from securing a livelihood.
2. Keeping children from leaving school because of inability to pay fees or labor needed at home.
3. Enabling people to invest in a small income-generating activity.
4. Increasing the agency of communities where local organizations participate in targeting, monitoring, or service delivery.

Impacts

Various studies have supported the expanded use of cash transfer programs.  In their report, Adato and Bassett state that "there is considerable evidence that unconditional cash transfer programs have increased food expenditure and food consumption."  Cash transfer induced food expenditure increases are closely followed by increased spending on clothing, shoes, blankets, household items and education. 

Conditional cash transfers (CCT) with regard to education have been linked to increased school enrollment and attendance.  With regard to health and nutrition, CCTs have increased the use of health services and have reduced the incidence of illness.  Also, with improved quality and quantity of food consumption have come improvements in nutritional status of participants.  Beyond the predictable results, the Child Support Grant and Old Age Pension in South Africa, for example, as lead to an elevation in the school enrollment rate, similar results were exhibited in Namibia and Lesotho.  Such studies have proven that "old age pensions are an effective way of supporting children’s education."  Evidence also supports the notion that cash transfer programs targeted at the elderly can improve the nutritional status of children as well.

Targeting

• The extremely poor - Targeting the very poor and those affected by AIDS can help to reach the community’s most vulnerable populations.
• Individuals on antiretroviral therapy (ARV) - Recent studies have shown a close relationship between effectiveness of ARV therapies and nutrition.  Food transfers can provide direct nutritional support while cash transfers for those on ARV therapy can help to defray the costs of getting to a clinic to pick up medications. 
• Orphans and vulnerable children - Targeting OVC is quite complex with regard to defining "vulnerable child" and categorizing how disadvantaged orphans are as compared to non-orphans, children with ill parents and those disadvantaged due to other forms of trauma.  Relationship between the OVC and caregivers, socioeconomic status and household demographics all play a role in the wellbeing of each individual child.  The report notes that "a consensus is building around targeting cash transfers based on poverty and multiple vulnerability criteria, rather than targeting orphans or families living with AIDS."
• The elderly - According to the report, "more than half of orphans living in six countries in southern and east Africa were living with grandparents."  Targeting cash transfer s to the elderly may be a reliable method of reaching vulnerable children as well.
• AIDS-affected families - Targeting AIDS-affected families has been a difficult task due to issues of exclusion and distinctions as to where populations are situated with regard to the poverty line.
• Community-based targeting - Community-based programming is the most common form of cash transfer programs in southern and eastern Africa.  It has been a successful method in that the community determines the recipients, the aid reaches the intended populations and is a result of consensus, rather than conflict within the community. 

The following additional conclusions are a result of recent research:  benefits should be targeted to women, geographic and community-based targeting is better suited to rural areas than urban and targeting methods must be carefully developed so as to avoid missing groups that self-exclude or face discrimination by community members.

Conditionality

Social externalities, power, autonomy and political economy all play a part in the conditionality debate and suggest that it must be considered carefully when shaping cash transfer programs.  While research in countries outside of sub-Saharan Africa has been mostly limited to conditional cash transfer programs, it has yet to be proven how conditionality would play out in sub-Saharan Africa, as strong concerns exist over availability of services and administrative capacity in the region.  In the near term, the report suggests that unconditional cash transfers might be most appropriate for this region and that conditionalities should be tailored program by program in order to reach targets and objectives.

Other forms of social protection

Livelihoods activities, microcredit and public works programs are more likely to be appropriate for AIDS-affected families that are "less affected" financially and with regard to labor constraints.  These types of programs are also more difficult to scale up to meet urgent needs.  Conversely, food and nutritional transfers may be most useful to those affected most by AIDS (children and those on ARV therapy).  Though, food transfers are highly vulnerable to rising food prices and logistical difficulties, making cash transfers the preferred type of social protection.  The report further underscored the notion of heterogeneity among those affected by AIDS and the need for a mixed approach, versus a one-size-fits-all program.  Knowledge gaps must be addressed in order to provide effective programming and delivery of services. 

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