Social protection in the Context of the HIV epidemic

What is social protection why is it important, what’s new and relevant to HIV, AIDS and the MDGS?

Unite for Children.

Unite against AIDS.

Acknowledgements

Members of UN working group on social protection – particularly UNAIDS.

Miriam Temin – author of evidence paper on Social protection and HIV outcomes

Institute of Development Studies (Mark Davies and Jerker Edstrom)

Overview

What is social protection? What are the links to HIV and AIDS? Where is the evidence? Where are the gaps?

What is ‘Social Protection’?There are many definitions but often described

as

“ all public and private initiatives that provide income or consumption transfers to the poor, protect the vulnerable against livelihood risks, and enhance the social status and rights of the marginalised; with the overall objective of reducing the economic and social vulnerability of poor, vulnerable and marginalised groups.”

(Devereux &, Sabates-Wheeler , IDS 2004)

Added value of social protection to health systems and community systems strengthening

Health Systems

Social Protection

Community Systems

• Training & employment of community health workers, incl. PLHIV and MARPs

• Social health financing• Health insurance

• Care & Support• Psychosocial support• Home based care

• Community child protection • Community social workers• Employment & public works• Job training, job creation & income generation

• Livelihoods support• Social transfers• Savings & credit

• Human resources for health

• Delivery of health services including drug supplies

• Social welfare systems strengthening

• Social work training• Social transfers• Alternative care

• Community empowerment marginalised groups –voice accountability

• Programmes, activities & services Community service delivery mechanisms

• Community networks, linkages & partnerships

• Communication & Outreach

• Resources and capacity building

These SP components in UNAIDS Business Case

Financial protection including through targeted social transfers (such as food or cash) to protect some minimum level of consumption for the very poor

Initiatives to promote Access to affordable quality services, (health, education) e.g. social insurance, fee waivers and social care (home based care, child welfare workers who link under-served and marginalised to services)

Laws, policies and regulation to empower marginalised people to participate fully in development, such as addressing systemic discrimination - often referred to as ‘transformative measures’

Social protection and potential to reduce vulnerability to infection, disease progression and downstream impacts

Upstream determinants

Midstream interactions

Downstream impacts

Financial ProtectionAccess to services

Legislation, policy and regulation

HIVinfection

Healthoutcomes

Vulnerability and resilience of people/ individuals within a multi- level context

Edstrom , 2010

Where’s the evidence ?

Good evidence on positive impact of social transfers on care and support including OVC

Emerging evidence social protection’s

contribution to HIV prevention and treatment uptake and adherence (see World Bank press statement July 18th)

Care and support/OVC

Adato and Bassett review (2009) of 20 cash transfer programmes looking at potential for children affected by AIDS.

Small payments ($10- $15 per household/month) positive impact nutrition, education and possibly health seeking (Malawi)

The Role of Social Grants in Mitigating the Socio-Economic Impact of HIV/AIDS, South Africa Relatively high levels of access to disability grants and foster care

grants in AIDS affected households Review of impact of largest cash grants schemes show how bring

AIDS affected households up to poverty levels of non-affected households

Booyson, F. (2003) ―The role of social grants in mitigating the socio-economic impact of HIV/AIDS: Evidence from the Free State Province. CSSR Working Paper. University of Cape Town

AIDS sensitive public work programmes ?

Opportunities to categorize home based care workers/ child care workers as ‘public work’ e.g. South Africa

“Connective tissue” between communities and health facilities

Prevention: Social Transfers Cash & food transfers

get & keep children in school

OVC protection needs: adolescent girls affected by AIDS at high risk

Schooling protects girls from HIV infection – causal pathway unclear;

Prevention: Social Transfers continued

Zomba Cash Transfer Experiment for Adolescent Girls Compared impact of cash transfers unconditional & conditional

on health & education outcomes Significant improvements in school attendance, early marriage,

pregnancy, and self-reported sexual activity Impacts similar in conditional/non-conditional arms Amongst beneficiaries who were enrolled in school at baseline,

HIV prevalence 60% lower then control group – BUT HIV data not collected at baseline

Baird et al.,2009, World Bank, 2009/10; Ozler 2010

Treatment: Social Transfers continued

› Cash transfers as incentives for VCT Even small incentive – 1/10 of daily wage – increased returns for results by 50%. Thornton R.(2006) The demand for and impact of learning HIV status: Evidence from a field experiment. Harvard Univ.

› Cash Transfers to Cover Clinic Transportation Costs Improve Adherence and Retention in Care in a HIV Treatment Program in Rural Uganda. Use of transfers to cover transport costs. Adherence scores significantly higher in intervention group Emenyonu, N et al (2010) Uganda

Cash Transfers and STI results – CCT lowering STI by 25%

RESPECT study Tanzania (de Walque World Bank)

Transformational approaches to social protection

Empowerment of people - particularly in key populations at increased risk of infection

Importance of addressing social and economic vulnerabilities and responding to needs and rights of marginalized populations

Sex worker programme in Sonagachi India – sex workers themselves determined most relevant intervention

Stigma index – developed with PLHIV

Where are evidence gaps? What optimal combination of transfers in

different epidemic contexts (food, cash, vouchers) for HIV impacts?

How best to target to make programmes AIDS sensitive not AIDS exclusive?

Qualitative and quantitative studies to better understand barriers to access

Participatory studies involving PLHIV Social health financing e.g. impact of

community health insurance models