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.

 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)

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

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 )

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

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’

Upstream determinants Midstream interactions Downstream impacts Financial Protection Access to services Legislation, policy and regulation HIV infection Health outcomes Vulnerability and resilience of people/ individuals within a multi- level context Edstrom, 2010

 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 18 th )

 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

 Opportunities to categorize home based care workers/ child care workers as ‘public work’ e.g. South Africa  “Connective tissue” between communities and health facilities

 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;

 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

› 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)

 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

 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