Washington D.C., USA, 22-27 July 2012www.aids2012.org

Michael SamsonEconomic Policy Research Institute, South Africa

msamson@epri.org.za www.epri.org.za

Operationalizing HIV-sensitive social protection: opportunities and challenges

AIDS 2012 Symposium Social protection: Promoting a more effective response

23 July 2012

EconomicPolicyResearchInstitute

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Social protection for equitable HIV responses

Global Commitments to Universal Access to HIV prevention, treatment care and support

HIV epidemic has put equity issues in the spot light (gender, income, social exclusion)

Importance of addressing economic deprivations and social exclusion

Emerging priority area for UN cosponsors and development partners

Washington D.C., USA, 22-27 July 2012www.aids2012.org

2000 9 countries, 25 programs

2010 35 countries, 120 programs

2012 41 countries,

245 programs

2000 2012

SOURCE: Garcia and Moore (2012)

Social cash transfer programmes have emerged in countries all across sub-Saharan Africa over the past 12 years

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Govern

ment

Other

DFID

Worl

d Ban

k

UNICEF

Oxfam

Save t

he Chil

dren

EU/ECHOCARE

UNHCR

USAID0%

10%

20%

30%

40%

50%

60%50%

40%

20%

12% 12% 10% 8% 7% 7% 6% 4%

SOURCE: Marito Garcia and Charity Moore. 2012. Cash Dividend: The Rise of Cash Transfer Programs in Sub-Saharan Africa. Washington, D.C.: The World Bank.

Government is the main funder of cash transfers in Africa, followed by DFID, the World Bank, and UNICEF

Washington D.C., USA, 22-27 July 2012www.aids2012.org

A framework for HIV-sensitive social protection evidence

Reaching people with HIV-sensitive social protection: ● Exclusive versus inclusive approaches ● Targeting versus more universalism

Achieving core impacts: ● Prevention ● Treatment ● Social and economic care and support

Enhancing impacts: building complementary linkages and moving to more comprehensive approaches ● Synergies with development sectors ● Critical enablers

Expanding and sustaining HIV-sensitive social protection ● Resources required ● Financing ● Investment returns

Design and Implementation

1

4

3

2

Washington D.C., USA, 22-27 July 2012www.aids2012.org

HIV-sensitive social protection’s transmission mechanisms to impact follow complex pathways

Broad-based HIV-sensitive social protection policies and programmes

Income protection and livelihoods support Direct access to

vital goods and services

Better treatment and improved health outcomes

reduced poverty, better nutrition, increased educational access

Reduced mortality and morbidity

Reduced new infections (particularly for girls and young women)

Reduced susceptibility to HIV infection

Greater economic power for vulnerable groups

Washington D.C., USA, 22-27 July 2012www.aids2012.org

National scale programmes are yielding positive impacts on HIV-related outcomes

• South Africa’s Child Support Grant…– targets with inclusive approaches that effectively

reach HIV-affected households – generates behavioural impacts that strengthen

prevention efforts• Kenya’s scaling up of its OVC programme may

be yielding similar results• Research in ongoing in Ghana, Lesotho and

Malawi—and with other projects around the world

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Important opportunities exist to ensure greater coverage of HIV-affected populations and

strengthen HIV-related impacts

• Inclusive versus HIV-specific targeting– Reaching excluded groups– Addressing stigma

• Maximising the empowerment effect of social protection– Addressing economic vulnerability

• The role of the Investment Framework in maximising impact• An appropriate and efficient mix of instruments• The virtuous circle of effective impact as well as

developmental multipliers strengthening political will and leading to increased resources, improving coverage and propelling the virtuous circle

Washington D.C., USA, 22-27 July 2012www.aids2012.org

HIV-affected households in South Africa are twice as likely to receive the Child Support Grant than are non-affected households

0%

10%

20%

30%

40%

50%

60%

70%

No Social Grants Child Support Grantonly

Other Grants

prob

abili

typrobability of grant receipt by HIV-affected household status

likely HIV-affected not likely HIV-affected

SOURCE: EPRI micro-simulation model calibrated with National Income Dynamics Survey 2010

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Adolescents in South Africa receiving the Child Support Grant are less likely to engage in a range of risky behaviours

SOURCE: EPRI/Government of South Africa/UNICEF CSG impact assessment (2012)

• EPRI’s impact assessment of South Africa’s Child Support Grant (CSG) demonstrates reductions in risky behavior resulting from both early (within 2 years from birth) and current receipt:– Early CSG receipt reduces the likelihood adolescents

engage in sexual intercourse, use alcohol or drugs, become pregnant and work outside the home.

– Household receipt of the CSG in adolescents’ teenage years is important in reducing absences from school as well as engagement in the above risky behaviours.

Washington D.C., USA, 22-27 July 2012www.aids2012.org

‘Sensitive periods’ in early brain development

Binocular vision

0 1 2 3 7654

High

Low

Years

Habitual ways of respondingLanguage

Emotional controlSymbol

Peer social skillsRelative quantity

Central auditory system

Early childhood intervention is a key driver of impact

SOURCE: Handa (2007) citing and adapting Heckman & Carneiro (2003)

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Systemic challenges limit opportunities to scale up HIV-sensitive social protection

• Weak systems for cross-sectoral linkages

• Resource constraints limiting adequate financing

• The interaction of these two challenges is particularly constraining: when resources are limited, support for inter-sectoral linkages erodes

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Reduce RiskReduce the

likelihood of transmission

Reduce mortality and

morbidity

Critical Enablers

Basic Programme

Activities

• PMTCT• Condom promotion and distribution• Key populations • Treatment care and support to PLWH • Male Circumcision• Behavior Change Programmes

Synergies With Development Sectors including social protection

Investment Framework (Schwartlander et al., 2011)

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

pro

gram

mes

Pre

venti

on se

rvic

es

Prim

ary

heal

th c

are

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health outcomes Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

pro

gram

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Pre

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on se

rvic

es

Prim

ary

heal

th c

are

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health outcomes Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

Nut

rition

pro

gram

mes

Pre

venti

on se

rvic

es

Prim

ary

heal

th c

are

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health outcomes Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Identified knowledge gaps limit opportunities for scale-up

• Do existing programmes reach and effectively cover households affected by HIV and AIDS?

• How can social protection programmes promote behavioural change that strengthens prevention initiatives?

• How do social protection programmes reinforce capabilities for treatment adherence?

• How can integrated social protection systems better achieve these impacts?

• What are the benefits (investment returns) to more integrated and comprehensive approaches to HIV-sensitive social protection?

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

pro

gram

mes

Pre

venti

on se

rvic

es

Prim

ary

heal

th c

are

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health outcomes Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

calculatormode

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

+1

calculatormode

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

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es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

+1 +1

calculatormode

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

calculatormode

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

+1 +1

calculatormode

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

calculatormode

+2+1 +1+2

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

calculatormode

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

calculatormode

+1 +1 +1 +1 +1 +1 +1 +1 +1

Cas

h tr

ansf

ers

Hea

lth In

sura

nce

Anti

-stig

ma

mea

sure

s

Nut

rition

Pre

venti

on se

rvic

es

Prim

ary

heal

th ca

re

Edu

catio

n

Soc

ial c

are

serv

ices

Liv

elih

oods

supp

ort

Poverty reduction Social risk management Equal rights Improved nutrition Reduced infection rates Improved health Human capital development Improved well-being Economic growth

Policy instruments (INPUTS)

Social protection

HealthO

ther

Policy objectives (OU

TPUTS)

Social Protection

Health sector Other sectors

calculatormode

+6+5

+4

+2+4+2

+3+2

+1 +1 +1 +1 +1 +1 +1 +1 +1+4

Washington D.C., USA, 22-27 July 2012www.aids2012.org

Conclusions• A rich evidence base on HIV-sensitive social protection is

emerging• In many countries key policy-makers are open to using this

evidence to design and implement better policies and programmes

• Identified gaps exist across the spectrum of areas of policy interest

• In particular, policy-makers see robust and credible evidence on cross-sectoral investment returns as essential for scaling up successful programmes

• Research partnerships with development partners and key stakeholders can help build the required evidence