What is the Potential of Cash Transfers to Strengthen Families affected by HIV and AIDS? A Review of the Evidence on Impacts and Key Policy Debates

The international trend toward investing in social protection in poor countries has reached sub-Saharan Africa, taking on a new urgency as HIV and AIDS interact with other drivers of poverty to simultaneously destabilize livelihoods systems and family and community safety nets. A new focus on the vulnerability of families, and threats to the human capital of children with lifelong and intergenerational consequences, has accelerated international, regional, and national commitments to social protection programs in heavily AIDS-affected countries. Social protection in the form of cash transfers—which can provide support for food purchases, transportation, education, health care and other expenses—is receiving increasing recognition as an important part of a comprehensive AIDS response. The urgency of cash assistance for food purchases is underscored by emerging evidence on the effect of good nutrition to slowing the progression of AIDS, and to the effectiveness of antiretroviral therapy, with consequences not only for people living with HIV but also their children, broader families and communities. More commonly a feature of social policy in wealthier countries, social protection has emerged as a political possibility for poor countries, with an increasing number experimenting with program options. 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 because of, for example, age, illness, disabilities, discrimination, or their position within the social and economic structure of their society. If designed to do so, social protection can enable people to move structurally out of poverty by building assets, and by altering social relations. Among different forms of social protection, a momentum is gathering around cash transfers, now found from El Salvador to Kenya to Bangladesh to Cambodia. In sub-Saharan Africa, national governments, donors, multilateral agencies, international and national non-governmental organizations (NGOs), are cooperating to pilot and roll out programs intended to reach hundreds of thousands of people within a few years. More than a dozen countries in southern and East Africa currently have cash transfers programs, most at early stages, and more countries are planning or considering them. Questions are raised, however, with respect to their effectiveness in mitigating the impacts of HIV and AIDS, reducing poverty, and protecting human capital, and their affordability, sustainability, political support, targeting, and design. This brief is based on a comprehensive review of the same title. The original paper, reviewing over 300 documents, examines how social protection can be used to protect children and families affected by HIV and AIDS, and specifically, how well cash transfers can fare with respect to securing basic subsistence and reducing poverty, while also protecting the human capital of children—specifically, their education, health and nutrition. The paper reviews evidence to date on the impacts of programs under different designs, and reviews key policy debates that accompany decisions about whether to adopt cash transfers and how to design them to be responsive to the context of HIV and AIDS. In particular, it examines systems, experiences and dilemmas of targeting, and the debate on conditionality, i.e. whether cash transfers should be conditioned on beneficiaries’ participation in education and health services. Cash transfer programs can take many forms. They can be given to households as a unit because they meet poverty or vulnerability criteria, to an individual such as an elderly person or disabled person, or to families based on the presence of individuals such as children, girls, or fostered orphans. Cash transfers can be unconditional—given without obligations—or conditional—tied to obligations of recipients to participate in work or training, education, health, nutrition, or other services or activities—or they can be linked to these activities but not obligatory. Cash transfers provide for current basic needs of adults and children such as food and clothing. They can also contribute to development processes, by enabling or encouraging investment in assets that increase people’s chances of breaking out of poverty in the long-term. Cash transfer programs can also have additional benefits such as increasing women’s autonomy and capacities, or strengthening capacities of local organizations. Globally, the vast majority of cash transfer programs have been designed and rolled out in contexts where AIDS was either not a large-scale problem requiring different attention in social protection policy, or was not taken specifically into account. Under any circumstances, determining whether and which type of program should be undertaken