Economic Strengthening in the PEPFAR Program

Jason Wolfe, Senior Technical Advisor

March 4-5 2014 • SPCS WG • UNAIDS • Geneva

Role of Economic Strengthening

• Orphans & Vulnerable Children– Family strengthening

• Care & Treatment– Socioeconomic determinants of ART adherence– Food security and nutrition

• PMTCT– Socioeconomic determinants of ANC attendance and MNCH

• Prevention– Structural drivers of HIV transmission– Socioeconomic determinants of sexual risk behavior

Policy Guidance

Hypotheses

1. Segmentation based on vulnerability improves efficiency (scale) and effectiveness (impact)

2. Most are “moderately vulnerable”

3. Savings groups are best entry point for most beneficiaries

4. Comprehensive programs build resilience

5. Tweaks and complementary interventions are necessary for many individual-level outcomes

1. Segmentation by Vulnerability for Better Programming

Most Vulnerable

ModeratelyVulnerable

LeastVulnerable

Consumption Support

Money Management

Grow / Diversify Income

2. Most are Moderately Vulnerable

• Tanzania | current OVC & HBC beneficiaries

• Rwanda | current OVC beneficiaries

• Uganda | current OVC beneficiaries

12% 66% 22%

16% 73% 11%

20% 51% 29%

3. Savings Groups as Entry Point

• Ethnographic evidence that poor people use financial tools Rutherford 1999 • Collins, Morduch, Rutherford & Ruthven 2009

– Generating useful lump sums of cash – Weathering bad times – Funding day-to-day expenses

• Experimental evidence that access to savings can increase investments in a range of domains– Agriculture & small business Duflo, Kremer & Robinson 2010 • Dupas & Robinson 2011a

– Health Dupas & Robinson 2011b

– Food security Gash & Odell 2013

• Non-experimental evidence suggests HIV-specific impacts Barber 2011 • Beck 2012 • IMARISHA 2013

3. Savings Groups as Entry Point

contributeregularsavings

repay with interest

make loans

( for working capital orconsumption smoothing )

cycle continues 6-12

monthsshare outsavings

+interest

15-25trusted peers

come together & make their rules

How Savings Groups Work

4. Comprehensive Program Builds Resilience

Most_

x000d_Vulnera

ble

Modera

tely

_x000d_Vulnera

ble

Least_x000d_Vuln

erable

2010

2012

2013

Distribution of BeneficiariesRwanda | Higa Ubeho

Most Mid LeastM

ost

Mid

Lea

st

2,676

2,211

12

3,447 1,165

1,029576

1 6Bas

elin

e V

uln

erab

ilit

yFollow Up Vulnerability

5%got worse

51%got better

44% stayed the same

Beneficiary TransitionUganda | SCORE

4. Comprehensive Program Builds Resilience

4. Comprehensive Program Builds Resilience

• Implications for beneficiaries– Increased savings, assets, income– Increased food security– Improved mental outlook– Increased expenditures on education– Increased expenditures on health

• Implications for donors and governments– Reduce reliance on direct subsidies (e.g., school fees, transport)– Free up resources to enroll/support more beneficiaries– But there will always be a need for subsidies and safety nets

5. Tweaks and Complementary Interventions

• Money is a means to an end• How beneficiaries spend their money is what matters• Improved household welfare ≠ individual welfare

– Role of gender– Role of age

• Spending decisions are messy– Competing priorities– Time inconsistencies– Infrequent, lumpy expenses are hard to plan for

• Supply-side factors

5. Tweaks and Complementary Interventions

• Savings groups as a flexible model– Timing of share-outs– Multiple funds (e.g., emergency, education, health)– Collective purchases reduces costs and applies social pressure– Goal setting

• Savings groups as a platform for integration– Community outreach for clinics/service providers (e.g., HTC) – Discussion groups (e.g, parenting, nutrition, GBV/IPV)– Peer support (e.g., positive living, mothers)– Collective action (e.g., ARV collection)

Current and Planned Research

• Zambia & Tanzania– Food security for OVC families

• Malawi– PMTCT and pediatric care & treatment

• Côte d’Ivoire– Risk reduction for sex workers

• Mozambique– Education for OVC

• South Africa– Adolescent transition (OVC & prevention)

THANK YOU!

Jason WolfeSenior Technical Advisor, Economic Strengthening & Social ProtectionUSAID Office of HIV/AIDS • jwolfe@usaid.gov • +1 (202) 712-1882