Overview of PEPFAR's strategic interests and experiences with economic strengthening for the Social Protection, Care & Support IATT and UNAIDS staff, March 4-5, 2014 in Geneva

1. Economic Strengthening
in the PEPFAR Program
Jason Wolfe, Senior Technical Advisor
March 4-5 2014 • SPCS WG • UNAIDS • Geneva

2. 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

3. Policy Guidance
1
The U.S. President’s E
m
e r g ency Pl an fo r AIDS Re l ief
GUIDANCE FOR THE
PREVENTION OF SEXUALLY
TRANSMITTED HIV
INFECTIONS
August 2011
!
1!
!
Prioritization of PEPFAR Care and
Support Interventions
Evidence summaries and
resources to assist country teams
in prioritizing Adult Care and
Support Interventions
!
PEPFAR!Adult!Care!and!Support!Technical!Working!Group!
January!2014!
!

4. 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

5. 1. Segmentation by Vulnerability for Better Programming
Most
Vulnerable
Moderately
Vulnerable
Least
Vulnerable
Consumption
Support
Money
Management
Grow / Diversify
Income

6. 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%

7. 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

8. 3. Savings Groups as Entry Point
contribute
regular
savings
repay with
interest
make
loans
( for working capital or
consumption smoothing )
cycle continues
6-12
months
share out
savings
+
interest
15-25
trusted peers
come together &
make their rules
How Savings Groups Work

9. 4. Comprehensive Program Builds Resilience
Most
Vulnerable
Moderately
Vulnerable
Least
Vulnerable
2010
2012
2013
Distribution of Beneficiaries
Rwanda | Higa Ubeho

10. Most Mid Least
MostMidLeast
2,676
2,211
12
3,447 1,165
1,029576
1 6
BaselineVulnerability
Follow Up Vulnerability
5%
got worse
51%
got better
44%
stayed the same
Beneficiary Transition
Uganda | SCORE
4. Comprehensive Program Builds Resilience

11. 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

12. 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

13. 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)

14. 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)

15. THANK YOU!
Jason Wolfe
Senior Technical Advisor, Economic Strengthening & Social Protection
USAID Office of HIV/AIDS • jwolfe@usaid.gov • +1 (202) 712-1882