170 CHAPTER 10
very poor households and also in better-off households that can afford to take them in. Some studies find that orphans are disadvantaged with respect to food security, nutrition, health, and education; other studies find that they are not. These findings are not necessarily contradictory but rather are con- tingent on variables such as the relationships between children and care- givers, their poverty or wealth status, and household demographics and struc- ture. Targeting to respond to these variations at a household level would be infeasible. In light of concerns around accuracy, equity, and stigma, a con- sensus is building around targeting cash transfers based on poverty and mul- tiple vulnerability criteria rather than targeting orphans or families living with AIDS. A more difficult ethical quandary surrounds people on ART. Evidence of
the importance of nutrition to the effectiveness of ART has motivated pro- grams providing food transfers to clients, and more recently there have been suggestions that cash transfers be targeted similarly. However, food is likely to be a better form of transfer for those on ART given the primary nutritional objective of the transfer and the immediate need for food support as well as food with particular nutritional properties. But cash provides flexibility to meet other needs of patients, such as transportation to pick up their drugs. There is no research to date comparing food versus cash transfers for ART patients, and such research would be helpful. However, cash and food trans- fers have different objectives: administered in conjunction with ART, the latter provide not so much social protection as nutritional rehabilitation, and many programming guidelines require cutting off the food when the patient has improved (to a certain BMI). In this light, a direct food transfer for ART patients received in conjunction with their treatment, coupled with a cash transfer for households or children, would be optimum. Another set of targeting issues relates to the methods best suited to tar-
get AIDS-affected families within the context of administrative capacities. There are currently three main systems that predominate with respect to targeting cash transfers. In Latin America, where there is administrative and financial capacity to carry out data-intensive proxy means test surveys and analysis, these programs tend to perform well in targeting extreme poverty. This method is probably not practical or cost efficient in the context of low administrative capacity and sparsely populated areas and would also likely be politically problematic if there was no community involvement in decisions in which as little as 10 percent of a community received transfers. The system used in South Africa, applying an application-based means test, has worked reasonably well as long as the burden of proof for the means test has not been unreasonable in the socioeconomic context: in the past, when documentation was required that people could not access, there were very large exclusion
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