176 CHAPTER 10


and employment—public works, school feeding, and cash and food for assets and consumption, combined with skill building, are recommended. For the 25 percent who are “moderately poor”—whose needs are for employment, skills, capital, productive assets, and protection from asset erosion—agricultural input subsidies, public works, insurance, and microfinance are needed. “AIDS-affected families” do not constitute a homogenous category; they


embody many variations with respect to wealth or poverty, education, house- hold structure, stage of illness progression, dependency ratios, social status, and access to assets. This argues for a mix of social protection approaches rather than a single approach. However, pursuing a mix does not conflict with a national strategy of scaling up cash transfers for the most vulnerable fami- lies. Cash transfers are featured here because they offer an effective strategy for relatively quickly reaching AIDS-affected families who are the very poor- est, most constrained, and at risk with respect to human capital. These are important considerations given the extent and nature of deprivation, the long-term risk to human capital, and the current international and national political willingness to act surrounding HIV and AIDS. Additional knowledge gaps remain. These include gaps on operational


issues such as the appropriate size of the cash transfer and how to give it flexibility under changing circumstances (for example, prices, markets); the number of transfers per household; whether, when, and how to transition households out of a program and into what to transition it; and how to scale up a program and the roles for government, NGOs, and CBOs in program implementation and service delivery.1 Other questions pertain to human capital objectives and service delivery: what is the current status of services, what is the potential for improving them, and how can these constraints be overcome? Although poor infrastructure and low levels of administrative capacity are real constraints to the functioning of social protection programs, these have been overcome in some very poor countries and can be mitigated by careful program design and oversight and by the use of NGOs where gov- ernment services are insufficient. Still other questions pertain to political economy: how much will the program cost, is this “affordable,” who will pay for it, and how can this strategy be made politically viable? The last question is perhaps the most critical; ambitious plans to scale up in some countries have not received the follow-through anticipated, in substantial part due to political ambivalence. Another concern is the relative cost-effectiveness of different social pro- tection mechanisms, such as cash transfer programs versus free healthcare.


1See Fiszbein and Schady et al. (2009) and Samson, van Niekerk, and MacQuene (2006) for reviews of other cash transfer design issues.


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