Candace Miller

Why are antiretroviral treatment patients lost to follow-up? A qualitative study from South Africa.

Objectives  To better understand the reasons why patients default from antiretroviral treatment (ART) programmes to help design interventions that improve treatment retention and ultimately, patient outcomes.

Orphan Care in Botswana’s Working Households: Growing Responsibilities in the Absence of Adequate Support

OBJECTIVES Botswana has one of the worlds highest HIV-prevalence rates and the worlds highest percentages of orphaned children among its population. We assessed the ability of income-earning households in Botswana to adequately care for orphans. METHODS We used data from the Botswana Family Health Needs Study (2002), a sample of 1033 working adults with caregiving responsibilities who used public services, to assess whether households with orphan-care responsibilities encountered financial and other difficulties. Thirty-seven percent of respondents provided orphan care, usually to extended family members. We applied logistic regression models to determine the factors associated with experiencing problems related to orphan caregiving. RESULTS Nearly half of working households with orphan-care responsibilities reported experiencing financial and other difficulties because of orphan care. Issues of concern included caring for multiple orphans, caring for sick adults and orphans simultaneously, receiving no assistance, and low income. CONCLUSIONS The orphan crisis is impoverishing even working households, where caregivers lack sufficient resources to provide basic needs. Neither the public sector nor communities provide adequate safety nets. International assistance is critical to build capacity within the social welfare infrastructure and to fund community-level activities that support households. Lessons from Botswanas orphan crisis can provide valuable insights to policymakers throughout sub-Saharan Africa.

Perceptions of per diems in the health sector: evidence and implications

Per diems are used to pay work-related expenses and motivate employees, yet they also can distort incentives and may be abused. This study was designed to explore perceptions of per diems among 41 high-, mid- and low-level government officers and non-governmental organization (NGO) officials in Malawi and Uganda. Interviews explored attitudes about per diems, benefits and problems for organizations and individuals, and risks and patterns of abuse. The study found that per diems provide benefits such as encouraging training, increasing staff motivation and supplementing salary. Despite these advantages, respondents voiced many discontents about per diems, stating that they create conflict, contribute to a negative organizational culture where people expect to be paid for all activities, and lead to negative changes in work time allocation. Work practices are also manipulated in order to maximize financial gain by slowing work, scheduling unnecessary trainings, or exaggerating time needed for tasks. Officials may appropriate per diems meant for others or engage in various forms of fraud for personal financial gain. Abuse seemed more common in the government sector due to low pay and weaker controls. A striking finding was the distrust that lower-level workers felt toward their superiors: allowances were perceived to provide unfair financial advantages to already better-off and well-connected staff. To curb abuse of per diems, initiatives must reduce pressures and incentives to abuse, while controlling discretion and increasing transparency in policy implementation. Donors can play a role in reform by supporting development of policy analysis tools, design of control mechanisms and evaluation of reform strategies.

Targeting Cash to Malawi's Ultra-Poor: A Mixed Methods Evaluation

Governments target transfers so that limited resources reach impoverished households; targeting errors therefore indicate inefficiency in resource use and inability to reach the poorest households. This article examines the Malawi Social Cash Transfer Scheme (SCTS), using mixed methods and multiple data sources, including examination of underlying assumptions, the operationalisation of key concepts, questions of implementation, and errors of inclusion and exclusion. Despite serious challenges, the schemes error rates are within the range of global averages. Its impressive impacts provide strong motivation for improving the targeting process before it is scaled up to the national level.

PEPFAR’s Support For Orphans And Vulnerable Children: Some Beneficial Effects, But Too Little Data, And Programs Spread Thin

Sixteen million children in developing and middle-income countries have been orphaned by HIV/AIDS, and at least another million children per year are rendered vulnerable by parental HIV/AIDS-related illness. Since 2003 the US government has provided approximately

ARVs and cash too: caring and supporting people living with HIV/AIDS with the Malawi Social Cash Transfer.

1.6 billion to give four million of these children care and support through the Presidents Emergency Plan for AIDS Relief (PEPFAR). We conducted five studies to evaluate the effectiveness of PEPFARs interventions for such children in East Africa and southern Africa. We found evidence of beneficial changes in school enrollment rates and on the psychosocial well-being of children. However, we could not demonstrate empirically the impact of most of the PEPFAR initiatives that we examined, primarily because of a lack of baseline data and clear outcome and impact indicators. We also found that many programs were spread so thin across a vulnerable population that little in the way of services actually reached beneficiaries, which raises questions about whether PEPFAR funds are sufficient, or if the program is attempting to do much with too few resources. We offer several recommendations, including better measuring the effect of programs for orphans and vulnerable children by collecting baseline data and conducting well-designed, rigorous outcome and impact evaluations.

Interrupting the intergenerational cycle of poverty with the Malawi Social Cash Transfer

Objectives  The Malawian Social Cash Transfer Scheme (SCT) is a social protection programme for ultra poor and labour‐constrained households, including people living with HIV/AIDS (PLWHA). We aimed to gain insight into respondents’ circumstances prior to becoming transfer beneficiaries and to examine how PLWHA used transfers to support themselves and their families.

Cash Transfers and Economic Growth: A Mixed Methods Analysis of Transfer Recipients and Business Owners in Malawi

Cash transfer programs throughout the world were designed within a Social Protection framework to alleviate poverty in the short term and to interrupt the long-term intergenerational cycle of poverty. In this study, we examine the potential of the Malawi Social Cash Transfer Scheme (SCTS) to interrupt the intergenerational cycle of poverty in ultra-poor and labor-constrained households in Malawi. Using qualitative data from 16 focus groups with 163 children, we map the voices of children to various dimensions in a framework of intergenerational poverty. The framework identifies financial, material, environmental, human, social, cultural and political capital as important inputs for older generations to transfer to younger ones in order to avoid lifelong poverty. We found that focus-group participants reported dramatic and widespread changes in their lives resulting from the cash transfer in nearly all of the frameworks dimensions. Participants reported that the cash allowed them to gain access to goods and materials, including food, healthcare, school supplies, clothing, blankets, housing and livestock. Respondents described changes in their lives, such as providing less labor for the household, allocating more time to schooling, enjoying adequate and high-quality foods, accessing healthcare and purchasing medicine. They also described better mental health, with new hopes and dreams for the future. These changes have the potential to interrupt the intergenerational cycle of poverty. Nevertheless, despite these widespread and positive benefits to children, whether the SCTS will become part of the national policy, and the schemes long-term sustainability, is still uncertain.

Measuring Vulnerability Among Orphans and Vulnerable Children in Rural Malawi: Validation Study of the Child Status Index Tool

Social protection policies that simultaneously reduce poverty and stimulate economic growth and development will be transformational for direct recipients and disadvantaged communities. This study assessed whether the Malawi Cash Transfer stimulates economic growth in the communities where it is operational. Data collection was conducted in Mchinji Malawi from 2007-2009. This study is based on data from two sources including 1) a randomized community control trial designed to measure the impact of the cash transfer and 2) qualitative interviews with business owners. Over the course of one year, the cash transfer intervention group had increased demand for and increased expenditures on foods, basic necessities, livestock, healthcare, and schooling supplies versus the comparison group whose expenditures remained low throughout the study. Additionally, cash transfer households invested in productive assets and farming equipment, which led to greater agricultural production, consumption and sales. The majority of business-owner respondents confirmed that transfer recipients are frequent customers and reported that sales to transfer recipients were an important part of their business. Respondents reported that the transfer strengthened local markets by providing a steady source of customers and cash, with reliable sales even during the rainy season. Business owners grew their businesses, earned additional profits and some made investments in infrastructure and capital. This study yields insights into the mechanisms by which cash transfers impact economic growth and contributes to the discourse on social protection strategies. Once the cash transfer scheme is operational throughout Malawi, it appears as though there will be important impacts for recipients, non-recipients and local businesses. Findings from this study may be applicable throughout resource-poor countries in Africa. Still, continued follow up and larger studies are needed to determine the consistency and scale of impacts on economic growth and development.

The impact of the Social Cash Transfer Scheme on food security in Malawi

Objectives:To validate the Child Status Index (CSI) as an instrument that can meaningfully measure the vulnerabilities of orphaned and vulnerable children, including those infected and affected by HIV/AIDS. Methods:Two age-specific instruments, comprised of previously validated tools and indicators commonly considered best practice, were administered to 102 children aged 5-10 years and 100 children aged 11-17 years in Mchinji, Malawi. Respondents were randomly sampled from a roster of children recently scored with the CSI. For each of the CSIs 12 subdomains, we assessed construct validity using Spearman Rank correlation coefficients. We also calculated cross tabulations to explain the resulting correlation coefficients. Analyses were conducted separately for the 2 age groups. Results:No relationships exceeded the standard for high construct validity (≥0.7). Only 2 were moderate (0.3-0.7), both for the younger age group: food security (0.4) and wellness (0.36). All other relationships were weak or negative. In most subcategories, a substantial proportion of surveyed children indicated distress that was not evident from CSI scores. In the abuse and exploitation subdomain, all children were rated as “good” or “fair” by the CSI, but among surveyed children aged 11-17, 20% or more reported being beaten, kicked, locked out of the house, threatened with abandonment, cursed, and made to feel ashamed. Conclusions:In this rural Malawi population, we were not able to validate the CSI as a tool for assessing the vulnerabilities of orphaned and vulnerable children. We recommend caution in interpreting CSI scores and revisions to the tool before global scale-up in its use.