An Overview: Linda Richter Global Partners Forum, Dublin, 2 October 2008

What is JLICA?

• Diverse, independent, multidisciplinary, time-limited

• 4 Learning Groups (Framework)

• 40+ authoritative research outputs – all externally reviewed

• Thousands of inputs

• Providing solid evidence for bold action

Presentation

The global response to date:

• Accepting our failures

• Reframing the response

• New directions for policy and action

Accepting Failures - 2007• 17% of new infections – failures of vertical

prevention

• 2.1m children living with HIV globally – 90% in SSA

• <10% of eligible children receive• early diagnosis of HIV at 6 weeks• co-trimoxasole or ARV treatment

• Increasing parental deaths

• Only 15% children/families receive external help

Children living with HIV globally 1990-2007

0

500,000

1,000,000

1,500,000

2,000,000

2,500,00019

90

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Num

ber o

f Chi

ldre

n

Asia Eastern Europe & Central Asia LAC Sub-Saharan Africa Global

Global

SSA

Orphaned children in SSA

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

1990 1995 2000 2002 2003 2004 2005 2006 2007

Num

ber

of O

rpha

ns

Orphan misunderstandings

• AIDS orphans ±37% of orphaning – 18.2m orphans!

• 80% of “AIDS orphans” have a surviving parent

• “Orphan” - confusing, miscomm-unicated, distorting the response

• Orphans are not the only or necessarily the most needy

Problems with data• Lack of data – gaps (5-14 years)

• Not consolidated - age inconsistencies, across agencies

• Poor data – 71% of 273 studies don’t define orphan

• Proliferation of non peer-reviewed grey literature

• Available good data not well used or disseminated

Child-headed households

• <1% in 40 SSA surveys

• Very small, if any, in DSS sites in SSA

• 0% in Karonga (Malawi) and Kisesa (Tanzania)

• <2% in Africa Centre (SA)• Only data errors in Agincourt (SA)

• <1% across 5 cross-sectional HH surveys (1995-2005) (SA)

October Household

Survey 1995 (%)

October Household

Survey 1997 (%)

October Household

Survey 1999 (%)

General Household

Survey 2002 (%)

General Household

Survey 2005 (%)

Note: Source: Own calculations based on Stats SA data.No child in household

- - - - -

No adult - only children

0.11 0.34 0.45 0.67 0.66

Skip-generation 1.69 2.44 2.23 2.3 2.29

Young adult (18-25) with children

1.22 1.86 1.71 1.88 2.27

Single adult with children

7.31 9.28 9.39 9.71 11.27

Other 89.68 86.09 86.22 85.44 83.52Total 100 100 100 100 100

Percentage of children living in different household types in

South Africa (1995-2005)

Source: Richter and Desmond 2008

Roots of our failure

1. It is not only orphaned children who are affected

2. Critical gaps in essential services3. Families, many in extreme

poverty, support children without assistance

4. Family poverty & gender inequality undermine children’s outcomes

1. It is not only “AIDS orphans” …

• Parental mortality in general

• JLICA reviewed 383 “orphan” studies• 75 empirical • Consistent detrimental effects• Neither poverty nor HIV controlled• Effects adversity and/or ill-health?

• Education is a vulnerable area, but gap narrowing (data 15 countries)

• Stigmatising effects of targeting

2. Implementation failures and gaps

• PMTCT, infant testing, prophylaxis, treatment

• Children much less likely to receive treatment than adults in the same settings

• Integration of HIV/AIDS services

• Universal primary health care

• Universal primary education

3. Families support children

• HIV and AIDS cluster in families

• >95% of affected children live in families

• Only 15% receive external help

• Families absorb ±90% of cost of impact on children

• Families are a critical network to expand prevention, treatment & care

4. Undermining child outcomes

• Family poverty• + 60% of children in SSA live in poverty• By very low poverty lines• Kagera survey RIATT: $3.5/month average

family of 3• HIV/AIDS impoverish families – 25%pm• Consumption drops – food, education, care• Child labour increases• May limit expansion of prevention and

treatment

• Gender inequalities• Drive infections

Reframing the response

Five key lines of action:1. Support children through families2. Build social protection to protect the

weak and vulnerable3. Expand income transfers to poor families4. Implement comprehensive & integrated

family-centred services5. Address powerlessness of women &

girls

1. Support children through families

• Optimal care arrangement for children• Most children are in family care• Families have responded – at cost• Preferable to orphanage/ group

residential care • Families are a critical entry point for

prevention, treatment & care• Strengthen the capacity of families

Strong arguments against orphanages

• Cater overwhelmingly for poor rather than orphaned children

• Well-established negative effects on brain, language, cognitive, emotional & social behaviour

• Cost up to 10 times family care• Opportunity cost of not investing in families • De-institutionalisation is very costly to

children & society

Strengthen families

• Family-centered PMTCT & other HIV/AIDS interventions

• Keep families intact through treatment• Support extended family fostering• Provide home health visiting & ECD• Support community organizations that

backstop families• Build social protection

2. Build social protection

• Individual, family & social impoverishment makes it harder to prevent HIV & mitigate AIDS

• Responds to children’s needs – cut consumption, schooling, care and increase labour & mobility

• On developmental agenda & responds to popular concerns

• HIV/AIDS adds impetus to human rights arguments

3. Expand income transfers

• Provide relief, avert borrowing, sale of assets• Demonstrated effectiveness in poor

countries• Can take variable forms• Affordable eg Mozambique, Lesotho• Reduces intermediaries, overheads• Enables uptake of essential services• The entry point for improved social

protection

Transfers increase spending on children’s basic needs

Use of Cash Transfer by Program

0%

10%

20%

30%

40%

50%

60%

70%

80%

Food Education Health Other Savings &Investment

South Africa OAP Zambia SCTS

Kenya Cash Transfer for OVC Mozambique INAS (urban)Namibia Old-Age Pension (urban) Malawi DECT

Malawi FACT

Source: Adato and Bassett, 2008 JLICA

4. Integrated family-centred services

Income transfers increase use of services.JLICA review of successful programmes:• Partnerships under government leadership• Community-based care system linking

medical & social support services• HIV/AIDS services integrated with poverty

reduction (income transfers, job creation)• Community health workers• Funding commitments (least 5 years)

4. Structural changes for girls

• Empower women through increased social protection & income transfers

• Keep girls in school – secondary education

• Increase physical safety of girls

• Address men’s values, roles and prospects – work

Directions – way forward• National social protection, starting

with income transfers, is critical to improve children’s outcomes

• Target programmes based on need, not HIV or orphan status

• Adopt family-centered models in social policy & service delivery

• Prioritize structural prevention measures to address gender inequalities

The Joint Learning InitiativeThe Joint Learning Initiative on Children and HIV/AIDSon Children and HIV/AIDS

www.jlica.org