The Role of Families Among Orphans and Vulnerable Children in Confronting
8.6 Strategies for Intervening to Support Vulnerable Children and Families
8.6.1 Targeting the Most Vulnerable Children and Their Families
Policy makers and service providers struggle with which children and families will receive scarce services. Targeting effective prevention and treatment programs will result in benefi cial effects on children and families. In one study, access to antiret-roviral therapy among adults led to an 81% reduction in mortality in their under 10-year-old uninfected children and orphanhood was estimated to be reduced by 93% (Mermin et al. 2008 ) .
While orphans and their families are faced with multiple challenges, they are not the only children who are at risk for poor developmental outcomes. Programs that only target children that have been orphaned are missing large numbers of children who are vulnerable, either due to their parent’s illness or other social or economic reasons.
Resources may then be distributed inappropriately and inequitably (Foster 2006 ) . Targeting vulnerability based on need refl ects a paradigm shift from individual orphans to highly vulnerable children within highly vulnerable families in the con-text of widespread, chronic poverty (Irwin et al. 2009). This is based on fi ndings that vulnerability is inextricably tied to poverty. Local community input can help to develop context-specifi c criteria for resource distribution (Schenk et al. 2008 ) . Characteristics which are associated with children most in need of external support are (1) children living with someone chronically ill, (2) children taken in from another household, (3) children living with other children who have been taken in from another household, and (4) children living in a household headed by someone who is female, elderly, or widowed.
Having identifi ed the children and families most in need of support, the report entitled Children on the Brink (UNICEF 2006 ) proposes fi ve core strategies to guide the response to those children and families most in need of external support:
(1) strengthen and support the capacity of families and communities to cope and care for their children; (2) mobilize and strengthen community-based responses;
(3) strengthen the economic capacity of children and adolescents to realize their
rights and fulfi ll their basic needs; (4) build on the ability of government to protect the most vulnerable children and provide essential services; and (5) raise awareness within societies to create a supportive environment for affected children and fami-lies. Additional reports issued by UNICEF since the Children on the Brink report have continued to lay out concrete goals for those working to help children and families affected by HIV/AIDS (UNICEF 2010 ).
8.6.2 Economic Strengthening
Considerable attention has been focused on strategies to improve the economic cir-cumstances of families. Economic strengthening has been defi ned as “approaches to strengthen the capacity of caregivers and communities to address the fi nancial issues to ensure vulnerable children are able to access essential services, including safety, healthcare, education, and other basic needs” (USAID 2008 p.11). A range of pro-grams have been developed: (1) cash transfer propro-grams, (2) child support grants, and (3) youth savings accounts.
8.6.2.1 Cash Transfer Programs
Cash transfer programs or income transfers provide support to poor families for a range of needs, including food, transportation, education, and health care (Adato and Bassett 2008 ) . Transfers can be tied to requirements that the recipients must follow such as attending health care appointments and attending school (conditional cash transfers, CCT) or they can be provided without any requirements (uncondi-tional cash transfers, UCT). CCT programs have proven to be effective in reducing poverty in the short term and health outcomes by increasing household incomes among poor families (Lagarde et al. 2009 ) . They have also increased school enroll-ment and attendance, especially in middle school. Substantial improveenroll-ments in health and nutrition have been observed in the children enrolled in these programs.
While most cash transfer programs have been developed in Latin America, there is increasing interest in adopting this strategy in sub-Saharan Africa. Because the economy in South Africa is the most similar to Latin America, an experiment called Scaling Up is currently underway. There are also pilot programs in Malawi (Baird et al. 2009 ; Schubert et al. 2007 ) and Zambia (Schubert et al. 2007 ) which are both areas with high HIV prevalence. Most of these cash transfer programs have focused on health outcomes and the use of health services (Adato and Bassett 2008 ; Lagarde et al. 2009 ) , and school enrollment and attendance (de Janvry and Sadoulet 2004 ; Schultz 2004 ) . A cash transfer study by The World Bank (Baird et al. 2009 ) found that there were strong effects on schooling after 1 year among students who had already dropped out of school at baseline as well as for those who were still in school. The baseline dropouts tended to be older, more sexually active, and from poorer households that are more likely to be female headed. Researchers are
beginning to document more distal outcomes such as sexual behavior (Baird et al.
2009 ) , whereby youth receiving cash transfers reported less sexual activity.
A report on children, AIDS, and poverty reviewed over 50 studies and suggested that “income transfers as ‘a leading edge’ intervention to rapidly improve outcomes for extremely vulnerable children and families” (Irwin et al. 2009). This report suggests that cash transfers to women in households improve children’s outcomes.
A review of cash transfer programs found that even though families were targeted on the basis of poverty, 70% of cash transfer programs ended up targeting HIV/
AIDS affected families (Adato and Bassett 2008 ).
8.6.2.2 Child Support Grants
In order to address the needs of children living in poverty, a number of sub-Saharan countries provide child support grants to families in need. One of the largest pro-grams is in South Africa which is a nonconditional means-tested cash transfer tar-geted at poor children. The program initially tartar-geted children under 7 years old, but this has been periodically raised and now includes all children under the age of 18 years old (Kibel et al., 2010 ). Child support grant systems identify a child’s pri-mary caregiver as the person who has the pripri-mary responsibility for the child on a daily basis and that person receives the support. In an evaluation of the program, 36% of all children under the age of seven have had some contact with the child support grant system, with no difference in the contact for girls and boys (Case et al.
2005 ) . Children for whom the grant is being obtained have parents who are less well educated and who are less likely to be employed. Children whose fathers have died are signifi cantly more likely to be receiving a grant. While there has not been a controlled study, an evaluation did fi nd that school enrollment among 6 and 7 years old children was higher for those who had received a grant. An added benefi t of these programs is the likelihood that more adults are willing to take in an orphan if there is assistance to the family and nondirect fi nancial assistance, such as paying for the child’s education and providing for a trained person to assist in care, were included ( Freeman and Nkomo 2006a, b ) . However, 28% of best friends, 29% of strangers, 15% of fathers, and 17% of grandparents said they would decline to take children if they were HIV positive.
8.6.2.3 Children Savings Accounts
Asset theory predicts that an orphaned adolescent who does not believe that there will be family funds to support postprimary education is more likely to experience high levels of depression, academic diffi culties, drop out of school, and experience negative health consequences (Zhan and Sherraden 2003 ; Sherraden 1990 ) . If fami-lies and children can be provided with the economic means, children’s expectations for the future and their well-being lead to continued schooling, and positive health