Social Transfer Schemes according to ART Patients

CARE International Zambia Learning Product May 2012

Cash or Food?

17 Clients Tell their Story
This Learning Product looks at the Katete ART Adherence Study – from the perspective of 17 clients: Out of a total of 351 beneficiaries of either cash or food transfers, these 17 have consented to share their experiences. All of them are HIV positive – and all of them are on Anti-Retrovirals (ARVs). The Katete ART Adherence Study took place in Katete District in Eastern Province, where most of the clients live in villages dotted around the district. Katete is a predominantly rural district, with the majority of the beneficiaries relying on agriculture-related activities for both food and income. Produce such as maize, onions and tomatoes are typically sold at markets or roadsides. Even if income comes from sources other than agriculture, such as brick-making or radio repair, almost everyone is cultivating a field or small garden for their own consumption. Accordingly, most clients ploughed part of their cash into agriculture, buying inputs such as seed and fertiliser, livestock such as chickens, cows and pigs in particular, and ox-carts. Even if the clients received food transfers, their disposable income increased, as they would use their own money, otherwise intended for food, for other necessities. Some clients, such as Estele Banda, even sold part of her food transfers.

The Katete ART Adherence Study
Adherence to Anti-Retroviral Treatment (ART) is a key factor to its success, by maintaining viral suppression and preventing drug resistance. However, several factors influence ART adherence, including food insecurity. Patients, who are poorly nourished are more likely to experience side-effects of ARVs such as nausea, vomiting, dizziness and fainting. They have higher rates of mortality and morbidity, and are more likely to drop out of treatment due to side-effects. Among several social protection measures, cash or food transfers are increasingly being used as methods for improving nutrition and adherence to treatment. However, there is limited information on their comparative impact and cost effectiveness. The Katete ART Adherence Study sought to address this gap by comparing two equal value transfer packages for clients initiating ART. Clients either received a monthly food transfer (25 kg roller maize meal, 4 kg beans, 2 kg sugar, 2.5 litres vegetable oil and 1 kg salt) or the equivalent in cash, varying from K100,000 ($20) in August 2010 to K150,000 ($30) in September 2011. Clients received their transfers for 8 months, and were evaluated at baseline, midline and endline. The interviews, which form the basis of this Learning Product, were carried out at endline. A total of 351 clients (male and female aged 18 to 55 years) were enrolled in the study, but at endline the number had dropped to 305, as some clients died after having started ART too late, while others moved away. The ART Study was carried out by the Government of Zambia’s National Food and Nutrition Commission (NFNC), University of Zambia (UNZA), University of the Free State (South Africa), St. Francis Hospital in Katete, and CARE International Zambia; and was funded by UK aid from the Department for International Development (DFID).

After her husband died in 2010, Estele Banda, 40, decided to get tested – and was found positive. She soon started on food transfers, but sold part of the received beans, sugar, salt and cooking oil, and used the proceeds to buy tomatoes and onions for re-sale at a profit. Estele said the extra food made her fit to do many chores including tending to her business. Estele looks after five children of her own plus two dependants, and part of the money was used to pay school fees and clothes.

CARE’s work in Social Protection
Since 2004, CARE International Zambia has worked with DFID, UNICEF and the Platform for Social Protection, a Zambian civil society network, on a number of Social Protection projects, aimed at increasing the capacity of institutions and the most vulnerable in society to better manage risks associated with food insecurity, destitution and HIV/AIDS.

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Anasi Sakala, 40, used to be too weak to do much work, but she only went to the clinic when her 7-year-old daughter fell sick and tested positive. Anasi used her cash transfers to buy food until her field started producing. Then, she bought reed mats and plates. Despite her body weight dropping during the study, Anasi said she had regained her strength on ART and can now perform household chores such as collecting firewood, farming and cutting grass for sale. Anasi is not married and has four children.

Clients prefer Cash over Food
The majority of the 17 clients interviewed for this Learning Product preferred cash over food transfers (see table): Among the 10 beneficiaries receiving cash, 8 stated they preferred it this way – and 2 of the 6 clients on food transfers would rather have received cash, with one of them even selling some of the received food to convert it into cash. Most beneficiaries pointed out that cash can be used to buy food AND to pay for other expenses such as clothes, school fees, agricultural inputs and housebuilding. Many mentioned the need to look beyond the ART study by investing in the future. Eletina Tembo, Elifasi Banda, Julia Daka and Zenaida Mbewe all bought pigs for breeding, and several clients invested in their respective businesses, with most of them selling farm produce such as maize, onions and tomatoes. Anasi Sakala pointed out that cash can be used to pay others, when one is too weak to work in the field – and when strength returns, “there is no need to receive food”, said Nelson Phiri, as you now can grow it yourself. Both Julia Daka and Zenaida Mbewe preferred cash because it is cheaper to buy two buckets of maize and have it ground into mealie meal, instead of receiving a 25 kg bag of roller meal, as the two buckets will last more than a month – and leave cash for other things. And Tionenji Banda and Pearson Jere said cash enabled them to buy food of their liking. Only three clients preferred receiving food over cash. Andilola Kondanani Mwanza and Mathew Banda, both on food transfers, pointed out that food prices may change, forcing clients on cash transfers to compromise on quantity or quality of food. Especially because there is a risk of misusing cash for other things than food – as pointed out by Nicholas Miti; the only cash-receiving client to say he would have preferred food over cash. The support staff at St. Francis Hospital also recommended food transfers, emphasising that cash could be misused – and reported that cash transfers sometimes could cause problems in households, with one woman telling her husband: “What can you tell me, I have cash to sustain myself!”

Surrounded by his green maize, Nelson Phiri, 50, is a testimony to the importance of proper nutrition. When he was put on cash transfers, Nelson was bedridden, leaving his wife to feed the family including its two children. “I used to feel hungry quite often,” explained Nelson. He used the cash to buy food and other items such as soap, fertiliser and hoes. He now considers himself very fit, with the energy to grow enough food for the family – and has encountered a new problem: People have begun stealing from his field.

Andilola Kondanani Mwanza, 66, was bed-ridden before he started on food transfers. The food helped him take his medicine and gain strength. He is now able to cycle the eight kilometre roundtrip from Kapiko Village to Katete – and to cultivate his fields. Andilola has neither wife nor children but his small farm supports seven people. He shared the transfers with everyone, and used his own money to buy clothes and other goods such as plates, fertiliser and seeds. “I have lots of clothes now,” Andilola grinned. The ART study has also made him share his HIV status with his family and community, helping other people to come to terms with their HIV status.

Zenaida Mbewe, 46, is apprehensive about the future, now that her cash transfers have ceased. She is divorced and looks after five children. Zenaida explained that she spent about K90,000 ($18) per month of her transfers on maize and vegetables, and that the food had helped her adhere to the ARVs and regain her strength. The rest of the transfers she saved to buy a pig for breeding. She hopes the money raised from the sale of pigs will allow her to buy enough food for the family beyond the eight months’ support.

Katete Client Preferences (cash versus food): Received: Prefer No of clients Received: Prefer No of clients CASH Cash Food Undecided/undisclosed 8 FOOD Cash Food Undecided/undisclosed 2 2 3 1 1

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Learning Product

When Julia Daka’s husband became very sick, she, being a trained caregiver, advised him to get HIV tested. Both of them tested positive, and Julia, 45, was enrolled on cash transfers. She used the money to buy food, fertiliser and two pigs. Julia explained that the food helped her regain her strength, and put her weight-loss during the study period down to the pressure of harvesting. She complained that the transfers were insufficient, but did manage to buy enough food to last until the next transfer. Julia is very open about her HIV status: “In this way I have helped a lot of people to get tested,” she said.

Tionenji Banda, 40, is alone with five children after her husband died in 2010. She explained that the food transfers under the ART study had brought her closer to self-sustenance. Before starting on ARVs, she was too sick to cultivate her garden, but the food helped her take the drugs without problems. “I now feel stronger,” explained Tionenji, who is back in her garden, producing vegetables, which she sells at the market. She used her own money for other requirements such as soap, clothes and plates. Tionenji’s increased income has also enabled her to buy a cow at K1,000,000 ($200).

Mathew Banda’s wife divorced him after both of them were found HIV positive. Due to failing health, he had to move in with his sister, who already had seven dependents. In October 2010, he started on ART and enrolled on food transfers. The food cushioned the side-effects of the ARVs and helped him regain weight and strength. Mathew, 35, can now assist his sister in cultivating the field. He pointed out that the ART study had encouraged many people to seek medical help.

Henry Jailos Zulu, 47, had been unwell for a long time. When he finally went to the clinic, he had a low CD4 count of 54 - and was put on ARVs and cash transfers. With the cash he bought food such as maize, vegetables and fruits for himself and his HIV-positive son (Henry’s other four children are away at school). The food minimised the ARVs’ side-effects and restored him to an active life, Henry explained. He used part of the money to pay school fees and still managed to save K50,000 ($10) every month. The savings were put into cement and roofing sheets to build a grocery shop (although he is now short of capital to stock it). Henry has also started making and selling bricks to supplement the cash support.

Elifasi Banda, 43, is looking after his five children, after his wife died in 2010. That same year he tested positive to both HIV and TB - and was enrolled on cash transfers. With a remarkable weight gain from 52.6 kg (baseline) to 74 kg (midline), he now has the strength to build houses, providing him with an income, which he reckons will sustain him beyond the study. Part of his earnings was used to build his own house. The cash transfers were used for food, school fees and investments, including two pigs worth K300,000 ($60) and five iron roofing sheets for his house. The cash support “has helped me rebuild my life,” said Elifasi.

Persistent headache and weakness sent Gladys Chakonda Daka, 41, to the clinic. She was enrolled on cash transfers at a critical time, when she was struggling to raise money for food. She used part of the money to start a business selling scones and fritters, which generates a monthly income of about K100,000 ($20). Gladys said she had regained her strength since starting on ARVs, and is now doing a lot of household chores and a bit of farming. She is separated and lives with four children.

Bernadet Banda, 20, was enrolled on food transfers in January 2011. Her unstable health had prevented her from weaving reed mats, reducing her income, but now she has a big garden with onions for sale, and Bernadet has used part of the proceeds to buy an ox-cart worth K2 million ($400). The food transfers enabled her to use her own money on other household items. Bernadet explained that the food helped her controlling nausea and vomiting when taking ARVs. She is married with no children.

Pearson Jere, 43, had an exceptionally low CD4 count of 7, when he started on ARVs and cash transfers. With his wife having passed away, the money enabled a bedridden Pearson to feed himself and his five children. The food enabled him to adhere to his ARVs, as he no longer felt weakness and mental stress after taking them. His CD4 count increased to 72, and he has restarted his business of repairing radios and computers. He used part of the cash transfers for school fees, bricks for a toilet and a second-hand TV. “If it wasn’t for this support I could have died,” Pearson said.

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Learning Product
Talakwanji Banda, 26, got tested because she was feeling “uncomfortable in the body”. Both she and her husband tested positive, and Talakwanji was later enrolled on food transfers. The food helped her adhere to the ARVs. Before, she felt dizzy, and had even fallen over. She is now strong enough to grow onions and maize for sale, and the family has bought an ox-cart worth K2,000,000 ($400). Her own money has been used on items such as clothes and school fees. Talakwanji shared her food transfers with the whole family, especially her five children and their grandmother. Nicholas Miti, 49, used to be a heavy beer drinker, and found it difficult to stop after starting ART: “It took time for me to stop drinking beer,” he sighed. Nicholas was later enrolled on cash transfers, and the combined support of the ART study and his wife has helped him to recover enough to revamp his garden. He now sells tomatoes, and the proceeds are used to buy food and pay school fees for his four school-going children (Nicholas has nine children altogether). With the cash transfers he also bought four egg-laying chickens, and saved at least K50,000 ($10) per month to buy roofing sheets for his house.

Client Recommendations
• Transfers were administered through an e-voucher system:
A client would receive a scratch card at St. Francis Hospital, which would be converted to cash or food at one of two retail agents (Isusyas General Dealers or Makwacha Agent). Mobile phone and internet services were required at both stages for client ID. The reliance on technology posed a problem (Henry Jailos Zulu complained about delayed vouchers and Isusyas General Dealers suggested to not rely on the internet in the future: “You don’t have to keep a patient waiting for six hours to get K150,000 ($30)”). However, most clients were happy with the system. Men especially pointed out that they had been treated with respect, although some women had been paid too little by Makwacha, allegedly due to shortage of change. In most cases this problem had been resolved by CARE.

• Decentralise the voucher system (Anasi Sakala sometimes
missed her next transfer, if she failed to borrow money for transport, and St. Francis Hospital pointed out that some clients were frail and weak). suggested to include fertiliser and St. Francis Hospital suggested business development skills training). (Eletina Tembo and Julia Daka). (Andilola Kondanani Mwanza).

• Increase the study’s sustainability (Talakwanji Banda • Increase cash transfer to K200,000 ($40) • Distribute breakfast meal rather than roller meal

End Note
Social Transfer Schemes (cash or food) are increasingly seen as crucial to ART adherence; however, their comparative impact on key outcome indicators (ART adherence, CD4 count and nutritional status as measured by Body Mass Index) is still subject to debate. The 17 clients in this review certainly preferred cash, referring to the need to invest for the future; but the study’s midline evaluation showed significant improvements in all indicators, with no apparent differences between food and cash transfers. It would therefore be relevant to look at long-term household sustainability when comparing the impact and cost-effectiveness of the two transfer types. All the 17 clients in this review had a success-story to tell, lending impetus to the need for scaling up Social Transfer Schemes to all ART patients in Zambia; however the 17 volunteered to be interviewed, and may not be representative of all clients in the ART study. Findings will be corroborated by the study’s end survey.

Two health education sessions about HIV testing convinced an otherwise healthy but pregnant Eletina Tembo, 33, and her husband to get tested. Both tested positive, and Eletina was enrolled on cash transfers in February 2011. She used the cash to buy food, fertiliser for her maize field and to pay school fees for her two dependants. She also continued with her business of selling oranges, tomatoes and bananas. Although Eletina complained that the cash transfers failed to sustain her for one month, she still managed to save enough to buy two pigs, “which I am keeping for future sale”. One day, after falling suddenly sick, Tisauke Sakala, 25, tested HIV positive, but when she told her husband, he announced he had been on ARVs for some time without telling her. This broke her heart and led to their divorce. Tisauke now lives with her two (HIVnegative) children at her grandparents’ house. Tisauke explained that the food transfers had saved the family from starvation because they arrived at a time when there was no farm produce and the grandparents’ brick-making business made inadequate money. The food helped her adhere to ART, and she can now do household chores, farm and mould bricks. She has moulded 1,000 bricks, which she expects to sell for about K1,250,000 ($250).

Republic of Zambia

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For further information, pleace contact: CARE International Zambia, Protea Road, Fairview, P.O. Box 36238, Lusaka, tel: +260 211 221701, email: info@carezambia.org

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