OVC CARE: INDIA
Boston University OVC-CARE Project
Assessing the Karnataka Cash Transfer
Site visit to Bangalore, Mysore, Dharwad and Bagalkot
Dr. Candace Miller
Center for Global Health and Development
Boston University School of Public Health
801 Massachusetts Avenue, Crosstown 3rd Floor
Boston, MA 02118, USA
Candace@bu.edu
617-414-1216
The USAID | Project SEARCH, Orphans and Vulnerable Children Comprehensive Action Research
(OVC-CARE) Task Order, is funded by the U.S. Agency for International Development under
Contract No. GHH-I-00-07-00023-00, beginning August 1, 2008. OVC-CARE Task Order is
implemented by Boston University.
OVC-CARE India Work Plan
2/18/2011
Table of Contents
Map of Karnataka.......................................................................................................................................... 3
Acronyms ...................................................................................................................................................... 4
Methods ........................................................................................................................................................ 5
Context .......................................................................................................................................................... 5
Leadership ..................................................................................................................................................... 5
Policy debates ............................................................................................................................................... 6
Collaboration................................................................................................................................................. 6
Design............................................................................................................................................................ 6
Possible Linkages........................................................................................................................................... 7
“Hidden agenda”........................................................................................................................................... 7
Targeting ....................................................................................................................................................... 7
Benefits ......................................................................................................................................................... 8
Implementation ............................................................................................................................................ 8
Current operations........................................................................................................................................ 8
Ongoing activities.......................................................................................................................................... 9
Concerns by group ........................................................................................................................................ 9
Conditions ..................................................................................................................................................... 9
Scale up of Cash Transfer ............................................................................................................................ 10
Monitoring and evaluation ......................................................................................................................... 10
Capacity Building ......................................................................................................................................... 10
Impacts........................................................................................................................................................ 10
Grievance procedures ................................................................................................................................. 11
Sustainability ............................................................................................................................................... 11
Strengths ..................................................................................................................................................... 11
Weaknesses ................................................................................................................................................ 11
Opportunities .............................................................................................................................................. 12
Threats ........................................................................................................................................................ 12
Research and evaluation questions ............................................................................................................ 12
Citations ...................................................................................................................................................... 13
Annex 1 ....................................................................................................................................................... 14
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Map of Karnataka
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Acronyms
ART
Center Antiretroviral Center
AHSA
Accredited Social Health Activist
ANM
Auxiliary Nurse Midwife
AWW
Anganwadi Worker
CDPO
Child Development Program Officer
KHPT
Karnataka Health Promotion Trust
KSAPS
Karnataka State AIDS Program
ICDS
Integrated Child Development Service
VHC
Village Health (and Sanitation) Committee
WCD
Women and Child Development
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Karnataka Cash Transfer
Karnataka, India
Methods
In July 2011, Dr. Candace Miller conducted interviews in Karnataka India for two weeks
in order to document key aspects of the Karnataka Cash Transfer, including program design,
activities, the targeting strategy, delivery mechanisms, frequency and level of benefits, scale up
plans, sustainability, linkages to other programs, and other implementation issues. The research
activities included key informant interviews and focus group discussions with stakeholders at the
national, district, and village levels. Dr. Miller met with representatives from the Karnataka
Health Promotion Trust (KHPT), the Directorate at the Women and Child Development, District
Executive Officers and Deputy Directors of Women and Child Development at Districts, Child
Development Program Officers, Gram Panchayatts, workers from Voluntary Counseling Centers,
Village Health and Sanitation Committees (VHC or VHSC), Anganwadi workers (AWW),
Accredited Social Health Assistants (ASHA), Auxilary Nurse Midwives (ANM) and their
supervisors and KHPT link workers. Key informant Interviews and Focus Group Discussions
took place in Bangalore, Mysore, Hubli/Dharwad and Bagalkot (see Annex 1).
Information from this study will be used to assess program quality, sustainability and
provide information for further scale up.
Context
Karnataka is one of the five states in India most affected by HIV. In 2009, HIV
prevalence was 1%-1.9% across the 30 districts.1 In Karnataka, most orphans and vulnerable
children (OVC) do not receive support, despite their needs. In communities, stigma and
discrimination of people living with HIV//AIDS and their family members is still a serious issue
that undermines efforts to care and support this population. Moreover, despite existing program
and policies, many stakeholders agree that the “government machinery does not always work for
children.” As a result, a new mandate has emerged, which is a collaborative response to identify
and support children infected and affected by HIV/AIDS.
Leadership
Leadership for the response to children infected and affected by HIV/AIDS comes from
the USAID funded Karnataka Health Promotion Trust (KHPT), the Karnataka State AIDS
Program (KSAPS), the State Women and Child Development Ministry (WCD) and the National
Rural Health Mission. The response to infected and affected children has been about two years in
making, with the policy choice evolving after several programmatic attempts and ongoing
learning and collaboration.
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Policy debates
The early policy debates focused on the institutionalization of infected and affected
children. However, this approach was piloted and observed. Stakeholders found this approach to
be harmful to children. When children are taken from the homes of surviving parents,
grandparent or aunt/uncles, they are separated from their siblings, village, and schools.
Policymakers and implementers observed how children were emotionally distraught for two
weeks after a monthly family visit. Furthermore, the financial allocation was not sufficient to pay
for housing and staff; as well as the child’s nutrition, health, and education costs.
Another policy option was the food and nutrition supplement provided to the infected or
affected child only. This effort, funded by the Clinton Foundation, was a one year pilot project.
However an evaluation showed that the food support was not effective because the food support
was too small. When the meager food supply was spread throughout the family, the nutrition
intervention yielded no change in children over time.
Following these two efforts, policymakers, in consultation with communities, moved to a
cash transfer to support infected and affected children in family care. In 2010, the government of
Karnataka allocated 1 crore for the transfer program (approximately US$222,300).
Collaboration
Sensitizing stakeholders and obtaining “buy-in” for the Karnataka Cash Transfer was a
collaborative effort between the Karnataka Health Promotion Trust (KHPT), Voluntary
Counseling & Treatment Centers (VCT) and multiple levels of government including the
Ministry of Women & Child Development (WCD) at the national level; Executive Officers and
the Deputy Directors of Women and Child Development at the District level; Child Development
Program Officers (CDPO), Gran Panchayats, and Village Health Committees (VHC) at the
village level; and finally, Link workers, Accredited Social Health Activist (ASHA), Angawadi
workers (AWW), and Auxiliary Nurse Midwives (ANM) within communities.
Design
The Karnataka Cash Transfer provides cash to families to support orphan and vulnerable
children that are infected or affected by HIV. The program fits with and compliments the
Integrated Child Development Service developed and implemented by the Ministry of WCD.
With the cash scheme, ART clinic lists are used to identify eligible children (other programs rely
on people seeking out benefits).
Community level front line workers conduct Family Health Assessments. Initially KHPT
and the VCT link workers conducted all assessments; however the responsibility of identifying
children and families in need as been handed over to village level AWW, ASHA, and ANM.
Once families are identified and assessed, the households are approved by Village Health
Committees (VHC), Gram Panchayats, Child Development Program Officer (CDPO), District
WCD, and finally, the Executive Officer. Next, funds are released to Districts by the WCD
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Directorate at State. Funds are transferred to CDPOs and VHCs to be deposited in recipients’
accounts.
Possible Linkages
Once the cash transfer scheme is fully established, the front-line workers (i.e. AWW,
ASHA, and ANM) responsible for building relationships with families, conducting the Family
Health Assessments and monitoring how families use the cash transfer, may also be able to link
families to other supports available through the National Rural Health Commission. Linkages
may include nutrition and medical supports, counseling, ARV provision; connections with the
education sector to reintegrate out of school children back into school; and to other services
within the Integrated Child Development Services (ICDS) through the Department of Women
and Child Development. The cash transfer program creates the mechanism by which families can
be connected to the appropriate supports without duplication of programs and services.
“Hidden agenda”
Scheme designers described how the Cash Transfer Scheme has two hidden agendas,
including 1) reducing HIV stigma and discrimination, which can be reduced as infected and
affected children are adequately cared for within family structures. They will be able to be cared
for adequately so that their HIV status is not obvious or a limiting factor in their lives. The
second agenda is for the scheme to eventually be extended to all orphans and vulnerable children
in need, regardless of HIV status. While separate programs do exist for children (e.g. school
uniforms, lunch programs, and free health services) and special programs for scheduled castes
and tribes and ex sex workers, many of these programs are under-utilized due to limited
knowledge and few referrals. The Cash Transfer Scheme can change this as ASHA, AWW, and
ANM become aware of children’s needs.
Targeting
The Karnataka Cash Transfer is targeted to households with children aged 0 to 18 years
who are infected or affected by HIV/AIDS. Additionally, the child and family must be in need
of cash support. Families do not have to show a BPL “Below Poverty Line” certificate because
it is often a difficult and lengthy process to obtain these certificates. Households will be reassessed annually to determine ongoing need. However, in order to be considered during the
first Family Health Assessment, the family must have been registered with an ART clinic.
These families must consent to home visits and allow the community worker to do the
assessment. If a family and child are affected by HIV/AIDS, but are not registered with the
ART clinic, they will not be assessed.
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Benefits
The cash benefit of the Karnataka Cash Transfer was set in 2009. Families may receive
up to 800 Rupies per month per child. The Foster care benefit, which is cash to a household
caring for a non-biological orphan, is R750. The Sponsorship benefit, which is cash to a
household caring for their own child (such as by the biological mother or father or grandparent)
is R650. Families may also receive cash for nutrition, education, and housing. However, the per
child total benefit may not exceed R800 per month per child. The amount of money is
determined by the AWW, ASHA or ANM worker during the Family Health Assessment process.
Implementation
The implementation of the Cash Transfer Scheme includes the following activities:
1. Ongoing sensitization of District and Community officers (Executive Officer, District
Officials, etc.)
2. Training of ASHA, AWW, ANM, CDPO, Village Health Committees and Gram
Panchayat (GP))
3. ARV Centers provide family names to WCD
4. AWW, ASHA and ANM complete family health assessments; build rapport with
families; link to other services
5. CDPO, GP, District WCD, and Executive Officer sign off on assessments
6. Money transferred to districts
7. Households receive cash in their bank accounts
8. Ongoing monitoring of how money is used
9. Regular auditing of District accounts
To date, all activities have occurred with support and technical assistance from KHPT.
Current operations
As of July 2011, 14 districts are implementing the Cash Transfer Scheme or are ready to
implement. However, within these districts, not all Taluks (administrative units) are ready to
implement. In fact, only the Taluks where KHPT has worked have been fully sensitized to the
Cash Transfer Scheme. For example, in Bagalkot 2/6 Taluks have been trained. The training
plans have been articulated, but they must still be implemented. Moreover, there are 16 districts
remaining to be trained and sensitized before the Cash Transfer Scheme can be launched.
While many districts and Taluks have completed the Family Health Assessments, still
only a few families are receiving the transfer as of July 2011. Money has been held up at the
District level or CDPO as officials wait for official directions to disburse funds.
Finally, the scale up of the Cash Transfer Scheme could be hampered where ART centers
are hesitant to give client lists to government. The ART centers worry that it would be a breach
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of confidentiality to give client lists to the District WCD department, despite the fact that
children and families would receive benefits. In Taluks where the scheme is operational, the
WCD has the lists because they have signed off to pay these families.
Ongoing activities
The need for sensitization of EOs, Gran Panchayats, CDPO, Village Health Committees,
AWW, ASHA, families is ongoing given the election cycle and employee turnover. Again,
sensitization action plans have been developed for some Taluks. Still, capacity building and
technical assistance was universally requested by District Women and Child Development in
order for them to fully and effectively implement the scheme.
Concerns by group
The following concerns were expressed by stakeholders at the different levels:
Stakeholders
State Government
Executive Officers &
District Officials
Zilla & Gram Panchayatt
Concerns
One major advocate involved from beginning; without Deputy Director
WCD, program is at risk
Responsible for 30-60+ other programs; if not sensitized, will not support
CDPO
Supportive of program; could possibly take on financing in future if impact
is positive; sensitization needed in new Taluks, Districts
Concerns about releasing cash; Not sure how to monitor program
Village Health
Committee
AWW, ASHA, ANM
(often same as Gram Panchayatt); Have many programs; this is relatively
small; Also not clear how to monitor program
Have other responsibilities; low pay, need ongoing sensitization;
KHPT
Provided ongoing Technical Assistance but is closing out project, leaving
major gap in implementation technical expertise
Conditions
There are no behavioral or spending conditions attached to the Karnataka Cash Transfer;
however it is expected that the money will be used to improve the child’s nutrition, health and
educational outcomes. However, many have concerns about how families will use money and
wonder: “Will the cash be used for children?” While not currently being considered, conditions
might be acceptable and helpful to achieve program goals.
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Scale up of Cash Transfer
If the Karnataka Cash Transfer is to be scaled up throughout Karnataka, NGO technical
assistance is required throughout the 14 districts where the program has been launched and more
especially in the 16 outstanding districts. Stakeholders universally agree that there will be an
important gap without KHPT providing technical assistance and support. Specifically to scale up
throughout Karnataka, the Cash Transfer must be expanded to include 30 Districts, which
contain 27 Zilla Panchayats, 175 Taluk Panchayats, and 5659 Gram Panchayats.
Additionally, several problems must be overcome, such as Cash Transfers being stuck at
Districts because some District Officers are still unsure of the program, the EO or Deputy
Director WCD is still requesting a letter from the WCD Directorate at the state level to proceed,
and CDPOs must be instructed to release funds.
Nevertheless, funding for the Cash Transfer is available through state government so
hopefully the implementation and scale up challenges will be overcome.
Monitoring and evaluation
As of July 2011, the program has just been launched and there were no monitoring and
evaluation activities under way, nor had an M&E plan been developed. The Districts do ¼ to ½
year financial audits, but these do not encompass program or beneficiary monitoring
implemented.
Ideally, a monitoring system will be articulated where activities and beneficiaries are
frequently monitored, and problems are flagged so that they can be addressed swiftly and early.
An adequate monitoring system can ensure that program activities are implemented and impacts
are achieved. Implementers can ‘course correct’ before the
Cash Transfer Scheme gets far off track. At the community level, AWW, ASHA, ANM
and VHC members are willing to monitor, however with low capacity for monitoring and using
data to course correct, training and technical assistance is essential.
Capacity Building
Technical assistance and capacity development are essential to help build an M&E
system for the Karnataka Cash Transfer Scheme; to train all AWW, ASHA, ANM, VHC, District
WCD officers, and to manage and utilize monitoring data.
Impacts
It is still unclear what the program impacts will be given that the program has just been
launched. In Mysore, where families have begun to receive cash, there are anecdotal reports of
families enjoying improved nutrition (including high quality proteins and dairy), improved
ability to send children to school, improved health, confidence that they will have a “good life”,
and concerns over confidentiality and disclosure of the child or family members HIV status.
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Grievance procedures
The Karnataka Cash Transfer Scheme does not have its own, separate grievance
procedures, but rather will be reliant upon the regular government Panchayat procedures,
whereby District officers visit villages monthly in order to hear grievances. The time and
meeting location where citizens can submit grievances is set in advance and communicated.
These procedures are often used for other programs and are generally considered an effective
way for community members to have grievances heard and rectified. Given that this scheme is
linked to the child’s infected or affected status, stigma and fear of disclosure may inhibit families
from engaging in the process. However, once the Cash Scheme is established, this system should
work for this program.
Sustainability
The sustainability of the Karnataka Cash Transfer Scheme is still unclear given that
KHPT, the main technical assistance provider, is closing out their final contract year. It is not
clear, in the absence of KHPT, who will write proposals, manage the scale up, validate data, map
and update info. The Karnataka Cash Transfer Scheme is just one of many government programs
that is unlikely to continue without NGO support. Nevertheless, sustainability depends upon the
program’s positive or negative program impacts; whether training and sensitization continues,
and whether government has NGO support.
Strengths
The Karnataka Cash Transfer Scheme has many important strengths including the
following: First, the Karnataka Government wants this scheme to continue. There is a nearly
universal perception that fraud and corruption is unlikely because of many bureaucratic layers.
The policy option is child-friendly whereby children remain at home without any sibling
separation. Stakeholders believe the program design will help maintain the dignity of the child
and family because the HIV status does not have to be disclosed at the community level and
families do not have to beg for assistance. Community workers identify families within villages
who often do not come forward on their own. Moreover, the scheme has been community driven
with a bottom up design and ongoing community consultations. Finally, the Karnataka Cash
Transfer Scheme is evidence based, drawing upon the literature on cash transfers and experience
based, as stakeholders explored policy alternatives and then designed this program and made
adjustments to the design as needed.
Weaknesses
The Karnataka Cash Transfer Scheme also has weaknesses that must be addressed. Still,
despite ongoing efforts, there is still a high level of sensitization required for community
workers, elected officials, and district officers. The Karnataka Cash Transfer Scheme may lead to
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HIV disclosure, stigma, and discrimination if information is not handled confidentially. Also,
there are many layers of approvals necessary, which may reduce corruption, but could also cause
bureaucratic delays. Additionally, the community workers (AWW, ASHA, and ANM) have
limited education, low pay, and many competing responsibilities so their ability to prioritize or
simply carry out activities for this program, without incentives, may be limited. Moreover, the
children from families that are not registered as ART center clients may be overlooked despite
their needs. Another issue is that the Karnataka Cash Transfer Scheme is implemented slightly
differently across districts, which may yield differences in the quality of implementation. The
Scheme may soon need updating as the Family Assessments were completed and the transfer
value set in 2009. There have been no subsequent updates despite the evolving situation of
families and inflation. Finally, from the time when Family Assessments were completed to when
cash is first delivered is still way too long such that children and families have important unmet
needs.
Opportunities
Once the Karnataka Cash Transfer Scheme is launched and is operating effectively, it
could be expanded to include all OVC and all children in need. Every AWW, ASHA, ANM and
VHC member knows of additional children in community needing a transfer too; however if
children do not meet the program guidelines they are not currently included. Still, in the future,
this program could link well with all other programs to ensure comprehensive supports to all
children in need, while avoiding duplication and exclusion. The Karnataka Cash Transfer
Scheme utilizes a well designed assessment procedure with community input so this process can
be replicated and utilized for other coordinated programs. Additionally, if implemented well, it
could reduce HIV stigma over time.
Threats
The treats to the Karnataka Cash Transfer Scheme include the fact that stigma and fear of
disclosure may keep families from joining the scheme. One suggestion is to broaden the scheme
for all orphans (OVC implies HIV) to reduce HIV stigma. Of course, framing the transfer for “all
orphans” means more will children and families will be eligible, creating budgetary implications
and possibly concerns about the program size. Another threat is that if AWW, ASHA, ANM re
not well trained, they will not utilize the program. Finally, if lack of awareness and sensitization
of program persists, the risk of abandonment is real
Research and evaluation questions
Several research and evaluation questions should be answered as the program is launched
and scaled up. For example, 1) Will all eligible children be identified? What are the errors of
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inclusion and exclusion? 2) How much money will reach families? 3) How will families use
money? 4) What are short and long term impacts of cash within families and communities?
Citations
1. Karnataka State AIDS Program (KSAPS). (2011) Annual Action Plan Online at
http://stg1.kar.nic.in/ksaps/AAP_2011-12_Karnataka_June_28th,_2011_PDF.pdf.
Accessed July 29, 2011.
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2.
Annex 1
Name
Troy Cunningham
Mr Vishwanath
Mr Ashokanand
Dr Manish Kumar
Ms Narmada Anand
Dr Bharat Shetty
Srikante Gowda
Mysore District
Mysore District
Village Health and Sanitation
Committee
Angawadi (AWW), Auxiliary
Nurse Midwives (ANM) and
ASHA workers
Cash Transfer beneficiaries
Mr Venkatesh Sabnis
AWW, ASHA, ANM
Usmali
Village Sanitation Committee
Executive Officer
DD, WCD (Assistant)
CDPO
DD, WCD (Assistant and
Director)
CEO ZP –
Ms Tejswini
AWW, ASHA, ANM
CDPO
Link workers
2 Orphanages in Bagalkot
Home organization
Engender Health
KPHT
KHPT, 28 years Indian Administrative Services
Deputy Chief of Party
Deputy Director Women and Child Development
KHPT
CEO Mysore
KHPT
Director Women and Child Development
District Aids Director, District Supervisor VHC, District CDPO (All
at Executive Office)
Mysore, Gram Panchayat
Mysore, Gram Panchayat
Mysore (were at KHPT office)
Hubli KHPT
Hubli, Gram Panchayat
KHPT
Hubli, Gram Panchayat
Hubli District Government, Zilla Panchayat
Dharwad/Hubli
Dharwad
Bagalkot
Dharwad and Bagalkot
KHPT Bagalkot
Bagalkot
Bagalkot
KHPT Bagalkot
Because orphan facilities are main policy alternative to cash transfers
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