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1/13

Oxfam G

Qualitative methods for assessing conditional cash-transfer programmes: the case of PanamaAuthor(s): William F. WatersSource: Development in Practice, Vol. 20, No. 6 (August 2010), pp. 678-689Published by: Taylor & Francis, Ltd.on behalf of Oxfam GBStable URL: http://www.jstor.org/stable/20750167.

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2/13

Development

in

Practice,

Volume

20,

Number

6,

August

2010

jj^

^HfaSaoup

Qualitative

methods for

assessing

conditional cash-transfer

programmes:

the

case

of Panama

William F. Waters

Governments

in atin

America

and elsewhere have

implemented

conditional

cash-transfer

pro

grammes

to

improve

standards

of

living

in

populations defined

as

vulnerable and excluded

from

the

benefits of

development,

in

order

to

improve

access

to

education

and health

services,

and

to

improve

human

capital.

Qualitative

research conducted

among

three

indigenous

groups

in

Panama

provides

lessons

for

assessing

these

programmes

on

the basis

of

the

perceptions

and

culturally informed beliefs

and

practices

of potential beneficiaries.

This article shows

that

required

co-responsibilities

should be matched with

high-quality

services

that

are

consistently available and socially, culturally, and linguistically appropriate.

Methodes

qualitatives

pour

evaluer les

programmes

conditionnels de

transfertd'argent:

le

cas

de

Panama

Les

gouvernements

d'Amerique

latine

et

d'ailleurs

ont

mis

en ozuvre

des

programmes

condition

nels de

transfert 'argent

pour

ameliorer les

conditions de

vie

au

sein

des

populations definies

comme

vulnerables

et

exclues des

avantages

decoulant du

developpement, afin

d 'ameliorer

leur

acces aux

services

d'education

et

de

sante,

ainsi

que

le

capital

humain.

Des

recherches

quali

tatives

menees

parmi

trois

groupes

autochtones de

Panama

fournissent

des

enseignements

pour

revaluation

de

ces

programme

sur

la base des

perceptions

et

des

convictions

et

pratiques influ

encees par la culture des beneficiaires potentiels. Cet article montre que les responsabilites

requises

doivent

etre

assorties

de

services de

qualite

constamment

disponibles

et

appropries

sur

les

plans

social,

culturel

et

linguistique.

Metodos

qualitativos

para

se

avaliar

programas

de

transferencia

de dinheiro condicionais:

o

caso

do

Panama

Governos

da America

Latina

e

de

outros

lugares

tern

implementado

programa

de

transferencia

de dinheiro

condicional

para

melhorar

os

padr?es

de vida

das

populag?es

definidas

como

vul

ner?veis

e

excluidas dos

beneficios

do

desenvolvimento,

para

melhorar

o acesso

?

educag?o

e a

servigos

de sa?de

e

para

melhorar

o

capital

humano.

Pesquisa qualitativa

conduzida

entre tres

grupos indigenas no Panama oferece ligoes para avaliar esses programas com base nas per

cepg?es

e

convicg?es

culturalmente-informadas

e

pr?ticas

de

benefici?rios

em

potencial.

Este

artigo

mostra

que

co-responsabilidades

requeridas

devem

ser

combinadas

com

servigos

de alta

qualidade

que

estejam

consistentemente

disponiveis

e

que

sejam

socialmente,

cultural

mente

e

linguisticamente apropriados.

678

ISSN

0961-4524 Print/ISSN

1364-9213 Online 060678-12

?

2010

Taylor

& Francis

DOI: 10.1080/09614524.2010.491526

Routledge Publishing

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3/13

Qualitative

methods

for

assessing

conditional

cash-transfer

programmes

Metodos

cualitativos

para

la

evaluaci?n

de

programas

de

transferencias

en

efectivo

condicio

nadas:

el

caso

de Panama

Los

gobiernos

de America

Latina

y

de

otras

regiones

han

implementado

programas

de

trans

ferencias de efectivo condicionadas para mejorar los niveles de vida de poblaciones vulner

ables

y

excluidas de

los

beneficios

del

desarrollo,

facilitar

su acceso

a

servicios de

educacion

y

salud,

y

mejorar

el

capital

humano.

Esta

investigacion

cualitativa,

realizada

en

tres

pueblos

indigenas

de

Panama,

arroj?

datos

que

permiten

analizar

este

tipo

de

programas

enfunci?n

de las

percepciones,

las creencias

culturales

y

las

experiencias

de los

beneficiarios

potenciales.

El

ensayo

muestra

que

la

corresponsabilidad

que

se

exige

debe

estar

acompanada

de

servicios de alta

calidad,

constantemente

disponibles

y

apropiados

en

terminos

sociales,

culturales

y

lingmsticos.

Key Words: Methods; Governance and public policy; Social sector; atinAmerica and theCaribbean

Introduction

Social

protection

programmes

are

implemented

by

governments?often

in

association with

international donors?in order

to

reduce

poor

people's vulnerability

to

adverse

economic,

social,

and environmental

conditions;

to

cushion them

against

the

impact

of

financial

crisis;

to

improve consumption;

to

provide

for

greater

equity;

and

to

contribute

to

long-term

develop

ment. Incomes of thepoorest population segments of poor countries seldom enable the satisfac

tion

of

even

the

most

basic

needs,

and

downturns in

social and economic conditions threaten

not

only

livelihoods,

but also lives

(Lustig

2001).

After

remarkably widespread application

in less than

two

decades,

conditional

cash-transfer

(CCT)

programmes

represent

a new

generation

of

approaches

to

social

protection.

These

programmes

provide periodic

monetary

transfers

to

targeted

segments

of

the

population,

while

requiring

fulfilment of

co-responsibilities generally

related

to

school

attendance and

use

of

appropriate

health-care

services,

including

vaccinations

and

regular

checkups

for

children,

and antenatal

and

postnatal

care

(and

sometimes

institutional

child-births)

for

women.

Hence,

CCTs

implicitly

focus

on

the

development

of human

capital.

CCT programmes have been implemented innearly 30 countries inAfrica, Asia, thePacific,

the

Middle

East,

southern

Europe,

and

throughout

Latin America and theCaribbean

(Valencia

2008).

Pioneer

programmes

began

in the

early

1990s inMexico

(Progresa,

now

called

Opor

tunidades)

and Brazil

{Bolsa

Escola,

now

part

of

Bolsa

Familia).

CCT

programmes

are com

parable

on

four

points:

(i)

objectives

and

components,

(ii)

criteria

for

selecting

and

including

participants,

(iii)

specific co-responsibilities,

and

(iv)

impacts.

CCT

programmes

have

been

thoroughly

documented and evaluated

in

most

cases,

and evidence

suggests

that

they

can

provide important gains

in

consumption,

diet,

and infant

nutrition

(Valencia

2008).

Despite

the

potential

for

improved

coverage

of

health and education

services, however,

the

potential

of CCT

programmes

has

not

always

been

fully

realised,

because barriers

to

access

to

education and health services are not necessarily adequately addressed. One of theprincipal

reasons

for

this has been

an

inability

to

understand

why

services

remain

unacceptable

to

poten

tial

beneficiaries,

even

when

cash transfers

re

provided.

In

particular,

education

and health

ser

vices

may

not

be

consistently

provided

or

adequately

take into

account

culturally

informed

beliefs and

practices

that

are

often

closely

related

to

ethnic

identity

in

groups

who

experience

high

levels of

poverty

and

exclusion.

Development

in

Practice,

Volume

20,

Number

6,

August

2010

679



4/13

William F.

Waters

This

article

presents

a

qualitative methodology

used

to

assess a

CCT

programme

that

in

early

2007

was

in

the initial

implementation

stage

in

Panama's

indigenous

territories

comarcas).

The

purpose

was

to

assess

whether the

programme

would be

compatible

with

culturally

informed

practices and beliefs. The methods discussed here can be applied to other interventions,pro

vided that

those

practices

and beliefs

are

taken into

account.

Panama's Red de

Oportunidades

(Opportunities

Network)

programme

aims

to

reduce critical

poverty

and

enhance human

capital,

in

large

part

through

CTs.

Eligible

households?irrespec

tive of

their

composition?receive

the

equivalent

of

US

100

(initially

70) every

two

months

and

are

required

to

demonstrate

regular

school

attendance

and the

use

of

appropriate

health

ser

vices,

including

vaccinations

for

under-fives and antenatal

care

(MIDES

2007;

World Bank

2007).

While transfers

are

intended

to

promote

the

use

of the

services,

no

limitations

are

placed

on

how the funds

are

actually

spent.

Although public

services

are

nominally

free,

costs

that families

must

assume

include

transport,

school

uniforms and

shoes,

registration

fees, and school supplies. CCTs inLatin America typically amount to at least 20 per cent of

national

poverty

lines

(Handa

and Davis

2006).

In

Panama,

the

poverty

line is

US

905

per

person

per year;

assuming

five

persons per

family,

and the transfer

represents

26.5

per

cent

of

this

sum.

The

programme

targets

all

poor

families,

but focuses

on

the inhabitants of

indigenous

comar

cas.

Indigenous

Panamanians

represent

about 10

per

cent

of

the

total

population

but

comprise

about

half of

current

or

potential recipients

of

the

CCT

programme.

Roughly

half of the

coun

try's

indigenous

population

resides

in

comarcas,

and because

more

than

90

per

cent

of

comarca

residents live

in

critical

poverty,

they qualify

for the cash transfers

without

submitting

to

the

proxy

means

test

used

to

determine

eligibility

in other

potential

beneficiaries

(MIDES

2007;

World Bank 2007).

Several

important questions

arise about

the

programme's acceptability

in the

comarcas,

and

are

relevant

elsewhere. Are

the

health

and

educational services

appropriate,

and

are

the

required

co-responsibilities acceptable

to

potential

recipients?

Are

they

available and

accessible?

Are

the

cash-transfermechanisms

appropriate,

and

will the funds be used

to

improve

school attendance

and health

behaviours

or

to

satisfy

other needs?

This

article discusses how

qualitative

methods

were

used

to

assess

Panama's Red de

Opor

tunidades

programme,

in

order

to

determine the

degree

to

which

its

components

are

consistent

with

perceptions

and

expectations

of

comarca

residents. The

study

was

conducted

among

the

three

largest indigenous

groups:

the

Ng?be-Bugle,

who inhabit the

rugged

mountains of

Bocas del Toro and Chiriqui near thewestern border with Costa Rica; theEmber?-Wounaan,

living

in the

isolated

Darien

region

adjacent

to

Colombia;

and

the

Kuna,

whose

comarca

is

spread

out

among

many

tiny

San

Bias islands

in

the Caribbean

and

a

thin slice of the

nearby

mainland.

The article also addresses the

potential

use

of

qualitative

research in

programme

development, planning,

and needs

assessment.

Poverty, nequality,

ealth,

nd

ethnicity

Poverty

and

inequality

contribute

significantly

to

development

outcomes

in

nutrition,

health,

and education

(Savedoff

and Schultz

2000;

World

Bank

2006).

The

appropriateness

of social

protection programmes, including CCTs, begins with an understanding of how these factors

interact.

In Latin

America,

ethnicity

is

closely

related

to

poverty,

inequality,

and social

exclu

sion,

and

specifically

to

access

to

and

outcomes

related

to

health

care

(Lloyd-Sherlock

2000),

nutrition

(Larrea

and Freire

2002),

and education

(Hall

and Patrinos

2005).

Examples

of

the

relationship

between

ethnicity,

poverty,

and health

include

higher

rates

of

morbidity

and

mortality

in

indigenous populations;

diseases related

to

the

epidemiologic

transition;

and the

680

Development

in

Practice,

Volume

20,

Number

6,

August

2010



5/13

Qualitative

methods

for

assessing

conditional

cash-transfer

programmes

persistent

interplay

between traditional

and modern health-related

attitudes,

practices,

and

beliefs

(Montenegro

and

Stephens

2006).

Ethnicity

is also

closely

related

to

poverty

in

Panama,

being

related

to

poor

housing

conditions; inadequate access to potable water, sanitation, and electricity; high rates of

chronic malnutrition

in

under-fives;

inadequate consumption;

and

linguistic

isolation

(MIDES

2007;

World Bank

2007).

Infant

mortality

rates

among

indigenous

inhabitants

of

rural

areas

are

four times

greater

than

those

of

non-indigenous

residents

of

urban

areas.

Patterns

of

literacy

and school attendance

are

similar:

37.8

per

cent

of

indigenous

adults

were

illiterate

in

2000,

compared

with

5.5

per

cent

of

non-indigenous

people,

and

illiteracy

was

even more

prevalent

among

indigenous

women.

Differences in

school attendance

are

also

striking:

while

96.8

per

cent

of

non-indigenous

children between 6 and 12

years

of

age

attend

school,

only

78.7

per

cent

of

indigenous

children

do;

the

respective

figures

for

13-19-year-olds

are

70.6

and

44.3

per

cent

(CEPAL/BID

2005:

62-64).

Methodology

In

order

to

assess

Panama's

new

CCT

programme,

qualitative

research

was

conducted in

the

Kuna

Yala,

Ng?be-Bugle,

and Ember?-Wounaan

comarcas

between October

2006

and

January

2007.

Three

teams

of

two

bilingual

native

speakers

of

indigenous

languages

(two

Ng?bes,

two

Ember?s,

and

two

Kunas)

conducted

a

total of 18

focus-group

discussions: six in

each

comarca

(one

with

adult

men

and

one

with

adult

women

in

each of three

communities in

the

respective

comarcas).

In

addition,

32

key

informants

were

interviewed

in the

selected

com

munities in

order

to

obtain additional

insights

on

findings

derived from

focus-group

discussions.

Focus groups are designed to elicit perceptions, opinions, and ideas froma set of individuals

who

share

at

least

one

important

characteristic

such

as

gender

or

socio-economic

status.

They

provide

a

safe environment in

which

all

participants

are

encouraged

to

contribute; and,

since

indi

vidual

perceptions

and attitudes

are

shaped by

their social

context

and

are

often best

expressed

in

response

to

the

opinions

of

others,

they

allow

for

the

interplay

of

ideas

and

comments

that

build

upon

one

another. The focus

group

represents

a

natural

setting

where

the

topic

of conversation is

directive,

but,

at

the

same

time,

perceptions

and ideas

are

expressed

in

the

participants'

own

terms,

rather than forced into

externally

imposed categories

(Krueger

and

Casey

2000).

Key-informant

interviews

were

conducted

in order

to

shed

further

light

on

these

issues and

to

better

understand

them in the context

of

community

structure.

These interviews

involved

individuals who are prominent because of theirformal or informal leadership positions (includ

ing

traditional local

authorities),

or

because

of

their

knowledge

of the

topic

of interest

by

virtue

of

their

position

or

occupation

(in

particular,

teachers

and

health

workers).

Key

informants

represent

an

excellent

source

of information

about the

community,

its

organisation, history,

members,

and relations with the

state

and

external

agencies.

The

communities

were

selected

according

to

criteria

related

to

income,

resource

endowment,

and

access

to

roads and

services,

in

order

to

identify

and

designate

one

community

in

each

comarca

as

very poor,

one as

intermediate,

and

one as

better

off

than other

communities.

In

the

Ember?-Wounaan

comarca an

additional criterion

was

that

at

least

one

community

should be located in

each of

the

two

separate

districts of

Cemaco and

Samb?. Before the

focus-group discussions and key-informant interviewswere initiated, permission to conduct

the

fieldwork

was

granted by

local authorities.

Individual

participants

in each

of the

selected

communities

were

screened and

recruited

for

participation

in

the focus

groups,

and

suitable

venues

(classrooms

or

other

places

free

of

inter

ruptions)

were

secured. The discussions lasted

between

one

and

two

hours

and

were

recorded.

Supplementary

notes

ensured

the

accuracy

of

the

transcriptions

and

allowed for

the

Development

in

Practice,

Volume

20,

Number

6,

August

2010

681



6/13

William F. Waters

identification

(using

first

ames

only)

of

participants

in the

discussions

(Krueger

and

Casey

2000;

Ulin

et

al

2005).

A

total

of

224 adults

(124

women

and 100

men)

participated

in the

focus-group

discussions.

The question guide for thefocus-groupdiscussions addressed perceptions related to (i) the func

tioning

of

the

conditional CCT

programme; (ii)

factors that ould

affect

the

capacity

of

recipients

to

satisfy

theconditions

or

co-responsibilities

(such

as

distance,

availability,

schedule,

costs,

treat

ment

received,

language,

environmental

factors,

and

culturally

informed

beliefs);

(iii)

logistical

aspects

of the

monetary

transfers;

iv)

use

of the

transfers;

v)

traditional

and modern health

prac

tices and

beliefs;

(vi)

the inclusion of families who

are

absent from the

comarcas

for extended

periods

because of labour

migration

or

other

reasons;

and

(vii)

other

factors considered

relevant

or

important.

The

question guides

were

written

in

Spanish,

but

all

focus-group

discussions and

most

key-informant

interviews

were

conducted in the

respective

indigenous

languages.

Transcripts

of

the

focus-group

discussions

were

developed

by

the

bilingual

team

members in

therespective indigenous language fromthe audio tapes, supplemented by field notes. Verbatim

notes

were

taken

in

the

case

of

individual interviews. The

notes

and

transcripts

were

translated

into

Spanish by

the field

teams

and

analysed by

the

author,

using

a

three-stage

coding

pro

cedure.

First,

open

coding

was

used

to

identify concepts

and their

properties

and dimensions.

This

step

often

concentrates

on

response

patterns

to

individual

questions

posed

in the

focus-group

discussions.

Second,

axial

coding

was

used

to

relate the

categories

developed

in

the

previous

stage,

to

further

refine

emerging categories,

and

to

link

categories

on

the

basis

of

underlying properties

and dimensions.

Finally,

selective

coding

was

employed

to

integrate

and

refine

the

major

themes and

relationships

among

them

(Strauss

and Corbin

1998).

Results

Knowledge

and

perceptions

concerning

the

CCT

programme

Knowledge

of the

programme

varied

among

and within the

three

comarcas.

Accurate knowl

edge

was

most

complete

in the

Kuna

Yala

comarca,

not

only

because

one

of the

communities

had

already

received its first

cash

transfer,

ut because

-

despite

the

transport

and communi

cation difficulties

(communities

are

widely dispersed

on

small

islands)

-

information had

pre

viously

been

provided by

visiting

government

representatives.

Nevertheless,

some

misperceptions persisted

(for

example,

that

the

programme

provided

loans rather than

grants). Levels of awareness were approximately equal among men and women and in the

three communities

studied.

In

contrast,

there

was

less

knowledge

about the

programme

in

the

Ng?be-Bugle

and

Ember?-Wounaan

comarcas,

probably

because there had been less

contact

with

government

officials.

Among

the

Ember?-Wounaan,

women were

less

informed then

men

about

the

programme,

while

in

the

Ng?be-Bugle

comarca none

of the

participants

(male

or

female)

in

any

of the communities

demonstrated much

awareness

of the

programme.

Among

those who knew

about the

programme,

two

perceptions

predominated.

First,

it

was

viewed

positively

and

regarded

as

both

necessary

and

potentially

important

to

improved

well-being.

Second,

however,

general

distrust of

the

government

extended

to

the

programme

because

of doubts related

to

its

likely

continuity

and

duration;

suspicions

of its

possible

political

motivations (i.e. that its truepurpose was to garner political support); and a feeling thatnon

indigenous people

would

benefit earlier

or more

than

indigenous people.

A

contrasting

view,

expressed

most

often

by

Kuna

participants,

was

that the

money

would

be

misused

if

not

care

fully

monitored

by

traditional leaders

and

community

residents.

In

sum,

it

was

thought

that the

programme

would contribute

to

resolving problems

related

to

poverty

and

limited

consumption,

although,

as

noted

below,

it

was

also

felt that the size of the

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Qualitative

methods

for assessing

conditional

cash-transfer

programmes

transfer

would

not

be

enough

to

contribute

significantly

to

closing

the

gap

between available

resources

and unsatisfied

needs.

For

me

it is

not

bad that this rogramme comes;

to

the

contrary,

it is

a

gift rom God,

who

knows

that

we

all need

it,

nd

it is

to

improve

our

lives

here in

the

comarca.

(Crecencia,

Ember?)

Factors

inhibiting

r

promoting

ompliance

with

rogramme

requirements

Three themes

emerged

from

the focus

groups

regarding

fulfilment

of the

programme's

co

responsibilities,

and

were

confirmed

by key

informants.

First,

access

to

public

services

in

many

cases

is

severely

limited

by geography

and

topography.

In

the

Ng?be-Bugle

and

Ember?-Wounaan

comarcas,

thedistances

from

villages

to

health

posts

or

centres

are

often sub

stantial and isolation is compounded by the difficult terrain. Residents of themountainous

Ng?be-Bugle

comarca

may

have

to

walk for

eight

to ten

hours

to

the

nearest

health

centre,

although

access

to

primary

schools

is somewhat less limited

in

this

respect.

Access

by

motor

vehicle is

extremely

limited:

during

the

rainy

season

many

of the roads

are

virtually impassable,

and

many

communities

are

not

accessible

by

road

at

all.

The few roads

in

the

Ember?-Woonan

comarca

are

equally

treacherous,

and travel is fre

quently by

canoe or

motorboats

that

ply

up

and down the

region's

many

rivers.

In

theKuna

Yala

comarca,

access

to

services

is limited

by

the distances between the islands and the

main

land and between the

islands.

Particularly

during

thewinter

months,

the

seas

are

rough,

severe

thunderstorms

re

common,

and travel

can

be

dangerous.

In

all three

comarcas,

public

transport

is available: trucksand small buses in theNg?be-Bugle and Ember?-Wounaan comarcas, and

motor

or

sail boats

in the

Kuna

Yala

comarca.

Even

when weather

permits,

however,

public

transport

s

limited,

expensive,

and often

extremely

difficult,

as

the

following

case

illus

trates:

...

that road

is

terrible;

at

times

when

it is

raining

there

is

no

way

for

car

to

get

through,

and because

ofthat,

not

long

ago,

they

took

a

boy

injured

in

the

mouth;

an

animal attacked

him,

and

he lost all

of

his teeth.

They

took him

to

the

ort,

where

they

waited three

days,

the

boy dying.

How

were we

going

to

get

through, raining

all those

days,

and

the road

damaged?

(Sixto,

Ember?)

A second barrier relates tonegative perceptions about thequality of public services. The most

relevant factor

in this

regard

is that residents

of

all three

comarcas

(both

men

and

women,

and

independent

of the

community's

socio-economic

level)

expressed

strong

concern

about

the

lack

(or

complete

absence)

ofmedicines

and

other

supplies,

and the

irregular

presence

of health-care

personnel.

This

factor is related

to

access

because

people

are

reluctant

to

risk

spending

time and

money

to

reach facilities that

in

their

experience

may

not

provide

the

required

services.

...

if

we

are

talking

about

health,

that is another

delicate

point

because the

health

center

never

has

medicines;

we

don't know

if

the

Ministry of

Health

sends

medicine

or

not;

that

we

do

not

know.

(Magaleno,

Ember?)

... there isa health center but inname only,a shell,with nothing inmedicines, nordoctors.

With

a

situation like

that,

we

can't

fulfil

[the

co-responsibilities];

if they

ut

conditions

of

that

kind,

how will

we

take

our

child

to

be

vaccinated,

or

how will he

get

an

exam,

how will

one

go

for prenatal

care

when

one

is

pregnant,

if

there

is

no

doctor,

not

even a

nurse?

There is

only

an

auxiliary,

but this

one,

what does

he

know

about

pregnancy

or

how

will he

attend

one

in serious cases?

(Crecencia,

Ember?)

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in

Practice,

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2010

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8/13

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F.

Waters

Similarly,

there

is

a

strong

perception

in all

three

comarcas

that

while

primary

schools

are

gen

erally

available

and

accessible,

opportunities

for

attending

beyond

the sixth

grade

are

limited.

Secondary

education is

extremely

expensive,

because

high

schools

are

located

only

in

large

towns, so that families must meet the costs of transport,rent, and food. Associated costs of

primary

and

secondary

education

can

be

prohibitive; they

include school

supplies

and

(most

often noted

by participants)

uniforms and

shoes,

which

are

universally required.

Ember?

partici

pants

also noted that

primary

schools

are

poorly equipped,

so

they

are

considered

to

be

poor

value.

Third,

both female and male

participants,

especially

in theKuna Yala

comarca,

expressed

concern

about

the

treatment

received

by indigenous

people

who seek

public

health-care services

or

who attend school.

Specifically,

the

perception

is

that their

language

and cultural

traditions

are

not

respected,

even

though

in

some cases

this

problem

is offset

by

the

presence

of

indigen

ous

education and health

professionals.

...

/

see

that

language affects

[school attendance]

since

many

children don't

speak

Spanish,

like

their

mothers,

and

they

an't

communicate

with their

atino

(waga)

teachers.

(Teobaldo,

Kuna)

In

this

regard,

as

noted

below,

the

use

of health-care services

by

indigenous

Panamanians is

conditioned

by culturally

informed

practices

and beliefs

related

to

an

understanding

of the

nature

of health and

illness,

and

perceptions

regarding

the

appropriateness

of traditional

or

Western

health

care.

In

sum,

respondents reported

crucial

impediments

to

accessing

services

in

order

to

comply

with

co-responsibilities.

Nevertheless,

while

there

is

considerable

diversity

of

opinion

regarding

theuse towhich the cash transferswould be put (see below), theperception among bothmen

and

women

in all

three

comarcas

is that the

programme

will reduce

cost-related barriers

to

health

care

and education.

Sometimes

I

don't take

my

son

to

the

hospital

to

keep

his

vaccinations

up

to

date

because

we

don

yt ave

money;

but since

they

re

going

to

give

us

money,

we are

going

to

take

[our

children]

to

the

hospital

and

fulfil

all

of

the conditions.

(Rolando,

Ember?)

In

particular,

comarca

residents

place

enormous

value

on

education,

and

parents

in

all

three

comarcas

expressed impressive

willingness

to

make

sacrifices

so

that their children

can

study,

not

only

at

the

primary

level but also

in

secondary

schools outside

the

community

and

inuniversities in the capital city.

We

-

the

father

and

I

-

make

the

effort

o

that

my

son can

study

[at

the

university]

and

at

times

we

have

to

save

to

send

a

little

money

to

my

son so

that

here,

we

are

left

without

money,

without

anything

to

eat,

even

eating

boiled

plantains

with

just

some

salt

so

that

our son can

study

and

not

leave

his studies

[in

order

to

be able

to]

get

ahead.

(Georgina,

Ember?)

Distribution

f the ash

transfer

Beyond the logistical problems related to the cash transfers,two critical issues related todistri

bution

were

mentioned

by

potential

beneficiaries.

First,

the

programme

was

designed

to

benefit

households,

defined

as

the

related

individuals

living

under

a

single

roof

and

sharing

resources.

However,

many

households

in the

indigenous

comarcas are

composed

of

multigenerational,

extended families

consisting

of several nuclear

families,

each

with

parents

and their

respective

children.

In

addition,

some

households

include

unrelated

individuals who

are

linked

to

other

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methods

for

assessing

conditional

cash-transfer

programmes

household members

through

Active

kinship

(compadrazgo)

or

friendship.

While extended

family

and

kinship

ties

are

highly

valued,

the

nuclear

family

is understood

to

be the basic

social and

cultural

building

block.

While

living

quarters

and,

to

some

degree,

resources are

shared by household members, decisions and behaviours related to health and education are

made

at

the level

of

the

nuclear

family.

Consequently,

an

important

theme

that

emerged

from the

focus-group

discussions

(and

con

firmed

by key

informants)

was

that

for

two

reasons

the cash transfers should be made

to

nuclear

families rather than

households.

First,

particularly

in

the

poorer

communities,

the level

of

the

transfer

was

regarded

as

insufficient

to

cover

the basic needs

of the

family

in

general,

or

even

to

effectively

facilitate

compliance

with the

programme's


There

was

no

difference

in

opinion

on

this

matter

among

participants

in

the three

comarcas

or

between

men

and

women.

If they re going topay, theyshould pay per family because thefamily for us is our wife

and children.

(Caballo, Ember?)

The second issue

is that the limited

amount

of

cash involved

can

constitute

a

potential

source

of

unfairness and

even

conflict.

Equitable

division of

the cash

transfer ithin the extended house

hold

was

viewed

as

problematic

(particularly

by

Ng?be-Bugle

and

Ember?

participants),

in that

household

members

might

disagree

with decisions taken

by

women

household heads who

receive the transfers.

/

live with

my

six

children;

they

give

me

money

for

my

family

and that

is

good

because

I

live alone with

my

family

in

my

house.

But

for

those who have

more

than

one

family

in

a

house, who live with theirfather-in-law, their son-in-law and theirchildren, or a sister;

they

are

different

amilies

and

several

beneficiaries

have

to

be

[identified]

in

a

single

house.

Let

each

family

have

this

benefit;

this

must

be

understood.

(Carlos

Luis,

Ember?)

The second issue related

to

distribution

concerns

the actual

recipients

of the

cash

transfers,

defined

by

the

programme

as women

heads

of

household.

For

three

reasons,

this

policy

is

accep

table

to

comarcas

residents

(remarkably,

to

male

as

well

as

female

participants

in

the focus

groups).

First,

women are

regarded

as

better

administrators,

largely

because

they

are more

experienced

than

men

in

caring

for the needs of

family

members

(especially

children),

particu

larly

with

regard

to

health, nutrition,

and education.

...if[ the transfer] isfor our children, itwould be good that it ome in thename of thewife,

because she

is

the

one

who

administers

better,

for food

or

other

necessities.

(Lencho,

Ember?)

Second,

especially

among

theKuna and

to

some

degree

the

Ng?be-Bugle,

men aremore

likely

to

be

absent because

of labour

migration,

and

thus

less

able either

to

facilitate

compliance

with

the

co-responsibilities

or

be

present

to

receive the transfer

tself.

Third,

men

are

viewed

(by

men

as

well

as

women)

as

irresponsible

and

prone

to

misspend

the

money

on

alcohol

or

other

waste

ful

purposes.

...it

would be

better

if

t

comes

in

the

name

of

us

the

women,

because

we women are more

responsible than them; I think n thatway because we thewomen, if ne goes for a certain

thing

to

a

place,

one runs

an

errand that

one

must

do

and

returns

home.

(Lucinda,

Ember?)

[If

I

receive

the

transfer]

am

going

to

throw

down

a

couple,

two

or

three

pints [of

beer]

or

whatever else

I

do,

even

sleeping

with

women.

And

it

shouldn

't

be

that

way;

it is

better

if

that

opportunity

[the

transfer]

is

given

to

the

women.

(Sixto,

Ember?)

Development

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10/13

William F.

Waters

Use of

cash transfers

The

use

to

which

the cash transferswould be

put

can

be

divided into four

categories:

(i)

costs

directly

related

to

compliance

with thehealth and education

co-responsibilities, including

trans

port

and

purchase

of

required

school

supplies

and

clothing;

(ii)

expenses

for basic

needs

not

directly

related

to

the

programme,

such

as

food,

home

repairs,

and

agriculture;

(iii)

investment

in

starting

small

businesses;

and

(iv)

savings,

especially

for

emergencies.

While

most

partici

pants

viewed

any

necessary expense

as a

legitimate

use

of the cash

transfer,

thers

were

less

sure.

An

exchange

between

two

Kuna

participants exemplifies

this

uncertainty:

If they

give

me

the

money,

I

would

set

up

a

small business

to

live

off of

the income

so

that

[the

money]

will

not

end.

(Flavian, Kuna)

No,

the

government

is

not

giving

[money]

to

set

up

businesses but rather

for

education,

food, and health of our children. So I don't agree with you. (Anacleto, Kuna)

Many

respondents

in

all three

comarcas

(particularly

women)

lumped

together

expenses

for

health and

education with

the

cost

of

satisfying

other basic

needs,

especially

food. The

importance

of

access

to

preventative

health-care

services,

including

vaccinations,

antenatal

care,

and

family

planning,

was

also

recognised;

and

in

particular

women

expressed

the

perception

that the cash

transferswould facilitate the

payment

of

registration

fees and the

purchase

of school

supplies,

shoes,

and

uniforms. The

programme

was

also

seen as

an

opportunity

to

make house

repairs.

Respondents

in the

Ember?

and

Ng?be-Bugle

comarcas,

especially

in

the

poorer

commu

nities,

thought

that

expenditure

on

agriculture

and small animal and

poultry husbandry

would

represent

a

good

use

of the cash transfers.For

example,

seeds could be

purchased

and

temporary

wage

labour could

be

employed

to

expand

areas

under

cultivation.

Along

the

same

lines,

participants

in the intermediate and better-off communities

recognised

that

the

pro

gramme may

not

continue

indefinitely,

so

that

itwould be wise

to

start

a

business

or

other

investment,

even

though

the

amount

received would

not

necessarily

suffice for that

purpose.

Given the

precarious

nature

of

household economies

in

the

comarcas,

it is

not

surprising

that

participants

felt

that

saving

part

of the transfers

for

unplanned

expenses

(especially

emergen

cies)

would

be

an

important

part

of

their

strategies.

This

is often the

case

in

the

rural

poor

in

general,

and

resources

such

as

domestic animals

may

be

kept

less

to

provide regular

income

than

as

in-kind

savings.

Given the

uncertainty

and

high

transport

osts,

savings

was a

frequently

expressed strategy,particularly

in

the

poorer

communities.

Beliefs

and

practices regarding

ealth

Health

practices

and the

use

of

specific

health services

are

related

to

beliefs and

perceptions

about

the

nature

of health and

illness,

and such factors

are

taken into

account

by

successful

public-health

strategies

(Haider 2005).

This

point

is

particularly

relevant

in

the

case

of

indigen

ous

cultures that retain

strong

beliefs

about traditionalmedicine

and

practices.

Residents

of the

three

comarcas

under

study

hold traditional

beliefs

about health and

illness,

as

well

as

the

appropriate

steps

to

be

taken when

a

person

falls ill.

These

beliefs,

in

turn,

shape

the choice

of health-care alternatives and

may

affect

compliance

with the

co-responsibilities

of the

conditional

monetary

transfer

rogramme.

The

difference

between

traditional

beliefs and

practices

and Western

(or,

to

use

a

term

employed

in

the

comarcas,

'Latino')

approaches

to

health

care

is

well understood

by

residents

of

the

three

comarcas,

but

is

not

just

a

matter

of health-care

options

or

even

simple

access.

According

to

Ember?,

Ng?be,

and

Kuna

respondents,

some

illnesses

are

'ours' and

are

different

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Qualitative

methods

for

assessing

conditional

cash-transfer

programmes

from

those

experienced by non-indigenous

people.

In

brief,

traditional illnesses

are

viewed

as a

result of

imbalances between

the

individual

and the

surrounding biophysical

or

social

environ

ment

or,

alternatively,

may

be the

product

of

supernatural

forces.

Consequently,

the

appropriate

response to illnesses regarded as traditional is the use of traditionalmedicines and practices,

which

can

be

either self-administered

or

provided

by

traditional health

practitioners.

In

particu

lar,

maternal

health

practices

are

very

much informed

by

traditional

beliefs,

and child birth often

takes

place

in

the

home,

frequently

with

the

assistance of

a

traditional

birth attendant.

All

respondents reported

that their

decision

to

use

Western

or

traditional health-care

services

depended

on

availability

and

access,

as

well

as

the

perceived

nature

of

the

specific

illness. An

additional

defining

factor is

the

perceived

severity

of

a

given

case.

According

to

most

respon

dents,

traditionalmedicine is the

first

option,

especially

if the

condition is

not

judged

to

be

severe.

In

contrast,

some

respondents

(especially

women

in the

better-off rnbera

community)

felt that thehealth

centre

is thefirst

resort,

followed

by

traditional

medicine if the

response

is

not

satisfactory.

If

the illness is

a

Latino

one,

we

go

to

the

health

center

first

so

the

doctors

can

check

it

because

they

know the

illnesses.

But

when the

doctors don't know

what kind

of

illness

it

is,

and

they

end

you

home because this

happens,

we

take them

to

the

traditional

medicine.

(Samuel,

Ernbera)

A

final

consideration

is

that

traditional health

care

is

regarded

as

a

reasonable

alternative when

access

to

and

quality

of

care

in

the

public-health

centre

and

hospitals

are

perceived

to

be

inadequate.

Conversely,

there

is

evidence

of

a

slow

erosion of

traditional

health

practices

because

younger

people

are

not

learning

the

skills

and beliefs

related

to

traditional

medicine,

and also because (in theErnbera-Wounaan comarcd) traditionalpractices thatrevolve around

concepts

of

the

supernatural

are

viewed

as

antithetical

to

religious

beliefs

associated

with

evan

gelical

Protestantism

practised

there.

Discussion

Conditional

cash-transfer

programmes

have the

potential

to

generate

multiple

benefits,

particu

larly

in

populations

that

to

date have

been

excluded from

improvements

experienced

by

others.

These

programmes

represent

a

potentially

welcome

response

to

the

inability

to

satisfy

basic

needs

in

populations

that

experience

persistent

poverty

and

exclusion,

and

they

can

contribute

to long-termhuman-capital formation.The Panamanian case provides several lessons forpro

gramme

design

and needs

assessment

elsewhere.

From

a

methodological

perspective,

it

shows

that

qualitative

research

can

be useful

for

detecting

underlying

perceptions

that

may

be

critical

to

programme

success

and

which

may

not

be

easily

detectible

through quantitative

techniques.

The

usefulness of

qualitative

methods

can

be

optimised

when

they

are

applied

in

the

potential

beneficiaries'

communities in

their

own

language,

particularly

when

using

multicultural,

indi

genous

field

teams

familiar

with the

study

sites.

Focus

groups

and

structured

individual inter

views

allow

programme

participants

to

articulate

complex

perceptions

and

opinions

in

environments

that

promote

interaction

and

self-disclosure

(Kreuger

and

Casey

2000).

They

can

be used

alone

or

to

complement

quantitative

ex-ante

or

impact

evaluations.

Validity is a critical issue inqualitative research and is based on therigorous application of

standardised

techniques

and

maintaining

objectivity

with

regard

to

the

research

(Kreuger

and

Casey

2000;

Ulin

et

al.

2004).

The

localities

included in

this

study

were

selected

on

the

basis

of field

researchers'

first-hand

knowledge,

but

selection

could

have

been

complemented

by

community-level

statistical

information,

had

the

latter

existed

at

the

time.

Finally,

it

would

be

interesting

to

compare

the

results

reported

here

with

findings

that could

be

obtained

Development

in

Practice,

Volume

20,

Number

6,

August

2010

687



12/13

William

F.

Waters

after

several

years

of

programme

intervention,

in

order

to

determine

the

degree

to

which

the

participants' perceptions

had been taken

into

account.

With

regard

to

the

specificities

of

CCTs,

several issues stand

out. In

general,

the

co-respon

sibilities related tohealth and education are viewed as acceptable because they correspond to

services

that

people

value

and

want

in

any

case.

But

the

availability, quality,

and

appropriate

ness

of health

care

and

education

lie

at

theheart of theultimate

success

of these

programmes.

In

requiring

fulfilment

of

specific

co-responsibilities,

it

is

essential that

high-quality

services be

consistently

available and

provided

in

ways

that

are

culturally

and

linguistically appropriate.

Panama

is

a

'high

human

development'

country

according

to

UNDP

measures,

with

a

human

development

index

(HDI)

of .812.

Investment

in

health is

relatively

modest

(5.2

per

cent

of

GDP

in

2004

and

only

632

per

capita)

and

also

in education

(3.8 per

cent

of GDP and 8.9

per

cent

of

public expenditure

from 2002

to

2005).

Nevertheless,

subtracting

Panama's

HDI

rank from its

rank

in

GDP

yields

a

positive

difference

of

15,

suggesting

a

relatively

effective

use of limited resources in addressing human development (UNDP 2007).

Ultimately,

the

success

of CCTs

will

depend

not

only

on

attention

to

the 'demand side'

(through promotion

and social

marketing)

but also

on

improving

the

'supply

side',

including

the

recruitment,

training,

and

retention of health-care

professionals

who

are

willing

and able

to

provide

services

in

facilities

that

are

appropriately equipped,

which

maintain

regular

sche

dules,

and

which

are

well

distributed

in urban and

rural

areas.

In

addition,

particularly

with

regard

to

the

requirement

of

co-responsibilities

related

to

the

use

of health

facilities,

it is

par

ticularly

important

to

take into

account

culturally

informed beliefs

and

practices.

The

degree

to

which traditional

and modern

services

are

incorporated

into

health

systems

varies

throughout

the

world

(Nigenda

et

al.

2001).

Norms

and values

that nfluence

culturally

informedbeliefs and

practices are often deeply held, and may be incorporated into institutional health services

without

affecting quality.

For

example,

the

incorporation

of traditional health-care

providers,

including

midwives,

can

be

part

of

a

process

of

quality improvement

in

public

health.

Similar

provisions

related,

for

example,

to

bilingual

classes and materials

can

help

to

make

educational

services

more

culturally

appropriate.

The

provision

of

quality

services

must

be

accompanied

by

a

good

understanding

of

the

struc

ture

of

the

beneficiary population.

For

example,

iffunds

are

to

be transferred

o

households,

then

these

must

be

appropriately

defined

as

nuclear

or

extended.

This issue

was

the

greatest

source

of

criticism

of

the

Panamanian

programme,

because

there

was

broad

consensus

that the

amount

provided

may

be

diluted,

because extended

households include

many

children

in several

nuclear families, all with very great needs as well as co-responsibilities to comply with.

Nominally

free education

and

health services

in fact

involve

substantial

out-of-pocket

expenses,

so

that

the

money

provided

to

several

nuclear families

would be

insufficient

to

address

needs

adequately

or

to

comply

with


Hence,

themethod of

distribution

employed

in

Panama has the

potential

to

generate

unequal

or

inequitable

distribution

to

nuclear

families

and,

therefore,

to

generate

conflict

among

household

members. On

the other

hand,

women

heads

of

households

are

generally

viewed

as

the

most

appropriate

recipients

for

two

reasons.

First,

they

are more

knowledgeable

about the

health and welfare

of their children.

Second,

they

are

better administrators

of the

funds,

being

more

likely

to

invest them

in health and

edu

cation rather

than

non-essential

expenditures.

In sum,CCTs may not representa comprehensive solution topoverty and inequality,but they

can

play

a

role

in

improving

household

economies

while

enhancing

their

ccess

to

health and edu

cation. Governments

that

are

serious

about these

issues

will also be

interested

in

optimising

their

impact

through

the

application

of

field-based

methodologies

discussed

here,

which

can

assure a

match between

programme

features

and

the

expectations

and

perceptions

of beneficiaries.

688

Development

in

Practice,

Volume

20,

Number

6,

August

2010



13/13

Qualitative

methods

for assessing

conditional

cash-transfer

programmes

Acknowledgements

The

author thanks

Kris Merschrod

and

two

anonymous

referees for useful

comments.

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The author

William F. Waters is Professorof Public Health and

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Development

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Number

6,

August

2010

689

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