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Qualitative methods for assessing conditional cash-transfer programmes: the case of Panama
Author(s): William F. Waters
Source: Development in Practice, Vol. 20, No. 6 (August 2010), pp. 678-689
Published by: Taylor & Francis, Ltd. on behalf of Oxfam GB
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Development

inPractice, Volume 20, Number 6, August 2010

^HfaSaoup

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methods
for assessing
Qualitative
conditional
cash-transfer
programmes:
the case of Panama
William F. Waters
Governments inLatin America and elsewhere have implemented conditional cash-transfer pro
grammes to improve standards of living inpopulations defined as vulnerable and excluded from
thebenefits 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

cas de Panama
Les

gouvernements

d'Amerique

latine

et d'ailleurs

conditionnels de transfertd'argent:

ont mis

en ozuvre

des programmes

le

condition

nels de transfertd'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
tativesmenees parmi troisgroupes autochtones de Panama fournissent des enseignements pour

revaluation de ces programme sur la base des perceptions et des convictions etpratiques 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 ternimplementado 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
DOI:

1364-9213

Online 060678-12

10.1080/09614524.2010.491526

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2010 Taylor & Francis

Routledge

Publishing

Qualitative

methods

for assessing

conditional

cash-transfer

programmes

cualitativos para la evaluaci?n de programas de transferencias en efectivo condicio

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

Metodos
nadas:

trespueblos 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;Latin America 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 themost basic needs, and downturns in social and economic conditions threatennot
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 in nearly 30 countries inAfrica, Asia, thePacific,
theMiddle East, southern Europe, and throughoutLatin 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
parable on four points: (i) objectives and components,
participants, (iii) specific co-responsibilities, and (iv)
thoroughly documented and evaluated in most cases,

Familia). CCT programmes are com

(ii) criteria for selecting and including
impacts. CCT programmes have been
and evidence suggests that they can

provide important gains in consumption, diet, and infantnutrition (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 the principal
reasons for thishas been an inability to understand why services remain unacceptable to poten
tial beneficiaries, even when cash transfersare 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

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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 inPanama'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 throughCCTs. Eligible households?irrespec

tive of their composition?receive

the equivalent of US$ 100 (initially $70) every twomonths
are
and
required to demonstrate regular school attendance and theuse 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 in Latin 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 theCCT 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 transferswithout submitting to the
proxy means test used to determine eligibility in other potential beneficiaries (MIDES 2007;
World Bank 2007).
Several importantquestions arise about the programme's acceptability in the comarcas, and
are relevant elsewhere. Are thehealth and educational services appropriate, and are the required
co-responsibilities acceptable topotential 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 towhich its components are consistent
with perceptions and expectations of comarca residents. The studywas 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; the Ember?-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 theCaribbean 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.

health,and ethnicity
Poverty, inequality,
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

680

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related to the epidemiologic

transition; and the

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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

in under-fives; inadequate consumption; and linguistic isolation

(MIDES 2007; World Bank 2007). Infantmortality 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
chronic malnutrition

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

comarcas
and Ember?-Wounaan
Yala, Ng?be-Bugle,
two
teams
Three
of
2007.
native
January
bilingual
speakers
Ng?bes, two Ember?s, and twoKunas) conducted a total of 18
Kuna

research was conducted in the

between October 2006 and
of indigenous languages (two
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 informantswere 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 from a set of individuals
who share at least one important characteristic such as gender or socio-economic status. They
provide a safe environment inwhich 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 thatbuild
upon one another. The focus group represents a natural settingwhere 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 interviewswere conducted in order to shed furtherlighton 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 theirknowledge of the topic of interestby 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
comarca an additional criterion was that at least one community
the Ember?-Wounaan
should be located in each of the two separate districts of Cemaco and Samb?. Before the
focus-group discussions and key-informant interviews were 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
Development

notes ensured

the accuracy

of the transcriptions and allowed

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for the

681

William

F. Waters

identification (using firstnames 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-group discussions addressed perceptions related to (i) the func
tioning of the conditional CCT programme; (ii) factors thatcould 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 informedbeliefs); (iii) logistical
aspects of themonetary transfers; (iv) use of the transfers; (v) traditional andmodern health prac
tices and beliefs; (vi) the inclusion of families who are absent from the comarcas for extended
periods because of labourmigration 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 interviewswere conducted in the respective indigenous languages.
Transcripts of the focus-group discussions were developed by thebilingual teammembers in
the respective indigenous language from the audio tapes, supplemented by field notes. Verbatim
notes were taken in the case of individual interviews. The notes and transcriptswere 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 theirproperties 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 furtherrefine emerging categories, and to link categories on the basis
of underlying properties and dimensions. Finally, selective coding was employed to integrate
and refine themajor themes and relationships among them (Strauss and Corbin 1998).

Results
Knowledge and perceptionsconcerningtheCCT programme
Knowledge of the programme varied among and within the three comarcas. Accurate knowl
edge was most complete in theKuna Yala comarca, not only because one of the communities
had already received its first cash transfer,but because - despite the transport and communi
- informationhad
cation difficulties (communities are widely dispersed on small islands)
pre
some
been
Nevertheless,
government
visiting
representatives.
viously
provided by

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, therewas 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
comarca none of the participants
about the programme, while in the Ng?be-Bugle
awareness of the programme.
or
demonstrated
much
in
of
the
communities
any
female)
(male
two
about
the
those
who
knew
programme,
perceptions predominated. First, itwas
Among
as
both necessary and potentially important to improved
viewed positively and regarded

men

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 itspossible political
motivations (i.e. that its true purpose was to garner political support); and a feeling that non
indigenous people would benefit earlier or more than indigenous people. A contrasting view,

expressed most often by Kuna participants, was that themoney would be misused ifnot care
fullymonitored by traditional leaders and community residents.
In sum, itwas thought that the programme would contribute to resolving problems related to
poverty and limited consumption, although, as noted below, itwas also felt that the size of the

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Qualitative

methods

for assessing

conditional

cash-transfer

programmes

transferwould not be enough to contribute significantly to closing the gap between available
resources and unsatisfied needs.
For me it is not bad that thisprogramme comes; to the contrary, it is a giftfrom God, who
knows thatwe all need it,and it is to improve our lives here in the comarca. (Crecencia,
Ember?)

orpromotingcompliancewithprogrammerequirements
Factors inhibiting
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
and
many cases is severely limited by geography and topography. In the Ng?be-Bugle
comarcas, thedistances from villages tohealth posts or centres are often sub
stantial and isolation is compounded by the difficult terrain.Residents of themountainous
comarca may have towalk for eight to ten hours to the nearest health centre,
Ng?be-Bugle
access
to primary schools is somewhat less limited in this respect. Access by motor
although
vehicle is extremely limited: during the rainy season many of the roads are virtually impassable,
Ember?-Wounaan

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 thatply up and down the region's many rivers. In theKuna
Yala comarca, access to services is limited by the distances between the islands and themain
land and between the islands. Particularly during thewinter months, the seas are rough, severe

thunderstormsare common, and travel can be dangerous. In all three comarcas, public transport
is available: trucks and 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 is limited, expensive, and often extremely difficult,as the following case illus
trates:

... that road is terrible; at timeswhen it is raining there is no way for car to get through,
and because ofthat, not long ago, they took a boy injured in themouth; an animal attacked
him, and he lost all of his teeth.They took him to theport, where theywaited threedays, the

boy dying. How were we going to get through, raining all those days, and the road
damaged? (Sixto, Ember?)

A second barrier relates to negative perceptions about the quality of public services. The most
relevant factor in this regard is that residents of all three comarcas (bothmen 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 irregularpresence 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.

... ifwe are

talking about health, that is another delicate point because the health center
never has medicines; we don't know if theMinistry ofHealth sends medicine or not; that
we do not know. (Magaleno, Ember?)
... there is a health center but inname
only, a shell, with nothing inmedicines, nor doctors.
With a situation like that,we can't fulfil [the co-responsibilities]; if theyput conditions of
thatkind, 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 ispregnant, 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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F. Waters

Similarly, there is a strongperception in all three comarcas thatwhile 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 thatprimary 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 treatmentreceived 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
like
their
mothers, and theycan't communicate with theirLatino (waga) teachers.
Spanish,
(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
the use towhich the cash transferswould be put (see below), the perception among both men
and women in all three comarcas is that the programme will reduce cost-related barriers to
health care and education.

Sometimes I don't takemy son to the hospital to keep his vaccinations up to date because
we don yt
have money; but since theyare going togive 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
in universities in the capital city.
We - thefather and I - make the effortso thatmy son can study [at the university] and at
timeswe have to save to send a littlemoney tomy son so that here, we are leftwithout
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?)
Distributionof thecash transfer
Beyond the logistical problems related to the cash transfers,two critical issues related to distri
bution were mentioned by potential beneficiaries. First, theprogramme 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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Qualitative

methods

for assessing

conditional

cash-transfer

programmes

through Active kinship (compadrazgo) or friendship.While extended

are highly valued, the nuclear family is understood to be the basic
ties
and
kinship
family
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

household members

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
transferwas regarded as insufficient to cover the basic needs of the family in general, or
even to effectively facilitate compliance with the programme's co-responsibilities. There was
no difference in opinion on thismatter among participants in the three comarcas or between

men

and women.

If theyare going topay, they should pay per family because

and children. (Caballo, Ember?)

thefamily for us is our wife

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 transferwithin the extended house
hold was viewed as problematic (particularly byNg?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; theygive me money for my family and that is good because
I live alone with myfamily inmy house. But for those who have more than one family in a
house, who live with theirfather-in-law, their son-in-law and their children, or a sister;

they are differentfamilies and several beneficiaries have to be [identified] in a single

house. Let each family have thisbenefit; thismust be understood. (Carlos Luis, Ember?)

The second issue related to distribution concerns the actual recipients of the cash transfers,
defined by theprogramme as women heads of household. For three reasons, thispolicy is accep
table to comarcas residents (remarkably, tomale as well as female participants in the focus
groups). First, women are regarded as better administrators, largely because they are more
experienced thanmen in caring for the needs of familymembers (especially children), particu
larlywith regard to health, nutrition, and education.

...if[ the transfer] isfor our children, itwould be good that itcome 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 theNg?be-Bugle, men aremore likely
to be absent because of labourmigration, and thus less able either to facilitate compliance with
the co-responsibilities or be present to receive the transferitself.Third, men are viewed (bymen
as well as women) as irresponsible and prone tomisspend themoney on alcohol or otherwaste
ful purposes.

...it would be better if itcomes in thename of us thewomen, because we women are more
responsible than them; I think in thatway because we thewomen, ifone goes for a certain
thing to a place, one runs an errand thatone must do and returns home. (Lucinda, Ember?)
[If I receive the transfer] I am going to throwdown a couple, two or threepints [of beer] or
whatever else I do, even sleeping with women. And it shouldn 'tbe thatway; it is better if
that opportunity [the transfer] is given to thewomen. (Sixto, Ember?)

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685

William

Use

F. Waters

of cash

transfers

The use towhich 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,others were less
sure.An exchange between two Kuna participants exemplifies this uncertainty:

If theygive me themoney, I would set up a small business to live offof the income so that
[the money] will not end. (Flavian, Kuna)
the government is not giving [money] to set up businesses but ratherfor education,
food, and health of our children. So I don't agree with you. (Anacleto, Kuna)
No,

Many respondents in all three comarcas (particularly women) lumped together expenses for
health and education with thecost of satisfyingotherbasic needs, especially food. The importance
of access topreventative 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 tomake house repairs.
comarcas, especially in the poorer commu
Respondents in the Ember? and Ng?be-Bugle
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-offcommunities 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 thatpurpose.
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 importantpart 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 transportcosts, savings was a frequently
expressed strategy,particularly in the poorer communities.

Beliefs and practices regardinghealth

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 strongbeliefs 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 transferprogramme.

The difference between traditional beliefs and practices and Western (or, to use a term
employed in the comarcas, 'Latino') approaches to health care iswell understood by residents
of the three comarcas, but is not just a matter of health-care options or even simple access.
According toEmber?, Ng?be, and Kuna respondents, some illnesses are 'ours' and are different

686

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inPractice, Volume 20, Number 6, August 2010

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All use subject to JSTOR Terms and Conditions

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 theproduct 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 verymuch informedby traditional beliefs, and child birth often
takes place in the home, frequentlywith the assistance of a traditional birth attendant.
All respondents reported that theirdecision 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 tomost 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-offErnbera community)
felt that thehealth centre is thefirstresort, followed by traditionalmedicine

if the response is not

satisfactory.

If the illness is a Latino one, we go to the health centerfirst so the doctors can check it
because theyknow the illnesses. But when the doctors don't know what kind of illness it
is, and theysend you home because thishappens, 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 traditionalmedicine,

and also because (in theErnbera-Wounaan comarcd) traditional practices that revolve 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 thepotential 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 for pro
gramme design and needs assessment elsewhere. From a methodological perspective, it shows
thatqualitative research can be useful for detecting underlying perceptions thatmay be critical
to programme success and which may not be easily detectible throughquantitative
techniques.
The usefulness of qualitative methods can be optimised when they are applied in the potential
beneficiaries' communities in theirown 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 in qualitative 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-handknowledge, 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

inPractice, Volume 20, Number 6, August 2010

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687

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 to health and education are viewed as acceptable because they correspond to
services thatpeople 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 fulfilmentof specific co-responsibilities, it is essential that high-quality services be
consistently available and provided inways that are culturally and linguistically appropriate.

is a 'high human development' country according toUNDP 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 inGDP yields a positive difference of 15, suggesting a relatively effective
use of limited resources in addressing human development (UNDP 2007).
Panama

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
Ultimately,

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
towhich traditional and modern services are incorporated intohealth systems varies throughout
theworld (Nigenda et al. 2001). Norms and values that influence 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 tomake
educational services more culturally appropriate.
The provision of quality services must be accompanied by a good understanding of the struc

tureof thebeneficiary population. For example, iffunds are tobe transferredtohouseholds, then
thesemust be appropriately defined as nuclear or extended. This issue was the greatest source of
criticism of the Panamanian programme, because therewas 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 themoney provided to several nuclear families would be insufficient to address needs
adequately or to comply with co-responsibilities. 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
heads of households are generally viewed as themost
First, they are more knowledgeable about the health
they are better administrators of the funds, being more

the other hand, women

appropriate recipients for two reasons.
and welfare of their children. Second,
likely to invest them in health and edu

members. On

cation rather than non-essential expenditures.

In sum,CCTs may not represent a comprehensive solution topoverty and inequality, but they
can play a role in improving household economies while enhancing theiraccess tohealth and edu
cation. Governments that are serious about these issues will also be interested in optimising their
can assure a
impact through the application of field-based methodologies discussed here, which
match between programme features and the expectations and perceptions of beneficiaries.

688

Development

inPractice, Volume 20, Number 6, August 2010

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methods

Qualitative

conditional

for assessing

cash-transfer

programmes

Acknowledgements
The

author

and

thanks Kris Merschrod

two anonymous

referees

for useful

comments.

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The author
William F. Waters is Professor of Public Health and Sociology and co-directorof the Institutefor
Research inHealth andNutrition at theUniversidad San Francisco de Quito. <wwaters@usfq.edu.ec>

Development

inPractice, Volume 20, Number 6, August 2010

This content downloaded from 132.248.241.216 on Fri, 17 Oct 2014 13:02:08 PM

All use subject to JSTOR Terms and Conditions

689