In July 2013, I huddled closely with Yesenia Paqari (not her real name), a mother of two and a respected community leader. We sat on a low wooden bench in the quiet green courtyard behind her modest home, high in the brown Andes mountains of northern Peru.
I met Paqari while doing research on a conditional cash transfer program (CCT), which have grown tremendously in popularity over the past decade and a half. Like thousands of mothers across the global south, she received a monthly cash benefit if she met a set of “conditionalities” like sending her children to school, taking them for regular health check-ups, and if pregnant, attending prenatal appointments. If she met these conditionalities, she could spend the cash however she saw fit. Most recipients would spend the cash on basic needs like protein, school supplies, home repairs, mobile phone credit, and medicine. But if Paqari didn’t meet the conditionalities, she could be expelled from the program.
I had called Paqari earlier that morning, hoping for one last visit before I returned home. She was unusually upset when she answered the phone, and so I immediately set out for her house. She was alone, under her Andean eggplant tree, folded over in despair. She told me that she had been diagnosed with breast cancer. Sobbing, she clutched my hand to her breast, asking if I could feel the noxious lump.
The nearest cancer treatment center was an 18-hour bus ride away. Going there would mean leaving her two children behind, and her husband worked as a migrant laborer on the faraway coast; who, she wept, would care for her daughters? And would getting treated for cancer make her ineligible for the income from the cash transfer program?
Paqari worked as an unpaid, voluntary caregiver; she said there were no opportunities for paid work in the village. The money she received from the CCT program helped her provide for her children, but it wouldn’t be enough to cover the cost of travel and lodging to seek cancer treatment. Worse, if she wasn’t able to meet the program’s conditionalities, she risked losing that income altogether.
WWhen I looked at CCTs through the everyday experiences of individual women, it became immediately clear that Paqari’s situation was not unique. Conditionalities, lauded by policymakers as the closest thing we’ve got to a magic bullet in development, are actually creating significant, but uncounted, harm.
Governments, donors, nonprofits, and social entrepreneurs globally are investing in CCT programs to break cycles of poverty, build human capital, and meet the Sustainable Development Goals (SDGs). In 1997, two countries had CCT programs (Mexico and Brazil). By 2017, 67 countries had implemented at least one CCT. The gender implications of this are striking: More low-income women in the global south have access to social assistance than ever before.
There is a lot of experimental research showing that conditionalities effectively generate demand for health and education services. For instance, in Colombia, CCTs increased children’s attendance at growth monitoring appointments; in India, they led to a rise in women’s use of antenatal care services; and in Brazil, CCTs have had a positive impact on school attendance.
But women’s actual experiences of meeting conditionalities show that we’re collecting the wrong data.
Many studies supporting the use of conditionalities focus on a handful of narrow, quantitative metrics relating to service usage (e.g. school matriculation, attendance and graduation, attendance at health appointments, rates of vaccination, and in-facility births). However, they often overlook metrics related to the quality, accessibility, and availability of those services, and what it costs women–in time, labor, and dignity–to reach them.
There’s another body of qualitative, gender-sensitive research, of which mine is a part, that investigates these questions. Over 10 months between 2012–2013, I conducted an institutional ethnography of Peru’s CCT program. I divided my time between Lima, where the CCT is designed and administered, and two rural districts in the northern department of Cajamarca where it is implemented, including the village where Paqari lives. I interviewed high-level government officials, program administrators, school and health clinic staff, local government, social program workers, frontline CCT staff responsible for monitoring and enforcing conditionalities, and women who participate in the CCT program.
The main takeaway of my research, and of other feminist scholars, is that imposing conditionalities in the absence of accessible services produces unintended consequences, inefficiencies, and hidden costs, especially to women. And to meet the SDGs — and achieve gender equality — we need to address these conditionalities.
One of the central issues with conditionalities is that they mask poor service quality. Studies on health and education in Latin America, South Asia, Southeast Asia, and Africa show that governments that use conditionalities often do not adequately invest in improving education or health services. This is because they don’t have to. When donors and policymakers impose conditionalities, the burden of finding subpar services falls on the women receiving the cash.
For example, in rural areas in Peru and Colombia, pregnant women and mothers with children can walk for hours to reach the nearest health clinic. They may arrive to find them short-staffed or closed altogether. In order to meet a health conditionality, they have to return again, and again, until the clinic is open and someone can see them. The data only show whether or not services were used, not what it cost to use them.
Another major unintended consequence is that conditionalities create opportunities for coercion. CCT staff, government officials, teachers, principals, and clinicians can and do use the threat of program suspension to get women to do things that the CCT program does not officially require of them. I call these activities “shadow conditions” because for many women, the line between what is officially required and what more powerful people tell them to do is often blurry.
Under threat of suspension from the program, CCT recipients are sometimes required to participate in political parades; paint the program logo on their houses; clean public spaces; take Zumba (exercise) classes; maintain tidy houses; build ecological refrigerators; produce handicrafts for NGOs; and do whatever other things local authorities tell them to. Some of these activities may be enjoyable or beneficial, while others are shameful, undignified, and stigmatizing. All of them are coercive and drain women’s time, without ensuring that development goals are met.
Cash provides critical economic support to individuals and families, but conditionalities take the “protection” out of social protection, and remove the “safety” from safety net. What happens when opportunities for temporary paid work conflict with conditionalities? What happens when other life events–like breast cancer–make compliance difficult? In these cases, women like Paqari worried that they would lose the little support that cash transfers provide.
NNearly four years after Paqari sat under her eggplant tree, I found myself back in her courtyard. On this visit, she looked happy and strong. She had survived. Paqari recounted how she had sought treatment at the public hospital in Lima, Peru’s capital. To access that care, she endured 18-hour bus rides between rounds of chemotherapy and radiation, and like others seeking treatment, she queued for hours, in the rain and in the sun, patiently waiting her turn.
Paqari also owed her survival to the unpaid caring labor of her sister, who lived in Lima. Her sister housed her, fed her, and nursed her throughout the course of her treatment. Her time, and her sister’s unpaid work, subsidized the government’s inadequate investments in functional and accessible public services.
Evidence suggests that mothers will go to great lengths to seek poor or non-existent care, especially if we apply conditionalities. But that isn’t going to help us meet the SDGs, and it sure isn’t going to help us achieve gender equality.
Proponents of CCTs insist on demonstrating a connection between conditionality and women’s empowerment. But these attempts elide the existing — and growing — body of evidence that improving women’s social, political, and economic status requires more than access to cash, and that women disproportionately bear the hidden costs of conditionalities. We should be designing social protection systems with women’s everyday lives at the core. The voices of mothers like Paqari are loud and clear.
