Relational Well-Being in Policy Implementation in Mexico: The Oportunidades-Prospera Conditional Cash Transfer 3030747042, 9783030747046

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Relational Well-Being in Policy Implementation in Mexico The Oportunidades-Prospera Conditional Cash Transfer Viviana Ramírez

Relational Well-Being in Policy Implementation in Mexico

Viviana Ramírez

Relational Well-Being in Policy Implementation in Mexico The Oportunidades-Prospera Conditional Cash Transfer

Viviana Ramírez Puebla, Mexico

ISBN 978-3-030-74704-6 ISBN 978-3-030-74705-3 (eBook) https://doi.org/10.1007/978-3-030-74705-3 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Cover illustration: Maram_shutterstock.com This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To the participants of this study, for sharing their lives and their experiences of social policy in Mexico To those who accompanied me in the journey of thinking, writing, and rewriting this book

Acknowledgments

I am deeply indebted to Sarah C. White, Séverine Deneulin, Laura Camfield, Joe Devine, Mariano Rojas, Ricardo Velázquez-Leyer, and Oscar Garza for their invaluable comments and support in the process of conducting the research for this book and writing it. The book proposal and the production process for this book was conducted with the sponsor of the Universidad de las Américas Puebla, the Cambridge-UDLAP Visiting Fellowship, the Centre of Latin American Studies (CLAS) at the University of Cambridge, the Institut des Hautes Etudes de l’Amérique Latine (IHEAL), and the Centre de Recherche et de Documentation Sur Les Amériques (CREDA) at the Sorbonne Nouvelle University in Paris. Finally, the research project behind the data presented here was possible thanks to the financial aid of the Consejo Nacional de Ciencia y Tecnología (CONACyT) in Mexico and the University of Bath.

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Contents

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Introduction Subjective Well-being and Public Policy Relationships in Well-being and Public Policy The Oportunidades-Prospera Program and the Officer–Recipient Interactions Contributions and Structure of This Book Methodological Notes The Research Design The Well-being Framework: Inner Well-being (IWB) Quantitative Scales Inner Well-Being Model (IWB) Subjective Well-being (SWB) Quality of Relationships with Officers scale (QoR) The Research Contexts Nexpan and Cualcan: Brief Descriptions Health Clinics in Nexpan and Cualcan Participants Participants of the Qualitative Study Participants of the Quantitative Study Bibliography

11 15 17 22 24 26 26 27 27 28 28 30 30 31 33 33

Well-Being: A Framework to Assess Relationships in Policy Implementation Subjective Well-Being

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Differing Subjective Well-Being Approaches The Overarching Significance of Relationships for Well-Being Relationships in SWB and PWB Relationships in Critical Well-being Approaches Relational Well-Being in Social Policy Frontline Officers: From the Control Over Resources to the Potential Well-Being Impacts Officer–recipient Relationships Summary Bibliography 3

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Oportunidades-Prospera and the Provision of Health Care Social Protection Programs and Oportunidades-Prospera Oportunidades-Prospera The Historical Evolution in Brief Distinctive Features of Oportunidades-Prospera Evaluations and Broad Results of the Program Quantitative Evaluations Qualitative Evaluations: Focus on Relationships Evaluations from a Well-Being Perspective The provision of health in Oportunidades-Prospera Empirical Evidence of the Implementation of Health Summary Bibliography Street-Level Bureaucrats: From Obedience to Participation The Context of Implementation: Between the Program’s Discourse and the Officer’s Job Position Oportunidades-Prospera’s Discourse of Conditionality Identities and Intersectionality Temporary Officer Versus Permanent Officer The Officer–Recipient Relationship: From Obedience to Empathy Authority through Power and Obedience: Permanent Officers Authority through Communication and Support: Temporary Officers The Good and the Bad Recipient

47 52 54 62 68 71 73 79 80 95 95 97 100 101 106 106 108 109 112 115 121 122 129 130 130 132 134 135 136 141 144

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Explaining Opposing Relationships Having a Contract The Health Ministry Relationships Among Staff Relationships Within Localities The Wider Culture of Discrimination in Mexico Summary Bibliography 5

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Recipients: Between Medical Attention and Mistreatment The Centrality of Oportunidades-Prospera for Well-Being From Medical Attention to Mistreatment Ambivalent Interactions with Officers Communication, Kindness, and Dedication: Relationships with (Temporary) Officers in Cualcan Mistreatment, Humiliation, and Abuse of Power: Relationships with (Permanent) Officers in Nexpan Narratives of Well-Being During Policy Delivery Summary Bibliography The Well-Being Impacts of Officer–Recipient Relations: A Quantitative Perspective Participants Measures The Inner Well-Being Scale Interpreting the IWB Factors The Quality of Officer–Recipient Relationships Scale Interpreting the QoR Factors Mapping the Well-Being of Oportunidades-Prospera’s Recipients Relationships in Policy Implementation and Their Well-Being Impacts The Quality of the Relationship with Officers in Nexpan and Cualcan The Well-Being Effects of Frontline Officers Summary Bibliography

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145 146 147 149 152 152 153 155 157 158 164 171 174 177 182 189 190 193 194 195 198 200 203 204 206 217 217 221 232 233

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Conclusion The Characteristics and Quality of Officer–Recipient Relationships Factors Mediating the Officer–Recipient Relationship The Implications of Relationship Quality Over the Program’s Outcomes Well-Being and Policy-Engendered Relationships The Shape of the Well-Being of Oportunidades-Prospera Recipients in Nexpan and Cualcan The Significance of Oportunidades-Prospera in the IWB of Recipients Inner Well-Being and the Relationship Between Officers and Recipients Academic, Methodological, and Policy Implications The Need for a Broader Outlook Toward Relationships and Well-Being Methodological Contributions The Value of a Well-Being Lens in Public Policy in Practice Policy Implications of the Well-Being Impacts of Officer–Recipient Interactions Bibliography

Index

237 238 240 243 244 244 245 247 251 252 253 255 257 262 265

List of Figures

Fig. 1.1 Fig. 2.1

Inner Well-being Model (Source Well-being and Poverty Pathways Briefing Paper No. 1) Dimensions of well-being (Source White [2010] and Gough and McGregor [2007])

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List of Tables

Table 1.1 Table 3.1 Table 3.2 Table 3.3 Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 6.11 6.12 6.13 6.14 6.15

Table Table Table Table

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Summary of research design Top countries with more conditional cash transfer programs Evolution of the coverage of Oportunidades-Prospera Monthly cash transfers of Oportunidades-Prospera (Mexican Pesos, MXN) Demographics Inner well-being Indicators QoR indicators Factor analysis of the IWB model IWB model fit IWB factors and items Factor analysis of QoR scale QoR Model Fit QoR factors and items Descriptive statistics SWB and IWB Correlations IWB and SWB against demographics Pearson correlation IWB and SWB Linear regression analysis of SWBi over IWBi Descriptive statistics PveQoR and NveQoR Descriptive analysis of QoR by affiliation to Oportunidades Correlation QoR scales and IWB domains Descriptive statistics independent variables Regressions IWBi over PveQoR and NveQoR Regressions IWBi over QoR

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CHAPTER 1

Introduction

In his foreword to Duncan Green’s (2012) book From Poverty to Power, Amartya Sen explains that more than a 100 years ago George Bernard Shaw argued that ‘The greatest of evils and worst of crimes is poverty’ (p. ix). Following Sen, this statement not only describes poverty as an atrocity that affects millions around the world but as something that has a human cause. This is not to say that we can single out the criminals that place people in poverty as this is a complex process that has a variety of causes. But, it does point out an important characteristic of poverty that can be extended to other close-connected dimensions such as well-being: it is something created in relationship with others. In this sense, the point of departure of this book is that both poverty and well-being should be understood as an experience constructed in interaction with others. Different social relationships mediate the resources people can have, how they can access and make use of them, and the way they feel and think about themselves and their lives. They are also key in shaping the strategies people can or cannot use to be well in different dimensions. This emphasizes the necessity to place human relationships at the center of well-being research and of wellbeing-driven policy-making. However, these relational processes remain understudied, especially at the level of policy. It is in this area where the heart of this book lies, on exploring the value of a well-being lens in the assessment of those relationships created in the process of policy © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 V. Ramírez, Relational Well-Being in Policy Implementation in Mexico, https://doi.org/10.1007/978-3-030-74705-3_1

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implementation, particularly, those created between frontline officers and program participants. In an era of evidence-based policy, the evaluation of policy success has become an area of study in its own right. Still, one might wonder success in terms of what? Traditionally, policy evaluations have focused on economic outcomes and on the mechanisms of policy delivery, leaving behind human-centered aspects such as well-being. Yet, in recent decades, researchers from various disciplines have made a strong argument in favor of relocating the person as the primary aim of policies; and thus, to evaluate their success based on their capacity to improve people’s lives in multidimensional terms (Devereux & McGregor, 2014; Forgeard et al., 2011; McGregor et al., 2015; Rojas, 2009; Stiglitz et al., 2009). In this context, subjective well-being approaches emphasize that policy decision-making must pay attention to people’s feelings and perspectives of their lives as they provide valuable information about what people truly value and what really matters in their personal and social life (UNDP, 2012). There is substantial agreement about the normative case of placing the person and her well-being as a goal of development and policy (e.g., Gough & McGregor, 2007; McGregor et al., 2015; ONS, 2011; OECD, 2013a; Rojas & Martinez, 2012; Stiglitz et al., 2009; UNDP, 2012). Yet, efforts have largely dedicated on making international comparisons of aggregate well-being reports to evaluate general outcomes of government structures, actions or policies. In the words of the OECD (2013b, p. 36): [B]eing grounded in peoples’ experiences and judgements on multiple aspects of their life, measures of subjective well-being are uniquely placed to provide information on the net impact of changes in social and economic conditions on the perceived well-being of respondents.

In line with this aim, numerous governments, NGOs and international think tanks have started to use subjective measures of well-being to assess the state of societies. These indicators have been incorporated into large international polls (e.g., Gallup, World Values Survey, and Latinobarometro), as well as adopted by many national statistics offices (e.g., Mexico’s BIARE-INEGI, UK’s Measuring National Well-being, Australian National Development Index and Bhutan’s Gross National Happiness; see OECD 2013b for a review), and international organizations (e.g., OECD, 2013a). While these efforts are indeed valuable, they

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do not examine the links between well-being and policies at the frontline level (see McGregor et al., 2015; White & Abeyasekera, 2014). This implies inspecting the advantages and limitations of applying a well-being framework to directly design, evaluate and improve social programs that have immediate contact with the final receiver: citizens. It is at this level of analysis that this book is situated. Although this book recommends the use of well-being in public policy more generally, it mainly concentrates on the more specific area of social policy: those policies and programmes concerned with social welfare and social problems, and the provision of government services that address these. Without ignoring the importance of aggregate analyzes, this ‘frontline’ perspective is well suited for the aim of this book to examine the benefits of a well-being approach to assess the outcomes and processes of policy implementation. To do this, the context of the research is the largest social program in Mexico, the Oportunidades-Prospera conditional cash transfer program. Many areas of this program could be evaluated from a well-being lens. However, the stage of policy implementation and the relational processes that occur within it are especially important for two reasons. First, well-being research has provided cumulative evidence about the centrality of relationships for people’s lives (e.g., Haller & Hadler, 2006; Ryan & Deci, 2000; Ryff, 1989a; White, 2010; Zavaleta et al., 2014). However, while much research has been conducted on the well-being effects of close relationships (romantic, marital, family, friends), the interactions created in the contexts of policy have been largely neglected. Second, these interpersonal relationships are key mediums through which many social policies concerned with the provision of services achieve their goals as they create and depend on the direct contact of frontline officers with different population groups. In the case of OportunidadesProspera, its conditional nature extends and intensifies the character of these interactions by imposing actions that need to be fulfilled by recipients and supervised by different kinds of officers. These two pieces of evidence from well-being research and public policy indicate that relationships created by policies need to be placed under closer scrutiny to truly enhance and understand people’s well-being and the way it is affected by, and through, public policies. It is in these regards in which the major contributions of this book lie.

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Subjective Well-being and Public Policy The relevance of well-being in policy has been emphasized by several authors (e.g., McGregor et al., 2015; White, 2010; Stiglitz et al., 2009). It is generally agreed that well-being offers a holistic view that avoids reducing people’s lives into specific government areas or policy aims; while subjective well-being specifically offers a bottom-up outlook as it incorporates people’s own perspectives and values more directly, rather than relying on externally imposed indicators or aspects (Diener 2000; Rojas, 2011). Acknowledging the benefits of including a wellbeing framework in policy, however, does not say anything about what well-being is. Defining well-being is a challenging task. Researchers have defined it in different ways, often using related but different concepts like quality of life, happiness, or life satisfaction. Yet, in broad terms, subjective wellbeing comprises people’s feelings and perceptions about their lives and their circumstances (Diener, 2006). This can include people’s evaluations of their lives as a whole or of different aspects such as physical health, leisure, employment, community environment, social relationships, and subjective states like mental health, affect, motivation, and purpose. Underneath this comprehensive definition, those approaches that include subjective aspects of well-being are quite diverse. Psychologists were among the first to empirically analyse subjective perceptions of well-being most directly. A common way of distinguishing approaches within this field is in terms of their philosophical standpoints: eudaimonic and hedonic approaches. The former- or also called psychological approaches (PWB)—understand well-being as eudaimonia, which concentrates on what makes life worthwhile and meaningful, as well as people’s self-realization, motivation and flourishing (e.g., Ryff, 1989a, 1989b; Ryff & Keyes, 1995; Ryan & Deci, 2000, 2001). The latter— hedonic approaches or also called ‘subjective well-being’ (SWB)—see well-being as the maximization of people’s happiness and the minimization of their pains and sufferings (e.g., Diener, 2006; Diener et al., 2000; Rojas & Veenhoven, 2010). Both, however, primarily focus on the individual experience of well-being mostly understood as people’s mental and emotional relationship to the world. They also tend to employ quantitative and statistical tools for their study, creating a multiplicity of models that have been included in national and international surveys monitoring

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social development and well-being outcomes (e.g., Gallup, World Values Survey, etc.). In recent years, psychosocial approaches, another group that is not part of the former classification has arisen from the separate efforts of researchers in development studies, sociology, and anthropology. Informed by a sociological outlook, psychosocial frameworks are not only concerned about people’s psychological experiences but also include how they perceive the material and social dimensions of life (e.g., Gough et al., 2007; McGregor & Sumner, 2010; PADHI, 2009; White, 2010; White et al., 2014). They also emphasize more strongly the role of culture and the context in the meaning and experience of well-being, and promote the use of broader epistemological and methodological approaches like qualitative and mixed methodologies. There are, nonetheless, contested matters about the employment of subjective perspectives of well-being in public policy that need to be clarified, as this book does not deal with these directly. An extreme and disputed proposal is the use of subjective well-being as the supreme goal of policy decision-making and as the paramount indicator of the progress of societies. This stance, linked to a utilitarian interpretation of subjective well-being, takes the indicators of hedonic frameworks like happiness and life satisfaction as the main approach (e.g., Layard, 2005, see UNDP, 2012 for a discussion on this). However, others rightly disagree with this proposal by arguing that these approaches are inadequate for such ambitious use as they are mainly engrossed with outcomes while neglecting important aspects of the meaning and dynamics of well-being such as the processes and the normative values through which they are achieved (UNDP, 2012). Other critiques are directed to the emphasis subjective well-being gives to people’s feelings and perceptions, the limitations of subjective indicators to capture people’s ‘true’ experiences and their disconnection with other aspects of well-being such as material needs and opportunities (e.g., White et al., 2012c). In this regard, probably the most important challenge to the use of subjective indicators is adaptive preferences. Mainly raised in the capabilities and human development literature (Austin, 2016; Sen, 1985), adaptive preferences involve the unconscious mechanisms through which people adapt themselves and their aspirations to the circumstances in which they live. Hence, we have the cases of the depressed rich, the happy poor or the satisfied but mistreated client of a social program. Arguably, adaptive preferences are particularly worrying

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in deprived groups since they may lead to the acceptance of the status quo and a diminished sense of entitlement, making well-being research difficult. One could say that the issue of adaptive preferences could affect certain approaches more than others within subjective well-being—especially those that lie at the extreme of the subjective continuum by not defining the meaning of happiness or life satisfaction, leaving it to the intepretation of the person answering the survey question (see Diener et al., 1999; Schwartz & Strack, 1999). At the same time, it could be argued that in order to establish that a form of adaptive preferences is occuring, the ‘true,’ ‘valuable’ or ‘authentic’ preferences need to be defined. This, however, involves making certain value judgments that are contrary to the philosophy of subjective well-being which takes as true people’s own subjective feelings and experiences. Hence, although this book does not engage in these discussions difficult to settle, it takes some steps or measures to minimize possible biases and identify in different ways what people feel and think about their lives. Firstly, although the adaptive preferences critique is certainly challenging to any subjective approach, this book decides to take a psychosocial approach. In chapter two, it defends that their outlook toward subjectivity and well-being—not as detached from but as embedded in time and space, in particular relational and material circumstances—is able to minimize this problem. This is combined with a mixed-methods approach to obtain a deeper understanding of self-report scores obtained through subjective indicators. Finally, the book gives stronger weight to the relational processes behind subjective well-being experiences by measuring the quality of social relationships directly. Secondly, the view taken here is that although the supreme goal of policies should be people’s well-being, well-being should be understood as a multidimensional phenomenon. Of course, well-being not just relates to people’s feelings and perceptions of their lives. Objective approaches such as capabilities and basic needs are very useful complementary measures of well-being. Nonetheless, despite the usefulness of objective measures, any well-being approach that aims at really placing the individual at the center must necessarily acknowledge the importance of subjective well-being. Therefore, any well-being approach must always be used in

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conjunction and communication with other evaluation tools and wellbeing approaches.1 In this sense, this book follows closely the outlook proposed by the Well-being in Developing Countries (WeD) research group that sees well-being as involving at the same time material, relational and subjective aspects that can be studied at different levels and with different tools (e.g., Gough & McGregor, 2007). Thirdly, rather than advocating for the use of subjective well-being as a supreme and sole goal of policy, this book takes a step back by emphasizing that this lens brings a valuable and innovative way of evaluating the processes and implementation of policies. By giving a stronger emphasis to what people value and experience, subjective well-being provides a practical tool to uncover new dimensions of social programs that contribute to better their design, implementation and evaluation. For instance, subjective well-being can help expose the significance of relational interactions in the processes of policy delivery, the main focus of this book.

Relationships in Well-being and Public Policy Subjective well-being research has uncovered and confirmed that there are many aspects of life that are central for well-being and that lie well beyond income. Probably the most consistent and significant has been social relationships. Indeed, most studies attest that being in relationship with others as well as the quantity and quality of our interactions is essential to live well across the life cycle and different types of populations. The significance of relationships is so strong and recurring in well-being that no matter the approach or methodology employed all agree that relationships are the most important contributor of a good, flourishing and happy life (e.g., Helliwell et al., 2017; Ryan & Deci, 2001). From an SWB perspective, Argyle (2001) claims that relationships are ‘one of the greatest sources of happiness’ and Ashcroft and Caroe (2006) propose positive relationships as the most important contributor of a thriving life. From the outlook of PWB, Ryan and Deci (2001) claim ‘it is the quality

1 The stance taken here agrees with most researchers who recognize the complementarity between both. For example, the capabilities approach, one of the most influential ‘objective’ frameworks, recognize the importance of the subjective dimension by incorporating happiness as another valuable capability and endorsing subjective measures of psychological and social capabilities (e.g., Alkire, 2007; Reyles, 2007).

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of relatedness which engenders well-being’ (p. 155). And from the development perspective, White (2009) has suggested well-being is ‘something that happens in relationship’ (p. 11). The substantial evidence provided by so far and the prominence family and friends have for well-being as they have attested, has been beneficial in justifying the design of policies that promote and foster family, social, and community interactions. However, focusing only on close relationships can ignore the role that programs themselves have in creating new social scenarios that affect the program’s own successes and at the same time the well-being of people as they become clients of the state. One such social scenario occurs at the interface between the frontline officers that implement the program and the final recipients. Frontline officers constitute the most immediate link through which a policy, a social program or a development initiative achieves its goals. They can take different roles such as physicians, nurses, counselors, teachers, bureaucrats, or public servants. Their main characteristic is that they are the face recipients see of the program and are the direct gatekeepers of the resources or services the program provides. The interactions of frontline officers with recipients are extensively explored by the Street-Level Bureaucracy literature since the 1970s, starting with the seminal work of Michael Lipsky. This literature argues that policy is not made at the design; rather it is at the last link—the implementation—where many of the successes and failures of policies take place. Its findings have been revolutionary in helping us understand the implementation and remains relevant even in the changing environments of policy administration of the last decades (Ellis, 2011). Nevertheless, officer–recipient interactions are often studied insufficiently or only in relation to their effects on the success of policy delivery (e.g., Lipsky, 2010; Simmons & Elias, 1994; Williamson & Robinson, 2006), leaving behind an analysis of the relational process through which these are achieved (Johannessen, 2019) and their potential well-being impacts. Moreover, while the analysis of how frontline officers execute their work and transform policy has expanded rapidly in countries like the UK (e.g., Ellis, 2011) and the Netherlands (e.g., Loyens & Maesschalk, 2010), more research in developing countries and with officers interacting with vulnerable groups is necessary to broaden our understanding of officer–recipient interactions. Despite these gaps in the street-level bureaucracy literature, the empirical evidence related to social programs around the world suggests that

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officer–recipient relationships need to be scrutinized more closely as they have important implications beyond the success of policy implementation. In this regard, Narayan and colleagues’ (2000) large multi-nation qualitative study on poverty show the common patterns of abuses of power, negligence, humiliation, shame, and mistreatment people experience in their encounters with state corruption and service providers (see also Roelen, 2017; Walker & Chase, 2015). These stories happen especially in developing countries and in social programs reliant on service provision for their implementation. Poor people report that their interactions with state representatives are marred by rudeness, humiliation, harassment and stonewalling. Poor people also report vast experience with corruption as they attempt to seek health care, educate their children and claim social assistance or relief assistance, get paid, or receive protection from the policy and justice from local authorities. (Narayan et al., 2000, p. 8)

Therefore, ignoring these relationships may reduce the ability of social policies to adequately capture their impacts on people’s well-being. In addition to the street-level bureaucracy literature, this book uses some of the insights of the literatures on medical sociology and development studies to explore the characteristics of this relationship and their possible roles on subjective well-being. On the one hand, it will take the works of medical sociology focusing on the specific interaction between healthcare personnel and patients in Mexico, particularly those of Vania Smith-Oka (2009, 2012, 2014, 2015) given their geographical closeness to the research settings of this book. On the other hand, it will look at the development literature that highlights the inherently political and hierarchical nature of this relationship in development agencies and programs (e.g., Eyben, 2006, 2010; Moncrieffe & Eyben, 2007; Shaffer 1985; Wood, 1985). For these studies, this is a relationship grounded on the authority officers are awarded by institutions; as well as on the contrasting social identities between officers and recipients in terms of gender, ethnicity, social status, and professional knowledge. As these relationships can affect people’s objective and material circumstances by restricting access to the valuable resources and services provided by the program, the main concern here is their effects on the recipients’ subjective well-being. Particularly, how the officers’ forms of engagement with recipients can be well-being enhancing or well-being

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diminishing. Even if social programs and policies include a well-being approach in their design, the procedures of implementation can work against these holistic aims through the interface between officers and recipients on the ground. To directly and adequately consider these interactions and their potential effects in people’s lives, a well-being outlook able to recognize the aforementioned social, political, and cultural processes that shape this specific kind of social interaction is necessary. This points to one of the main arguments in chapter 2. Namely, the fact that distinct subjective frameworks approach well-being and relationships differently, which in turn, could have important implications into how they assess this specific relationship and feedback on policy implementation. Therefore, this book critically compares the three key frameworks of subjective well-being mentioned above in these terms (subjective wellbeing, psychological well-being, and psychosocial approaches), arguing in favor of a psychosocial approach. The argument goes as follows: the outlooks of development and psychosocial approaches comprise an important challenge to the dominant conceptions of well-being and relationships offered by SWB and PWB and a better approach to assess officer–recipient relationships. SWB and PWB have largely contributed to our understanding of the association between well-being and relationships. Yet, they implicitly and explicitly understand them as external buffers of well-being and their association as simply cause-and-effect. A view that ignores the more complex and intricate ways in which well-being and social relationships can be associated. In contrast, the proposals of critical well-being research in sociology, development studies, and psychosocial approaches echo a more comprehensive understanding of well-being and relationships for the policy realm. They recognize well-being as something that is socially and inter-subjectively construed, actively negotiated in and through our relationships with others and influenced by larger relational processes that permeate into individual interactions like cultural values, identity formation, and power struggles. This book mainly relies on the proposals of the Well-being and Developing Countries research group (Gough et al., 2007; White, 2010), the Inner Well-being approach (White et al., 2014), and psychosocial approaches advanced particularly for development agencies (Galappatti, 2003; PADHI, 2009; Salih & Galappatti, 2006; Williamson & Robinson, 2006). These frameworks, while acknowledging the centrality of the

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material, relational and subjective dimensions of well-being, also emphasize the close interrelationship between these and give a stronger emphasis to relationality in the construction of well-being. This larger outlook not only offers a more relational understanding of subjective well-being, it permits including a broader range of types of relationships beyond family and friends. More importantly, allows analyzing social policies and programs from a relational well-being perspective. As a starting point to the analysis of the practical contribution of wellbeing in social policy on the one hand, and of the complex role of social relationships in well-being and policy implementation on the other, this book uses the case of the Oportunidades-Prospera program.

The Oportunidades-Prospera Program and the Officer–Recipient Interactions In recent decades, the eradication of poverty became a key element for social and economic development and a goal of international development. The Post-Washington Consensus and the Millennium Development Goals (MDGs) placed it on the mainstream international policy agenda in the 1990s. The Sustainable Development Goals (SDGs) continued this trend by strengthening the efforts to ‘leaving no one behind’ to 17 goals and 169 targets that must be achieved through a global partnership that include developed and developing countries. One of the key instruments to reach these goals have been social protection programs, that consist of a number of initiatives designed to improve the capabilities of the poor and vulnerable to get out of poverty and to better deal with the risks and shocks associated to it. Cash transfers are part of social protection programs and constitute one of the most used policy tools to tackle poverty globally, with dozens of countries implementing these strategies, especially in the developing world. Cash transfers are programs that provide direct and regular monetary payments to poor families with the purpose of increasing and stabilizing their incomes (Arnold et al., 2011). They can be unconditional or conditional. Unconditional programs offer monetary transfers to targeted families without strings attached. In contrast, conditional programs offer these transfers but require certain behaviors and actions if recipients are to benefit from the program. These actions mainly focus on expanding human capital, such as health care, education, nutrition, among others (see Ladhani & Sitter, 2018 for a critical review).

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The prominence of cash transfers was brought to light recently by COVID-19, the global pandemic that is expected to generate hundreds of millions of poor around the globe (Sumner et al., 2020) and threaten economies altogether. In the first few months of this global crisis, at least 13 more countries in all parts of the globe started implementing them as part of their basic strategy to cope with the social and economic crisis that the pandemic was generating (Gentilini et al., 2020). This broad uptake of cash transfers makes it clear that they are here to stay, at least for now. The Oportunidades-Prospera program was a conditional cash transfer (CCT) and a pivotal part of this global movement toward placing the poor at the center of national development goals. For decades, it was the most renowned cash transfer in the world, considered an archetypal model, inspiring the creation of many others in Latin America and other regions. Implemented between 1997 and 2019, this was the biggest social program in the country, reaching at least 20% of the population (Bastagli, 2009). However, at the end of 2018, the newly elected president Andrés Manuel López Obrador, decided to terminate the program with allegations of corruption, inefficient implementation, and the ineffectiveness of its conditional nature. Despite running a leftist anti-establishment campaign and promising not to cancel social programs, López Obrador linked Prospera to the neoliberal agenda he wanted to break away from. By February 2019, the Ministry of Well-being (Secretaría de Bienstar) announced the termination of the health conditionality and the repackaging of the education conditionality of Prospera into the Benito Juárez Scholarships (Becas Benito Juárez), a largely unconditional cash transfer program focus on education. Despite its recent termination, the two-decade-long duration of this program permitted analyzing a number of elements of conditional and anti-poverty programs. One of such elements is how conditional programs are implemented at the front line. In terms of implementation, Oportunidades-Prospera was a very complex program. It aimed at reducing the intergenerational transmission of poverty through three key components: education, health, and nutrition. In practice, this implied that the program provided bimonthly cash transfers directly to female heads of households (mothers) with the condition that they send their children to school, attend to routine health checkups and receive workshops on preventive health care. The delivery of these components is heavily reliant on frontline officers that directly interact with recipients. This happens at different stages

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of program implementation: through bureaucrats during targeting and the distribution of the cash transfers, through teachers in the delivery of schooling, and through health staff in the provision of the health workshops and consultations. Conditional cash transfers like OportunidadesProspera are also ideal settings to study interactions between program participants and frontline officers because the element of conditionality requires the constant supervision of participants’ behaviors and compliance by officers themselves. Conditioning monetary transfers place recipients in a new social scenario where they have to interact with frontline officers during the provision of compulsory services and the monitoring of their compliance. Debates about conditioning cash transfers have increased in recent years. Many focus on who bears the responsibility of complying with them; what are the gendered effects of conditions targeted to mothers (Cookson, 2018); whether conditions are needed to avoid dependency and to improve uptake of services (Baird et al., 2014); and if it is just to impose conditions on services that are enshrined in the international convention of human rights (Freeland, 2007). Other more programmatic debates focus on the state’s capacity to offer the services they are conditioning, to offer them to an appropriate quality level, and to hire and train the adequate staff to monitor compliance (see Ladhani & Sitter, 2018). This book also contributes to this debate by exploring how conditions are implemented in Oportunidades-Prospera through frontline officers and how this influences relationships between officers and recipients. Given the size and complexity of Oportunidades-Prospera, it would be too ambitious to analyze the processes of implementation of the program as a whole. Therefore, this book concentrates on the health conditionality. Health is a sector that is at the center of the development agenda. The SDGs and the MDGs placed health as a strategic development goal for all societies by including child mortality, maternal health, and diseases like HIV/AIDS, malaria and others in the global agenda. This involves not only increasing access but also improving the quality of healthcare services, in which interactions between officers and recipients are a key mediating factor. In Oportunidades-Prospera, the compliance with the health component is crucial for families to remain adhered to the program. Its activities are strictly enforced and monitored by health professionals at first level clinics. These clinics offer basic health services to recipients and all citizens. The health activities that are monitored can be classified into two

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groups, those that are formally stipulated by the program and those that have been informally developed and used for the administration of the health procedures. The formal or official conditions involve attending monthly health workshops directed to mothers and complying with regular family medical checkups, aside from the regular appointments when a member of the family falls ill. The informal conditions require participants to perform what could be described as unpaid jobs under the supervision of health officers. These can include tasks such as cleaning and conducting maintenance work at the clinic and in local public places, as well as participating in health campaigns that involve marching around their communities. These informal conditions can have important implications on the nature and quality of the interaction between officers and recipients. They can bring a new set of hierarchies to a relationship that, arguably, is already charged with issues of power, authority, and forms of control that are potentially problematic for well-being. In spite of this, they are not stipulated nor regulated by the program officially, causing an important gap in their evaluation. In conjunction, the formal and informal conditionalities generate repeated and long-lasting interactions between program participants and health officers that could influence the potential outcomes of the program over its direct aims and over the well-being of recipients. Yet, little research exists about this. Indeed, chapter three examines the latest research on the challenges of the quality of healthcare provision in Mexico (e.g., Adato et al., 2000; Gutiérrez et al., 2008; Skoufias, 2005); as well as studies on the role of the attitudes and behaviors of health officers for overcoming them (e.g., Agudo Sanchiz, 2012; Campos, 2012). Moreover, the bulk of quantitative and qualitative evaluations of Oportunidades-Prospera is also reviewed, especially focusing on evidence about the processes of implementation of the health conditions. Despite the large volume of evaluations and research on the program, there is not sufficient knowledge about the success of the OportunidadesProspera program in two ways. Firstly, from a subjective well-being perspective and secondly, from a process perspective emphasizing the relationality that is created during implementation. Although the relational processes of policy implementation are increasingly included in well-being focused evaluations (e.g., Devereux et al., 2013) and ‘small n’ methods of evaluation (e.g., Cargo & Warner, 2013), traditional evaluations have largely concentrated on objective program outcomes

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such as school attendance, compliance with the health conditionalities, increases in nutrition levels and decreases in morbidity rates. These objective outcomes, nonetheless, provide insufficient information about what people can achieve with them, exclude people’s perceptions of the program and neglect program processes at the level of implementation that can have an important effect on people’s well-being. They disregard the social processes that can contribute to keeping people in deprived situations and the extent to which the program reinforces or challenges these relational constraints during implementation. My hope is that this book contributes to meet this gap, by providing a more holistic understanding of people’s well-being experiences during their interface with Oportunidades-Prospera and its implementation procedures. Particularly, analyze how frontline officers can transform the outcomes of the program in well-being terms.

Contributions and Structure of This Book The overall purpose of this book is to examine how a well-being lens can improve public policy at the frontline by looking at the relationships created during policy implementation. Through this analysis, this book makes three central contributions to well-being research, development studies, and social policy. The first is exploring the ways in which a well-being approach can contribute to evaluating policy processes, particularly relational forms of policy implementation. It argues that taking a broader outlook toward relationships and program outcomes through a well-being lens can help to grasp better their complex forms of association, some of which are particularly relevant in a policy scenario. The second is identifying the characteristics of officer–recipient relationships in the delivery of conditional cash transfer programs such as Oportunidades-Prospera. While the issue of whether frontline offices can alter the course and effectiveness of the programs has been largely answered (e.g., Ellis, 2011; Lipsky, 2010), this book focuses on showing what kind of officer–recipient interactions are created as a result of the institutional, sociocultural and programmatic contexts in which they happen. The third contribution of this book is mapping through mixed methodologies the effects of officer– recipient relationships over the subjective and psychosocial well-being of recipients. These goals are achieved through the seven chapters outlined next.

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Chapter 2 presents the theoretical framework of the book. It elaborates on what well-being has to offer to development and public policy, particularly to assess officer–recipient relationships. For this, it shows the significance of social relationships in well-being research, comparing findings in the dominant approaches to subjective and psychological wellbeing on the one hand, and psychosocial well-being on the other hand. It serves to substantiate the contribution of a psychosocial approach for the analysis of policy implementation. In light of this discussion, this chapter ends with the literature on service delivery and policy implementation, arguing the need to move beyond the traditional focus on the influence of frontline officers in programming and resource provision, to start scrutinizing their attitudes, perspectives and interactions with recipients during delivery and their potential well-being effects. Chapter 3 has the purpose of presenting the policy context of this book. It discusses the extensive reach of social protection programs around the globe and the widespread use of frontline officers in delivery, especially in conditional programs like Oportunidades-Prospera. This serves to explain why CCTs in general and the Mexican CCT in particular are ideal scenarios to study the well-being effects of officer–recipient relationships. This chapter then moves on to exploring well-known evaluations on the program’s and on other CCT and defends that looking at the potential well-being effects of this relationship could show critical unaccounted consequences of CCTs—and social programs more generally—for people’s lives. Chapter 4 examines officer–recipient relationships from the perspectives of officers. This involves analyzing the officers’ descriptions of recipient families, of their relationship with recipients, and of their roles in the implementation of the program and in the procedures of the clinic. Following the findings from the observations and interviews with health officers, this chapter characterizes the relationship and the larger processes that shape it, including the program’s discourse of conditionality, identity differentiation and the officers’ job position within the clinic. Chapter 5 focuses on the narratives of recipients about their experiences during the health workshops and consultations, their relationship with physicians and nurses, and—the primary focus of this chapter—the channels through which this relationship influences well-being. The analysis is based on the interviews and focus groups performed with recipients and observations conducted in the clinics.

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Chapter 6 concentrates on the quantitative analysis of the channels through which officer–recipient relationships influence well-being outcomes. The chapter introduces the construction of the indicators used to measure well-being and the quality of officer–recipient interactions. Then it maps the role of the program on the well-being of recipients, identifying differences between recipients depending on their role in the program and the informal conditions. The chapter ends with a regression analysis of the association of this relationship with different domains of well-being. In chapter 7, the book ends with some concluding remarks that bring together the findings and critically examine how these illuminate the nature of officer–recipient relationships and the contribution of a well-being approach in policy analysis. The book concludes that paying attention to the psychosocial well-being impacts of officer–recipient relationships deepens understanding of the overall effect of social policies on their clients, highlighting unintended effects that are usually unaccounted for by traditional policy evaluations. In addition, it underscores that the significance of relationships in implementation indicates a vital dimension of the policy process that requires direct attention if social policy and programs are to achieve their full potential to improve people’s wellbeing. This chapter culminates with some policy implications for CCTs implemented around the globe.

Methodological Notes The empirical findings of this book are derived form a mixed method research conducted in Mexico with the participation of recipients and workers delivering the health conditionalities of Oportunidades-Prospera. This section deals with the methodological approach taken, describes the research design and presents the sample. There are several reasons for taking a mixed method approach to evaluate the quality of relationships during policy implementation and their well-being impacts. In recent years, many academics in the areas of public policy, development and well-being have come forth in favor of combining quantitative and qualitative methodologies. For instance, in policy evaluation research (e.g., Adato, 2007; Devereux et al., 2013; Kanbur & Shaffer, 2005; Ravallion, 2009), in studies of client–agent interactions (Simmons & Elias, 1994) and in the development and well-being literature (e.g., Camfield et al. 2009; Fattore et al., 2007; Jones & Sumner, 2009; Roelen

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& Camfield, 2015; White & Jha, 2014; White et al., 2016). In the realm of policy, Devereux and colleagues (2013) argue that introducing mixed methodologies permits observing program processes and the social dynamics behind their outcomes that cannot be observed using quantitative methods alone. In turn, Simmons and Elias (1994), studying relationships between client and officers in health contexts, argue that mixing qualitative and quantitative tools allow observing the meanings of these interactions rather than only focusing on their quantifiable characteristics such as their frequency. Finally, well-being research is increasingly recognizing the value of qualitative methods for uncovering the subjective nature, the social processes and the contextual embeddedness of well-being, as well as for improving measurement accuracy and relevance (Camfield et al., 2009). Despite the increased advocacy for mixed-methods, surveys and statistics have had the utmost credibility in the social sciences for decades. This has implied that for any empirical study that wishes to influence both the academic world and public practice, quantitative instruments are almost an unavoidable requirement (Adato, 2007). There is of course fair justification behind the ample use of quantitative methods. In well-being research, the possibility of quantifying subjective experiences has provided knowledge of the factors related with people’s own evaluations of their lives in different nations and contexts (e.g., Helliwell et al., 2017; OECD, 2013b; Rojas & Martinez, 2012). Although their policy implications have not yet been fully explored, these measurements are a promising tool for designing and evaluating well-being-driven policies at the local and national levels (e.g., ONS, 2011). The appearance of objectivity, formalization and systematization of quantitative methods hide, however, non-negligible challenges in wellbeing indicators that are particularly relevant for this book. The issues typically discussed are measurement and social desirability biases, such as people’s adaptation to life circumstances (Frederic & Loewenstain, 1999); issues of social comparison, in which people’s life evaluations are influenced by their perception of how their life is going in contrast to that of others (see Kahneman & Tverskey, 1984); and cultural differences in the way questions and categories are understood and responded (Diener et al., 1995, 1999). In addition to limitations in measurement, research has suggested that dominant well-being models and indicators can be culturally specific and inappropriate for contexts other than where they arose (see

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Camfield, 2004; Christopher, 1999; Devine et al., 2008; Kagitcibasi, 2005; Wierzbicka, 2004). This stands at odds with the (diminishing but lingering) tendency to develop and test self-report indicators in Western/Northern countries or with samples composed of educated (e.g., university students) and urban populations, raising doubt about the validity of well-being indicators across diverse social groups. These practices, potentially obscure rather than illuminate on the well-being of non-Western, non-urban, illiterate, and indigenous groups. Furthermore, there are aspects of social phenomena that are difficult to measure since they do not constitute simple observable facts but can be dynamic, ambiguous, interpretative, or even contradictory. This is significant for the study of well-being and social relationships since many intricate linkages between them, salient in qualitative studies (such as power, conflict, negotiation, and the coexistence of positive and negative aspects of relationships), are largely unaccounted for by common quantitative approaches. One of the reasons for this could be the difficulty of measuring these aspects since quantitative indicators tend to require simplified unipolar items to reach meaningful statistical results. Simmons and Elias (1994) report this, observing that responses to an indicator of satisfaction with health staff were often in dissonance with what was captured through qualitative tools. People tended to evaluate interactions with staff more positively in surveys than in interviews. These findings reaffirm Wilk’s (1999) compelling claim that ‘any indicator no matter how clever is going to miss an essential quality of what needs to be measured’ (p. 92). These challenges point toward the value of complementing quantitative methods with the more flexible approach of qualitative methods. Qualitative methods seek to collect in-depth data about the attitudes, perspectives and experiences of a relatively small but well-defined sample with the aim of observing the multifaceted and dynamic dimensions of the subject under study (Carvalho & White, 1997). It is concerned with the meaning that social phenomena and social action has for the actors involved, and stresses that various meanings about the same reality can exist (Bryman, 2008). This situates the context, social relationships and the diversity of people’s perspectives at the heart of qualitative research. Such outlook goes hand in hand with the purposes of this book of understanding the role of a particular kind of social relationship in the subjective well-being of policy participants.

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Most qualitative explorations of well-being come from the fields of development, sociology and anthropology (e.g., Calestani, 2009; Devine et al., 2008; Fischer, 2014; Jiménez, 2008; Thin, 2005).2 Camfield and colleagues (2009) suggest that qualitative methods provide ‘holistic and contextual understanding of people’s perceptions and experiences’ (p. 5). Therefore, by giving priority to people’s situated interpretations of wellbeing and using their own language, narratives, and values, qualitative methods can observe those essential aspects difficult to measure or break down into ‘objective’ domains or unipolar indicators. These include the processes and meanings of well-being, such as how it is dynamically interrelated and grounded in people’s values, aspirations, culture, social interactions and power relations (White & Pettit, 2004). In addition to the intrinsic value of qualitative methodologies, they hold an instrumental value. Disciplines like the quality of life (e.g., Roelen & Camfield, 2015), health (e.g., Bowden et al., 2002), child well-being (Jones & Sumner, 2009), and psychosocial well-being (e.g., White & Jha, 2014) have shown the value of qualitative tools for generating and validating subjective measures in distinct populations. Qualitative methods can observe how people respond to the measures and the extent to which they are actually conveying something significant for them. This includes the possibility of shifting the focus from the abstract measures to what the measures mean to people and how they respond to them in different settings, potentially improving their accuracy by ensuring they are based on what matters and what makes sense to the participants (Camfield et al., 2009). Of course, qualitative methodologies are not without their challenges either. However, it is because of the advantages and disadvantages of each methodological approach that quantitative and qualitative methods are indispensable complementary means to appraise essential but distinct aspects of well-being experiences and social relationships. The possibility of combining the strengths of the instruments while reducing their weaknesses, permits drawing out better conclusions than would be possible using either method alone (e.g., Greene et al., 1989). This is the basic principle of mixed-methods, integration (Johnson et al., 2007). This book agrees with this view and thus uses this approach. The capacity of qualitative methods to capture complexity, social structures, and situated interpretation is an essential counterpart to the ability 2 Although less frequently, qualitative methods are also used to conduct research from a SWB perspective (e.g., Ponocny et al., 2015; Tonon, 2015).

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of quantitative methods to observe its general shape through subjective indicators. However, mixing methods is about much more than simply combining techniques, it involves dealing with various challenges and tensions in the process of mixing (Kanbur & Shaffer, 2005). Hence, using mixing-methods is attached to two decisions: (1) what is the philosophical paradigm for this methodological approach, and (2) how to best combine the contrasting approaches of quantitative and qualitative methodologies. In relation to the first decision, there is no single philosophical paradigm for mixed-methods (Creswell & Plano Clark, 2007; Hall, 2013; Tashakkori & Teddlie, 2003). Although pragmatism has been developed particularly for this approach (see Johnson & Onwuegbuzie, 2004), recently critical realism has received increasing attention (Maxwell & Mittapalli, 2010; Sayer, 2000). This book takes a critical realist perspective whose main purpose is to reconcile the interpretative position typically associated with qualitative research and the positivist stance typically associated with quantitative. Neff and Olsen (2007), who developed a convincing case for a critical realist approach in well-being research, describe it as a paradigm that proposes social phenomena as dynamically constructed through social values, meanings and perceptions but at the same time endorses explanation as a reasonable aim of social research. For critical realism, to explain social phenomena is to identify the structures and powers that construct them. The advantages of taking a critical realist stance are many. For the analysis of relationships and well-being in policy implementation, two are particularly important. Firstly, the richer interpretative approach permits socializing the subjective and seeing it as partly shaped by people’s experiences in a particular time and place (Maxwell & Mittapalli, 2010; Neff & Olsen, 2007). Hence, it would understand well-being as real, as something that people can report, and has real causes and effects, although we can only imperfectly observe them. At the same time, it would recognize that well-being is not a homogeneous reality as it can be dynamically coconstructed in larger social norms, cultures, institutions and in the often power-heavy interactions with others. Although mainstream well-being approaches implicitly take the positivist stance given the dominance of quantitative thinking in the field, critical realism is not entirely new in well-being research (see Neff & Olsen, 2007; Gough et al., 2007). Secondly, critical realism distinguishes itself by highlighting the importance of being reflective, clear, and consistent about the philosophical stance taken as it has implications on the priority given to each of the

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methods employed and to the data obtained through them. In this book, both methodologies and their findings were given equal weights and were analyzed in their own terms. The data obtained from qualitative methods offered a richer and more holistic picture of the participants’ well-being and relational experiences with the officers at the local clinic. While the data obtained from quantitative methods was delimited by the language used, questions asked and answers obtained from participants but provided a better sense of the larger structural contexts of responses (by locality, socio-demographic characteristics, and others). Together, they permitted generating a thicker understanding, at the same time as individually corroborating or contrasting the findings of the other. Ultimately, this also gave insights about the advantages and disadvantages of using each method (separately or together) which are discussed with the findings when relevant.

The Research Design Mixed-methods research designs can be classified in terms of the sequencing and dominance of qualitative and quantitative methodologies (Morse, 2003). The design of the investigation behind this book was a sequential approach—first qualitative data was collected and then quantitative surveys were applied—where both methodologies were equally important during the design and analysis stages. The sequencing of the methods during the data collection process involved two stages. The first stage consisted of a period of observation in the health clinics, focus groups with recipients, and in-depth semi-structured interviews with recipients and health officers delivering the health conditions of Oportunidades. These scrutinized, among other things, the encounters between recipients and officers, their characteristics and factors that influenced them, and explored the pathways in which these interactions influenced recipients’ well-being. The qualitative data obtained from the focus groups and interviews with recipients served as the basis to design a battery of indicators evaluating the quality of officer–recipient interactions (Quality of Relationships with Officers scale, QoR). Another round of interviews were conducted to test the relevance and clarity of the survey questions (piloting) in the second stage of data collection. This is the instrumental value of qualitative methods defended by Camfield and colleagues (2009). The second stage consisted of the design, piloting, and application of the quantitative survey. The survey included four sections assessing (1) the quality of relationships with health officers, (2) well-being based

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on the psychosocial model of Inner Well-being and two general questions of happiness and life satisfaction, (3) the recipients’ affiliation to Oportunidades and (4) socioeconomic characteristics (Table 1.1). Table 1.1 Summary of research design Method

Instruments Observation (1.1)

Qualitative Study (Phase 1)

Semistructured Interviews (1.2)

Focus Groups (1.3)

Sample N/A

Inner Well-being (IWB) (2.2) Subjective Well-being (SWB) (2.3)

Familiarize with contexts and observe interactions between officers and recipients in local clinics

Recipients: 15 in Nexpan, 15 in Cualcan

Explore how recipients narrated experiences in the program, their interactions with health officers and their role on well-being

Officers: 4 in Nexpan, 2 in Cualcan

Analyze how health officers described recipients, their relationship, and their functions in the health clinic and in Oportunidades

Recipients: Nexpan: 1 focus group with 10 participants, Cualcan: 1 focus group with 9 participants

Observe how recipients exchanged and produced ideas and experiences about the implementation of the health component, their relationship with health officers and the influence of officers on their well-being Scale composed of 14 items and designed based on the interviews with recipients and the information about what constituted a positive and negative relationship with officers

Quality of Relationships with Health Officers (QoR) (2.1)

Quantitative Study (Phase 2)

Goal/Description

Recipients: 170 in Nexpan, 142 in Cualcan

A psychosocial model of well-being with a more social emphasis. The model defines well-being as “how people feel and think about what they can do and be” (White et al., 2014). It is composed of seven domains measured through 36 items Measures of global evaluations of subjective well-being: Life Satisfaction and Happiness

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The Well-being Framework: Inner Well-being (IWB) The Inner Well-being (IWB) approach was used to scrutinize the wellbeing outcomes of recipients. Inner Well-being is a psychosocial model designed in and for developing contexts to address issues of policy and development (White, 2010). It has its roots in the Well-being and Poverty Pathways (WPP) research project developed at the University of Bath and funded by the ESRC/DFID between 2010 and 2014. IWB was the preferred approach for at least three reasons. First, IWB is a multidimensional model composed of seven distinct but interrelated domains that were found to constitute well-being, both theoretically and empirically (see White, 2010, White et al., 2014). The domains are: economic confidence, agency and participation, social connections, close relationships, physical and mental health, competence and self-worth, and values and meanings (Fig. 1.1). These domains include some of the most important aspects identified in psychological

Fig. 1.1 Inner Well-being Model (Source Well-being and Poverty Pathways Briefing Paper No. 1)

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well-being approaches such as competence, self-worth, and social relationships, as well as those advocated in the development literature such as economic confidence, agency and participation. The key advantage of using this multidimensional approach for this book lies in the possibility of exploring the differential role of officer–recipient relationships in diverse aspects of well-being. Indeed, rather than solely evaluating whether these relationships are positive or negative for overall happiness, for example, the IWB approach permits tracing which domains are more influenced by this relationship compared to others. A second advantage of this seven-domain model is that is grounded in and for developing countries as it was influenced by extensive mixedmethods research in rural localities in Zambia (White et al., 2012a) and India (White et al., 2012b). Its foundation in developing countries constitutes advancement from approaches like SWB and PWB developed—conceptually and methodologically—primarily based on Western values and samples. This is especially appropriate for the research context of this investigation, focusing on recipients of an anti-poverty program implemented in impoverished localities of Mexico. The IWB approach also recognizes the role of culture in what well-being means and how it can be measured and thus advocates for the adaptation of the model to the contexts in which it is applied (Well-being and Poverty Pathways Briefing No. 1, 2013). Therefore, the wording and emphasis of the items contained in the domains could be localized to this research context through qualitative procedures. The IWB model is also cornerstone toward a greater acknowledgement of relationships in well-being research for several reasons. Firstly, the model includes relationships in the domains of close relationships and social connections, and measure their quality directly. Secondly, most domains include items that recognize how these aspects can be experienced in relational contexts. For instance, competence includes items assessing people’s ability to positively influence others (family and community) and to fulfil duties and responsibilities to the family. Similarly, self-worth includes items on people’s sense of being recognized by others and of having a place in the world. Finally, beyond the relational cast of the IWB’s empirical model, this approach is founded upon two conceptual frameworks that give relationships a greater role in the experience of well-being: the Well-being in Developing Countries (WeD) research group and the Psychosocial Assessment for Humanitarian Interventions (PADHI) from the University

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of Colombo. Following these frameworks, IWB argues that well-being involves an active negotiation that happens in interactions with others at different levels, personal, communal and institutional. These interactions are responsible for creating and reproducing issues of discrimination, marginalization and power that both constrain and facilitate the strategies people use to live well. That is, they can regulate the resources people can have and how they access and use them but also their subjective wellbeing. As will be discussed in chapter two, this has wider implications for the benefits of a well-being approach in the analysis of policy and development interventions as it underlines that the promotion of wellbeing should move beyond people’s psychological and personal traits and start to analyze the relational processes that transform well-being experiences. In the context of Oportunidades-Prospera and the interactions between health officers and recipient families, this conceptual awareness of the dynamics and power embedded in social interactions is especially important.

Quantitative Scales The three scales used to measure well-being and quality of officer–recipient relationships in Oportunidades-Prospera are: Inner Well-Being Model (IWB) This the main model used to assess the well-being of the recipients of Oportunidades. In the survey applied for this study, the IWB scale (White et al., 2014) was composed of 36 items. This scale measures 7 domains of well-being which include (1) Economic Confidence, (2) Social Connections, (3) Close Relationships, (4) Agency and Participation, (5) Physical and Mental Health, (6) Competence and Self-worth, and (7) Values and Meaning. Each domain contains five items (except the Close Relationship domain which includes 6 since the piloting and contextualization process suggested that another question was necessary) that aim to capture different aspects of what people think and feel about what they can do and be. Some examples of the items are: For the Close Relationships domain, ‘When you need to talk about something important to you, is there someone you can go to?’ For the Agency and Participation domain, ‘How often do you feel that you have the freedom to make your own decisions?’ (See Table 6.2 for all items). All indicators are ordinal and

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measured in a 5-point Likert scale, the higher the scores, the better the reported levels of well-being in each domain. White et al. (2014), Gaines (2014), and White and Ramírez (2016) reported that the scale shows satisfactory reliability in terms of internal consistency and good construct validity for the contexts of India and Zambia. Subjective Well-being (SWB) Two of the most used global indicators of SWB were employed: happiness and life satisfaction. The happiness question reads as follows, ‘In general, how happy would you say you are?’ The life satisfaction question asked, ‘Taking all things together, how satisfied are you with your life as a whole?’ To keep a consistent scale throughout the survey, these items were also measured in five ordinal levels. The scale was coded as (1) Very unhappy/unsatisfied, (2) Unhappy/Unsatisfied, (3) Neither happy/satisfied nor unhappy/unsatisfied, (4) Happy/Satisfied, and (5) Very happy/satisfied. As recommended in the literature (Bradburn, 1983; International Well-being Group, 2006), because of the general nature of these questions, they were located earlier in the survey and before the IWB scale to avoid influencing the participant’s responses with the more substantive questions posed by the IWB domains. These two items have been validated in diverse contexts and are now internationally renowned measures to assess people’s emotional and cognitive evaluations of their lives. These measures have also been extensively used in Mexico (see Rojaz & Martínez, 2012 for a review) and are now formally included in the BIARE questionnaire which was designed by the National Institute of Statistics and Geography in 2012 specifically to measure the SWB of the Mexican population (see BIARE, 2012). Quality of Relationships with Officers scale (QoR) A set of questions designed to measure the quality of the relationships with the health officers were construed from the interviews and focus groups conducted with recipients. As mentioned above, the qualitative study had the specific objective of exploring the recipients’ experiences in the local clinic, their perceptions of the quality of their interactions with the staff, their understanding of what could be a good quality of relationship with them, and ultimately the ways in which this relationship affected their well-being.

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Qualitative analysis was the basis to construct the 14 items of the Quality of Relationships with Officers (QoR) scale. Two examples of these items are: ‘Do you feel physicians treat you with kindness and respect?’ ‘Are physicians sensitive to you and your needs?’ (see Table 6.3 for all items). While the main source for constructing the questions was the narratives of recipients themselves, the wording and formatting of the questions was triangulated with previous surveys evaluating the quality of the relationship with medical staff in other contexts (e.g., Picker Institute Europe, n.d.; CAHPS, 2012; Merkouris et al., 1999; Saha et al., 2003; Steine et al., 2001). Keeping consistency with the rest of the survey, these items are of ordinal nature and measured in a 5-point Likert-scale, where 1 represents the most negative evaluation of the relationship, and 5 the most positive evaluation.

The Research Contexts The fieldwork took place between 2013 and 2014 in the state of Puebla located at the heart of the country, approximately 100 km east of Mexico City. Historically, this state has been among the poorest in the nation. According to the National Council of Evaluation of Social Development Policies (CONEVAL), in 2015 Puebla was the fourth state with the highest multidimensional poverty, with 61% of the population living in moderate poverty (3.79 million people) and 10.9% living in extreme poverty (680,000 people) (CONEVAL, 2015). As a result, in 2011 Oportunidades-Prospera supported approximately half a million families in the state (Gobierno Municipal, 2011). Nexpan and Cualcan: Brief Descriptions The selection of the localities for this project was guided by their sociodemographic characteristics. The opening benchmark was urbanization. Urban and rural localities are distinct in many ways, from the economic activities that predominate, the cultural traditions that linger, to the accessibility in terms of roads, information and access to services. These generate rather diverse realities in which relationships develop and wellbeing is experienced. Ethnicitywas another relevant criterion for sample selection. Indigenous groups in Mexico are highly affected by poverty, inequality (CONEVAL, 2010), and discrimination (ENADIS, 2010), and

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data suggests that indigenous and rural recipients are particularly discriminated against by health officers in Oportunidades-Prospera (Campos, 2012;Smith-Oka, 2015). Therefore, it was hypothesized that the quality of encounters could differ depending on the ethnic identity of the actors involved. Finally, although gender could be significant in shaping officer– recipient relationships, the possibility of gathering a diverse sample in terms of gender was not possible due to the mechanism of program delivery directed to women. The two localities studied are located in the state of Puebla and are called Nexpan and Cualcan for anonymity reasons. Nexpanis a semi-urban locality at the outskirts of the city of Puebla, the capital of the state. The municipality records show that in 2013 (the year this fieldwork took place) its population was 6,959 people of which 356 families were recipients of the program. The population is mainly mestiza (94.7% reported not speaking an indigenous language), with farming and cleaning households in the nearby cities of Cholula and Puebla as main sources of livelihood for female recipients. Catholicism and religious festivities and traditions are strongly ingrained in the locality. These often involve large processions, lengthy gatherings with music, food, and drinks, and fireworks. These celebrations are coordinated and sponsored every year by elected individuals that perform as church officials throughout the year. While these celebrations are deep-rooted in their ways of life, in modern times people often commute to the city to work making it difficult to have the time required to attend meetings and organize the celebrations. Cualcan, in contrast, is a rural and indigenous locality with 97.9% of the population speaking the indigenous language Nahuatl as their mother tongue. Whereas most of the population can speak Spanish as a second language—though not necessarily fluent—not all (especially the elderly) can read and write. In 2013, the locality had a population of 6,823 people of which 699 families were recipients of Oportunidades-Prospera. Cualcan is located four hours away from the capital of the state, in the northern highlands. Farming (coffee, corn, beans, pepper, and fruits) and selling traditional craftwork were the most important sources of livelihood. This locality has an ancestral culture and traditions that show a clear syncretism between Catholicism and prehispanic customs. The town celebrations happen in September in which for four consecutive days the whole community participates in prayers and recreations of their myths through dances. The celebrations involve many people collaborating in

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the fabrication of handicrafts, food, and traditional suits for the dancers, who hold special status in the locality. Health Clinics in Nexpan and Cualcan The health clinics through which Oportunidades-Prospera was delivered offered primary medical attention to urban and rural localities across Mexico. They offered dozens of medical services and interventions that included vaccinations, prenatal attention, infant development strategies, medical exams, and prevention strategies, including workshops and talks about nutrition, disease prevention, hygiene and sometimes psychological topics. In most cases, these clinics were small, with reduced resources and a limited medical team that included doctors, nurses, dentists and other types of health promoters. In both localities, the health clinics were built partly with public funds and partly through collections among the local inhabitants (Tochimani, 2015). The health center in Nexpan was composed of one waiting room, two medical consultation rooms, one curative and pap smear room, one vaccination room, one dental consultation room, a pharmacy, a kitchen, bathrooms for patients, three bathrooms for health staff, two dorms for a doctor and a nurse, a storage room, a service patio, and a parking lot. At the time of the fieldwork, the health staff included one chief doctor, one intern, two dentists, and two nurses. In Cualcan, the health center was composed of one waiting area, one consultation room, one vaccination room, the pharmacy, and one dorm for doctors and nurses, one toilet for staff, one toilet for patients, a storage room and a parking lot. The health staff encompassed two nurses, one auxiliary nurse and one intern who also performed as a chief doctor since no permanent doctor was hired by the National Health Ministry that year.

Participants The participants of the study were the recipients and health officers (doctors, interns, dentists, nurses) of Oportunidades-Prospera in the two localities introduced above. Recipients can be divided into three groups based on the roles they took in the program: recipients, health committee members and vocales. The basic role—recipients—are female heads of households that are responsible for receiving the benefits, managing them at home

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and making sure their family members comply with the conditionalities. Health committee members were recipients selected (randomly in Cualcan and in alphabetical order in Nexpan) to conduct cleaning chores, sanitation and other tasks at the local clinics under the supervision of health officers. Many recipients had been part of this committee before this research, and therefore their narratives cannot be but influenced by these experiences. Vocales , in contrast, were female recipients selected to be part of the Committee of Community Promotion (Comité de Promoción Comunitaria) that made them the direct liaison between recipients and program officials. Vocales is the plural of the term vocal, which in Spanish relates to the position of ‘spokesperson’ in an organizational structure. In addition to the standard responsibilities of recipients, they were in charge of passing information of the program to recipients and for this, they received additional training and knowledge about the procedures of the program and had more frequent contact with the frontline officers implementing the conditionalities. At the time of fieldwork, ten health officers were working at the clinics (all female, 6 in Nexpan and 4 in Cualcan). This included three doctors, five nurses, and two dentists. However, in the analysis of the interviews it was obvious that a more relevant way to distinguish officers was in terms of their job position within the clinics, either as permanent or contract-based and temporary or student-based. Permanent officers were the direct employees of the Ministry of Health, having more responsibilities and authority within the clinic, whereas temporary officers were non-paid interns conducting their yearlong training in the locality. Participants of the Qualitative Study In each locality, 15 interviews with recipients were conducted. In Nexpan, three of the 15 participants were vocales of Oportunidades (all female) and two participants were male. In Cualcan, three participants were or had been vocales of Oportunidades (all female) and only one participant was male. Recipients were recruited during the health workshops of Oportunidades in which I acted as observer. The interviews took place in any space that was convenient for the participant. In most cases this was their home and, in a minority of cases, the interview happened in a public park or the local school. The interviews were recorded and took 45 minutes to one hour.

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One focus group was conducted in each locality. In Nexpan 10 female recipients volunteered to participate. This group comprised two women who were or had been vocales of Oportunidades, one that was currently part of the health committee in the clinic and the rest were just recipients. The focus group took place in a classroom of the local primary school. In Cualcan, nine female recipients volunteered to take part in the group interview. This group included two vocales and four were or had been part of the health committee, three were just recipients. The meeting was organized in the house of one vocal who kindly offered it for the activity. Each focus group was recorded and lasted between 1.5 and 2 hours. The interviews with health officers happened in the local clinics in any space that ensured privacy (usually the consulting room). The number and type of health officers working at the clinics at the time limited the selection of the interview participants. Of the ten health officers working at the clinics (all female, six in Nexpan and four in Cualcan), six officers were interviewed. In Nexpan, these included the director of the clinic, one dentist, one intern, and one nurse. In Cualcan, the director of the clinic and one nurse were interviewed. Four officers were not interviewed because they refused to participate (one permanent officer in Cualcan) or because they were not based at the clinics and their interactions with recipients were sporadic (for example, they were only responsible of delivering medicines or applying vaccinations). All participants were recruited by asking for their voluntary participation. Before each interview and focus group, the participant was asked to read and sign a consent form explaining the research’s objectives, the procedures of the interview, and their rights to anonymity, confidentiality, to reject responding to any question, and to withdraw at any moment without the need of providing justification. To record the conversations, participants were asked for their permission, reassuring them all information was strictly confidential and their identities be kept in anonymity. When a written consent was not possible, an oral consent was solicited. Ethical approval covering issues like voluntary participation, consent, anonymity, and protecting people from harm, was sought from the University of Bath’s Departmental Ethics Committee and approval was granted in November 2012.

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Participants of the Quantitative Study The final survey was completed by three hundred and twelve participants, 142 in Cualcan and 170 in Nexpan. An opportunity or convenience3 sampling procedure was used given that the surveys were applied during the monthly health workshops delivered at the local clinics. This was the procedure chosen since it granted access to large numbers of recipients in a single time and place, and with the space (seats) for everyone to respond to the survey comfortably. Conducting the surveys during a time that recipients already had reserved for Oportunidades was also beneficial since it minimized the hazards incurred by recipients in terms of time and costs (e.g., of not working). To apply the survey in these settings, permission from the directors of the clinics was asked. The date was set in a day most of the health staff were not present because of work activities they had outside the clinic. This was ideal, as it reduced any influence their presence could have on the responses of recipients.

Bibliography Adato, M. (2007). Combining survey and ethnographic methods to improve evaluation of conditional cash transfer programs. IFPRI, Working Paper No. 40. http://www.tandfonline.com/doi/abs/10.5172/mra.455.2.2.222 Adato, M., Coady, D., & Ruel, M. (2000). An operations evaluation of PROGRESA from the perspective of beneficiaries, promotoras, school directors, and health staff (Progresa Final Report) (p. 298). International Food Policy Research Institute (IFPRI). Agudo Sanchíz, A. (2012). The social production of conditional cash transfers’ impacts. International Policy Centre for Inclusive Growth, No. 172. Alkire, S. (2007). The missing dimensions of poverty data: Introduction to the special issue. Oxford Development Studies, 35(4), 347–359. https://doi.org/ 10.1080/13600810701701863 Argyle, M. (2001). The psychology of happiness (2 ed., repr,). Routledge. Arnold, C., Conway, T., & Greenslade, M. (2011). DFID cash transfers Literature review. DFID. Ashcroft, J., & Caroe, P. (2006). Thriving lives: Which way for well-being? (p. 43). Relationships Foundation.

3 This type of sampling procedure is defined as “one that is simply available to the researcher by virtue of its accessibility” (Bryman 2008).

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Austin, A. (2016). On well-being and public policy. Are we capable of questioning the hegemony of happiness? Social Indicators Research, 127 (1), 123–138. https://doi.org/10.1007/s11205-015-0955-0 Baird, S, Ferreira, F. H. G., Özler, B., & Woolcock, M. (2014). Conditional, unconditional and everything in between: A systematic review of the effects of cash Transfer programs on schooling outcomes. Journal of Development Effectiveness, 6(1). https://doi.org/10.1080/19439342.2014.890362 Bastagli, F. (2009). From social safety net to social policy: The role of conditional cash transfers in welfare state development in Latin America [Working paper no. 60]. International Policy Centre for Inclusive Growth. BIARE. (2012). Módulo de bienestar autorreportado. INEGI. Bowden, A., Fox-Rushby, J., Nyandieka, L., & Wanjau, J. (2002). Methods for pre-testing and piloting survey questions: Illustrations from the KENQOL survey of health-related quality of life. Health Policy and Planning, 17 (3), 322–330. https://doi.org/10.1093/heapol/17.3.322 Bradburn, N. M. (1983). Response effects. In P. H. Rossi, J. D. Wright, & A. B. Anderson (Eds.), Handbook of survey research. Academic Press. Bryman, A. (2008). Social research methods (3rd ed.). Oxford University Press. CAHPS. (2012). Patient experience measures from the CAHPS® Clinician & Group Surveys (No. 1309). CAHPS® Clinician & Group Surveys and Instructions. Calestani, M. (2009). An anthropology of “The Good Life” in the Bolivian plateau. Social Indicators Research, 90(1), 141–153. https://doi.org/10. 1007/s11205-008-9317-5 Camfield, L. (2004). Subjective measures of well-being in developing countries. In W. Glatzer, S. Von Below, & M. Stoffregen (Eds.), Challenges for quality of life in the contemporary world (pp. 45–59). Springer. https://doi.org/10. 1007/978-1-4020-2903-5_4 Camfield, L., Crivello, G., & Woodhead, M. (2009). Well-being research in developing countries: Reviewing the role of qualitative methods. Social Indicators Research, 90(1), 5–31. https://doi.org/10.1007/s11205-008-9310-z Campos Bolaño, P. (2012). Documento compilatorio de la Evaluación Externa 2007–2008 del Programa Oportunidades. Secretaría de Desarrollo Social Coordinación Nacional del Programa de Desarrollo Humano Oportunidades. Cargo, M., & Warner, L. (2013). “Realist evaluation” in action: a worked example of the Aboriginal Parental Engagement Program. Australian Institute of Family Studies. https://aifs.gov.au/cfca/2013/12/05/realist-evaluationin-action-a-worked-example-of-the-aboriginal-parental-engagement-program Carvalho, S., & White, H. (1997). Combining the quantitative and qualitative approaches to poverty measurement and analysis: the practice and the potential. World Bank.

1

INTRODUCTION

35

Christopher, J. C. (1999). Situating psychological well-being: Exploring the cultural roots of its theory and research. Journal of Counselling & Development, 77 , 141–142. Consejo Nacional de Evaluación (CONEVAL). (2015). Informe de pobreza multidimensional en México, 2015. Consejo Nacional de Evaluación de la Política de Desarrollo Social. Consejo Nacional de Evaluación (CONEVAL). (2010). Informe de pobreza multidimensional en México, 2008. Consejo Nacional de Evaluación de la Política de Desarrollo Social. Cookson, T. P. (2018). Unjust conditions. Women’s work and the hidden cost of cash transfer programs. University of California Press. Creswell, J. W., & Plano Clark, V. L. (2007). Designing and conducting mixed methods research. sage. Devereux, S., & McGregor, J. A. (2014). Transforming social protection: Human well-being and social justice. European Journal of Development Research, 26(3), 296–310. https://doi.org/10.1057/ejdr.2014.4 Devereux, S., Roelen, K., Béné, C., Chopra, D., & Leavy, J. (2013). Evaluating outside the box an alternative framework for analyzing social protection programs. IDS. https://doi.org/10.1111/idwp.2013.2013.issue-431/ issuetoc Devine, J., Camfield, L., & Gough, I. (2008). Autonomy or dependence—Or both? Perspectives from Bangladesh. Journal of Happiness Studies, 9(1), 105– 138. https://doi.org/10.1007/s10902-006-9022-5 Diener, E. (2000). Subjective well-being. The science of happiness and a proposal for a national index. American Psychologist, 55(1), 34–43. Diener, E. (2006). Guidelines for national indicators of subjective well-being and ill-being. Journal of Happiness Studies, 7 (4), 397–404. https://doi.org/10. 1007/s10902-006-9000-y Diener, E., Diener, M., & Diener, C. (1995). Factors predicting the subjective well-being of nations. Journal of Personality and Social Psychology, 69(5), 851– 864. Diener, E., Scollon, C. K., Oishi, S., Dzokoto, V., & Suh, E. M. (2000). Positivity and the construction of life satisfaction judgements: Global happiness is not the sum of its parts. Journal of Happiness Studies, 1, 159–176. Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. L. (1999). Subjective wellbeing: Three decades of progress. Psychological Bulletin, 125(2), 276–302. Ellis, K. (2011). Street-level bureaucracy’ revisited: The changing face of frontline discretion in adult social care in England. Social Policy and Administration, 45(3), 221–244. Encuesta Nacional de Discriminación (ENADIS). (2010). National survey on discrimination in Mexico. National Council to Prevent Discrimination.

36

V. RAMÍREZ

Eyben, R. (2006). The power of labelling in development practice. Institute of Development Studies (28). Eyben, R. (2010). Hiding relations: The irony of “Effective Aid.” European Journal of Development Research, 22(3), 382–397. https://doi.org/10.1057/ ejdr.2010.10 Fattore, T., Mason, J., & Watson, E. (2007). Children’s conceptualisation(s) of their well-being. Social Indicators Research, 80(1), 5–29. https://doi.org/10. 1007/s11205-006-9019-9 Fischer, E. F. (2014). The good life: Aspiration, dignity, and the anthropology of well-being. Stanford University Press. Forgeard, M. J. C., Jayawickreme, E., Kern, M. L., & Seligman, M. E. P. (2011). Doing the right thing: Measuring well-being for public policy. International Journal of Well-being, 1(1). https://doi.org/10.5502/ijw.v1i1.15 Frederick, S., & Loewenstein, G. (1999). Hedonic adaptation. In D. Kahneman (Ed.), Well-Being: Foundations of hedonic psychology (pp. 301–329). Russell Sage Foundation. Freeland, N. (2007). Superfluous, pernicious, atrocious and abominable? The case against Conditional cash transfers, IDS Bulletin, 38(3), 75–78. https://doi. org/10.1111/j.1759-5436.2007.tb00382.x Gaines, S. (2014). Evaluation of the inner wellbeing model in Zambia. Psychology of Well-Being Theory Research and Practice, 4(1), 16. https://doi.org/10. 1186/s13612-014-0016-5 Galappatti, A. (2003). What is a psychosocial intervention? Mapping the field in Sri Lanka. UNICEF. Gentilini U., Almenfi, M., & Orton, I. (2020). Social Protection and jobs responses to COVID-19: A real-time review of country measures. World Bank. http://www.ugogentilini.net/wp-content/uploads/2020/03/globalreview-of-social-protection-responses-to-COVID-19-2.pdf Gough, I., & McGregor, J. A. (Eds.) (2007). Well-being in developing countries from theory to research. Cambridge University Press. http://www.dawsonera. com/depp/reader/protected/external/AbstractView/S9780511322273 Green, D. (2012). From poverty to power. Practical Action Publishing Ltd. Greene, J. C., Caracelli, V. J., & Graham, W. F. (1989). Toward a conceptual framework for mixed-method evaluation designs. Educational Evaluation and Policy Analysis, 11(3), 255–274. https://doi.org/10.3102/016237370 11003255 Gutiérrez, J. P., Leroy, J., López Ridaura, R., DeMaria, L., Walker, D., Campuzano, J. C., & Bertozzi, S. (2008). Evaluación de la calidad de los servicios de atención a la salud asignados a la población beneficiaria de Oportunidades. In Evaluación externa del Programa Oportunidades 2008. A diez años de intervención en zonas rurales (1997–2007). Tomo II, El reto de

1

INTRODUCTION

37

la calidad de los servicios: resultados en salud y nutrición. Secretaría de Desarrollo Social. Hall, R. (2013). Mixed methods: In search of a paradigm. In T. Le & Q. Lê (Eds.), Conducting research in a changing and challenging world (pp. 71–78). Nova Publishers. Haller, M., & Hadler, M. (2006). How social relations and structures can produce happiness and unhappiness: An international comparative analysis. Social Indicators Research, 75(2), 169–216. https://doi.org/10.1007/s11 205-004-6297-y Helliwell, John F., Huang, H., & Want, S. (2017). The social foundations of world happiness. In H. John, F. Richard Layard, & J. Sachs (Eds.), World happiness report 2017 . UN Sustainable Development Solutions Network. International Well-being Group. (2006). Personal well-being index. Australian Centre on Quality of Life, Deakin University. http://www.acqol.com.au/ iwbg/well-being-index/index.php Jiménez, A. C. (Ed.). (2008). Culture and well-being: Anthropological approaches to freedom and political ethics . Pluto Press. Johannessen, L. E. F. (2019). Negotiated discretion: Redressing the neglect of negotiation in ‘street-level bureaucracy.’ Symbolic Interaction, 42(4), 513–538. Johnson, R. B., & Onwuegbuzie, A. J. (2004). Mixed methods research: A research paradigm whose time has come. Educational Researcher, 33(7), 14–26. https://doi.org/10.3102/0013189X033007014 Johnson, R. B., Onwuegbuzie, A. J., & Turner, L. A. (2007). Toward a definition of mixed methods research. Journal of Mixed Methods Research, 1(2), 112– 133. https://doi.org/10.1177/1558689806298224 Jones, N., & Sumner, A. (2009). Does mixed methods research matter to understanding childhood well-being? Social Indicators Research, 90(1), 33–50. https://doi.org/10.1007/s11205-008-9311-y Kagitcibasi, C. (2005). Autonomy and relatedness in cultural context: Implications for self and family. Journal of Cross-Cultural Psychology, 36(4), 403–422. https://doi.org/10.1177/0022022105275959 Kahneman, D., & Tversky, A. (1984). Choices, values and frames. American Psychological Association, 39(4), 341–350. Kanbur, R., & Shaffer, P. (2005). Epistemology, normative theory and poverty analysis: Implications for Q-Squared in practice. World Development. https:// doi.org/10.1016/j.worlddev.2005.10.016 Ladhani, S., & Sitter, K. C. (2018). Conditional cash transfers: A critical review. Development Policy Review, 38, 29–41. Layard, R. (2005). Happiness: Lessons from a new science. Penguin Books. Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services (30th anniversary (expanded). Russell Sage Foundation.

38

V. RAMÍREZ

Loyens, K., & Maesschalk, J. (2010). Toward a theoretical framework for ethical decision making of street-level bureaucracy. Existing Models Reconsidered. Administration and Society, 42(1), 66–100. Maxwell, J. A., & Mittapalli, K. 2010. Realism as a stance for mixed methods research. In A. Tashakkori & C. Teddlie, SAGE Handbook of Mixed Methods in Social & Behavioral Research (pp. 145– 168). Sage. http://methods.sagepub.com/book/sage-handbook-of-mixedmethods-social-behavioral-research-2e/n6.xml McGregor, A., & Sumner, A. (2010). Beyond business as usual: What might 3D well-being contribute to MDG momentum? IDS Bulletin, 41(1), 104–112. https://doi.org/10.1111/j.1759-5436.2010.00111.x McGregor, A., Coulthard, S., & Camfield, L. (2015). Measuring what matters: The role of well-being methods in development policy and practice (p. 20). Overseas Development Institute. Merkouris, A., Yfantopoulos, J., Lanara, V., & Lemonidou, C. (1999). Developing an instrument to measure patient satisfaction with nursing care in Greece. Journal of Nursing Management, 7 (2), 91–100. https://doi.org/ 10.1046/j.1365-2834.1999.00104.x Moncrieffe, J., & Eyben, R. eds. (2007). The power of labelling: How people are categorized and why it matters. Earthscan. Morse, J. M. (2003). Principles of mixed method and multi-method research design. In A. Tashakkori & C. Teddlie (Eds.), Handbook of mixed methods in social & behavioral research. Sage. Narayan, D., Patel, R., & Schafft, K. R. (2000). Voices of the poor: can anyone hear us? (English). World Bank Group. http://documents.worldbank.org/cur ated/en/131441468779067441/Voices-of-the-poor-can-anyone-hear-us Neff, D. F., & Olsen, W. K. (2007). Measuring subjective well-being from a realist viewpoint. Methodological Innovation Online, 2(2), 44–66. https:// doi.org/10.4256/mio.2007.0011 Organization for Economic Co-operation and Development (OECD) (Ed.). (2013a). How’s life? 2013: Measuring well-being. OECD. Organization for Economic Co-operation and Development (OECD) (Ed.) (2013b). OECD guidelines on measuring subjective well-being. Paris. Office for National Statistics (ONS). (2011). National statistician’s reflections on the National Debate on Measuring National Well-being. Office of National Statistics Publishing. PADHI. (2009). A tool, a guide and a framework: Introduction to a psychosocial approach to development. Social Policy Analysis and Research Centre. Picker Institute Europe. (n.d.). Improving performance: Patient and service user survey services from the Picker Institute. Picker Institute Europe.

1

INTRODUCTION

39

Ponocny, I., Weismayer, C., Stross, B., & Dressler, S. G. (2015). Are most people happy? Exploring the meaning of subjective well-being ratings. Journal of Happiness Studies. https://doi.org/10.1007/s10902-015-9710-0 Ravallion, M. (2009). Should the randomistas rule? The economists’ voice, 6(2). https://doi.org/10.2202/1553-3832.1368 Reyles, D. Z. (2007). The ability to go about without shame: A proposal for internationally comparable indicators of shame and humiliation. Oxford Development Studies, 35(4), 405–430. https://doi.org/10.1080/136008107017 01905 Roelen, K. (2017). Shame, poverty and social protection. IDS Working paper 489. https://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/ 12998/Wp489_Online.pdf?sequence=174 Roelen, K., & Camfield, L. (Eds.). (2015). Mixed methods research in poverty and vulnerability: Sharing ideas and learning lessons. Palgrave Macmillan. Rojas, M. (2009). Enhancing poverty-abatement programs: A subjective wellbeing contribution. Applied Research in Quality of Life, 4(2), 179–199. https://doi.org/10.1007/s11482-009-9071-0 Rojas, M. (2011). La medición del progreso y del bienestar: propuestas desde América Latina. Foro Consultivo Científico y Tecnológico. Rojas, M., & Martínez, I. (2012). Medición, investigación e incorporación a la política pública del bienestar subjetivo: América Latina: reporte de la comisión para el estudio y la promoción del bienestar en América Latina. Foro Consultivo Científico y Tecnológico, AC. Rojas, M., & Veenhoven, R. (2010). Cognition and affect in the appraisal of life: Separate entries or two sides of the same coin? Erasmus University Rotterdam working paper. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68 Ryan, R. M., & Deci, E. L. (2001). On happiness and human potentials: A review of research on hedonic and eudaimonic well-being. Annual Review of Psychology, 52, 141–166. Ryff, C. D. (1989a). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57 (6), 1069–1081. Ryff, C. D. (1989b). In the eye of the beholder: Views of psychological wellbeing among middle-aged and older adults. Psychology and Aging, 4(2), 195– 210. Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69(4), 719–727.

40

V. RAMÍREZ

Saha, S., Arbelaez, J. J., & Cooper, L. A. (2003). Patient-physician relationships and racial disparities in the quality of health care. American Journal of Public Health, 93(10), 1713–1719. Salih, M., & Galappatti, A. (2006). Integrating a psychosocial perspective into poverty reduction: The case of a resettlement project in Northern Sri Lanka: Intervention, 4(2), 126–144. https://doi.org/10.1097/01.WTF.000 0237881.64899.1f Sayer, R. A. (2000). Realism and social science. Sage. Schwarz, N., & Strack, F. (1999). Reports of subjective well-being: Judgmental processes and their methodological implications. In D. Kahneman, E. Diener, & N. Schwarz (Eds.), Well-Being: The Foundations of Hedonic Psychology (pp. 61–84). Russell Sage Foundation. Sen, A. (1985). Commodities and Capabilities. Elsevier Science Publishers. Simmons, R., & Elias, C. (1994). The study of client-provider interactions: A review of methodological issues. Studies in Family Planning, 25(1), 1. https://doi.org/10.2307/2137985 Skoufias, E. (2005). PORGRESA y sus efectos sobre el bienestar de las familias rurales en México. International Food Policy Research Institute (IFPRI) Informe de investigación No.39. Smith-Oka, V. (2009). Unintended consequences: Exploring the tensions between development programs and indigenous women in Mexico in the context of reproductive health. Social Science & Medicine, 68(11), 2069– 2077. https://doi.org/10.1016/j.socscimed.2009.03.026 Smith-Oka, V. (2012). Bodies of risk: Constructing motherhood in a Mexican public hospital. Social Science & Medicine, 75(12), 2275–2282. https://doi. org/10.1016/j.socscimed.2012.08.029 Smith-Oka, V. (2014). Fallen uterus: Social suffering, bodily vigor, and social support among women in rural Mexico: Fallen uterus in Mexico. Medical Anthropology Quarterly, 28(1), 105–121. https://doi.org/10.1111/maq. 12064 Smith-Oka, V. (2015). Microaggressions and the reproduction of social inequalities in medical encounters in Mexico. Social Science & Medicine, 143, 9–16. https://doi.org/10.1016/j.socscimed.2015.08.039 Steine, S., Finset, A., & Laerum, E. (2001). A new, brief questionnaire (PEQ) developed in primary health care for measuring patients’ experience of interaction, emotion and consultation outcome. Family Practice, 18(4), 410–418. https://doi.org/10.1093/fampra/18.4.410 Stiglitz, J. E., Sen, A., & Fitoussi, J.-P. (2009). Report by the commission on the measurement of economic performance and social progress (p. 291). Sumner, A., Hoy, C., & Ortiz-Juarez, E. (2020). Estimates of the impact of COVID-19 on global poverty. WIDER Working Paper

1

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2020/43. https://www.wider.unu.edu/sites/default/files/Publications/Wor king-paper/PDF/wp2020-43.pdf Tashakkori, A., & Teddlie, C. (Eds.). (2003). Handbook of mixed methods in social & behavioral research. Sage. Thin, N. (2005). Happiness and the sad topics of Anthropology. WeD Working Paper 10, ESRC Research Group on Well-being in Developing Countries. http://www.welldev.org.uk/research/workingpaperpdf/wed10.pdf Tochimani, G. (2015). Ixtlamatitla Tezcahuaca. Rupturas y permanencias dentro de la historia de San Agustín Calvario 1865–1957 . PACMYC-PUEBLA. Tonon, G. (Ed.) (2015). Qualitative studies in quality of life (Vol. 55). Springer. https://doi.org/10.1007/978-3-319-13779-7 UNDP. (Ed.) (2012). Bienestar subjetivo: el desafío de repensar el desarrollo. Programa de las Naciones Unidas para el Desarrollo, PNUD. Walker, R. & Chase, E. (2015, July 8–10). Shame, stigma and policy effectiveness. Paper presented at Developing and implementing policies for a better future at work. 4th Conference of the Regulation for Decent Work Network. http://www.rdw2015.org/uploads/submission/full_paper/ 84/ShameWalkerChase.pdf Well-being & Poverty Pathways. (2013). Well-being and poverty pathways: An integrated approach to assessing well-being. Briefing No. 1 (Revised). University of Bath. White, S. C. (2009). Bringing well-being into development practice. WeD Working Paper 09/50, Well-being in Developing Countries ESRC Research Group (WeD). http://www.welldev.org.uk/wed-new/workingpapers/workin gpapers/WeDWP_09_50.pdf White, S. C. (2010). Analyzing well-being: A framework for development practice. Development in Practice, 20(2), 158–172. https://doi.org/10.1080/ 09614520903564199 White, S. C., & Abeyasekera, A. (Eds.). (2014). Well-being and quality of life assessment: A practical guide. Practical Action Publishing. White, S. C., & Jha, S. (2014). The ethical imperative of qualitative methods: Developing measures of subjective dimensions of well-being in Zambia and India. Ethics and Social Welfare, 8(3), 262–276. https://doi.org/10.1080/ 17496535.2014.932416 White, S. C., & Pettit, J. (2004). Participatory approaches and the measurement of human well-being. WeD Working Paper 08, ESRC Research Group on Wellbeing in Developing Countries. http://www.welldev.org.uk/research/workin gpaperpdf/wed08.pdf White, S. C., & Ramírez, V. (2016). Economics and subjectivities of wellbeing in rural Zambia. In S. C. White & C. Blackmore (Eds.), Cultures of wellbeing: Method, place, policy. Palgrave Macmillan. ISBN: 9781137536440.

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White, S. C., Fernandez, A., & Jha, S. (2016). Beyond the grumpy rich man and the happy peasant: Mixed methods and the impact of food security on subjective dimensions of well-being in India. Oxford Development Studies, 44(3), 332–348. https://doi.org/10.1080/13600818.2015.1120278 White, S. C., Gaines Jr., S. O., Jha, S., Marshall, N., & Graveling, E. (2012a). Well-being pathways report: Zambia Round 1. Well-being and Poverty Pathways: University of Bath. http://www.well-beingpathways.org/images/sto ries/pdfs/working_papers/zambiatime1report.pdf White, S. C., Gaines Jr., S. O., Jha, S., & Marshall, N. (2012b). Well-being pathways report: India Round 1. Well-being and Poverty Pathways: University of Bath. Retrieved from http://www.well-beingpathways.org/images/sto ries/pdfs/working_papers/indiatime1report.pdf White, S. C., Gaines, S. O., & Jha, S. (2012). Beyond subjective well-being: A critical review of the Stiglitz report approach to subjective perspectives on quality of life. Journal of International Development, 24, 763–776. White, S. C., Gaines, S. O., & Jha, S. (2014). Inner well-being: Concept and validation of a new approach to subjective perceptions of well-being—India. Social Indicators Research, 119(2), 723–746. https://doi.org/10.1007/s11 205-013-0504-7 Wierzbicka, A. (2004). “Happiness” in cross-linguistic & cross-cultural perspective. Daedalus, 133(2), 34–43. https://doi.org/10.1162/001152604323 049370 Wilk, R. (1999). Quality of life and the anthropological perspective. Feminist Economics, 5(2), 91–93. https://doi.org/10.1080/135457099337978 Williamson, J., & Robinson, M. (2006). Psychosocial interventions, or integrated programming for well-being? War Trauma Foundation, 4(1), 4–25. Wood, G. D. (Ed.) (1985). Labelling in development policy: Essays in honour of Bernard Schaffer. Sage and Institute of Social Studies. Zavaleta, D., Samuel, K., & Mills, C. (2014). Social isolation a conceptual and measurement proposal. Oxford Poverty & Human Development Initiative. http://www.ophi.org.uk/social-isolation-a-conceptual-and-measur ement-proposal/

CHAPTER 2

Well-Being: A Framework to Assess Relationships in Policy Implementation

For a long time, there has been a strong identification of development with economic growth. At national level, Gross Domestic Product (GDP) has been the most used indicator of societal progress, policy effectiveness and even as a proxy of people’s well-being. However, through time, it has become apparent that this equivalence is raised upon many wrong assumptions about the capacity of income to improve quality of life and to reduce ill-being and poverty (e.g., Constanza et al., 2009; Stiglitz et al., 2009). The challenges of using measures of income for purposes they were not initially designed to fulfil, thus, initiated a search for a bettersuited framework to capture the complexity of people’s lives. The notion of well-being provides such alternative framework and nowadays there is increasing consensus about the benefits of well-being as an alternative approach to social progress. Although the Stiglitz-SenFitoussi Commission is probably the most cited report on this regard (Stiglitz et al., 2009), the list of academics, governments, organizations, and think tanks endorsing well-being—even if from different standpoints—is much longer (e.g., White, 2017; Cummins, 2009; Forgeard et al., 2011; Helliwell et al., 2013; Layard, 2009; McGregor et al., 2015; OECD, 2013; ONS, 2011; Rojas & Martinez, 2012; Sen, 1999; UNDP, 2012). The international move toward well-being is overwhelming. In 1986, the United Nations Declaration on the Right to Development started defining development as ‘constant improvements of the well-being of the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 V. Ramírez, Relational Well-Being in Policy Implementation in Mexico, https://doi.org/10.1007/978-3-030-74705-3_2

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entire population and of all individuals’ (UN, 1986). Yet, it was until a couple of decades later when well-being became established in development discourse and practice. In 2011, the United Nations (UN) adopted resolution 65/309 titled ‘Happiness: towards a holistic approach to development’ which recognizes the incapacity of GDP to capture human well-being and identifies happiness as a universal goal. That same year, the Organization for Economic Co-operation and Development (OECD) launched the Better Life Initiative to measure and compare the wellbeing of member countries through a multidimensional index—including education, community, safety, work–life balance, life satisfaction, etc. In 2012, the World Happiness Report launched with the purpose of measuring ‘the state of global happiness’ every year. Finally, in 2015, the Sustainable Development Goals set 17 multidimensional goals and 169 targets, including SDG3 that has the specific purpose of ensuring good health and well-being for all at all ages. With this and the other SDGs, it became official that countries must track their progress toward well-being and that people’s views of what matters in their lives also need to be taken into account (e.g., Stiglitz et al., 2009; UNDP, 2012). Well-being contributes to our understanding of development and to guide public policies for several reasons. Overall, it involves a shift in priorities. It explicitly places the person at the center-stage and it proposes to evaluate progress, policies, and programs based on whether they ultimately contribute to generating the conditions for people to enjoy a good life (Rojas, 2009, 2014). Well-being also offers a holistic view of human life, recognizing that our ability to live well is complex and shaped by experiences and achievements in a number of areas of life. In public policy, this multidimensional lens challenges tendencies to operate in disciplinary or bureaucratic silos. It also implies moving away from only evaluating the efficacy of policies based on their a priori established outcomes to explore unintended or overlooked consequences for other spheres of people’s lives. Finally, well-being also offers a positive language and mind-set not commonly used within public policy and development, which have traditionally centered on the negatives, on what people lack or suffer such as poverty, unemployment, and mental or physical impairments, and how to remediate it (White, 2010). Although it is imperative to deal with life’s negative aspects—especially of the most marginalized and excluded— having these as the only focus runs the risk of deepening the gap

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between those doing ‘well’ and those doing ‘poorly,’ as well as reaffirming negative labels and judgments that can carry social stigma (ibid.). A wellbeing approach, therefore, reduces the tendency to divide people’s lives according to specific spheres, governmental institutions, or policy aims. It represents a conceptual unifier across distinct sectors of policy-making, even pointing toward areas of policy consideration that are not sufficiently taken up by governments (McGregor & Sumner, 2010; White, 2010). For these reasons, there are numerous initiatives taking a well-being approach in public policy (see UNDP, 2012 for a review). McGregor and colleagues (2015) identify two levels at which well-being is applied in public policy: at the national level and at the frontline level. On the one hand, the calculation of well-being indices at national level to compare across nations has played an important part in getting well-being onto the political agenda. The construction of robust measures has been critical in making the argument that well-being should influence policy debates. On the other hand, well-being approaches have been recommended to evaluate social programs and development initiatives at the frontline, particularly from the discipline of development studies (e.g., Devereux et al., 2013; McGregor et al., 2015; Molyneux et al., 2016; White, 2014). This implies using well-being findings and tools for designing, orienting, and evaluating the outcomes and procedures of social programs that have direct contact with the general population and vulnerable groups. This book contributes to this developing area. Focusing on the interactions between clients and frontline officers, it seeks to understand better how a well-being lens can contribute to observing the effectiveness of social programs and analyze their procedures, practices of implementation, and ultimate objectives from a human-centered perspective. As well-being gains public and political acceptance, it is time to make the transition toward a wider agenda for public policy (Devereux & McGregor, 2014; Devereux et al., 2013; Rojas, 2009). Yet, defining wellbeing is not an easy task. In the last decades, the question about what well-being is and how can it be observed has prompted significant theoretical and empirical research from a diversity of disciplines. This makes offering a broad sketch of the field a challenging task, not only because of the multiple disciplines involved, but also because of the number of possible ways to distinguish between approaches (see e.g., Dolan et al., 2006; Gasper, 2010; Phillips, 2006). So far I have been using wellbeing as an all-encompassing term without paying attention to the specific contribution of subjective approaches, the focus of this book.

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Subjective Well-Being Diener (2006) provides a comprehensive definition of subjective wellbeing as ‘an umbrella term for the different valuations people make regarding their lives, the events happening to them, their bodies and minds, and the circumstances in which they live’ (p. 400). The case for subjective well-being in policy is based on two main arguments: first, that it constitutes valuable information for assessing how individuals and societies are doing; and second, that how people think and feel about their lives can be reliably measured (Cummins et al., 2009; Devereux & McGregor, 2014; Rojas, 2007c). Nonetheless, the value of looking at people’s subjective perspectives of well-being in policy is still contested. Critiques relate to the difficulty of making cross-cultural comparisons (Christopher, 1999; Diener & Suh, 2000); the proximate factors that influence subjective evaluations, such as social desirability bias, social comparison bias (Kahneman & Tversky, 1984), and adaptive preferences (Frederick & Loewenstein, 1999; Gasper, 2007) (see Gough et al., 2007; Stiglitz et al., 2009 for general discussions on these limitations); and the adequate use of subjective indicators by governments (Frey & Stutzer, 2012). Some argue that subjective wellbeing should not be a policy goal because it is highly dependent on personal characteristics such as personality traits or genetics. Hence, the responsibility for subjective well-being should remain at the individual level (Wilkinson, 2007). However, evidence suggests that subjective wellbeing is not only determined by internal or personal aspects, but also by the external social circumstances and capabilities of the person, which remain a key area of influence of public policy and governments (UNDP, 2012). While some still contend that externally verifiable, objective measures are the only sound basis for public policy, researchers on social indicators have been testing self-report indicators for monitoring society since the 1960s (see Zapf, 2000). Initially this involved collecting people’s accounts of their external conditions, for example evaluating their perceptions of safety in their neighborhoods or the state of the national economy. They may also include social dimensions of people’s life experiences like their agency, participation in communities, and quality of their relationships. However, the distinctiveness of subjective well-being questions is that they measure aspects of life that do not have an ‘obvious objective counterpart’ and thus cannot be externally assessed (Stiglitz et al., 2009,

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p. 43; e.g., Andrews & Withey, 1976). These include questions about the balance between positive and negative emotions or satisfaction with life.1 In sum, the evidence suggests that while the possibility of measuring subjective well-being has been the focus of considerable debate and space to improve surely remains, there is increasing agreement that ‘is possible to collect meaningful and reliable data on subjective [well-being]’ (Stiglitz et al., 2009, p. 16, see also Rojas, 2011; Veenhoven, 2002). The adoption of subjective well-being measures in policy involves changing not only (1) what is measured but also (2) who is involved in the measurement. They move away from objective indicators of people’s life circumstances, which are taken as a proxy for their quality of life, and concentrate on a more direct form of assessment, what people say they think and feel about their lives. In theory, at least, this places people at the center of the assessment of well-being, although often the choice of measures and analysis remain in the hands of experts. Subjective well-being thus arguably has the potential to offer a more bottom-up form of evaluation. The need for bottom-up evaluations that concentrate on the people that policies seek to benefit is especially pressing in the case of poor, vulnerable, and diverse populations ‘who are usually excluded or disenfranchised in elite-dominated policy processes’ (McGregor et al., 2015, p. 2). In these contexts, moving away from taking an objective-external approach to well-being and instead listening to people’s own voices is invaluable because it reduces the elite bias of many policies. This in turn lessens the risk of inappropriate design, implementation and evaluation of policies and programs. Hence, although improving subjective well-being should not be considered the sole goal of public policy, it does provide a valuable dimension that is useful for policy-making and evaluation. Differing Subjective Well-Being Approaches The approaches that use subjective data are however varied. They have been developed in the intersection of many social disciplines— economics, psychology, and sociology primarily—resulting in not one but a number of models and conceptual frameworks. Three clearly distinguishable strands within the field are subjective well-being, psychological 1 The Well-being and Poverty Pathways (2013) Briefing No. 1 provides a useful analysis of the layers at which objective and subjective dimensions can be measured. This is also discussed in White and Abeyasekera (2014).

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well-being, and more recently psychosocial and relational well-being approaches. Each of these agrees on the importance of relationships, the main interest of this book. Yet, relationships are incorporated differently in their conceptual and methodological corpus, which could have diverse implications for the design, evaluation, and analysis of policies. Hence, a brief description of these distinct approaches is offered here. Firstly, subjective well-being (SWB) has its roots in the ancient belief that a good life is that in which experiences of pleasure outweigh experiences of pain. This is linked to a hedonic understanding of well-being and a utilitarian view of the maximization of happiness (Diener, 1984; Diener & Lucas, 2000; Diener et al., 1999). While SWB itself comprises a range of frameworks, it is commonly seen as a compound of two psychological spheres: cognition and affect (Diener, 1984; Rojas & Veenhoven, 2010). Affect is mainly concerned with ‘what makes experiences and life pleasant and unpleasant’ (Kahneman et al., 1999, p. ix). It denotes feelings and emotions that are associated with people’s reactions toward life circumstances (Diener, 2006). In contrast, cognitive evaluations can resemble the weighting of the pros and cons of one’s life and require a mental effort to recollect past experiences (Stiglitz et al., 2009). These can be made for life as a whole (Diener et al., 1985) or separated by domains (Diener et al., 2000, e.g. Cummins, 1996; Rojas, 2006, 2007a; van Praag et al., 2003). In practice, SWB is predominantly quantitative—people are asked to rate their lives according to a number on a scale. SWB thus stands at one extreme of the subjective continuum as an empirically driven approach that does not depend on any explicit theory of well-being nor make any judgment about the basis on which people make their evaluations (Diener, 2000). The features of its chief measures—the single-item global indicators of Life Satisfaction and Happiness—can illustrate this since they capture people’s overall evaluations of their lives into an abstracted, single number (Diener & Suh, 2000). For example, the 2017–2021 wave of the World Values Survey measures happiness as: ‘Taking all things together, would you say you are, very happy (1), rather happy (2), not very happy (3) or not at all happy (4).’ For life satisfaction, a 10-point Likert scale asks: ‘All things considered, how satisfied are you with your life as a whole these days?’ Hence, instead of defining the components of well-being theoretically, SWB researchers identify them through inferential analyzes and the selection of certain explanatory variables in each context or study.

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This process can result in finding distinct determinants of well-being from one context to another. Therefore, SWB can be understood not as a theory of well-being but as an empirical tool that can be used by a number of disciplinary areas and in public policy for international rankings of well-being. Indeed, their simplicity has meant that SWB indicators have been the most used measures, employed by a wide variety of researchers and governments (see OECD, 2013 for a review). The second major approach, psychological well-being (PWB) (Ryan & Deci, 2001; Ryff, 1989a, 1989b) has its origins in Aristotle’s understanding of the good life as something that can only be found in virtue, meaningfulness, and the expression of human potentials. This maintains that equating well-being to feeling happy is dangerous, since what makes you happy might not promote a flourishing life but instead have negative long-term effects (Ryan & Deci, 2001; Ryff, 1989a). For these philosophical foundations, PWB is usually characterized as eudaimonic well-being. Probably the most salient among psychological approaches are the model of Psychological Well-being (Ryff, 1989a) and the Theory of Self-Determination (Deci & Ryan, 2000; Ryan & Deci, 2000). The common characteristic of PWB approaches is that they conceptualize well-being as composed of a set of defining domains or components based upon theoretical research about what is a life with purpose and meaning. For instance, the construction of Ryff’s model began with a revision of various frameworks within the humanistic tradition of psychology, including research on personality, developmental and mental health theories (Ryff, 1989a, 1989b) and notions of positive functioning (Ryff & Keyes, 1995). The outcome was a six-domain model composed of autonomy, positive relationships with others, environmental mastery, personal growth, purpose in life, and self-acceptance (Ryff, 1995; Ryff & Singer, 1998). In line with its eudaimonic foundations, all domains are important, necessary, and irreducible for experiencing well-being. These constitute the essence of good living in every context and culture. Eudaimonic approaches thus propose universal models of well-being. Both SWB and PWB approaches, however, have been criticized for their cross-cultural applicability, which might be problematic when applied for policy guidance in particular contexts. For example, the claim that SWB is value free has been challenged on the grounds that it assumes a particular, individualized cultural understanding of the person (Atkinson, 2020; Christopher, 1999). This criticism is also levelled at

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PWB, where the choice of domains—particularly in Ryff’s model— appears to be bound to certain cultural understandings of well-being (Christopher, 1999; Devine et al., 2008; Kagitcibasi, 2005). In addition, PWB has been criticized as top-down for the predominance of theory and the role of experts in establishing its domains (Diener et al., 1998; Rojas, 2011, 2014). The third strand is composed of a myriad of psychosocial approaches influenced more strongly by sociology and development studies. For decades, the discipline of development has challenged the dominance of income and economic growth as indicators of development and poverty, and pushed for defining them in multidimensional terms. The concept of well-being is relatively new in development, yet, the interest in quality of life, poverty, and other related concepts has existed for a long time. For example, the internationally renowned capabilities approach has included the notion of well-being as people’s freedom to achieve the life they value (Sen, 1999). Similarly, studies on empowerment, agency (e.g., Kabeer, 2002), and gender (e.g., Marchand & Parpart, 1995), among others, have made considerable contributions to our understanding of different dimensions of well-being. Since the 1980s, efforts by Robert Chambers (1983) and others working on participatory approaches have proposed substituting top-down forms of elicitation with participatory tools that place people’s voices and perspectives of their own lives at the center of development and poverty analyses. Finally, in development practice, humanitarian initiatives and development aid programs have shown that looking at people holistically and listening to them more attentively can improve program effectiveness (Salih & Galappatti, 2006; UNICEF, 1997; Williamson & Robinson, 2006). Among these various efforts, it is worth underlining the innovative proposal of the Well-being in Developing Countries (WeD) research group (e.g., Gough et al., 2007) and the Well-being and Poverty Pathways research project (WPP) (White et al., 2014) at the University of Bath. These works offer a conceptual framework to assess well-being in developing contexts, emphasizing that living well is what happens in the interaction between three dimensions—the material, the subjective, and the relational. Therefore, breaking away from the traditional separation of the study of well-being between subjective and objective, and bringing the social at the forefront of the analysis. The WPP approach transformed this conceptual framework into a quantitative model that measures people’s

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subjective perceptions of their lives in eight dimensions of psychosocial well-being (see Fig. 1.1). A major distinction of this line of research compared with SWB and PWB is the call to move beyond relying primarily on quantitative indicators and for embracing qualitative and mixed methodologies (e.g., Calestani, 2009; Camfield et al., 2009a; Fischer, 2014; Jiménez, 2008). They also prioritize assessments of well-being in and for contexts of development, poverty, and/or humanitarian crisis. Nonetheless, their key contribution for this book is that the subjective is not conceptualized solely as an inner experience. Instead, researchers make explicit the influence of culture, values, social norms, and social interactions in shaping those inner and subjective evaluations in given contexts. As McGregor and Sumner (2010) argue, the subjective involves the ‘meanings that people give to the goals they achieve and the processes in which they engage’ (p. 105). Hence, a defining feature of this strand is that, although they maintain the emphasis on the person and her perspectives, they detach from the internal and psychological orientation of the approaches reviewed above by underlining that preferences, aspirations, and perceptions are grounded and negotiated in culture and social meaning (White, 2010). To these approaches, relationships coconstruct well-being. These frameworks are the forerunners of a contemporary trend that proposes a relational approach to well-being, which has received attention from researchers concerned with global issues that underscore the interconnectedness of the person with her society and her environment (e.g., Atkinson et al., 2020; Helne, 2021; Maricchiolo et al., 2021; White, 2017, 2018). As is possible to see from this brief review, well-being is a diverse field comprising significant differences in terms of concepts and methodologies. These differences are likely to have implications for how social relationships are studied and their usefulness for development and policy guidance. In fact, the way each approach treats relationships constitutes a particularly telling marker of the distinctions between the approaches. The next section discusses some of the key findings that attest the overarching and complex importance of relationships for well-being and how can they help in the assessment of officer–recipient relationships at policy implementation.

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The Overarching Significance of Relationships for Well-Being The social relationships are a central aspect of our life. They involve relationships with family, friends, and our community. From an evolutionary perspective, the gregarious nature of human beings provides substantial support for the centrality of social interaction for our survival and development. From a psychological perspective, Maslow’s hierarchy of needs place social relationships—the need for belongingness and love—right after the basic needs of physiological requirements and safety. At the same time, ever since we measure subjective well-being, the empirical study of the association of social relationships with well-being has expanded (La Guardia & Patrick, 2008). Within this literature, many themes have been analyzed, such as relationship satisfaction, the relative significance of quantity and quality of relationships, key features of relationships such as support, reciprocity, attachment, intimacy, and interdependence, and their impact on different aspects of well-being (see Baumeister & Leary, 1995; Haller & Hadler, 2006; La Guardia & Patrick, 2008 for reviews). From these studies, the most consistent finding is the centrality of social relationships across the life cycle, cultures and types of populations, leading many researchers to state that well-being has social foundations (Helliwell et al., 2017; Rojas, 2018). At the international level, the World Happiness Reports have explored subjective well-being across more than 150 countries. Helliwell and colleagues (2012) identify six key variables that explain a large proportion of the variation in life evaluations. Of these, four capture different aspects of the social context. The most important, however, is social support from family or friends. In the 2017 report, Helliwell and colleagues (2017) expand on this analysis, arguing not only the direct role of social relationships on quality of life, but also the non-negligible interconnection between the key variables that explain quality of life with social factors such as trust, corruption, social norms, and social support. For example, it shows that social support is significant for subjective well-being through its effects on physical and mental health. In addition, their empirical findings indicate that social support in and of itself has the strongest direct effect over self-reported well-being even after controlling for the effects of income and health. Its contribution is overwhelming:

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For a country to have 10% more of its population with someone to count on, (not a large change given the rage of 70% between the highest and lowest countries) is associated with an increase in average life evaluations of 0.23 points on the 0 to 10 scale. An increase of that size in life evaluations is equivalent to that from a doubling of GDP per capita… These effects are above and beyond those that might flow through higher incomes or better health. (Helliwell et al., 2017, p. 31)

This overarching significance of relationships worldwide is even larger in Latin America. Despite the many problems in the region in terms of insecurity, corruption, inequality and poverty, Latin Americans report surprisingly high levels of subjective well-being. The case of Mexico is particularly interesting. It stands high in the global rankings of crime, corruption, and human rights violations. Yet, it is the second happiest country in Latin America (just below Costa Rica) (Rojas, 2018), ranking number seven in the world in positive affect, and number 24 in happiness (Helliwell et al., 2020). The reason for this, according to Rojas (2018), is the abundance and centrality of social relationships in the region. Relationships are closer and warmer, even for those beyond family and friends (i.e., extended family, community); and life evaluations often incorporate relational features (e.g., making parents proud or watching their children grow up). In recent years, the importance of social relationships is increasingly acknowledged. Still, the multiple ways in which these act over well-being is still under scrutiny and has evolved through time. The review below will show how the well-being approaches discussed in this book have contributed to this understanding in various ways. To start with, a consensus: across the diversity of approaches, there is general agreement that social relationships are both instrumentally and intrinsically valuable to live well. Their instrumental value captures the ability of relationships to be resources or means for obtaining benefits. The social capital, social cohesion, and social exclusion literatures have contributed much to our comprehension of this aspect, underscoring how relationships can promote or hinder people’s ability to deal with economic crises, obtain employment, and access resources and services (e.g., Putnam, 2001; for a review see Zavaleta et al., 2014). However, relationships are not only instruments to acquire external things, but also enable people to feel safe, secure, and supported. Researchers have found relationships to be key vehicles to cope with

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stressful situations (Collins & Feeney, 2000; Stratton, 2007), as well as to gain a sense of safety (Downie et al., 2008). Cohen (2004) reviews some positive effects of social relationships, including positive health outcomes like reducing the risk of mortality, the incidence of some degenerative illnesses, anxiety, and depression, as well as reducing the effects of material and economic difficulties (see also Cummins, 2005; Diener & Seligman, 2002; Myers, 2000). In the case of Mexico, Rojas (2007a) showed that the difference in overall life satisfaction between poor and non-poor is much lower than the difference in income particularly because of the effects of relationship satisfaction (see also Camfield et al., 2009a for Bangladesh). In contrast, the intrinsic significance of social relationships underscores that relationality is good in itself. That is, having social contact, enjoying positive relations with others, experiencing a sense of belonging, and being able to participate in society is intrinsically valuable to live well (e.g., Ryan & Deci, 2001). Extensive research has confirmed that being married and involved in social, community, and religious activities increases happiness, life satisfaction, and psychological well-being (Cummins et al., 2009; Haller & Hadler, 2006; Krauss & Graham, 2013; Layard et al., 2012; Myers, 2000). Having social contact can promote a sense of belonging (Morrow, 2001), provide emotional support, care, and companionship (Demir & Weitekamp, 2007), and is a main motivation for engaging in activities such as employment, participating in church or sports clubs, and even taking time for leisure (Argyle, 2001). Several cross-cultural studies confirm these results using both qualitative and quantitative methodologies (e.g., Camfield et al., 2009a; Helliwell et al., 2017). Relationships in SWB and PWB Relationships have been explored by SWB and PWB approaches at different levels, however. Probably the most superficial level is exploring the role of ‘having or being in relationships’ on well-being. For instance, Haller and Hadler (2006) conducted a large multinational and multilevel regression analysis investigating the association between social relationships and social structures on happiness. At the micro-level, the authors included four ‘relationship variables’ that can be considered proxies of having close relationships and social networks: marital status, having children, religious participation, and membership of voluntary associations.

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Besides finding that people who are part of a family (are married and have children) and participate in social activities are significantly happier than those who do not, a noticeable characteristic of this study is that the relationship measures only assess the existence of social ties, probably the simplest level of association between social relationships and well-being. Other studies focus on the quantity of social connections. Quantity is generally understood as the number and frequency of interactions with others (Zavaleta et al., 2014). These can be family, friends, social, or religious groups we belong to, and some studies even include weaker ties such as acquaintances. There is, however, no consensus in the literature about the importance of the quantity of social relationships for wellbeing. Most studies have found evidence that people are less lonely, have a greater sense of belonging, and report more positive affect on days they socialize more with close others (Reis et al., 2000; Vittengl & Holt, 1998; Wheeler et al., 1983) and even with distant acquaintances like government officers or service providers. In a study conducted with university students and community members in British Columbia USA, Sandstrom and Dunn (2014) found that when people had more daily interactions with weak ties such as classmates, work colleagues, or a barista at a coffee shop, they reported greater feelings of belongingness and happiness. Conversely, other studies have maintained that the frequency and quantity of our social interactions are non-significant or even negative for well-being (Demir & Weitekamp, 2007). Nezlek and colleagues (2002) argue that a possible reason for such contradictory results might be the variety of factors involved in the number of interactions one has. For example, having infrequent interactions with others can be the result of a personal choice that can nonetheless increase well-being. Another possibility is that while these results do say something about the importance of avoiding social isolation for well-being, they do not say much about how the quality of these relationships (e.g., how supportive they are) might contribute differently to subjective well-being. Going beyond the focus on the presence or frequency of relations, another consistent finding is the strong influence of the quality of our social relationships for well-being. However, SWB and PWB approaches tend to explore quality in different ways. SWB has explored quality through the domain satisfaction approach, which measures quality indirectly through an indicator about the reported level of satisfaction with relationships (Diener, 1984). In this literature, life satisfaction partly

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depends on satisfaction with concrete areas of life in which social relationships is one of them (Rojas, 2006). In fact, relationships appear in most models of domain satisfaction, but in different forms, such as partner, children, friends, and community (e.g., Cummins, 1996). The majority of empirical studies have found that close relationships are one of the most important domains, and thus, most (if not all) studies of domain satisfaction include them (e.g., Argyle, 2001; Headey & Wearing, 1992). For example, in a study in Mexico, Rojas (2007b) found that satisfaction with partner, children, and family has the strongest effect on happiness above health, job, and economic satisfaction. The distinctive characteristic of this approach is that it asks participants to rate their satisfaction with different types of relationships. This implies evaluating the perceived quality of relationships without defining what quality means. This is in line with the aim of SWB of avoiding making any theoretical assumptions about the ‘good life.’ Nonetheless, this approach might be insufficient when assessing relationships in policy contexts. For example, Simmons and Elias’ (1994) article on client–provider interactions finds that quality of interactions and satisfaction with interactions do not necessarily vary together. The authors discovered that high levels of satisfaction with social interactions occur even when the quality of interactions during service provision is inadequate. This discrepancy, they claimed, is especially salient in developing countries probably because of greater social inequalities and a context of constant mistreatment. This, of course, raises a debate that is difficult to resolve about the tension between leaving in the hands of the person the decision about what a good relationship entails and defining more precisely what counts as a good interaction based on theoretical and empirical research. Eudaimonic frameworks (PWB) propose taking the latter approach by assessing quality based on how flourishing and meaningful relationships are using previous psychological research. Indeed, eudaimonic approaches have built on years of psychological knowledge about the qualitative attributes of a relationship. In this task, concepts like trust, commitment, attachment, belongingness, intimacy, support, and security have emerged as especially relevant (Baumeister & Leary, 1995; Reis & Patrick, 1996; Reis et al., 2000; Ryff & Singer, 2000). In 1995, Baumeister and Leary proposed the ‘belongingness hypothesis,’ which stated that ‘human beings have a pervasive drive to form and maintain at least a minimum quantity of lasting, positive and significant interpersonal relationships’ (p. 497). This suggests that the

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importance of relationships in people’s lives entails more than simply having social contact with others but also that these relationships have certain qualities. Eudaimonic approaches, thus, include a domain of the quality of social relationships in their models. For instance, the domain of Positive Relations in Ryff’s model of Psychological Well-being is defined as having warm, intimate, supporting, and trusting relationships, as well as experiencing feelings of empathy and affection for others (Ryff 1989a; Ryff & Keyes, 1995). Therefore, this domain not only captures the significance of quality but of reciprocal relationships in which receiving as well as giving contributes to well-being. In turn, for SDT enjoying a sense of belonging and attachment in our relationships is a basic psychological need captured in the need for relatedness. Relatedness is defined as feeling connected to and developing close relationships with others, this includes the needs to belong, be cared for, and have a sense of security (Baumeister & Leary, 1995; Ryan & Deci, 2000). According to La Guardia and Patrick (2008), for any relationship to effectively enhance positive functioning and well-being it should support all three psychological needs (relatedness, autonomy, and competence). They characterize a need-supportive relationship as one that: [A]ctively attempt[s] to understand the person’s interests, preferences, and perspectives (autonomy), provide clear, consistent, and reasonable expectations and structure (competence), get involved with, show interest in, direct energy toward the person and convey that the person is significant and cared for noncontigently (relatedness)… In contrast, [to relationships that] are excessively controlling, have unreasonable expectations, are overchallenging or rejecting. (La Guardia & Patrick, 2008, p. 202)

In this sense, this literature supports the idea that how well people do in any aspect of well-being could be directly mediated by the extent others support or undermine these aspects. The implications of relationships on various aspects of well-being are only recently explored in SWB studies (e.g., Helliwell et al., 2017). Yet, conducting these studies more systematically could help illuminate the multiplicity of paths through which relationships can influence well-being. Measuring the quality of social relationships, as PWB approaches do, might be beneficial for program evaluation as it provides a more detailed

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view about what people are thinking about when rating a relationship. Nonetheless, only assessing our satisfaction with relationships or even their quality, risks obscuring the negative aspects of social interactions, which can be particularly relevant in contexts of poverty and inequalities in which social programs occur. Well-being studies that explore relationships’ negative aspects are rare and instead, there appears to be an overemphasis on the positives, probably as a result of the field’s positive outlook. Yet, relationships and interactions often involve not only positive but also negative aspects such as conflict, rejection, power, and control that could have a differential effect on well-being (House et al., 1988; Goswami, 2012). Similarly, the type of support offered by relationships is not always positive, and can become damaging (Boutin-Foster, 2005; Lincoln, 2000). A few researchers have found that negative relationships are as significant for well-being as positive relationships and even have independent effects on it (e.g., Lansford et al., 2005). For example, Goswami (2012) conducted a study on child well-being investigating the life satisfaction (SWB) effects of positive and negative relationships independently. In the latter, they included experiences of bullying by other young people, being treated unfairly by adults, and negative affect in friendships. The results suggested that negative interactions had a ‘disproportionately greater effect’ on life satisfaction compared to positive interactions (p. 584; also see Finch et al., 1999; Hirsch & Rapkin, 1986; Rook, 1990). Examining separately positive and negative relationships could enrich our understanding of their implications for well-being (Antonucci et al., 1998), although of course most—perhaps all—relationships have aspects of both. This might be even more revealing if we evaluate, as suggested above, their differential role on particular aspects of well-being and not just global satisfaction or happiness. However, since this is not widely explored, it is not clear how significant positive and negative interactions would be for different aspects of well-being and in different types of relationships, such as those generated during program implementation. Another drawback of assessing the quality of relationships with established indicators is that these can limit the extent to which people can express the significance of relationships in their lives as well as the types of relationships that are important and the reasons why. As shown above, the relationship measures often used by PWB point toward features like attachment, intimacy, closeness, or belongingness (Springer & Hauser, 2006) that restrict the analysis to close relationships and might be less

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relevant for more distant or less intimate relationships such as those created in policy contexts. SWB’s and PWB’s outcome-focused approach to relationships also constitutes a limitation for their use in the policy realm. Firstly, studies on SWB and PWB only capture the final outcomes or impacts of relationships on well-being through their quantitative measures, ignoring the complex and fluid processes through which these are produced. Additionally, especially salient in SWB research is a view of relationships as external influences on well-being (Ryan & Deci, 2001), and well-being itself as construed within the individual and by her personality and biological traits. A good example is Cummins and colleagues’ (2009) understanding of social relationships as ‘external buffers’ of people’s life satisfaction (see also Carlquist et al., 2017). From their perspective, social relationships are external coping mechanisms when the SWB of the person fails to return to its homeostatic equilibrium (the set-point value for a given person). Relationships thus become an aspect of the environment in which people live that can have a cause–effect association with subjective well-being (Gergen, 2009). The global questions of happiness and life satisfaction reinforce this view since, as Christopher (1999) defends, these indicators ‘[cast] the individual as the possessor or owner of his or her own being’ (p. 143). Indeed, it could be argued that SWB and PWB risk presupposing persons as atomistic and discrete entities that are separate and independent from each other and from society (Gasper, 2010); whereas relationships are portrayed as external impacts on a personally created well-being (Atkinson, 2013; Gergen, 2009; White, 2016). This understanding can lead to a duality that is particularly problematic for the policy realm. When the person is seen as a self-defining unit that pursues self-chosen goals, her well-being becomes a personal property (Christopher, 1999) and can only be personally achieved (Sointu, 2005) or self-managed (Atkinson, 2013). Hence, any failure to achieve well-being is attributed to personal failure (Sointu, 2005). Atkinson (2013) rightly problematizes this outlook as it enters the policy realm, suggesting it can lead to policies that ‘focus primarily on individual deficits in fostering and sustaining positive well-being’ (p. 140). They also run the risk of ‘de-politicising well-being’ as the aim becomes ‘not to change the world but to change the way you feel about it’ (White, 2010, p. 167). Ultimately, taking this position implies losing the complexity of well-being and diminishing the role of the social and

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relational (Gasper, 2010). Indeed, relationships are barely static, they are constantly in flow, often ambiguous since they can be positive and negative at the same time or in different ways, and their implications for people’s lives can also vary in the short and the long term. Although these aspects are difficult to measure, they are still relevant for how people experience well-being. As this section has shown, the main concern of SWB and PWB research has been close relationships. This reflects the consistent and convincing findings that they have the strongest influence on well-being across the globe and the life span, compared to other types of relationships (Argyle, 2001; Downie et al., 2008; Land et al., 2001; Michalos et al., 2001; Rojas, 2007b). These findings are significant to the policy realm since they have led to several recommendations to governments and organizations to include positive close relationships as goals of their social programs and development initiatives (e.g., Camfield et al., 2009b; Cummins et al., 2009; Devine, 2002). Today there is a growing number of programs interested in this. Governments and NGOs are increasingly promoting the quality of marriage, reducing household violence, encouraging time with the family, and improving social connections and support at the community level. At the international level, the United Nation’s General Assembly and the Economic and Social Council have issued a number of resolutions encouraging governments to design, implement, and evaluate policies that address the needs of families, promote family well-being and social integration (e.g., resolution 2011/29). At the national level, countries like the United Kingdom have taken on this task by monitoring the quality of close relationships and social connections through the Measuring National Well-being initiative at the Office of National Statistics (ONS) (Randall, 2015). At the local level, NGOs have also done their part. One example is the British association Knowle West Media Centre that has developed two programs that seek to generate spaces for social gathering in localities throughout the country. Although the focus on close relationships is very valuable given the strong evidence about its role on well-being, in the policy context only focusing on them runs the risk of individualizing the responsibility of well-being. That is, understanding well-being as an individual experience that primarily occurs and is co-created at the household, ignores that policies and programs themselves generate new social scenarios and reproduce wider social structures that can be crucial not only for their own success

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but also for the subjective well-being of their participants. The importance of relationships in policy has been underscored by a number of development reports and studies. For instance, in the 2004 World Bank Report Making services work for the poor, the agency devoted a whole section on complex relationships between people and service providers during policy implementation and the need to improve their relationship for adequate service provision. Overall, very little subjective well-being research has been done focusing on relationships created in institutional contexts, except within health and social care (e.g., Cummins, 2005). While there are many studies exploring the health benefits of the quality of the social context (e.g., Theurer et al., 2015), after an extensive survey of the literature, only a handful of studies exploring quality of interactions between officers and clients and their connection to subjective or psychological well-being were found. Most of these studies are directed to caring relationships in nursing homes, hospitals, and other health contexts. An interesting contribution of these works was identifying that patients valued the interactions with healthcare providers not only in terms of the quality of the service offered, but also in terms of interpersonal qualities. For example, in a mixed-methods study from the nursing care literature, Merkouris and colleagues (2004) evaluated interpersonal aspects of care such as respect, courtesy, concern from staff, communication with staff, and the accommodation of personal preferences. Although the quantitative ratings about the quality of this relationship were around the average scale of 3 out of 5, the qualitative data showed that ‘nurses’ humane behavior and frank interest in patients’ well-being was highly valued by participants’ (p. 360). This discovery supports the relevance of assessing the quality and meaningfulness of the relationships that happen in institutional contexts and service provision. In terms of their association with well-being, Street and Burge (2012) explored staff–resident relationships in elderly homes, finding that positive relationships with staff were significantly associated with a positive change in the resident´s perceived quality of life after moving to the facilities. In addition, Custers and colleagues (2010) examine resident–staff relationships in nursing homes indicating that staff’s support for SDT’s three psychological needs is essential to reduce depression and increase life satisfaction of residents (see also Custers et al., 2012). In sum, the overwhelming evidence that SWB and PWB approaches have provided confirm the strong significance of relationships for how

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people evaluate their lives. These findings are certainly important for the policy realm as they can guide policy-makers into areas of action that are usually considered out of the scope of governments such as improving family and community relationships. However, despite the recent advancements, they also exhibit limitations in their practical usefulness for policy as they can obscure our understanding of relationships beyond family and friends, such as between clients and officers. Moreover, the overemphasis on measurement can disregard complex forms of association between well-being and relationships that might be necessary if applied to policy contexts. Can psychosocial approaches offer a better framework? Relationships in Critical Well-being Approaches Social relationships take a different form under the light of critical wellbeing research in development studies and psychosocial approaches. From these separate efforts, the idea of relational well-being is starting to emerge (White, 2017), echoing a significant challenge to the dominant conceptions of well-being examined earlier. Critical well-being approaches vary greatly, yet, the common ground between them is a conceptualization of social relationships as intricately linked to how people define and produce well-being in daily life. Relationships are seen to coconstruct well-being through various processes like daily interactions, cultural values, identity formation, and power struggles. These approaches also take a different epistemological and methodological stance and depart from or are applied in many cultures outside the global North, stressing the necessity of a contextual analysis of well-being. The Well-being in Developing Countries (WeD) research group contributed much to this line of inquiry. They engaged in a rich interdisciplinary debate about the meaning of well-being, its contextual and social grounding, and its relevance for development and policy (see Gough & McGregor, 2007; McGregor, 2007; White, 2010). Later on, the psychosocial model of Inner Well-being (IWB) was created based on this conceptual proposal. The overall aim of WeD was ‘to develop a conceptual and methodological approach for understanding the social and cultural construction of wellbeing in developing countries’ (WeD, 2008). This goal is reflected in their three-dimensional (3D) approach that conceptualizes well-being as composed of subjective, material, and relational dimensions (Fig. 2.1). Well-being, they argue, is what happens

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Subjective

Fig. 2.1 Dimensions of well-being (Source White [2010] and Gough and McGregor [2007])

Material

Relational

between what people have and do not have (material), what they can be and do (relational), and what they feel and think about what they have and what they can do and be (subjective) (White, 2010). The definition of well-being offered by WeD—and later transformed into an empirically model by IWB—mirrors the close and dynamic interaction between the three dimensions: [W]ellbeing is an umbrella concept, embracing at least ‘objective wellbeing’ and ‘subjective wellbeing’ (…) [However], both the objective circumstances and perceptions of them are located in society and also in the frames of meaning with which we live. Thus well-being is also and necessarily both a relational and a dynamic concept. States of wellbeing/illbeing are continually produced in the interplay within the social, political, economic and cultural processes of human social being. It cannot be conceived just as an outcome, but must be understood also as a process. (Gough et al., 2007, pp. 4–5)

The former quote also offers a number of key ideas about the relational dimension. Particularly about the distinctive way in which the group observed the centrality of relationships in well-being through the political, social, and cultural practices that ground it and their implications for transforming well-being into a dynamic and complex process. Many of these ideas are discussed here along with findings from other studies that give support to this view. The first aspect to explore is the close interconnection between the relational dimension and the other two.

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For WeD, as for other researchers within this broad approach, wellbeing is socially and inter-subjectively construed (McGregor, 2007). This acknowledgment is not only conceptual. In much of WeD’s empirical research, relationships were found to have a vital role in the subjective and the material reality of people, especially in contexts of poverty and vulnerability. In a study in Bangladesh, Camfield and colleagues (2009b) show that the well-being and social relationships of the poor—particularly family and community—are closely interlinked and probably as significant for well-being as their material deprivations. Moreover, following people’s accounts, relationships were not only important as a dimension in themselves; they were also connected to the economic and subjective experiences of poverty, including social exclusion, embarrassment, and shame (de Castro, 2017; Redmond, 2008). The second key contribution of these approaches is a recognition of the role of culture in shaping well-being. Several studies have shown that the meaning of well-being (Christopher, 1999), as well as the concepts used to describe it (Wierzbicka, 2004, 2009) vary across cultures and nations. This has been attested by all well-being approaches, although it is done with different purposes. Research in cross-cultural psychology has tested well-being theories in distinct contexts with the aim of confirming their universal validity and reliability. Although using the simplistic individualistic/collectivistic binary for characterizing cultures, cross-cultural psychology has found that emotions and the norms for expressing them vary between societies (Eid & Diener, 2001; Kitayama & Markus, 2000; Markus & Kitayama, 1991).2 If we take these results from a critical perspective, rather than as supporting a universal take to well-being, they make it evident that well-being is a situated experience, leading some to argue for a contextual rather than universal outlook (White, 2010). Conversely, critical well-being approaches have argued for a more dynamic understanding of culture in well-being analysis. For Gough and colleagues (2006), culture entails ‘systems of meaning, negotiated through relationships within society, that shape what different people can and cannot do with what they have’ (p. 25). Hence culture not

2 For instance, research has found that in individualistic societies, emotions tend to be self-oriented, internal, and private experiences. Yet, in collectivistic cultures, emotions are oriented to others and are interpersonal and inter-subjective processes, such as being harmonized with others and being connected to the collective way of well-being (e.g., Hitokoto & Uchida 2015; Uchida et al., 2004).

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only affects well-being at an abstract level, instead well-being is also constructed and maintained through the everyday meanings, practices, and actions infused with the diverse cultural values and traditions of a given society. Qualitative well-being research is better suited to capture these intricacies of culture in well-being. In his work with the Raramuri indigenous group in the North of Mexico, Loera-González (2015) identifies that the dominant discourse of well-being—promoted by the elders—particularly sought to preserve the cultural and political distinctiveness of this indigenous group. This discourse also set the normative view about what constituted an ideal life and the everyday expected behaviors in a Raramuri community. Yet, as happens in many societies, the younger people had a different view, constantly disputing this apparently shared conception of the good life. This case illustrates that well-being discourses and strategies are created and contested in specific socio, cultural, and historical contexts. Thus, well-being and the person who is experiencing it should be observed within the socioeconomic and cultural contexts in which they occur. Looking at well-being as a culturally and relationally grounded experience also has implications for how subjectivity is understood in critical and psychosocial approaches. For a long time, sociological research has suggested that through the process of socialization, people create their own identity, motivations, choices, preferences, aspirations, and behaviors (e.g., Giddens, 1982), all of which are associated with how people understand well-being and pursue it. In their mixed-method study in Bangladesh, Camfield and colleagues (2009a) conclude that relationships had profound influence in ‘individual´s values, choices, actions and indeed the construction of the self’ (p. 88). In another study, White (2009) claims that when people were asked about their well-being they often found it difficult to talk about their own experience in isolation from others. She argues that ‘their sense of how things are for them personally is intimately tied up to their sense of how those they identify as “their own” are doing. For some this might mean just a single person. For others it could be a very large category, even a national group’ (p. 13). Hence, here subjectivity is not detached from nor externally impacted by the social. Rather, there is a recognition that ‘people become who and what they are in and through their relatedness to others’ (White, 2010, p. 164).

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However, relationships not only shape well-being through the lenses people use to interpret life, this literature has also suggested that relationships can determine what people can do and be at present, and what they can achieve or become in the future. Hence, looking at well-being as a relational experience also implies focusing on how it is actively negotiated with others. Calestani (2009) conducted an ethnographic study in El Alto in Bolivia looking at the situated meanings of well-being. Besides pointing to the significance of social relationships, her findings show that, in this context closely linked to the Aymara indigenous culture, well-being is attributed to the notion of living well together. That is, having harmonious relations with others at different levels of social interaction including the household and the community. Calestani reported, however, that harmonious does not necessarily imply that the well-being of each individual is always prioritized. Instead, the experience of harmony often entailed individual sacrifice for the group, which was attached to a moral duty to contribute to the group’s quality of life.3 This tension between the well-being of the individual and that of others also relates to the ambiguous character of relationships in wellbeing. Research in different countries has found that positive aspects of relationships like cooperation and unity coexist with negative aspects like conflict and obligations. Rather than being two opposite poles, positive and negative aspects can occur at the same time within one relationship and are essential aspects of people’s ability to live a good life (Calestani, 2009; Huovinen & Blackmore, 2016). In their research of family and community relationships in Bangladesh, Camfield and colleagues (2009a) documented how ‘relationships are always malleable, and in the process of negotiating the terms of any relationship people acquire both a sense of identity (often a common identity) and a sense of position within the relationship’ (p. 82). As such, social relationships can make the achievement and experience of well-being a recursive process of negotiation and change as they can constrain or facilitate the strategies people use to be well (White, 2016). This recognition inevitably requires a discussion about power.

3 Her findings also indicate that well-being was defined in relational and collective terms through the concepts Suma Jakaña and Suma Qamaña. This society considers the individual and the family unit as the same thing, thus the first term refers to well-being at the individual and household level while the second refers to well-being at the community level.

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Critical approaches to well-being in development also underline the explicit and implicit power in social relationships and in the construction of well-being. Research on child well-being is particularly sensitive to the power dimension of relationships. Many have found that children are particularly affected by their hierarchical position in society and the usual power relationships in which they are placed within the household, the school and society in general (e.g., Jones & Sumner, 2007, see Crivello et al., 2009). Even though it is not surprising that children have such a relational experience of their lives, mainstream well-being research has failed to recognize enough that these mechanisms do not fade away in adulthood. As Cohen (2004) argued, our relationships with others ‘provide the opportunity for conflict, exploitation, stress transmission, misguided attempts to help, and feelings of loss and loneliness’ (p. 680). People’s well-being struggles are strongly shaped by the hierarchical terms in which their interactions with others happen, including relationships of dependence, exploitation, and unequal power relations (Huovinen & Blackmore, 2016; White, 2002). This reconfiguration of the role of relationships reinforces an understanding of well-being as a process rather than as a state or outcome (Atkinson, 2013; McGregor, 2007; White, 2010, 2016). A fundamental premise underlying a notion of relational well-being in these works is that all human beings need others to experience and pursue well-being. This is more visible when we consider the lives of the most vulnerable such as children, the elderly, or the disabled, who may not survive without the help of others. However, all human beings, regardless of their situation, depend on the help or at least from the absence of harm from others (Williamson & Robinson, 2006). In many ways, psychosocial and development approaches to well-being emphasize that relationships can mediate the resources people can have, how they can access and use them, and the way they feel about their lives and themselves. These relational mechanisms occur throughout the lifetime as well as in different relational spaces: within the family (Huovinen & Blackmore, 2016), between husbands and wives (Jha & White, 2016), between generations (parents and daughters/sons) (Calestani, 2009), within the community, the larger society (Loera-González, 2016), and with state institutions (Abeyasekera, 2014). The interest of this book lies specifically in the latter arena.

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Relational Well-Being in Social Policy Previous section sought to show how critical well-being approaches offer alternative conceptualizations and empirical evidence that place relationships at the heart of people’s daily struggles for well-being, not only as an environmental factor or as an external impact. Their distinct epistemological and methodological outlook help observe the contested, complex, and multifaceted nature of relational well-being. Recognizing that wellbeing varies across context and cultures, and that its accomplishment is a process that occurs in the interplay between people and the different relational scenarios in which they act and reside. This comprehensive role of relationships, has important contributions for policy and development programs, particularly for the analysis of the relationships created during policy implementation. The meaningfulness of the relational in well-being have led to increasing numbers of development and humanitarian interventions to include it through psychosocial programs. Psychosocial programs were originally designed for groups in situations of scarcity, conflict, and humanitarian crises. One of their defining features is a concern over the psychological and social dimensions of people’s experiences of these events. While acknowledging the importance of the material needs that arise in such contexts, they question the way that these are often the only dimensions of need to capture attention. However, probably the key dispute of these psychosocial approaches is with a-social psychological interventions. Psychosocial interventions emphasize the importance of attending not only to the psychological impacts of conflict and poverty, but also including social relationships more directly (Salih & Galappatti, 2006). For instance, many are directly addressed to social relationships such as establishing social, cultural, and educational activities, providing community-based social support, mobilizing social networks, and strengthening interpersonal skills and people’s sense of belongingness (Galappatti, 2003). Williamson and Robinson (2006) propose a well-being framework composed of seven aspects—biological, emotional, mental, cultural, spiritual, social, and material—in which the social and cultural are central. Although these seven aspects are proposed, they underline that each context should define the aspects of well-being that are more relevant to them, how to call them, or interrelate them. They argue that such an integrated well-being approach, one able to recognize better the various

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areas that support or undermine well-being and their interdependence, would ensure that appropriate programming attention is given to each of them. Despite the undeniable interrelationship between dimensions emphasized by psychosocial approaches, it is not uncommon that development initiatives primarily concentrate on the material dimension, while mainstream subjective well-being approaches (SWB and PWB) largely center on the subjective/psychological dimension. Yet, not taking into account the relational dimension of well-being could obscure the dynamic processes of well-being construction and negotiation that occur throughout life and at different contexts and relational spaces. This is the contribution of psychosocial well-being to the analysis of relationships in policy contexts. Indeed, relationships in policy have been explored by psychosocial approaches such as the Psychosocial Assessment for Humanitarian Interventions (PADHI) from the University of Colombo. PADHI is an initiative that analyzes how and what is done in development by accounting for the social, cultural, and psychological implications of development programs. As for all psychosocial approaches, for PADHI the experience of well-being (subjective) cannot be separated from the possibility of achieving it (social). Therefore arguing that the promotion of wellbeing through policy should move beyond recipients’ internal traits (e.g., coaching people how to cope with the environment) and start challenging the terms on which recipients ‘engage with others and others engage with them’ (White, 2010, p. 168). In addition to taking into account people’s personal and community relationships, development initiatives need to take into account the relational scenarios they create themselves, not just their intended outcomes. Indeed, psychosocial approaches rightly underscore that even if some development initiatives do take a more rounded approach by including psychological and social aspects of well-being, the procedures of implementation can often work against these comprehensive objectives through the ethical conflicts and processes of scrutiny conducted by frontline officers (Salih & Galappatti, 2006). In PADHI’s research in Sri Lanka they found that well-being was a daily struggle mediated by power, discrimination, and social connections. In this struggle, they argue, development interventions have a particular role as they can reinforce or challenge the relational systems that determine who benefits or losses from an intervention or program. Therefore, this approach proposes a framework based on the principle of social

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justice, which offers a method or tool to social programs and interventions to assess their impact on people’s well-being and their processes of implementation (Abeyasekera, 2014). Salih and Galappatti (2006) present a successful example of a poverty reduction strategy in northern Sri Lanka that follows such an approach, particularly taking into account the implementation strategies used by frontline officers. This initiative was directed to resettled women heads of households and integrated a revolving loan fund for income-generating activities with a conventional counselling service and a community socialwork approach. As is expected from a psychosocial approach, the initiative responded to the family and community processes that could thwart the women’s ability to live well in their new communities by designing activities that promoted the recipients’ autonomy, identity, and the relationships of support needed to cope with the hardships of poverty and resettlement. This initiative was also explicitly reflective about how the officers engaged with participants during service provision and community meetings, introducing procedures that underlined supportive ways of providing the interventions from the design. The initiative intentionally shifted the role of frontline officers from one that delivers and monitors, to one interested in how the family was doing overall, their current concerns and the situations of different family members. The authors, however, detected some challenges in the implementation of such an inclusive and horizontal approach to policy delivery. One limitation was the officers’ lack of training in the deployment of procedures not through the customary controlling and authoritative role, but through an outlook of mutual support within the group. They also identified tensions and contrasting expectations between key actors in the project, especially between officers at different levels of implementation. The close relationship between psychosocial workers and recipients permitted identifying pressing needs of recipients that would have not been uncovered with traditional implementation methods. However, officers at higher levels of implementation expressed finding it difficult to harmonize between the traditional demands and objectives of the program and the requirements of recipients that were voiced through psychosocial workers. In this initiative, the agency’s management was very supportive toward the psychosocial workers because their relevance was stipulated in the design. This, however, might not always be the case and

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thus underscores the imperative for coherence between program design and implementation. Despite these implementation challenges, these changes in the processes of program implementation and the terms of officer–recipient relationships into a more empathic and horizontal interaction resulted in positive well-being outcomes for recipients. This initiative was found to contribute ‘towards, and enhance, [participants’] psychosocial wellbeing by impacting almost directly on their own feelings of competence, their sense of being supported and the development of their skills in problem-solving and management’ (Salih & Galappatti, 2006, p. 139). In sum, presenting well-being not as a state but as a field of struggle reminds us that social programs that aim at improving well-being cannot separate themselves from considerations of social relationships (Taylor, 2010). This includes looking beyond the client to the family and community, the larger social processes that help shape people’s interactions, and the relationships created during the provision of programs and aid. Indeed, a well-being analysis such as the former remind us that it is not only crucial to focus on an adequate design of social programs, but also to monitor how the program itself challenges or reproduces the relational processes that keep people vulnerable. Interactions between frontline workers and policy participants play a key part in these relational processes. The next section expands on the characteristics that distinguish officer—recipient relationships and the scenario in which they happen through a review of the literatures on development and public policy—particularly street-level bureaucracy.

Frontline Officers: From the Control Over Resources to the Potential Well-Being Impacts Well-being matters emerge at all levels of policy-making, from the choice of the normative criteria used to justify program objectives to the use and satisfaction recipients can derive from the resources and services received. Yet, probably the most direct scenario is that which happens during policy implementation in the interactions between the recipients of the program and the frontline officers that provide the service or resource.4 4 The literature has used a number of concepts to refer to this relationship, such as client-agent , officer-beneficiary, or client-provider. In this book, officers can be called frontline officers or more specific kinds like health staff or physicians, etc. Program participants

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Initially, the relationship between officers and recipients was not a primary concern in public policy. This discipline was focused on an earlier piece in the policy process: the design. The assumption was that if you get the design of a program right this was enough to make it effective. In the 1970s, scholars began to question this, noticing that a significant aspect of program success was determined at the ‘last’ stage of the process, the implementation. The policy implementation literature is founded upon the idea that usually in practice there is a dissonance between what is stated in the design and how programs look on the ground. This implementation gap is often attributed to how frontline officers execute their work (Hudson & Lowe, 2009; Parsons, 1995). Frontline officers constitute the most immediate link through which a policy, a social program, or a development initiative achieves its goals. Different kinds of officers are in charge of directly interacting with individuals during the provision of services (e.g., physicians, nurses, counsellors, teachers), resources, or information (e.g., bureaucrats, public servants, social workers, development workers, receptionists), as well as during the policing of behaviors—as happens in conditional cash transfer programs like Oportunidades-Prospera that are attached to certain conditions. The street-level bureaucracy literature that spanned from Michael Lipsky’s investigations of US bureaucracies in the second half of the twentieth century has explored these interactions more thoroughly. However, these works have drawn their empirical findings primarily from bureaucracies in countries from the Global North, and it is only recently that frontline work is studied more deeply in the Global South, including Latin America (Eiró, 2019; Peeters et al., 2018; Zarychta et al., 2020). The literature on street-level bureaucracy has focused on analyzing how officers can transform the procedures and direct outputs and outcomes of programs, especially as the environment of public administration changes with time (Ellis, 2011; Erasmus, 2014). Yet, this level of analysis can disregard the relational processes that occur during implementation and that are materialized in the interactions of frontline officers with recipients

also have been identified in a number of ways, some concepts being more value-laden than others (see Wood, 1985a, 1985b; Goetz, 1997 for discussions on this). In contrast to the contested concept of beneficiary, this book uses the concepts of participant and recipient as they do not undermine the agency of the people partaking in a government or development program.

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studied here (Johannessen, 2019). Interestingly, in practice, social relationships are at the core of the jobs of frontline officers. Maynard-Moody and Musheno (2003) show that according to officers’ own descriptions, their work is demarcated more by relationships at different levels of policy than by the rules and procedures that frame their tasks. Among these relationships, those with program recipients are especially important. Officer–recipient Relationships A number of characteristics of frontline officers and their jobs identified in the literature shed light on the significance of looking more deeply at officer–recipient interactions to assess policy processes and outcomes through a well-being lens. During policy implementation, frontline officers are figures of authority. They constitute the recipient’s official gatekeepers to valuable resources, services, or information because of the power granted by the institutional architecture of social programs. In practice, however, this formal power intensifies as officers exercise informal discretion over the way the procedures are deployed to the final receiver, giving them sufficient sway beyond what is established or monitored by the program. Indeed, the concept of discretion is central to the definition of frontline officers first presented by Lipsky in his research on US bureaucracies. Lipsky was the first to coin the term ‘street-level bureaucrat’ to refer to frontline officers and to characterize their functions during implementation. According to this author, street-level bureaucrats are ‘[p]ublic service workers who interact with citizens in the course of their jobs and who have substantial discretion in the execution of their work’ (Lipsky, 2010, p. 3). Even today, discretion remains an essential characteristic of frontline officers’ work despite the increasing trends in the use of bureaucracy to manage and control implementation through better-specified rules and broader forms of supervision (Evans & Harris, 2004). Discretion does not have a single definition as many literatures have employed the concept, including law, economics, sociology and public policy (Hupe, 2013). Yet, in the context of street-level bureaucracy, it can be understood as the space for maneuver between the rules and procedures that govern officers’ work and the necessity to improvise to respond to the individual needs of their clients. Discretion is particularly necessary in developing countries where it is not rare that officers work under unclear rules and procedures and face a number of limitations to perform their jobs well.

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These include insufficient resources, large caseloads, demanding bureaucratic paperwork, and the non-typical situations that are impossible to outline in the program’s guidelines ex ante (Crook & Ayee, 2006; Gaede, 2016; Gilson, 2015). Such conditions are especially common in programs oriented to the provision of services that have the most direct link to well-being such as education and health (e.g., Dickson & Brindis, 2019). In an analysis of service provision for the poor in the developing world, the World Bank (2004) showed that public health clinics are critically understaffed; physicians are required to provide services to disproportionate numbers of patients and with inadequate means, such as inappropriate buildings without access to electricity and few resources like medicines and instruments. In remote rural areas, it is common for officers to receive low wages and the incentives for effective service delivery are frail or contradictory, thus absenteeism, mistreatment, corruption, and political patronage become widespread practices (see OECD, 2014 for data on Mexico). Hupe and Buffat (2014) call these challenging working conditions a public service gap, which is the situation in which ‘what is required of street-level bureaucrats exceeds what is provided to them for the fulfillment of their tasks’ (ibid., p. 556). Public service gaps, together with the difficulty of monitoring and controlling the actions of frontline officers, make discretion ‘the wild card of policy delivery’ (Brodkin, 2008, p. 326). In these uncertain and complex situations in which they work, frontline workers can develop coping mechanisms to make programs operational. Tummers and colleagues (2015) identify two types of coping strategies in frontline work, cognitive and behavioral. Cognitive coping strategies include attitudes of compassion toward clients, emotional detachment from clients, and cynicism regarding clients. Behavioral coping strategies, in contrast, include bending or breaking rules, routinizing, rationing, and using personal resources to help clients, or aggression toward clients. According to these authors, the various possible combinations of coping mechanisms can move frontline officers toward their clients, away from their clients or against their clients. The use of discretion and coping mechanisms might not always be negative for reaching policy goals more effectively and for fostering recipients’ well-being. Of course, many frontline workers may have the intrinsic or professional motivation or commitment to provide proper services, and thus they could use their discretion to positively adapt to these uncertain settings (Ellis, 2011). However, in contexts of high institutional failure,

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contradictory program goals, and excessively limited working conditions (as exemplified above), positive forms of coping mechanisms can be much more difficult to achieve for frontline officers. Officers might feel pushed to arbitrarily decide how to allocate the limited resources or services and structure the circumstances in which interactions with participants take place, their frequency, how much time is spent on each case, and the amount and quality of the information provided. For example, if physicians are overburdened with disproportionate program objectives like achieving large quotas on health treatment applications, they could decide to exert authority over clients’ decision-making about undertaking the treatments by making them a condition of access to other benefits. Even worse, in many contexts, officers can arbitrarily choose who deserves the support, what kind of support, and how they will provide it (Moncrieffe & Eyben, 2007). Although a number of factors influence the behavior of officers during interactions with recipients (Kaler & Watkins, 2001; Walker & Gilson, 2004), the reinterpretation and remake of policy by frontline officers is influenced by the type and structure of the organizations in which they work (Hill & Hupe, 2009). The more ambiguous policy goals, processes, and desired outcomes are, the greater the space for officers to use discretion in the exercise of their work. At the same time, the more bureaucratic a policy becomes, the greater the challenges officers face to commit to their clients’ needs and exercise professional skills and expertise in their decision-making during policy delivery (Evans, 2011). According to Ellis (2011), the pressures of bureaucratic tasks have led officers to act more in accordance to administrative rules than to ethical codes of conduct, although not eliminating the latter completely. The environments that permit maintaining ethical codes are those where there is a clear policy agenda directed to social inclusion and equal opportunities. When such an agenda is not part of the structure of institutions, however, this practice might be difficult to sustain at the street level. Hence, although the ultimate effects of frontline officers’ discretion vary, officers might find themselves between the conflicting needs of their superiors, their recipients,’ and their own, which may leave concerns for recipients’ well-being to last. In addition to the influence of formal rules and of the predictable and unpredictable circumstances of the job in shaping the behaviors of officers, the development literature also identifies the role of power in their interactions with recipients. This literature suggests that the provision of

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welfare policy is the result of various levels of interpersonal and institutional power relations. For example, between the theoretical knowledge in social sciences and policy discourses, between and within policy organizations, between policy discourses and officers, between officers themselves, and between frontline officers and clients (e.g., Chambers & Pettit, 2004; Groves & Hinton, 2004; Shutt, 2006). This book is focusing on the latter, the last link of this web of power relations, which of course cannot be but influenced by the rest. Wood (1985a) and Eyben (2006) examine power in officer–recipient relationships through the concept of labeling (see also Moncrieffe & Eyben, 2007). Labeling is of practical use in policy. The state and aid organizations tend to use it with the purpose of classifying the recipient population into easily managed categories. Frontline officers use it as an informal tool to deal with large number of cases, as well as resource and time constraints (Lipsky, 2010). Hence, labeling recipients might be useful to simplify their work. This, however, can also lead to groups being characterized in negative ways that reinforce the prejudices and stigma associated with that label, and that shape the treatment recipients receive. For example, labeling recipients as ‘beneficiaries’ has been disputed for positioning people as passive ‘users and choosers’ undermining their capacity to be ‘makers and shapers’ of their own destinies and lives (Cornwall & Gaventa, 2000, p. 50), usually considered a significant aspect of wellbeing. This concept (‘beneficiary’) also assumes that recipients ultimately benefit from policies and programs, which of course is not a given, but something that should be submitted to rigorous analysis and evaluation. The formal labels in social policy can be exacerbated by the identities participants have in the wider social scenario of policy implementation, producing stereotypes such as the ‘lazy poor’ or the ‘dependent beneficiary.’ In two microcredit programs directed to poor women in Bangladesh, Goetz (1997) found that frontline officers constantly characterized women as dependent, ignorant, incompetent, and timorous. In many unequal societies, the apparent reality of these labels is especially reinforced to policy-makers, becoming a tool to justify inappropriate actions or below-average accomplishments in their own and the program’s performance. In Goetz’s (1997) research, officers’ representations of gender and worth conveniently obscured their own responsibility in, for example, informally permitting husbands’ control over loans originally designed for women and women’s productive enterprises. Therefore, some have characterized these interactions as ‘micropolitical situations

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that parallel relations in society at large’ (Simmons & Elias, 1994 citing Waitzkin, 1991). The politics of identity that prevails in the outer social world in which the implementation occurs certainly plays an important role in the way power is exercised during officer–recipient encounters (Eyben & Moncrieffe, 2006). Yet, again, it is in conditions of scarcity and deep social stratification that the distance between the identities of these two actors can be magnified. In developing countries, the identity asymmetries between officers and recipients in terms of gender, class, race, and education tend to be striking. Officers are usually part of (relative) social elites as they are educated, middle class, and frequently male. In contrast, recipients of social programs usually hold identities structurally marginalized in their societies, such as poor, indigenous, illiterate, and (possibly) female. The fact that policy-engendered relationships involve interactions between people who are not among either’s main reference groups, facilitate the reproduction of hierarchical relationships and stereotypical conceptions and attitudes toward the other. This, according to Wood (1985b), can destroy identities and recreate them through differentiation. These hierarchies can exponentially increase as participants are associated to several ‘negative’ labels or identities at the same time. As Lipsky (2010) recognizes, ‘the poorer people are, the greater the influence street-level bureaucrats tend to have over them’ (p. 6). The higher the level of professional knowledge and technical skills of officers can also promote hierarchical and paternalistic relationships with policy participants. This is especially problematic in healthcare contexts where officers suit up as the doctor or clinician with an expertise able to save lives (Mandlik et al., 2014). Professional education can contribute to generate a form of paternalism that empowers officers to use their discretion, label recipients, and separate themselves from the ‘undeserving clients’ (Ellis, 2011; Lipsky, 2010). If clients counteract these attitudes through forms of empowerment and demand for rights, officers can perceive this as challenging their professional authority, provoking defensive practices (Ellis, 2011). Hence, health officers still have much scope to reinterpret the policy, use discretion, and engage in power-heavy interactions with recipients (Ellis, 1993, 2011). Neutralizing these practices can be especially difficult with healthcare professionals because interactions with recipients largely occur during consultations or professional

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assessments that remain a personal and private negotiation between the physician and the client (Evans & Harris, 2004; Foster et al., 2006). These forms of engagement can be hidden processes that yet limit the potential for positive interactions and increase their potential counterproductive consequences on the well-being of participants. Particularly relevant for this book is how these have the potential of not only affecting people’s objective circumstances by restricting access to resources and services for example, but also affecting their thoughts and feelings about their life and themselves (i.e., their psychosocial well-being). Not enough research has been done exploring these well-being effects directly. In characterizing officer–recipient relationships, Lipsky (2010) argued that officers have the ability to generate psychological sanctions during their interactions with policy participants, which can have disempowering impacts over participants. For example, given the disparities in status, officers might dismiss participants when they ask questions, degrade their understanding of the information provided, and have attitudes of hostility and superiority that can undermine the participants’ well-being (Ellis, 2011; Tanner, 1998). The way in which the actions and attitudes of frontline officers translate the program’s targeting and entitlement procedures to the recipient can also make program delivery a distressing experience. Salih and Galappatti (2006) exemplify this with statements of officers delivering poverty reduction programs in Sri Lanka. They argue that officers’ ‘claims that “it is difficult to know whether people come with complaints to receive counselling support or whether it is to receive the material benefits,” pave the way for clients having to prove they have been violated in order to secure socioeconomic support.’ (p. 133). These adverse forms of policy delivery and monitoring can diminish the legitimacy of the recipient’s testimonies and experiences, as well as violate and mistreat them all over again. Undoubtedly, the possible impacts of this relationship on well-being could become more critical, the more frequent the interactions with the policy officer are, and the more personal the service provided is. For example, it is widely acknowledged that the nature of healthcare services is very personal and could result in lasting (and even life-threatening) consequences for the individual’s quality of life and well-being (Fochsen et al., 2006; Mandlik et al., 2014). Yet, bad relationships in policy contexts do not appear to be isolated events that can disappear with the conclusion of one particularly negative encounter with an officer. These power relations seem to be built into the structure of policy institutions and thus have a

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cumulative effect on clients. In the words of Lipsky (2010), ‘[a]t the very least poor people who bounce from one agency to another have reinforced feelings of dependency, powerlessness, and, deriving from these, anger. After sustained exposure to the welfare system, for example, recipients have been found to see themselves as “undeserving” and ‘lucky to get anything at all”’ (p. 66).

Summary Well-being is opening up new ways of thinking about policy although it remains unclear how far this will translate into practical action for change. This book aims to contribute to this enterprise by examining the relationships that happen during policy implementation through a well-being lens. However, to do so, it was necessary to examine the way different well-being approaches capture social relationships and their benefits and limitations for assessing intervention-associated relationships. The literature on well-being testifies to the major role of social relationships in affecting how people think and feel about their lives. However, as this chapter showed, relationships and their association with well-being are not as simple as sometimes imagined and measured by mainstream approaches, and thus the usefulness of this literature for the policy realm can be contested. Indeed, SWB and PWB tend to concentrate primarily on the impacts of close relationships on global measures of happiness or life satisfaction. Ignoring the ways in which relationships can contribute or undermine different aspects of subjective evaluations and focusing on relationships qualities like attachment that are relevant only for more intimate relationships. They also tend to look at well-being as an individualized experience linked to psychological processes, which inevitably places relationships as features of the environment or external social determinants of well-being. In contrast, critical approaches to well-being in the development literature offer a more relational understanding of well-being. Without disregarding people’s life evaluations, these outlooks recognize the dynamic processes through which people co-construct their well-being with and through social relationship. They are concerned of the processes of power, negotiation, meaning creation that permeate interactions with others and shape people’s daily struggles for well-being. If well-being aims at guiding and evaluating policy it would need to prove capable of shedding light on these broader aspects of relationships. For these reasons, this book looks

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at officer–recipient interactions in the context of Oportunidades-Prospera through the lens of development and psychosocial approaches. Moreover, when we are concerned with the well-being outcomes of policy, not only the design of social programs and development initiatives is crucial, but also how they are carried out and implemented by program officers. As seen above, the behaviors and attitudes of frontline officers toward their work and recipients can be shaped by their position of authority within policies, their uncertain and complex working conditions, their use of discretion over policy administration and the delivery of benefits, and the sociocultural and institutional contexts in which they work. Yet, the literature on officer–participant interactions mostly situates its analysis on the effects of this relationship for the success of policies (e.g., Simmons & Elias, 1994), and with the aim of making programs more efficient and effective (e.g., Williamson & Robinson, 2006). The well-being outcomes of officer–recipient interactions remain largely unexamined. Despite this, the evidence until now suggests that these can reconstruct participants into objects of the state and potentially reduce the efficacy of programs as tools for development and well-being. This relationship potentially involves important processes of negotiation and meaning creation that might be relevant for the quality of this relationship and for the well-being experiences of recipients. The case of Oportunidades-Prospera and the provision of its health conditionalities is ideal for the analysis of these interactions. This is a program implemented for two decades, a period that allows observing the long-lasting and complex processes around officer–recipient relationships. Additionally, since the nature of healthcare services is exceptionally personal, inadequate officer–recipient interactions could result in significant well-being effects, making the analysis of these interactions particularly relevant. The next chapter presents the program and the existing empirical evidence about the implementation of its health conditionalities.

Bibliography Abeyasekera, A. (2014). A social justice approach to well-being: The PADHI psychosocial framework. In S. C. White & A. Abeyasekera (Eds.), Wellbeing and quality of life assessment (pp. 37–54). Rugby: Practical Action Publishing. http://www.developmentbookshelf.com/doi/10.3362/978178 0448411.004

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Andrews, F. M., & Withey, S. B. (1976). Social indicators of well-being: Americans’ perceptions of life quality. Springer. https://doi.org/10.1007/978-14684-2253-5 Antonucci, T. C., Akiyama, H., & Lansford, J. E. (1998). Negative effects of close social relations. Family Relations, 47 (4), 379. https://doi.org/10. 2307/585268 Argyle, M. (2001). The psychology of happiness (2. ed., repr). Routledge. Atkinson, S. (2013). Beyond components of well-being: The effects of relational and situated assemblage. Topoi, 32(2), 137–144. https://doi.org/10.1007/ s11245-013-9164-0 Atkinson, S. (2020). The toxic effects of subjective wellbeing and potential tonics. Social Science & Medicine. https://doi.org/10.1016/j.socscimed. 2020.113098 Atkinson, S., Bagnall, A. M., Corcoran, R., et al. (2020). Being well together: Individual subjective and community wellbeing. Journal of Happiness Studies, 21, 1903–1921. https://doi.org/10.1007/s10902-019-00146-2 Baumeister, R. F., & Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117 (3), 497–529. https://doi.org/10.1037/0033-2909.117.3.497 Boutin-Foster, C. (2005). In spite of good intentions: Patients’ perspectives on problematic social support interactions. Health and Quality of Life Outcomes, 3(52), 1–7. Brodkin, E. Z. (2008). Accountability in street-level organizations. International Journal of Public Administration, 31(3), 317–336. Calestani, M. (2009). An anthropology of “The Good Life” in the Bolivian Plateau. Social Indicators Research, 90(1), 141–153. https://doi.org/10. 1007/s11205-008-9317-5 Camfield, L., Choudhury, K., & Devine, J. (2009a). Well-being, happiness and why relationships matter: Evidence from Bangladesh. Journal of Happiness Studies, 10(1), 71–91. https://doi.org/10.1007/s10902-007-9062-5 Camfield, L., Crivello, G., & Woodhead, M. (2009b). Well-being research in developing countries: Reviewing the role of qualitative methods. Social Indicators Research, 90(1), 5–31. https://doi.org/10.1007/s11205-0089310-z Carlquist, E., Ulleberg, P., Delle Fave, A., Nafstad, H. E., & Blakar, R. M. (2017). Everyday understandings of happiness, good life, and satisfaction: Three different facets of well-being. Applied Research in Quality of Life, 12(2), 481–505. https://doi.org/10.1007/s11482-016-9472-9 Chambers, R. (1983). Rural development: Putting the last first. Longman. Chambers, R., & Pettit, J. (2004). Shifting power: To make a difference. In L. Groves & R. Hinton (Eds.), Inclusive Aid: Changing power and relationships in international development (pp. 137–162). Earthscan.

82

V. RAMÍREZ

Christopher, J. C. (1999). Situating psychological well-being: Exploring the cultural roots of its theory and research. Journal of Counselling & Development, 77 , 141–142. Cohen, S. (2004). Social relationships and health. American Psychologist, 59(8), 676–684. https://doi.org/10.1037/0003-066X.59.8.676 Collins, N. L., & Feeney, B. C. (2000). A safe haven: An attachment theory perspective on support seeking and caregiving in intimate relationships. Journal of Personality and Social Psychology, 78(6), 1053–1073. https://doi. org/10.1037/0022-3514.78.6.1053 Constanza, R., Hart, M., Posner, S., & Talberth, J. (2009). Beyond GDP: The need for new measures of progress (p. 4). Boston University. Cornwall, A., & Gaventa, J. (2000). From users and choosers to makers and shapers repositioning participation in social policy. IDS Bulletin, 31(4), 50–62. https://doi.org/10.1111/j.1759-5436.2000.mp31004006.x Crivello, G., Camfield, L., & Woodhead, M. (2009). How can children tell us about their well-being? Exploring the potential of participatory research approaches within young lives. Social Indicators Research, 90(1), 51–72. https://doi.org/10.1007/s11205-008-9312-x Crook, R., & Ayee, J. (2006). Urban service partnerships, ‘street-level bureaucrats’ and environmental sanitation in Kumasi and Accra, Ghana: Coping with organisational change in the public bureaucracy. Development Policy Review, 24, 51–73. Cummins, R. A. (1996). The domains of life satisfaction: An attempt to order chaos. Social Indicators Research, 38(3), 303–328. https://doi.org/10.1007/ BF00292050 Cummins, R. A. (2005). Caregivers as managers of subjective well-being: A homeostatic perspective. Journal of Applied Research in Intellectual Disabilities, 18(4), 335–344. https://doi.org/10.1111/j.1468-3148.2005.00267.x Cummins, R. A. (2009). Measuring population happiness to inform public policy. Presented at the 3rd OECD World Forum on “Statistics, Knowledge and Policy”. Charting Progress, Building Visions, Busan, Korea. Cummins, R. A., Lau, A. A. L. D., Mellor, D., & Stokes, M. A. (2009). Encouraging governments to enhance the happiness of their Nation: Step 1: Understand subjective well-being. Social Indicators Research, 91(1), 23–36. https://doi.org/10.1007/s11205-008-9324-6 Custers, A. F. J., Westerhof, G. J., Kuin, Y., & Riksen-Walraven, M. (2010). Need fulfillment in caring relationships: Its relation with well-being of residents in somatic nursing homes. Aging & Mental Health, 14(6), 731–739. https://doi.org/10.1080/13607861003713133

2

WELL-BEING: A FRAMEWORK TO ASSESS …

83

Custers, A. F. J., Westerhof, G. J., Kuin, Y., Gerritsen, D. L., & Riksen-Walraven, J. M. (2012). Relatedness, autonomy, and competence in the caring relationship: The perspective of nursing home residents. Journal of Aging Studies, 26(3), 319–326. https://doi.org/10.1016/j.jaging.2012.02.005 de Castro, G. (2017). El impacto relacional de la pobreza en la infancia y la adolescencia: Aportes desde el análisis del bienestar y los derechos de la infancia en España 2007–2015. Revista Brasileira de Planejamento e Desenvolvimento. Curitiba, 6(1), 6–21. Deci, E. L., & Ryan, R. M. (2000). The “What” and “Why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. Demir, M., & Weitekamp, L. A. (2007). I am so happy ’cause today I found my friend: Friendship and personality as predictors of happiness. Journal of Happiness Studies, 8(2), 181–211. https://doi.org/10.1007/s10902-0069012-7 Devereux, S., & McGregor, J. A. (2014). Transforming social protection: Human well-being and social justice. European Journal of Development Research, 26(3), 296–310. https://doi.org/10.1057/ejdr.2014.4 Devereux, S., Roelen, K., Béné, C., Chopra, D., & Leavy, J. (2013). Evaluating outside the box an alternative framework for analyzing social protection programs. IDS. http://onlinelibrary.wiley.com/doi/10.1111/ idwp.2013.2013.issue-431/issuetoc Devine, J. (2002). Ethnography of a policy process: A case study of land redistribution in Bangladesh. Public Administration and Development, 22(5), 403–414. https://doi.org/10.1002/pad.245 Devine, J., Camfield, L., & Gough, I. (2008). Autonomy or dependence—or both?: Perspectives from Bangladesh. Journal of Happiness Studies, 9(1), 105– 138. https://doi.org/10.1007/s10902-006-9022-5 Dickson, E. and Brindis, C. D. (2019). The double bind of school nurses and policy implementation: Intersecting the street-level bureaucracy framework and teaching sexual health education. The Journal of School Nursing. Early publication. https://journals.sagepub.com/doi/10.1177/105984051 9868764 Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95(3), 542–575. Diener, E. (2000). Subjective Well-being. The science of happiness and a proposal for a national index. American Psychologist, 55(1), 34–43. Diener, E. (2006). Guidelines for national indicators of subjective Well-being and Ill-Being. Journal of Happiness Studies, 7 (4), 397–404. https://doi.org/10. 1007/s10902-006-9000-y Diener, E., & Lucas, R. E. (2000). Explaining differences in societal levels of happiness: Relative standards, need fulfillment, culture, and evaluation theory. Journal of Happiness Studies, 1, 41–78.

84

V. RAMÍREZ

Diener, E., & Seligman, M. E. P. (2002). Very happy people. Psychological Science, 13(1), 81–84. https://doi.org/10.1111/1467-9280.00415 Diener, E., & Suh, E. M. (2000). Measuring subjective well-being to compare the quality of life of cultures. In E. Diener & E. M. Suh (Eds.), Culture and subjective well-being (pp. 3–12). MIT Press. Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The satisfaction with life scale. Journal of Personality Assessment, 49(1), 71–75. Diener, E., Sapyta, J. J., & Suh, E. (1998). Subjective well-being is essential to well-being. Psychological Inquiry, 9(1), 33–37. https://doi.org/10.1207/s15 327965pli0901_3 Diener, E., Scollon, C. K., Oishi, S., Dzokoto, V., & Suh, E. M. (2000). Positivity and the construction of life satisfaction judgements: Global happiness is not the sum of its parts. Journal of Happiness Studies, 1, 159–176. Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. L. (1999). Subjective wellbeing: Three decades of progress. Psychological Bulletin, 125(2), 276–302. Dolan, P., Peasgood, T., & White, M. 2006. Review of research on the influences on personal well-being and application to policy making. DEFRA Publications. Downie, M., Mageau, G. A., & Koestner, R. (2008). What makes for a pleasant social interaction? Motivational dynamics of interpersonal relations. The Journal of Social Psychology, 148(5), 523–534. https://doi.org/10.3200/ SOCP.148.5.523-534 Eid, M., & Diener, E. (2001). Norms for experiencing emotions in different cultures: Inter- and intranational differences. Journal of Personality and Social Psychology, 81(5), 869–885. Eiró, F. (2019). The vicious cycle in the Bolsa Familia program’s implementation: Discretionality and the challenge of social rights consolidation in Brazil. Qualitative Sociology, 42(3), 385–409. Ellis, K. (1993). Squaring the circle: User and carer participation in needs assessment. Joseph Rowntree Foundation/Community Care. Ellis, K. (2011). ‘Street-level bureaucracy’ revisited: The changing face of frontline discretion in adult social care in England. Social Policy and Administration, 45(3), 221–244. Erasmus, E. (2014). The use of street-level bureaucracy theory in health policy analysis in low- and middle income countries: A meta-ethnographic synthesis. Health Policy and Planning, 29(3) iii70–iii78. Evans, T., & Harris, J. (2004). Street-level bureaucracy, social work and the (exaggerated) death of discretion. British Journal of Social Work, 34, 871–895. Evans, T. (2011). Professionals, managers and discretion: Critiquing street-level bureaucracy. British Journal of Social Work, 41, 368–386. Eyben, R. (2006). The power of labelling in development practice. Institute of Development Studies, 28.

2

WELL-BEING: A FRAMEWORK TO ASSESS …

85

Eyben, R. (2010). Hiding relations: The irony of “Effective Aid.” European Journal of Development Research, 22(3), 382–397. https://doi.org/10.1057/ ejdr.2010.10 Eyben, R., & Moncrieffe, J. (2006). The power of labelling in development practice. Institute of Development Studies, 28. Finch, J. F., Okun, M. A., Pool, G. J., & Ruehlman, L. S. (1999). A comparison of the influence of conflictual and supportive social interactions on psychological distress. Journal of Personality, 67 (4), 581–621. https://doi.org/10. 1111/1467-6494.00066 Fischer, E. F. (2014). The good life: Aspiration, dignity, and the anthropology of well-being. Stanford University Press. Fochsen, G., Deshpande, K., & Thorson, A. (2006). Power imbalance and consumerism in the doctor-patient relationship: Health care providers’ experiences of patient encounters in a rural district in India. Qualitative Health Research, 16(9), 1236–1251. https://doi.org/10.1177/1049732306293776 Forgeard, M. J. C., Jayawickreme, E., Kern, M. L., & Seligman, M. E. P. (2011). Doing the right thing: Measuring well-being for public policy. International Journal of Well-Being, 1, 1. https://doi.org/10.5502/ijw.v1i1.15 Foster, M., Harris, J., Jackson, K., Morgan, H., & Glendinning, C. (2006). Personalised social care for adults with disabilities: A problematic concept for frontline practice. Health and Social Care in the Community, 14(2), 125–135. Frederick, S., & Loewenstein, G. (1999). Hedonic adaptation. In D. Kahneman (Ed.), Well-being: Foundations of hedonic psychology (pp. 301–329). Russell Sage Foundation. Frey, B. S., & Stutzer, A. (2012). The use of happiness research for public policy. Social Choice and Welfare, 38(4), 659–674. https://doi.org/10.1007/s00 355-011-0629-z Gaede, B. M. (2016). Doctors as street-level bureaucrats in a rural hospital in South Africa. Journal of Rural and Remote Health, 16(3461), 1–9. Galappatti, A. (2003). What is a psychosocial intervention? Mapping the field in Sri Lanka. UNICEF. Gasper, D. (2007). Uncounted or illusory blessings? Competing responses to the Easterlin, Easterbrook and Schwartz paradoxes of well-being. Journal of International Development, 19(4), 473–492. https://doi.org/10.1002/jid. 1383 Gasper, D. (2010). Understanding the diversity of conceptions of well-being and quality of life. The Journal of Socio-Economics, 39(3), 351–360. https://doi. org/10.1016/j.socec.2009.11.006 Gergen, K. J. (2009). Relational being: Beyond self and community. Oxford University Press. Giddens, A. (1982). Sociology, a brief but critical introduction. Macmillan. Gilson, L. (2015). Lipsky’s street level bureaucracy. Oxford University Press.

86

V. RAMÍREZ

Goetz, A. M. (Ed.). (1997). Getting institutions right for women in development. Zed Books. Goswami, H. (2012). Social relationships and children’s subjective well-being. Social Indicators Research, 107 (3), 575–588. https://doi.org/10.1007/s11 205-011-9864-z Gough, I., & McGregor, J. A. (Eds.). (2007). Well-being in developing countries from theory to research. Cambridge University Press. http://www.dawsonera. com/depp/reader/protected/external/AbstractView/S9780511322273 Gough, I., McGregor, J. A., & Camfield, L. (2006). Well-being in developing countries: Conceptual foundations of the WeD Program (WeD—Well-being in Developing Countries ESRC Research Group Working Paper No. 19). Gough, I., McGregor, J. A., & Camfield, L. (2007). Theorising well-being in international development. In I. Gough & J. A. McGregor (Eds.), Wellbeing in developing countries: From theory to research (pp. 3–43). Cambridge University Press. Groves, L. C., & Hinton, R. B. (Eds.). (2004). Inclusive aid: Changing power and relationships in international development. Earthscan. Haller, M., & Hadler, M. (2006). How social relations and structures can produce happiness and unhappiness: An international comparative analysis. Social Indicators Research, 75(2), 169–216. https://doi.org/10.1007/s11 205-004-6297-y Helliwell, J. F., Layard, R., & Sachs, J. (2013). World Happiness Report 2013 (p. 172). UN Sustainable Development Solutions Network. Helliwell, J. F., Huang, H., & Want, S. (2017). The social foundations of world happiness. In J. F. Helliwell, R. Layard, & J. Sachs (Eds.), World Happiness Report 2017 . UN Sustainable Development Solutions Network. Helliwell, J. F., Layard, R., & Sachs, J. (Eds.). (2012). World Happiness Report 2012. UN Sustainable Development Solutions Network. Helliwell, J. F., Layard, R., & Sachs, J. (Eds.). (2020). World Happiness Report 2020. UN Sustainable Development Solutions Network. Helne, T. (2021). Well-being for a better world: The contribution of a radically relational and nature-inclusive conception of well-being to the sustainability transformation. Sustainability: Science, Practice and Policy, 17 (1), 221–231. https://doi.org/10.1080/15487733.2021.1930716 Hill, M. J., & Hupe, P. L. (2009). Implementing public policy: An introduction to the study of operational governance (2nd ed.). Sage. Hirsch, B. J., & Rapkin, B. D. (1986). Social networks and adult social identities: Profiles and correlates of support and rejection. American Journal of Community Psychology, 14(4), 395–412. https://doi.org/10.1007/BF0092 2626

2

WELL-BEING: A FRAMEWORK TO ASSESS …

87

Hitokoto, H., & Uchida, Y. (2015). Interdependent happiness: Theoretical importance and measurement validity. Journal of Happiness Studies, 16(1), 211–239. https://doi.org/10.1007/s10902-014-9505-8 House, J. S., Umberson, D., & Landis, K. R. (1988). Structures and processes of social support. Annual Review of Sociology, 14(1), 293–318. https://doi. org/10.1146/annurev.so.14.080188.001453 Hudson, J. & Lowe, S. (2009). Understanding the policy process: Analyzing welfare policy and practice (2nd Ed.). Policy Press. Huovinen, R., & Blackmore, C. (2016). The dynamics of relational well-being in the context of mobility in Peru. In S. C. White & C. Blackmore (Eds.), Cultures of well-being (pp. 175–197). Palgrave Macmillan. http://link.spr inger.com/10.1057/9781137536457_7 Hupe, P. (2013). Dimensions of discretion: Specifying the object of street-level bureaucracy research. der moderne staat - dms: Zeitschrift für Public Policy, Recht und Management, 6(2), 425–440. https://nbn-resolving.org/urn:nbn: de:0168-ssoar-59188-7 Hupe, P. L., & Buffat, A. (2014). A public service gap: Capturing contexts in a comparative approach of street-level bureaucracy. Public Management Review, 16(4), 548–569. Jha, S., & White, S. C. (2016). The weight falls on my shoulders’: Close relationships and women’s well-being in India. In Culture of well-being: Method, place, policy (pp. 144–174). Palgrave Macmillan. Jiménez, A. C. (Ed.). (2008). Culture and well-being: Anthropological approaches to freedom and political ethics. Pluto Press. Johannessen, L. E. F. (2019). Negotiated discretion: Redressing the neglect of negotiation in ‘street-level bureaucracy.’ Symbolic Interaction, 42(4), 513–538. Jones, N., & Sumner, A. (2007). Does mixed method research matter to understanding childhood well-being? WeD—Well-being in Developing Countries ESRC Research Group. Kabeer, N. (2002). Resources, agency, achievements: Reflections on the measurement of women’s empowerment. Development and Change, 30(3), 435–464. https://doi.org/10.1111/1467-7660.00125 Kagitcibasi, C. (2005). Autonomy and relatedness in cultural context: Implications for self and family. Journal of Cross-Cultural Psychology, 36(4), 403–422. https://doi.org/10.1177/0022022105275959 Kahneman, D., & Tversky, A. 1984. Choices, values and frames. American Psychological Association, Inc., 39(4), 341–350. Kahneman, D., Diener, E., & Schwarz, N. (Eds.). (1999). Well-being: The foundations of hedonic psychology (1. paper cover ed). Russell Sage Foundation. Kaler, A., & Watkins, S. (2001). Disobedient distributors: Street-level bureaucrats and would-be patrons in community-based family planning programs in rural Kenya. Studies in Family Planning, 32(3), 254–269.

88

V. RAMÍREZ

Kitayama, S., & Markus, H. R. 2000. The pursuit of happiness and the realization of sympathy: Cultural patterns of self, social relations, and Well-being. In E. Diener & E. M. Suh (Eds.), Culture and subjective well-being (pp. 113–161). MIT Press. Krauss, A., & Graham, C. (2013). Subjective well-being in Colombia: Some insights on vulnerability, job security, and relative incomes. The World Bank. http:// elibrary.worldbank.org/doi/book/10.1596/1813-9450-6672 La Guardia, J. G., & Patrick, H. (2008). Self-determination theory as a fundamental theory of close relationships. Canadian Psychology/psychologie Canadienne, 49(3), 201–209. https://doi.org/10.1037/a0012760 Land, K. C., Lamb, V. L., & Mustillo, S. K. (2001). Child and youth well-being in the United States, 1975–1998: Some findings from a new index. Social Indicators Research, 56, 241–320. Lansford, J. E., Antonucci, T. C., Akiyama, H., & Takahashi, K. (2005). A quantitative and qualitative approach to social relationships and well-being in the United States and Japan. Journal of Comparative Family Studies, 36(1), 1–22. Layard, R. (2009). Well-being measurement and public policy. In A. B. Krueger (Ed.), Measuring the subjective well-being of nations: National accounts of time use and well-being (pp. 145–154). University of Chicago Press. http://www. nber.org/chapters/c5058 Layard, R., Clark, A., & Senik, C. (2012). The causes of happiness and misery. In J. Helliwell, R. Layard, & J. Sachs (Eds.), World happiness report. The Earth Institute, Columbia University. Lincoln, K. D. (2000). Social support, negative social interactions, and psychological well-being. Social Service Review, 74(2), 231–252. https://doi.org/ 10.1086/514478 Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services (30th anniversary expanded ed). Russell Sage Foundation. Loera-González, J. (2016). Authorised voices in the construction of well-being discourses: A reflective ethnographic experience in Northern Mexico. In S. C. White & C. Blackmore (Eds.), Cultures of well-being (pp. 240–259). Palgrave Macmillan. http://link.springer.com/10.1057/9781137536457_10 Mandlik, M. A., Glynn, M., & Hyde, K. (2014). Client contribution to professional service delivery: Implications for relationship quality. New Zealand Journal of Applied Business Research, 12(1), 19–34. Marchand, M. H., & Parpart, J. L. (Eds.). (1995). Feminism/postmodernism/development. Routledge. Maricchiolo, F., Mosca, O., Lauriola, M., & Krys, K. (2021). From ME to WE: A literature review on happiness and well-being focused on relational factors and social interconnectedness. Psicologia sociale, Rivista quadrimestrale, 1, 3–25. https://doi.org/10.1482/96851

2

WELL-BEING: A FRAMEWORK TO ASSESS …

89

Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion and motivation. Psychological Review, 98(2), 224–253. Maynard-Moody, S., & Musheno, M. (2003). Cops, teachers, counsellors. University of Michigan Press. McGregor, A., & Sumner, A. (2010). Beyond business as usual: What might 3D well-being contribute to MDG momentum? IDS Bulletin, 41(1), 104–112. https://doi.org/10.1111/j.1759-5436.2010.00111.x McGregor, A., Coulthard, S., & Camfield, L. (2015). Measuring what matters: The role of well-being methods in development policy and practice (p. 20). Overseas Development Institute. McGregor, J. A. (2007). Researching well-being: From concepts to methodology. In I. Gough & J. A. McGregor (Eds.), Well-being in developing countries: From theory to research. Cambridge University Press. Merkouris, A., Papathanassoglou, E. D. E., & Lemonidou, C. (2004). Evaluation of patient satisfaction with nursing care: Quantitative or qualitative approach? International Journal of Nursing Studies, 41(4), 355–367. https://doi.org/ 10.1016/j.ijnurstu.2003.10.006 Michalos, A. C., Hubley, A. M., Zumbo, D., & B., & Hemingway, D. (2001). Health and other aspects of the quality of life of older people. Social Indicators Research, 54(3), 239–274. Molyneux, M., Jones, W. N., & Samuels, F. (2016). Can cash transfer programs have “transformative” effects? The Journal of Development Studies, 52(8), 1087–1098. https://doi.org/10.1080/00220388.2015.1134781 Moncrieffe, J., & Eyben, R. (Eds.). (2007). The power of labelling: How people are categorized and why it matters. Earthscan. Morrow, V. (2001). Networks and neighbourhoods: Children and young people’s perspectives. Social Capital for Health Series. London: Health Development Agency. Myers, D. G. (2000). The funds, friends, and faith of happy people. American Psychologist, 55(1), 56–67. https://doi.org/10.1037/0003-066X.55.1.56 Nezlek, J. B., Richardson, D. S., Green, L. R., & Schatten-Jones, E. (2002). Psychological well-being and day-to-day social interaction among older adults. Personal Relationships, 9, 51–71. ONS. (2011). National statistician’s reflections on the National Debate on Measuring National Well-being. Office of National Statistics Publishing. Organization for Economic Co-operation and Development (OECD) (Ed.). (2013). OECD guidelines on measuring subjective well-being. Paris. Organisation for Economic Co-operation and Development (OECD). (2014). Estadísticas de la OCDE sobre la salud 2014 México en comparación. OECD. Parsons, W. (1995). Public policy: An introduction to the theory and practice of policy analysis. Edward Elgar.

90

V. RAMÍREZ

Peeters, R., Trujillo Jiménez, H., O’Connor, E., Ogarrio Rojas, P., González Galindo, M., & Morales Tenorio, D. (2018). Low-trust bureaucracy: Understanding the Mexican bureaucratic experience. Public Administration and Development, 38(2), 65–74. Phillips, D. (2006). Quality of life: Concept, policy and practice. Routledge. Putnam, R. D. (2001). Bowling alone: The collapse and revival of American community (1. touchstone ed). Simon & Schuster. Randall, C. (2015). Measuring national well-being: Our relationships, 2015. Office for National Statistics. Redmond, G. (2008). Children’s perspectives on economic adversity: A review of the literature (No. Innocenti Discussion Papers no. 2008-01). UNICEF. Reis, H. T., & Patrick, B. C. (1996). Attachment and intimacy: Component processes. In E. T. Higgins & A. Kruglanski (Eds.), Social psychology: Handbook of basic principles (pp. 523–563). Guilford. Reis, H. T., Sheldon, K. M., Gable, S. L., Roscoe, J., & Ryan, R. M. (2000). Daily well-being: The role of autonomy, competence, and relatedness. Personality and Social Psychology Bulletin, 26(4), 419–435. https://doi.org/10. 1177/0146167200266002 Rojas, M. (2006). Life satisfaction and satisfaction in domains of life: Is it a simple relationship? Journal of Happiness Studies, 7 (4), 467–497. https:// doi.org/10.1007/s10902-006-9009-2 Rojas, M. (2007a). A subjective well-being equivalence scale for Mexico: Estimation and poverty and income-distribution implications. Oxford Development Studies, 35(3), 273–293. https://doi.org/10.1080/13600810701514845 Rojas, M. (2007b). Enhancing poverty-abatement programs: A subjective wellbeing contribution (Working Paper 37). Well-being in Developing Countries ESRC Research Group (WeD), University of Bath. Rojas, M. (2007c). The complexity of well-being: A life-satisfaction conception and a domains-of-life approach. In I. Gough & J. A. McGregor (Eds.), Wellbeing in developing countries (pp. 259–280). Cambridge University Press. Rojas, M. (2009). Enhancing poverty-abatement programs: A subjective wellbeing contribution. Applied Research in Quality of Life, 4(2), 179–199. https://doi.org/10.1007/s11482-009-9071-0 Rojas, M. (2011). La medición del progreso y del bienestar: Propuestas desde América Latina. Foro Consultivo Científico y Tecnológico. Rojas, M. (2014). Poverty and people’s well-being. Springer. Rojas, M. (2018). Well-being in Latin America has social foundations. In J. F. Helliwell, R. Layard, & J. Sachs (Eds.), World Happiness Report, 2018. UN Sustainable Development Solutions Network. Rojas, M., & Martínez, I. (2012). Medición, investigación e incorporación a la política pública del bienestar subjetivo: América Latina: Reporte de la

2

WELL-BEING: A FRAMEWORK TO ASSESS …

91

comisión para el estudio y la promoción del bienestar en América Latina. Foro Consultivo Científico y Tecnológico, AC. Rojas, M., & Veenhoven, R. (2010). Cognition and affect in the appraisal of life: Separate entries or two sides of the same coin? (Erasmus University Rotterdam Working Paper). Rook, K. S. (1990). Parallels in the study of social support and social strain. Journal of Social and Clinical Psychology, 9(1), 118–132. https://doi.org/ 10.1521/jscp.1990.9.1.118 Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68 Ryan, R. M., & Deci, E. L. (2001). On happiness and human potentials: A review of research on hedonic and eudaimonic well-being. Annual Review of Psychology, 52, 141–166. Ryff, C. D. (1989a). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57 (6), 1069–1081. Ryff, C. D. (1989b). In the eye of the beholder: Views of psychological wellbeing among middle-aged and older adults. Psychology and Aging, 4(2), 195– 210. Ryff, C. D. (1995). Psychological well-being in adult life. Current Directions in Psychological Science, 4(4), 99–104. https://doi.org/10.1111/1467-8721. ep10772395 Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69(4), 719–727. Ryff, C. D., & Singer, B. (1998). The contours of positive human health. Psychological Inquiry, 9(1), 1–28. https://doi.org/10.1207/s15327965pli 0901_1 Ryff, C. D., & Singer, B. H. (2000). Biopsychosocial challenges of the New Millennium. Psychotherapy and Psychosomatics, 69(4), 170–177. https://doi. org/10.1159/000012390 Salih, M., & Galappatti, A. (2006). Integrating a psychosocial perspective into poverty reduction: The case of a resettlement project in northern Sri Lanka. Intervention, 4(2), 126–144. https://doi.org/10.1097/01.WTF.000 0237881.64899.1f Sandstrom, G. M., & Dunn, E. W. (2014). Social interactions and well-being: The surprising power of weak ties. Personality and Social Psychology Bulletin, 40(7), 910–922. https://doi.org/10.1177/0146167214529799 Sen, A. (1999). Development as freedom (1. ed., 6th print). Oxford University Press. Shutt, C. (2006). Power in aid relationships: A personal view. IDS Bulletin, 37 (6), 79–87. https://doi.org/10.1111/j.1759-5436.2006.tb00325.x

92

V. RAMÍREZ

Simmons, R., & Elias, C. (1994). The study of client-provider interactions: A review of methodological issues. Studies in Family Planning, 25(1), 1. https://doi.org/10.2307/2137985 Sointu, E. 2005. The rise of an ideal: Tracing changing discourses of wellbeing. The Sociological Review, 255–274. Springer, K. W., & Hauser, R. M. (2006). An assessment of the construct validity of Ryff’s Scales of Psychological Well-being: Method, mode and measurement effects. Social Science Research, 35, 1080–1102. Stiglitz, J. E., Sen, A., & Fitoussi, J.-P. (2009). Report by the Commission on the Measurement of Economic Performance and Social Progress (p. 291). Stratton, P. (2007). Well-being is not about the individual—It’s about relationships. http://www.guardian.co.uk/commentisfree/2007/feb/22/comment. healthandwell-being Street, D., & Burge, S. W. (2012). Residential context, social relationships, and subjective well-being in assisted living. Research on Aging, 34(3), 365–394. https://doi.org/10.1177/0164027511423928 Tanner, D. (1998). Empowerment and care management: Swimming against the tide. Health and Social Care in the Community, 6(6), 447–457. Taylor, D. (2010). Being well and doing well (enough): Towards a psychosocial study of well-being and welfare. University of Brighton. Theurer, K., Mortenson, W. B., Stone, R., Suto, M., Timonen, V., & Rozanova, J. (2015). The need for a social revolution in residential care. Journal of Aging Studies, 35, 201–210. Tummers, L. L. G., Bekkers, V., Vink, E., & Musheno, M. (2015, October). Coping during public service delivery: A conceptualization and systematic review of the Literature. Journal of Public Administration Research and Theory, 25(4), 1099–1126. https://doi.org/10.1093/jopart/muu056 Uchida, Y., Norasakkunkit, V., & Kitayama, S. (2004). Cultural constructions of happiness: Theory and empirical evidence. Journal of Happiness Studies, 5(3), 223–239. https://doi.org/10.1007/s10902-004-8785-9 United Nations (UN). (1986). Declaration on the right to development. Retrieved July 13, 2021, from https://www.un.org/en/events/righttodevelopment/ declaration.shtml United Nations Development Program (UNDP) (Ed.). (2012). Bienestar subjetivo: el desafío de repensar el desarrollo. Programa de las Naciones Unidas para el Desarrollo, PNUD. United Nations International Children’s Emergency Fund (UNICEF). (1997). Symposium on the prevention of recruitment of children into the armed forces and demobilisation and social reintegration of child soldiers in Africa. UNICEF.

2

WELL-BEING: A FRAMEWORK TO ASSESS …

93

van Praag, B. M. S., Frijters, P., & Ferrer-i-Carbonell, A. (2003). The anatomy of subjective well-being. Journal of Economic Behavior & Organization, 51, 29–49. Veenhoven, R. (2002). Why social policy needs subjective indicators. In M. R. Hagerty, J. Vogel, & V. Møller (Eds.), Assessing quality of life and living conditions to guide national policy (Vol. 11, pp. 33–45). Kluwer Academic Publishers. http://link.springer.com/10.1007/0-306-47513-8_3 Vittengl, J. R., & Holt, C. S. (1998). Positive and negative affect in social interactions as a function of partner familiarity, quality of communication, and social anxiety. Journal of Social and Clinical Psychology, 17 (2), 196–208. https://doi.org/10.1521/jscp.1998.17.2.196 Walker, L., & Gilson, L. (2004). ‘We are bitter but we are satisfied’: Nurses as street-level bureaucrats in South Africa. Social Science & Medicine, 59(6), 1251–1261. https://doi.org/10.1016/j.socscimed.2003.12.020 Well-Being & Poverty Pathways. (2013). Well-being and poverty pathways: An integrated approach to assessing well-being (Briefing No. 1; Revised Edition). University of Bath. Wellbeing in Developing Countries (WeD). (2008). Research statement. Retrieved November 10, 2016, from http://www.welldev.org.uk/research/ research.htm Wheeler, L., Reis, H., & Nezlek, J. B. (1983). Loneliness, social interaction, and sex roles. Journal of Personality and Social Psychology, 45(4), 943–953. https://doi.org/10.1037/0022-3514.45.4.943 White, S. C. (2002). Being, becoming and relationship: Conceptual challenges of a child rights approach in development. Journal of International Development, 14(8), 1095–1104. https://doi.org/10.1002/jid.950 White, S. C. (2009). Bringing well-being into development practice (WeD Working Paper 09/50). Well-being in Developing Countries ESRC Research Group (WeD). http://www.welldev.org.uk/wed-new/workingpapers/workin gpapers/WeDWP_09_50.pdf White, S. C. (2010). Analyzing well-being: A framework for development practice. Development in Practice, 20(2), 158–172. https://doi.org/10.1080/ 09614520903564199 White, S. C. (2014). Wellbeing and social policy in developing countries. Draft paper prepared for the UNRISD Conference 2014. Geneva, Switzerland. White, S. C. (2016). Introduction: The many faces of wellbeing. In S. C. White & C. Blackmore (Eds.), Cultures of well-being (pp. 47–65). Palgrave Macmillan. http://link.springer.com/chapter/10.1057/9781137536457_2 White, S. C. (2017). Relational wellbeing: Re-centring the politics of happiness, policy and the self. Policy & Politics, 45(2), 121–136. https://doi.org/10. 1332/030557317X14866576265970

94

V. RAMÍREZ

White, S. C. (2018). Moralities of wellbeing. Bath Papers in International Development and Wellbeing, 58(June), 1–23. White, S. C., & Abeyasekera, A. (Eds.). (2014). Well-being and quality of life assessment: A practical guide. Practical Action Publishing. White, S. C., Gaines, S. O., & Jha, S. (2014). Inner well-being: Concept and validation of a new approach to subjective perceptions of well-being—India. Social Indicators Research, 119(2), 723–746. https://doi.org/10.1007/s11 205-013-0504-7 Wierzbicka, A. (2004). “Happiness” in cross-linguistic & cross-cultural perspective. Daedalus, 133(2), 34–43. https://doi.org/10.1162/001152604323 049370 Wierzbicka, A. (2009). What makes a good life? A cross-linguistic and crosscultural perspective. The Journal of Positive Psychology, 4(4), 260–272. https://doi.org/10.1080/17439760902933666 Wilkinson, W. (2007). Pursuit of happiness research: Is it reliable? What does it imply for policy? Cato Institute Policy Analysis. Williamson, J., & Robinson, M. (2006). Psychosocial interventions, or integrated programming for well-being? War Trauma Foundation, 4(1), 4–25. Wood, G. D. (Ed.). (1985a). Labelling in development policy: Essays in honour of Bernard Schaffer. Sage Publications and Institute of Social Studies. Wood, G. D. (1985b). The politics of development policy labelling. In Labelling in development policy: Essays in honour of Bernard Schaffer (pp. 1–28). Sage Publications and Institute of Social Studies. World Bank. (2004). Making services work for poor people (World Development Report 2004). World Bank and Oxford University Press. Zapf, W. (2000). Social reporting in the 1970s and in the 1990s. Social Indicators Research, 51, 1–15. Zarychta, A., Grillos, T., & Andersson, K. P. (2020). Public sector governance reform and the motivation of street-level bureaucrats in developing countries. Public Administration Review, 80(1), 75–91. Zavaleta, D., Samuel, K., & Mills, C. (2014). Social isolation a conceptual and measurement proposal. Oxford Poverty & Human Development Initiative. http://www.ophi.org.uk/social-isolation-a-conceptual-and-measur ement-proposal/

CHAPTER 3

Oportunidades-Prospera and the Provision of Health Care

Social Protection Programs and Oportunidades-Prospera Conditional cash transfers are a type of social protection program that emerged partly because of the international shift toward neoliberal policies during the 1980s. During the so-called Washington Consensus era, the World Bank and the International Monetary Fund forced many developing countries to implement structural adjustment programs that reduced public spending and promoted the privatization of health care and education. In a decade, the negative effects of these policies over the quality of life of rural populations, ethnic minorities, and vulnerable groups started to appear (UNDP, 2003). In an attempt to counteract these impacts, the post-Washington Consensus era commenced. This era involved a continual support for privatization together with the creation of a number of social policies directed to the poor based on a principle of co-responsibility. This principle primarily underlines the responsibility of recipients to actively participate in the efforts to get out of poverty. Therefore, the idea behind these programs is that states and recipients collaborate to build the human capital—education and health—needed to better participate in the labor market. The use of social protection programs around the world consolidated with the subsequent creation of the MDGs and SDGs that have contributed to placing the poor and the

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eradication of poverty and hunger as key objectives of international social policy. This historical and political context of social protection programs is visible in the way the Organization for Economic Cooperation and Development (OECD) characterizes these programs as those ‘policies and actions which enhance the capacity of poor and vulnerable people to escape from poverty and better manage risks and shocks’ (cited in Arnold et al., 2011, p. 1). An established way of describing the strategies of social protection programs is the ‘3Ps’ framework: prevention, protection, and promotion. According to Ulrich and Roelen (2012), this framework reflects ‘the potential of social protection to protect people from hardship following poverty, to prevent people from falling into poverty and to promote people out of poverty’ (p. 6). Cash transfer programs are a particular strategy to achieve these goals (see Ladhani & Sitter, 2018 for a review). They can be defined as ‘direct, regular and predictable noncontributory payments that raise and smooth incomes’ (Arnold et al., 2011, p. 2). There are two kinds of cash transfer programs. Unconditional cash transfers provide a monetary transfer to clearly specified recipients without asking for anything in return. Conditional cash transfer programs (CCTs), in contrast, require certain behaviors and actions from the recipient families in order to receive the transfer. Today, the relevance CTs is huge. They have been the most used tool by dozens of governments around the world to tackle the economic and social consequences of the COVID-19 global pandemic. Yet, before the pandemic, at least 57 countries in the world introduced a form of cash transfer as part of their portfolio of social policies. Most of these are in the developing world, but as mentioned earlier, many developed countries are turning to these programs to counteract the effects of economic crises. It is estimated that close to one billion people are receiving a form of CT worldwide (Fiszbein et al., 2014). Moreover, by December 2020, the SocialProtection.org platform reported 536 social protection programs, of which 108 are CCTs: 10 in East Asia and the Pacific, 14 in the Middle East and North Africa, 12 in South Asia, 15 in Sub-Saharan Africa and 57 in Latin Americaand the Caribbean. Indeed, over the last few decades CCTs have become an increasingly popular kind of social protection program particularly in Latin America (see Adato & Hoddinott, 2007 for a brief overview). In fact, Brazil and Mexico are the two countries with the largest number of CCTs in their history (Table 3.1).

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Table 3.1 Top countries with more conditional cash transfer programs

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Country

CCT

Brazil Mexico Argentina Uruguay Honduras Colombia Bangladesh Chile Ecuador Guatemala Indonesia Pakistan

7 5 4 4 4 4 4 3 3 3 3 3

Source socialprotection.org

The implementation of many CTs has been accompanied by rigorous evaluations, particularly using quantitative methodologies like randomized control trials. Yet, despite their rigorous evaluations, these programs are primarily evaluated based on their direct impacts on health, nutrition, education, and poverty reduction, leaving behind considerations of well-being. Oportunidades-Prospera Mexico is a pioneer in the design and implementation of CCTs, launching Oportunidades-Prospera in different guises since 1997. The primary aims of the program were to reduce the intergenerational transmission of poverty by combining short- and long-term anti-poverty strategies with a principle of co-responsibility between the state and its citizens. The anti-poverty strategies encompassed investment in three basic components: education, nutrition, and health. Translated into practice, these components entailed the program’s commitment to provide bimonthly cash transfers (short-term) on the condition that families send their children to school, attend preventive health workshops and comply with regular medical check-ups (long-term) (Skoufias et al., 1999; Skoufias & McClafferty, 2001; Skoufias, 2005).

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The education component was targeted on children of school age since important portions of the cash transfers were intended as school scholarships for children to stay out of work. The size of scholarships increased with the school grade and were larger for girls than for boys from secondary school onwards. The rise in the size of scholarships was based on evidence that children have a higher risk of dropping out of school if they are girls and as the school grade increases. The scholarships were also tied to children’s attendance record at school. They needed to attend to at least 85% of school days each month to receive their scholarship. These scholarships were handed out for the ten months of the school cycle each year. In addition, at the beginning of school year, a one-time subsidy was given for school supplies and, to promote high school completion; those who finished their third year of high school also received a one-time cash transfer. The nutritional component was an important objective of this CCT since being nourished is key for being healthy in the short and the long run, while malnutrition is causally associated with a higher risk of infant and child morbidity and mortality and poorer cognitive development and productivity as adults (Hoddinott, 2010). Investments in nutrition also made the program’s investments in health and education more effective since being malnourished reduces child cognitive development, school progress, and academic achievement. This component consisted of a basic cash transfer received by all families and an in-kind nutritional supplement provided through the local health clinics, linking this component directly to the health component described below. In fact, the receipt of the nutritional benefits was circumscribed to families complying with the health conditions. The in-kind nutritional benefit entailed a supplement for infants between 4 and 24 months old, malnourished children between three and five years old, and pregnant or lactating mothers. This book is particularly interested in the health component of Oportunidades-Prospera and its delivery through frontline officers. In general terms, this component was established under the assumption that for the poor, being healthy is not only restricted by low incomes but by a low demand for preventive health services (Morris, 2010). Although it is interesting that in framing the problem as caused by recipient’s attitudes toward health services, any problems in the supply side of the equation can be (at least) minimized. Regardless of the assumptions behind, the health component involved two core activities that were in line with the national development plans.

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First, the attendance of all family members to medical consultations that have the purpose of detecting and preventing common illnesses of the poor in Mexico such as diabetes, tuberculosis, high blood pressure, obesity, diarrhea, and respiratory infections. Most CCTs focus on young children and pregnant and lactating mothers given their original concern of improving human capital and reducing the intergenerational transmission of poverty. Today, this emphasis converges with international policy concerns over child mortality and maternal health—such as those established in the SDGs. Although Oportunidades-Prospera gave especial emphasis to children and mothers as well, it required all family members enrolled (fathers, mothers, children of all ages, and the elderly) to comply with the health check-ups. Second, mothers were required to attend monthly health workshops in the local clinics that provided information about nutritional, reproductive, hygiene, and public health topics. Teenage recipients were also required to attend workshops that sought to reduce the incidence of drug addiction and teenage pregnancies. The health component was probably the most rigorously enforced conditionality and the most important in procedural terms since the family’s stay in the program was directly associated with their compliance with these activities. According to Levy (2006) the program provided a total of 42.5 million medical consultations in 2005. Although this is not an up-to-date figure, it illustrates quite clearly the significant increase in the population serviced by public health institutions as a result of the establishment of Oportunidades-Prospera. The program could not have been able to fulfill this component without relying on the national health system already in place. Therefore, these strategies were delivered through two partner health institutions: the National Health Ministry and the Mexican Social Security Institute (IMSS-Prospera). Implementing the program required the involvement of three ministries (the Ministry of Social Development (SEDESOL), the Ministry of Education (SEP) and the Ministry of Health (SSP)) at the federal, state and municipal level. At the frontline, the institutional complexity of the program required the involvement of an actor called promotor. In Spanish, promotor means the sponsor or supporter. This means that they were in charge of making sure the program was operating adequately across the different areas in charge of implementing its components. Hence, promotores (plural of promotor in Spanish) were direct employees of the program, coordinating delivery at the municipal level and acting as liaison between the program, the recipients (vocales worked closely with them),

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the directors of schools (employees of the Ministry of Education) and the directors of health centers (employees of the Ministry of Health). In the health centers, promotores monitored the recipient’s compliance, gave informative talks to recipients about the health campaigns and the importance of complying with the conditions, and worked closely with doctors and nurses when a health program (e.g., vaccination campaign) arrived to the locality. The Oportunidades-Prospera program was in direct contact with the recipient families mainly outside the health centers during the provision of the cash transfers and sporadic meetings with the promotor. The Historical Evolution in Brief As mentioned earlier, Oportunidades-Prospera had two predecessors (see Levy, 2006; Rocha Menocal, 2001 for historical and political perspectives of these transitions). It originally launched in 1997 as Progresa (Spanish acronym for Education, Health and Nutrition program) under the administration of President Ernesto Zedillo (1994–2000). With this program came an innovative narrative and design in Mexican social programs, untying them from the electoral and clientelistic interests that were common in earlier social policy. It was initially implemented in rural localities with 2,500 or less inhabitants since it was believed that rural poverty was the most extreme in Mexico (Levy, 1991). Its initial coverage was 300,000 families in twelve states around the nation, among them Puebla, one of the poorest states in the nation. For the first three years of implementation, the program incorporated a sophisticated system of evaluation that began with a quasiexperimental scheme to identify the differential impacts of the program on localities in treatment and control groups (IFPRI, 2002). In 2002, the program took the name of Oportunidades . Beyond the political causes of this change (the arrival of the opposition party to the presidency in 2000), the goal was enlarging the program to reach all families living in extreme poverty. Hence, the program scaled up to all national states, extended its reach in rural areas, and incorporated the urban poor (Gardner, 2008). By 2005, the program benefited 5 million families and it had a budget that comprised 0.36% of the national GDP (Levy, 2006). In January 2015, the program was renamed Prospera (Spanish acronym for Program for Social Inclusion). Prospera incorporates new aspects such

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Table 3.2 Evolution of the coverage of Oportunidades-Prospera National

2000 2005 2013 2015 2016

Puebla

Municipalities

Localities

Recipient families

Municipalities

Localities

Recipient families

2,166 2,435 2,451 2,456 2,456

53,232 86,091 109,852 115,561 115,275

2,476,430 5,000,000 5,922,246 6,168,900 6,073,764

210 217 217 217 217

3,388 4,358 5,258 5,432 5,378

205,941 385,118 483,367 491,467 484,516

Source Oportunidades-Prospera website, 2016

as the promotion of employment and labor inclusion, access to financial services, and extended scholarships up to higher education (Sedesol, 2016). Oportunidades-Prospera was considered one of the most successful CCTs in the world, praised internationally for its effective design and implementation (Barber & Gertler, 2010). Before the decision by the newly elected President Andrés Manuel López Obrador to terminate the program in December 2018, it was the biggest social program in the history of the country. In 2018, reached 6.5 million families—approximately one out of every five Mexicans was a recipient of the program. Table 3.2 presents the growth of the recipient population in key years of the program’s evolution at the national level and for the state of Puebla. Distinctive Features of Oportunidades-Prospera It is worth explaining a few basic characteristics of this CCT. Firstly, probably one of the innovative characteristics of OportunidadesProspera was its targeting criteria, which consisted of two levels of selection. At a geographical level, the program located those rural and urban communities with a per capita income lower than a certain threshold and whose indicators of marginality—such as housing, literacy rates, and access to public services—were significantly low. The indicators of poverty and marginality employed for this task were those developed by the National Population Council (Conapo) and the Technical Committee for the Measurement of Poverty (CONEVAL). At the earliest stages of the program, only rural localities with ‘very high marginality’ or ‘extreme

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poverty’ were incorporated. Then, progressively all rural and urban localities that fell into any levels of poverty and marginality were integrated. Once the community was selected, the second level of selection happened at the household level. The recipient families were identified through surveys and interviews that assessed their socioeconomic circumstances including household assets, dwelling conditions and the age, gender and education level of each family member (Dávila, 2016). At later stages of the program, families could apply for the benefit themselves. The second key feature of Oportunidades-Prospera is the element of conditionality. Conditionalities are embedded in the principle of coresponsibility. This entails that the government commits to provide cash transfers if recipients actively participate and contribute to alleviate their own poverty. Following Levy (2006), considered the architect of the program, there are several rationales for imposing conditions to the transfers. On the one hand, it is believed that imposing conditions raises the impact of cash transfers if they are linked to ‘socially desirable behaviors.’ Of course the meaning of ‘socially desirable behaviors’ can vary between contexts. Although in Mexico, as in most CCTs, these have been defined as attending school and using health services given the low levels of schooling and the incidence of specific health problems. On the other hand, the conditional framing also served the political purpose of validating the existence of the program to the eyes of the larger population. A recent study found that 74% of Mexicans think that the main causes of poverty are the ‘personal characteristics of the poor’ such as lack of education and substance abuse. However, 30% of these Mexicans (the largest proportion) specifically relate it to ‘laziness’ (CEEY, 2013). Hence, the emphasis on conditionalities could increase the legitimacy of the program and reduce the public’s perception of it as a handout or a gift to the ‘underserving’ poor. Yet, it could also promote and amplify these misconceptions of the poor that maintain them as socially excluded, vulnerable, discriminated, and ultimately poor. Indeed, the conditionalities of CCTs like the Oportunidades-Prospera program are not without its critics some of which can relate to a wider notion of well-being. For example, Martínez (2011) argued that while the conditionalities seek to promote the capabilities of participants in terms of education, health, and nutrition, they also limit their freedom and agency to choose what kind of interventions (particularly in terms of health) are appropriate and desirable for them. This way of implementing conditionalities could inhibit the transformation of recipients from passive receptors

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of benefits to empowered agents of their own progress, as the program claims to deliver. The determinants of the size and kind of benefits offered by Oportunidades-Prospera are its third distinctive characteristic. In addition to the families complying with the conditions, the size of the cash transfer and type of benefits received in the three components depended on the household composition, including age, gender, and household size. Over the years, the benefits delivered were gradually modified and many changes have been a consequence of the program’s response to the evaluations it has undertaken (Levy, 2006). Table 3.3 presents the evolution of the benefits. The top of the table shows the direct cash transfers provided to all families based on household composition. The nutrition and food transfers were delivered to all families, these summed to a minimum of $445 MXN each month in 2013 (the year the fieldwork for this book took place). To give context to this figure, in 2013 the minimum wage was 61.38 MXN a day, that is, approximately $1,227.6 MXN a month. Those families with infants or elderly (70 years and older) members receive extra cash transfers. The middle section of the table presents the education transfers—the education component—which increased with each school year and for girls (from secondary school onwards). At the early stages of the program, the scholarships ran from 3rd grade of primary school to the last year of secondary school. This gradually expanded to high school (2005) and higher education (2015). Finally, the cash transfers also established maximum amounts that any family can obtain (bottom of Table 3.3). According to Levy (2006) the rationale for placing ceilings on the size of the transfers is to discourage families from continuing having children to obtain a greater economic support from the program. This assumption is problematic to say the least, as it directly contradicts the program’s discourse of empowerment and reifies long-held negative stereotypes of the poor that could permeate in their interactions with frontline officers implementing the program’s conditionalities. The fourth and final characteristic of the program was its intention to specifically advance the interests of girls’ schooling and women’s health, prioritizing these over those of men and boys. This emphasis on girls’ education is based on evidence that poor parents often must give priority to the education of some of their children, a decision that tends to favor

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Table 3.3 Monthly cash transfers of Oportunidades-Prospera (Mexican Pesos, MXN) Direct Cash Transfer

1998

2006

2010

2013

2015

2016

95 – – –

180 – 250 –

215 120 305 100

315 130 345 115

335 140 370 120

335 140 370 120

– – 65 75 95 130

– – 120 140 180 240

– – 145 170 215 290

165 165 165 195 250 330

175 175 175 205 265 350

175 175 175 205 265 350

185 195

350 370

420 445

480 510

515 540

515 540

195 220

370 410

445 495

510 565

540 600

540 600

205 240

390 450

470 540

535 620

570 660

570 660

Male Female

– –

585 675

710 815

810 930

865 990

865 990

Male Female

– –

630 715

765 870

870 995

925 1,055

925 1,055

Male Female

– –

665 760

810 920

925 1,055

980 1,120

980 1,120

585

1,095

1,505

1,530

1,350

1,350

–

1,855

2,425

2,550

2,470

2,470

Nutrition Transfer Food Transfer Elderly Transfer Infant Transfer Education grants Primary school First year Second year Third year Fourth year Fifth year Sixth year Secondary school First year Male Female Second year Male Female Third year Male Female High school First year

Second year

Third year

Maximum amount of transfer Family with children in primary and secondary school Family with children in primary, secondary and high school

Source Adapted from historical data about the size and kinds of cash transfers (https://www.pro spera.gob.mx/swb/es/PROSPERA2015/Monto_de_los_apoyos)

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boys over girls. Female heads of households —mostly mothers—also receive a special role in the program by making them the principal connection between the program and the participant families. Paradoxically, the way in which the program achieves this is through reinforcing conventional gendered stereotypes of women and their roles within the home. In this sense, the cash transfers were directly delivered to mothers based on two assumptions. The first assumption is that women perform the traditional role of the housewife within the family. Thus, they have the time and the possibilities to comply with the activities of the program. The second assumption is based on an accumulation of research showing that the objectives of the program have a greater likelihood of being accomplished because of the nature of motherhood. That is, women are more likely to use the resources provided by the program for the good of their children and the family as a whole (Behrman, 2007). As a result, women are the principal responsible actor of the fulfillment of their own and their family’s co-responsibilities. However, as Molyneux (2006) argues, this strategy increases the responsibilities of women both within and outside the household and reinforces stereotypes of the role of women in society (Adato & Roopnaraine, 2010; Cookson, 2018). The program activities to which female recipients are accountable for were not few. These related to the two primary roles that female recipients took in the program. The first was adopted by all recipients and entailed them being responsible for receiving the benefits and managing these at home. The activities included traveling to the center of their municipality to collect their transfers, attending to meetings at school with teachers, routine meetings organized by vocales , regular visits to the health clinics for their own and their children’s medical appointments, and attending the health workshops. The second role taken was that of vocales . A vocal was a female recipients elected by their peers to be part of the Committee of Community Promotion (Comité de Promoción Comunitaria). There were four kinds of positions they could take: education, health, nutrition and control and surveillance. No matter the position taken, the functions of vocales were to be the liaison between the recipients and the program officials, they provided information to recipients about the components of the program they represented, made sure recipients comply with the conditionalities, and organized most activities of the program at the community level. Hence, vocales undertook additional activities on top of the usual deeds as recipients described above. For example, although this could vary across

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locality, vocales received additional workshops about the procedures of the program, about the requirements of their role, and about how to manage groups of people and other personal, social, and psychological skills. The number of vocales selected depended on the number of recipient families within each locality. The official length of the position was 3 years. It is important to note that vocales did not receive material or economic benefits from the program for conducting this role it was voluntary. From its inception, the program characterized by successfully eliminating the clientelistic practices that were common in former anti-poverty programs, although possibly sporadic incidents did occur. Vocales did benefit, however, from the knowledge they obtained through the training they receive as part of this role. At the same time, the burden of the additional work placed by the program could have been too large for many of them. Many juggled with the responsibility of motherhood, housekeeping, often formal or informal employment, the activities of the program and the responsibilities of the position (vocal ).

Evaluations and Broad Results of the Program The international praise of Oportunidades-Prospera partly comes from its continual internal and external evaluations and the government’s responsiveness to the resulting recommendations. In fact, probably the largest and most rigorous evaluations of social protection programs in general are based on this Mexican CCT (e.g., Adato & Hoddinott, 2010; Fiszbein & Schady, 2009). Hence, the literature that reports the outcomes of the program from its inception is exceptionally large. This section presents some of the major quantitative and qualitative evaluations and then concentrates on those findings that are more relevant for understanding officer–recipient relationships and their well-being outcomes. Quantitative Evaluations The data from the experimental evaluation of the program conducted between 1997 and 2000 (then Progresa) have largely confirmed the success of the program in increasing household income and consumption, raising school attendance, and improving health and nutrition (IFPRI, 2002; Campos, 2012), although they do not say much about broader impacts on the well-being of recipients.

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In terms of education, these studies find that the program has increased children’s school attendance, especially that of girls and at secondary school. If these effects are sustained over these children’s school life, some studies predicted that on average they will have an increase in years of education, from 0.5 to 0.9 years (Behrman & Parker, 2010) and 8% more income (Skoufias, 2005). Schultz (2000) also found that Progresa increased enrollment rates by 1.45% for girls and 1.07% for boys at primary school level, but up to 9.3% for girls and 5.8% for boys at secondary school level. Progresa also promoted school entrance at early ages, better grade advancement and less grade repetition (Behrman et al., 2010). In the short-run, children receiving the scholarships showed lower dropout rates and higher re-entry levels. Yet, while the program addressed issues of access to schooling, it did not address the quality of the education as there are no significant effects on school performance (Skoufias & Parker, 2001) and only limited increases in test performance (Behrman et al., 2010). In terms of health and nutrition, the incidence of disease decreased by 12% for children and 19% for adults (Gertler, 2000; Skoufias, 2005). Similarly, children between 12 and 36 months of age showed a reduction in their levels of stunting by 10% and a greater level of caloric intake because of the nutrition cash transfer of the program (Behrman & Hoddinott, 2001; Hoddinott, 2010; Hoddinott & Wiesmann, 2010). Therefore, families were indeed using the transfer for its intended purpose. As seems natural in a conditional program, visits to health clinics increased 18.2% after the first year of implementation (Gertler & Boyce, 2001). These were particularly high for pregnant women who attended their consultations during their first trimester of pregnancy. At the early stages of the program, evaluations found some initial problems in the provision of health. Recipients reported feeling uncomfortable receiving talks about pap smears and contraceptives from male doctors (Adato et al., 2000). They also found problems in the formula, provision, and use of the nutritional supplements (Rivera et al., 2004). This CCT constitutes one of the most comprehensive policy actions by combining a number of strategies to reduce poverty (income, health, education, and nutrition). Yet, the former review of key evaluations show that they have paid little attention to its impacts on a more holistic understanding well-being. It is noticeable that objective indicators that measure the most direct effects of the program dominate in these studies. In an

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analysis of 221 evaluations of CCTs like Oportunidades-Prospera, HagenZanker et al. (2011) found that the main indicators usually considered are education (27%), health (22%), and employment (13%); while the least included are food security (6%), inequality (4.5%), and food expenditure (1.8%) (personal calculations). Although these indicators constitute a useful tool since they involve logical areas of impact of the program, they are limited in at least three ways. Firstly, when the program evaluated is conditional, an important question to ask is whether some of these measures such as attendance to school or the health centers are capturing the success of the program in raising health and human capital, or whether they are simply reflecting the capacity and motivation of recipients to meet the conditions. Secondly, objective indicators leave important knowledge gaps as they provide very little information about what people can actually achieve with these ‘successes’ and exclude people’s perceptions and experiences of the program and of its effects on broader conceptions of well-being. Finally, at most these objective indicators can observe certain program outcomes while neglecting program processes at the level of implementation. The relational processes that occur during program delivery and in the interface between officers and recipients discussed in chapter two might have as great an effect on people’s well-being as the intended outcomes. Qualitative Evaluations: Focus on Relationships In contrast to the quantitative evaluations of Oportunidades-Prospera, a number of qualitative evaluations uncover quite a distinctive view of the program, especially in terms of unintended implications for the social relationships of recipient families and communities. In terms of the interactions that occur within the family, the gender bias in the program’s strategy intended to improve women’s position inside the household, not necessarily translated into positive outcomes in their empowerment (Molyneux, 2006; Escobar Latapí & González de la Rocha, 2004; Cookson, 2018). Although both positive and negative effects on the quality of husband–wife relationships have been found (Adato & Hoddinott, 2010), the competition for the control of the cash transfers increased the incidence of domestic violence (Molyneux, 2006). Another unintended consequence of the program’s procedures was an increase in the economic demands on women in addition to

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domestic ones, since studies suggest some men choose to contribute less economically to the family (Rubio, 2002). On the other hand, although there is evidence that the relationships between recipients have been strengthened as a result of their entrance to the Oportunidades-Prospera program (Adato, 2000), there are indications that the program has negatively transformed community relationships as a result of its targeting procedure and selection process (Escobar Latapí & González de la Rocha, 2004). A new label that differentiates people within communities was introduced: who is a recipient and who is not? As Adato (2000) notes, this social division created feelings of resentment and envy, as well as the proliferation of gossip between these groups. Some people did not understand why their neighbor was chosen to be recipient and they were not if, from their view, both shared the same poverty and living conditions. These feelings had consequences for the customary ways of interaction in the community as non-recipients decided to retreat from the traditional communal deeds because of the belief that the recipients of Oportunidades should participate more because they were obtaining government benefits. These indirect effects of the program on social relationships are intrinsically important for well-being since, as shown earlier in the book, having positive relationships between neighbors and within the family is a central aspect of living well from people’s perspectives. Evaluations from a Well-Being Perspective There is a small but emerging literature that evaluates CTs like Oportunidades-Prospera through a well-being lens. From a quantitative perspective, Handa et al. (2014a) incorporated SWB indicators in a largescale survey evaluating the Kenyan (unconditional) cash transfer program for Orphans and Vulnerable Children (CT-OVC). In terms of methods, their analysis confirms that subjective indicators of well-being can be applied in large-scale surveys and in a sample composed of rural participants in a developing country. More substantively, however, the study finds significant, strong, and positive effects of the cash transfer on present and future SWB. Specifically, recipients receiving the cash transfer were more likely to feel happy and to feel positive about their future than non-recipients. In another study, Handa et al. (2014b) demonstrate that the CT-OVC benefits contribute to the subjective well-being of parents, which in turn

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has a positive effect on the psychological well-being of their adolescent children through the development of a more positive family environment. In relation to psychological health, Kilburn et al. (2016) find that the same cash transfer reduces the probability of depressive symptoms by 24% among male adolescents receiving the transfers. In the context of Oportunidades-Prospera, Palomar-Lever and Victorio-Estrada’s (2014) article is the only study found to explore the well-being of recipients using PWB and SWB approaches. However, the article focuses on the wellbeing determinants of adolescent recipients and does not explore any role of the program on these well-being outcomes. These quantitative studies provide justification for the application of well-being indicators in the analysis of CTs that is valuable in its own right. Yet, they still employ a narrow set of indicators that are not able to explain the reasons behind these positive results beyond what is measured, including the processes through which these outcomes were achieved. In contrast to quantitative studies taking SWB and PWB approaches, a very recent series of articles published by researchers from the Overseas Development Institute (ODI) presents two (mainly) qualitative studies that take a psychosocial well-being approach to assess cash transfers in the Middle East and Africa. Samuels and Stavropoulou (2016) propose using the psychosocial model of inner well-being (IWB) to analyze the qualitative findings of (unconditional) cash transfers in the Middle East and Sub-Saharan Africa. They use the IWB approach to explore the differential role of the programs on each of the seven domains of IWB, a disaggregated analysis that is not possible to conduct with the global indicators of SWB. Their findings attest that receiving the cash transfer had positive effects on people’s sense of economic confidence (by increasing financial security), their sense of agency (by increasing their feelings of control over their lives and reducing their dependence on others), their mental health (since increased financial security reduced feelings of stress and anxiety) and their sense of competence and self-worth. The program also improved intra-household relationships between spouses and between parents and children (by increasing collaboration among family members and reducing tension and violence) and improved their social connections (by integrating people and reducing levels of discrimination and shame). Samuels and Stavropoulou’s data also showed that the cash transfer had adverse effects on inner well-being through several channels. For instance, mirroring the results of Molyneux (2006)’s qualitative study

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on Oportunidades, this study also identified that in some cases people’s close relations and social connections were negatively affected since the cash generated tensions and conflicts for its control within the family and increased feelings of envy between neighbors and extended family members. The authors also found adverse effects on the recipients’ competence and self-worth arising from two relational processes. First from the social stigma of becoming a recipient, and second from the mistreatment received from program implementers during their interactions. This study, thus, provide a more comprehensive view of the relational processes and the channels through which participating in a social program like Oportunidades-Prospera can affect well-being. On the other hand, Attah et al. (2016) provide evidence of the roles of cash transfers on psychosocial well-being from two studies, a crosscountry qualitative research from Ghana, Zimbabwe, and Lesotho and a mixed-method evaluation of a cash transfer in Kenya. Both studies reinforce previous findings about the association between the material benefits that the cash transfer provide and the subjective and relational well-being of recipients: [T]here’s a self-reinforcing cycle that leads from increased material wellbeing towards increased self-esteem (for example, ability to be clean and wear good clothes, ability to pay into risk-sharing arrangements, and so on), which then has effects on social integration and interactions (for example, diminished stigma from teachers, increased respect gained from other community members, and so on), which in turn can positively affect other relevant development outcomes (for example, improved performance in school, increased support from the community at a time of need, and so on). (pp. 1125–1126)

The conclusions of these articles highlight the added contribution of a relational approach to well-being for assessing CTs. According to Attah et al. (2016), their results reveal the difficulty of separating subjective aspects from relational aspects of well-being. Frequently, they argue, the accounts of recipients coupled their inner feelings (of purpose in life, selfesteem, and autonomy) with the social and relational contexts in which they experienced them (such as being respected and accepted by their neighbors, classmates, or program implementers, obtaining social status and being able to engage in different social scenarios and institutions). Both studies also briefly mention a possible role of frontline officers like program implementers (Samuels & Stavropoulou, 2016) and school

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teachers (Attah et al., 2016) on the well-being of recipients, even though their purpose was not to explore these relationships directly. Furthermore, Samuels and Stavropoulou (2016) concluded that a psychosocial approach to well-being like IWB is substantially useful to evaluate CTs and to design programs that provide a more holistic psychosocial support to recipients.

The provision of health in Oportunidades-Prospera Conditional cash transfer programs like Oportunidades-Prospera are ideal scenarios to explore the relationship between frontline officers and program participants. As was mentioned, they seek to transform people’s lives in terms of education, health, nutrition, and income. The mechanisms through which these objectives are pursued, however, place recipient families in new relational scenarios where they hold long-term interactions with frontline officials at different stages such as targeting, payment, delivery of services, and monitoring. The element of conditionality generates even more constant relationships than other social programs since different kinds of officers like teachers and health staff continuously supervise families’ behaviors and actions. The high importance of officer–participant interactions in the delivery of this program justifies MacAuslan and Reimenschneider’s (2011) proposition for ‘reconceptualising cash transfers as ongoing processes of intervention in a complex system of social relations’ (p. 60). Probably the most complex and significant interaction generated is that between recipients and the health staff. Given the amount of material, human and organizational resources needed to deliver the health component of the program, OportunidadesProspera partnered with the two largest health institutions in Mexico, the National Health Ministry (Secretaría de Salud) and the National Social Security Institute (Instituto Mexicano del Seguro Social, IMSSProspera). The health officers—doctors, nurses, dentists, and interns—in Oportunidades-Prospera were primarily accountable to one of these institutions and thus formally not direct employees of the program. Nonetheless, they had the crucial functions of delivering and supervising the health activities that the families (primarily mothers) need to comply with as a result of their involvement in the program. The health staff directly monitored the two core activities stipulated in the official regulations of Oportunidades-Prospera introduced earlier.

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To recapitulate, the first official condition was attending regular family medical check-ups scheduled twice a year with the requisite that all members enrolled in the program attend (usually at the same day/time). These usually entailed taking record of each patient’s weight, body-mass index, and a brief consultation with the doctor if necessary. Medical staff monitored pregnant or lactating women, and those who suffered from certain ailments once every two months. Health workshops, the second official conditionality, involved monthly talks about illnesses and preventive health measures delivered by the medical staff and directed to mothers. They usually lasted an hour, covered topics such as sanitation, illness detection, hygiene, family planning, and nutrition, and were scheduled by the health staff based on their own activities within the clinic. The health staff strictly and constantly monitored people’s compliance with these conditions through an attendance record retained at the clinic (‘S1 form’) and an appointment booklet that the family representative kept (‘carnet’ or ‘cartilla familiar’). This booklet contained the scheduled appointments for each family member during the entire calendar year (Adato et al., 2000). In practice, health officer signed each turnout from the recipient and then submitted to the Oportunidades-Prospera’s system electronically. Failure to comply with one appointment entailed an economic penalization in the next cash transfer, but failing to comply for four consecutive or six non-consecutive months caused the permanent expulsion form the program (Adato, 2000). Therefore, for recipients their attendance to the health activities and the signature of the health officer in their attendance record was critical. In addition to these two official conditionalities, there seemed to be a few unofficial requirements in place that implicated participants in unpaid jobs under the supervision of health officers. These could include different kinds of tasks such as cleaning and maintenance work at the clinic and in public places, as well as participating in campaigns promoting health treatments or sanitation activities. The recipients involved in these activities were rotated at varying rates, some activities conducted by all recipients but others by a specific group identified in some places as members of the health committees . These informal conditionalities are documented by a few studies (Adato, 2000, Adato et al., 2000; Agudo Sanchiz, 2012; Smith-Oka, 2013). However, the program did not appear to regulate these activities, suggesting these were informal practices behind the implementation procedures of Oportunidades-Prospera.

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In an external evaluation of Oportunidades-Prospera (then Progresa) conducted by the International Food Policy Research Institute (IFPRI), Adato (2000) examines these activities—or what she calls faenas. Faenas are volunteer activities not part of the program but informally associated with it in most localities. Adato (2000) tracks down their origins to the communal work traditionally conducted before the establishment of the program. In the two sites where the research for this book developed, officers and recipients alike described faenas as ‘volunteer’ activities, although in practice recipients had little say in their degree of involvement in them (see also Agudo Sanchiz, 2012). Physicians considered faenas to produce important environmental, hygiene, and health benefits for the localities (Adato et al., 2000). Arguably, however, tasks such as cleaning the clinic, doing plumbing work, fixing the cistern or paying for it to get fixed— examples of tasks conducted during the fieldwork of this study—should be fulfilled by the municipal government or the national health ministry and not by the recipients of a poverty program. The lack of information and their informality make it difficult to determine the frequency of these practices, the level of participant involvement and the types of tasks entailed. It is also difficult to reach any conclusion as to why they were allowed or practiced, and what are the incentives behind them. An administrative ‘explanation’ is that faenas were a useful tool for the national health office to achieve aims such as keeping certain levels of sanitation in the clinics without hiring cleaning staff, reducing the workloads of overburdened health officers, or meeting other targets such as promoting medical procedures to reach larger policy quotas (e.g., vaccinations and use of contraceptives). An important discussion that arises from the existence of faenas or health committees is their consequences on the relationships between officers and recipients. Indeed, for this book, the most important characteristic of these activities is that health officers designed and regulated them in each clinic, and used them as part of the requirements families must comply with to receive their benefits. These activities and their management through health officers inevitably involves a new set of hierarchies in an equation that—as argued in chapter two—is already charged with issues of power, authority, and forms of control that are potentially problematic for well-being. For instance, unregulated faenas can increase the ability of health officers to execute their discretionary power over the program’s procedures and over the participant’s activities within and outside of the program.

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In addition to these power-laden features of the officer–recipient relationship generated by Oportunidades-Prospera’s processes of implementation, the frequency of interactions is rather high for a social program. Levy (2006) estimated that recipient families met the health officers an average of 7.8 times every year for medical consultations, which in addition to the monthly workshops, they summed up to 20 days of formal interactions with officers. These figures, however, do not consider noncompulsory medical visits to the clinic (when people are ill) and the health campaigns organized and monitored by officers. They also do not include the interactions that health committee members and vocales have with officers during the fulfillment of their additional program roles. For instance, the days health committee members conducted unpaid work for the medical staff in the clinics, or the days vocales interacted with officers. Among the many roles vocales had in the program, they served as the link between all recipients (or the group they represented) and the medical staff—delivering messages, discussing any concerns from recipients, and helping with administrative work at the clinic such as collecting the signatures of recipients to record their attendance to meetings. Indeed, the role recipients had in the program closely related to the frequency of their interactions with the health staff, the terms of their relationship and its influence on well-being. Ultimately, what this suggests is that together, the official and the unofficial health conditionalities of Oportunidades-Prospera created repeated and long-lasting interactions between health officers and program participants that could influence the power dynamics that occurred during their interactions, the nature and quality of the relationship, and the effects of the program on well-being in non-negligible ways. The next section explores what is currently known about the officer–recipient relationships in the Oportunidades-Prospera program. Empirical Evidence of the Implementation of Health Not surprisingly, research on Oportunidades-Prospera’s health conditionalities has primarily concentrated in understanding the consequences of deficient implementation procedures (in terms of both poor implementation and inadequate health services) over program’s outcomes. In fact, the low quality of health care services are identified as one of the major obstacles to program effectiveness (CONEVAL, 2011) and the cause of the

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program’s relatively low positive effects on health indicators (Gutiérrez et al., 2008). Most evaluations recorded that although the access and use of health services increased because of the implementation of OportunidadesProspera, serious deficiencies in quantity and quality of healthcare provision remained (Escobar Latapí & González de la Rocha, 2000). These include challenges in administrative or procedural issues such as high workload for staff and insufficient personnel, incorrect application of medical procedures, and lack of medicines. For instance, Mexico has an average rate of 2.2 physicians and 2.6 nurses per 1,000 inhabitants, figures that are well below the OECD averages of 3.2 and 8.8, respectively (OECD, 2014). The number of patients also increased dramatically in the last decades mainly because of the conditions of Oportunidades-Prospera, while investment in health clinics and hospitals has also increased but not at the same rate. In terms of structural issues on health provision, Gutiérrez et al. (2008) found that health care units often suffered from energy cuts, 30% did not have access to tap water and 50% to sewage. The average distance between the health clinics and larger units with better medical capacities was 32 km or 1–4-hour walking distance, and only 10% of clinics had ambulances. There was a significant shortage of regular physical surveying tools such as scales and thermometers. More importantly, however, most clinics reported not having the necessary supplies to monitor the program’s key health conditions such as diabetes and high blood pressure or provide prenatal care. The need to improve medical attention in rural areas has been especially emphasized. Evidence suggests that clinics’ opening hours vary significantly between localities. Some clinics only offer services for short hours during the day, while others for no apparent reason do not open at all for days and in some cases although the clinic is open, doctors are not around during work hours (Bautista et al., 2008; Adato et al., 2000; Skoufias, 2005). These issues increased recipient dropout rates (Álvarez et al., 2008) and promoted a continual reliance on private medical attention that involved higher economic costs to families, paradoxically reducing the income effect intended by the cash transfer (Escobar Latapí, 2000). Escobar Latapí and González de la Rocha (2000) observed, however, that many of the reasons behind deficiencies in the quality of health care related more to the willingness of health officers to provide a proper

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service than to administrative or resource deficiencies. Gutiérrez et al. (2008) evaluated quality of care based on the procedures conducted by the health staff and their capacities to transform them into effective service delivery. Their results suggest that only a small percentage of staff performed the expected routine procedures and tests such as pelvic and breast exams for women, urine tests for diabetics, and general lab tests. After further exploring the reasons behind these omissions, they found that 59% of staff reported not requesting lab tests because they did not consider it necessary and only 23.6% because they did not have access to them. Indeed, not all issues of quality seem to be dependent on the availability of resources and instruments but instead on the way health staff choose to conduct their consultations and examinations. For example, despite the large incidence of respiratory problems, fever, and diarrhea in children and the importance given to children’s health by the program’s established procedures, only 62.9% of physicians reported evaluating the presence of cough and fever during a consultation, 3.8% the presence of diarrhea and only 5.2% monitoring feeding practices (ibid.). Overall, these results suggest that although some of the minimum required procedures were conducted, health staff does not always undertake the necessary medical revisions and counselling procedures that constitute a proper health consultation given the standards of both the national health institutions and Oportunidades-Prospera. These findings continue to stress the importance of paying attention to the quality of the services and, especially, to the nature and quality of the way officers relate to their clients. Despite the long list of studies that have attested the still insufficient quality of health services provided by Oportunidades-Prospera, only a handful have explored the quality of officer–recipient relationships directly. These findings have mainly come from qualitative studies, that depend on the recipients own narratives of their experiences in the program. One of the most notable conclusions is that recipients consider the quality of their relationship with officers as a significant aspect of the process of policy implementation. For instance, Saucedo (2013) found that whereas the program’s participants were well aware of the poor health services received, most of their complaints related to what they considered lack of courtesy experienced during the program’s health check-ups. These negative interactions with officers appear to be especially critical for indigenous recipients. According to Campos (2012) indigenous

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people have less access to the program’s health activities not because their localities do not have a health clinic due to the remoteness of some communities, as is usually believed. Instead, this is primarily a consequence of the attitudes and treatment offered by officers such as lower quality of medical care, mistreatment, abuse, and discrimination. This data gains significance when we take into account that what explains the large poverty gap between indigenous and non-indigenous is primarily the lower access to services and education of indigenous groups1 (GarciaMoreno & Patrinos, 2011). Furthermore, according to the national Council for the Prevention of Discrimination (CONAPRED), 27.1% of indigenous groups report feeling they do not have the same opportunities to receive quality health care (CONAPRED, 2011). Moreover, issues of abuse of power are documented in previous research on Oportunidades-Prospera’s health services. This occurs in general but more predominantly in rural areas (see Smith-Oka, 2014; Campos, 2012; Gutiérrez et al., 2008; Sánchez López, 2009). Escobar Latapí (2000) recorded in an extensive qualitative study that health staff used threats of expulsion from the program (and carried them out) to force women recipients to accept undergoing a pap smear. In rural localities in Chiapas and Oaxaca, Agudo Sanchiz (2012) found that the health officers considered recipients to have the ‘duty’ of granting them a certain amount of work hours within the clinic through faenas , even though these never were an official conditionality. He also finds that officers threatened recipients with reporting them absent in the otherwise official conditions if they did not comply with these unofficial requisites. This same author documented how officers informally adapted the official rules of the program in many instances. For example, some officers abused their power by directly imposing economic fees to recipients when they missed an appointment or workshop (official conditionalities). The program’s official protocol does not stipulate these penalties. The frequency of this practice and the destination of the money lied at the discretion of the officer. This process of implementation could lend Oportunidades-Prospera’s health activities to be misused, dangerously translating the program’s discourse of co-responsibility into one of obligation and punishment that 1 CONEVAL (2010) finds that 79.3% of indigenous people fall below the national poverty line and of these 40.2% are extremely poor.

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may cause significant unintended consequences on people’s well-being. Given these practices and the uneven power relations between officers and recipients, Agudo Sanchiz (2012) rightly questions the capacity of Oportunidades-Prospera of promoting the agency and participation of recipients intended in its design and advocated by some evaluations (e.g., Barber & Gertler, 2010). Instead, he argues, that these relations ‘rely on a different notion of reciprocity that is essentially based on clientelistic practices in which patrons dispense favors in exchange of the gratitude of their clients to guarantee the desired “outcome” of the policy’ (p. 1). A small number of empirical studies have built on this understanding of officer–recipient relationships as embedded in problematic conditions of asymmetric reciprocity and hierarchy. Smith-Oka (2013) argues that these conditions cannot be separated from the contrasting identities of both actors within and outside the program. In a further publication focused on obstetric relations between physicians and female patients in public hospitals in Puebla, Mexico, Smith-Oka (2015) argues that these conflicting identities and the larger historical processes of social and ethnic hierarchy facilitate officer’s exercise of what she defines as ‘microaggressions.’ ‘Microaggressions’ are defined by Smith-Oka (2015) as ‘subtle insults and demeaning behavior typically aimed at [problematic others] that reflect and enforce the perpetrators’ perceptions of their superiority’ (p. 9). In this health context, she identified four forms of ‘microaggressions’: microinsults, microassaults, microinvalidations, and corporeal microaggressions. These involve forms of verbal aggressions, reprimands, physical mistreatment, and passive aggressive teasing that reflect the physician’s negative stereotypes and labels toward patients’ identities, lifestyles, roles, and preferences. In the context of her research, physicians often described their patients as lazy, deceitful, disorderly, non-compliant, ignorant, and sexually loose. Microaggressions are used to cause shame on patients, making the medical encounter easier for physicians by causing a submissive and compliant behavior from patients and reinforcing the social divide between them. Some studies have found that the systematic acts of mistreatment, aggression, and power struggles that occur during these interactions are significant for the well-being of recipients, although they have not explored this in the context of Oportunidades-Prospera. For instance, the large qualitative study conducted by Molyneux and Thomson (2011) on CCTs in Peru, Ecuador, and Bolivia found that female recipients often

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expressed a lower sense of self-worth, agency, and empowerment when the interactions with health officers involved violence, shame, discrimination, and negative labeling. Although this study does not explicitly use a well-being approach, its results begin to display the possible wellbeing implications of this relationship. Similarly, as mentioned earlier, Samuels and Stavropoulou (2016) who used the IWB approach to analyze unconditional cash transfers in the Middle East and Sub-Saharan Africa, showed that feeling mistreated, stigmatized, and shamed by program implementers reduced the recipients’ sense of competence and self-worth. The former description of what could be considered a problematic relationship at least, contrasts quite strongly with the empowering aspirations of the program. The original design of Oportunidades-Prospera explicitly placed as an objective the empowerment of their recipients’ (particularly women): PROGRESA seeks to improve the condition of women and empower the decisive role they play in family and community development. The aim in this regard is to satisfy their healthcare and nutritional needs, while providing them with information and skills to promote their advancement. The focus in all cases is to ensure that mothers are the depositories and holders of all economic benefits of their households. (PROGRESA 1997, cited in Adato & Roopnaraine 2010, pp. 288–289)

The concern for women’s empowerment within the family and the community that the program shows in this quote is intrinsically valuable, although limited. It shows the typical omission of the program’s own role in the (dis)empowerment of their recipients through different processes, including program implementation. In social programs and development initiatives there is still a tendency to look outwards to the ‘field’ or the ‘recipients’ for things that need to be fixed. Yet, the potential empowering effect of programs like Oportunidades-Prospera cannot be known without a full analysis of the relationships that the program itself is fostering and obliging recipients to engage in. Until now, the evidence suggests that, at the implementation level, the relationships with frontline health officers could neutralize some of the potential empowering outcomes of the program.

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Summary The purpose of this book is to identify and assess the association between well-being and the relational processes that happen within the delivery of the Oportunidades-Prospera program that cannot be captured with the standard evaluation methods used (see Devereux et al., 2013 for a similar proposal). As seen here, most evaluations of Oportunidades-Prospera focus on objective outcomes such as school attendance and health improvements. There is, however, no sufficient knowledge about the well-being effects of the program, although research elsewhere begins to underscore the appeal of a psychosocial well-being approach to assess program outcomes and processes. In addition, similar to the gaps found in the well-being literature presented in chapter two, the available qualitative evaluations of the Oportunidades-Prospera program that discuss the social processes that occur around it concentrate primarily on household and community interactions. Although promoting access to health and education, and improving family and community relationships are fundamental steps toward tackling poverty and improving well-being, this outlook disregards how program processes and delivery mechanisms through frontline officers can affect program outcomes and the well-being for participants. This book explores the extent to which Oportunidades-Prospera reinforces or challenges these relational constraints to well-being during the provision of welfare. The characteristics of the implementation procedures of the health conditionality of Oportunidades-Prospera suggest that we should look more deeply into officer–recipient relationships in this context. Like many other CCTs and health policies around the world, the objective of the Oportunidades-Prospera’s health component was to reduce the incidence of preventable diseases through the delivery of medical consultations and health talks. The evidence confirms that officers achieve some of these policy goals. Yet, policy implementation is not only about delivering a service (e.g., applying a vaccination or offering medical consultation). It is also about what happens in the process of receiving it, a process in which the interactions between frontline officers and recipients have a fundamental role to play. This review exposes that frontline health officers behind Oportunidades-Prospera can thwart the effective delivery of services and distort the original objectives of the program stated in the design

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and discourse of co-responsibility. A few studies also problematize the quality of their relationship with recipients by analyzing the role of identity, power abuse, discrimination and mistreatment that can be exerted during the delivery of the program and find some noteworthy well-being effects. Quality of relationships with officers seem to be significant for recipients, yet, more research is needed. Arguably, what makes the evaluation of the officer–recipient relationship crucial is their possible long-term and unintended effects over the well-being of recipient families.

Bibliography Adato, M. (2000). The impact of PROGRESA on community social relationships (Final Report). Washington, DC: International Food Policy Research Institute (IFPRI). Adato, M., & Hoddinott, J. (2007). Conditional cash transfer programs a “Magic Bullet” for reducing poverty? IFPRI. Adato, M., & Hoddinott, J. (Eds.). (2010). Conditional cash transfers in Latin America. Johns Hopkins University Press. Adato, M., & Roopnaraine, T. (2010). Conditional cash transfer programs, participation, and power. In M. Adato & J. Hoddinott (Eds.), Conditional cash transfers in Latin America. Johns Hopkins University Press. Adato, M., Coady, D., & Ruel, M. (2000). An operations evaluation of PROGRESA from the perspective of beneficiaries, promotoras, school directors, and health staff . International Food Policy Research Institute. Agudo Sanchíz, A. (2012). The social production of conditional cash transfers’ impacts. International Policy Centre for Inclusive Growth, No. 172. Álvarez, C., Devoto, F., & Winters, P. (2008). Why do beneficiaries leave the safety net in Mexico? A study of the effects of conditionality on dropouts. World Development, 36(4), 641–658. https://doi.org/10.1016/j.worlddev. 2007.04.014 Arnold, C., Conway, T., & Greenslade, M. (2011). Cash transfers literature review. Department for International Development DFID. Attah, R., Barca, V., Kardan, A., MacAuslan, I., Merttens, F., & Pellerano, L. (2016). Can social protection affect psychosocial well-being and why does this matter? Lessons from cash transfers in Sub-Saharan Africa. The Journal of Development Studies, 52(8), 1115–1131. https://doi.org/10.1080/002 20388.2015.1134777 Barber, S. L., & Gertler, P. J. (2010). Empowering women: How Mexico’s conditional cash transfer program raised prenatal care quality and birth weight. Journal of Development Effectiveness, 2(1), 51–73. https://doi.org/10.1080/ 19439341003592630

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Bautista Arredondo, S., Bertozzi, S., Leroy, J., López Ridaura, R., Sosa-Rubí, S., Téllez Rojo, M., & Walker, D. (2008). Diez años de Oportunidades en zonas rurales: efectos sobre la utilización de servicios y el estado de salud de los beneficiarios. Secretaría de Desarrollo Social. Behrman, J. R. (2007). Policy-Oriented Research Impact Assessment (PORIA) case study on the International Food Policy Research Institute (IFPRI) and the Mexican PROGRESA anti-poverty and human resource investment conditional cash transfer program (Independent Impact Assessment Report No. 27). Washington, DC: International Food Policy Research Institute (IFPRI). Behrman, J. R., & Hoddinott, J. (2001). An evaluation of the impact of PROGRESA on preschool child height (Discussion paper No. 104). Washington, DC: International Food Policy Research Institute (IFPRI). Behrman, J. R., & Parker, S. W. (2010). The impacts of conditional cash transfer programs on education. In Conditional cash transfers in Latin America. Johns Hopkins University Press. Behrman, J. R., Sengupta, P., & Todd, P. E. (2010). Impact of PROGRESA on achievement test scores in the first year. Washington, D.C.: International Food Policy Research Institute. Campos Bolaño, P. (2012). Documento compilatorio de la Evaluación Externa 2007–2008 del Programa Oportunidades. Secretaría de Desarrollo Social Coordinación Nacional del Programa de Desarrollo Humano Oportunidades. Centro de Estudios Espinosa Yglesias (CEEY). (2013). Informe de movilidad social en México 2013. CEEY. Consejo Nacional de Evaluación (CONEVAL). (2010). Informe de pobreza multidimensional en México, 2008. Consejo Nacional de Evaluación de la Política de Desarrollo Social. Consejo Nacional de Evaluación (CONEVAL). (2011). Informe de la Evaluación Específica de Desempeño 2010–2011. Consejo Nacional de Evaluación de la Política de Desarrollo Social. Consejo Nacional para Prevenir la Discriminación (CONAPRED). (2011). National survey on discrimination in Mexico. Enadis 2010 Overall Results. Consejo Nacional para Prevenir la Discriminación. Cookson, T. P. (2018). Unjust conditions. Women’s work and the hidden cost of cash transfer programs. University of California Press. Dávila Lárraga, L. G. (2016). How does Prospera work? Best practices in the implementation of conditional cash transfer programs in Latin America and the Caribbean (Technical note no. IDB-TN-971). Social Protection and Health Division. Inter-American Development Bank. Devereux, S., Roelen, K., Béné, C., Chopra, D., & Leavy, J. 2013. Evaluating outside the box an alternative framework for analysing social protection programs. IDS. Retrieved from http://onlinelibrary.wiley.com/doi/10. 1111/idwp.2013.2013.issue-431/issuetoc

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Escobar Latapí, A. (2000). Progresa y el bienestar de las familias. Los hallazgos. In A. Escobar Latapí & M. González de la Rocha (Eds.), Logros y retos: Una evaluación cualitativa de Progresa en México. Secretaría de Desarrollo Social. Escobar Latapí, A., & González de la Rocha, M. (Eds.). (2000). Evaluación de resultados del Programa de Educación, Salud y Alimentación. Logros y retos: Una evaluación cualitativa de Progresa en México. Centro de Investigaciones y Estudios Superiores en Antropología Social (CIESAS). Escobar Latapí, A., & González de la Rocha, M. (2004). Evaluación cualitativa del Programa Oportunidades. Centro de Investigaciones y Estudios Superiores en Antropología Social. Fiszbein, A., & Schady, N. R. (2009). Conditional cash transfers: Reducing present and future poverty. Washington D.C.: World Bank Policy Research Report. https://openknowledge.worldbank.org/bitstream/handle/10986/ 2597/476030PUB0Cond101Official0Use0Only1.pdf?sequence=1&isAllo wed=y Fiszbein, A., Kanbur, R., & Yemtsov, R. (2014). Social protection and poverty reduction: Global patterns and some targets. World Development, 61, 167– 177. Garcia-Moreno, V. A., & Patrinos, H. A. (2011). Indigenous peoples and poverty in Mexico. The World Bank. Gardner, R. (2008). Conditional cash transfer programs in Latin America. SAIS Review, 28(2), 175–187. https://doi.org/10.1353/sais.0.0019 Gertler, P. (2000). El impacto del programa de Educación, Salud y Alimentación (PROGRESA) sobre la salud. International Food Policy Research Institute (IFPRI). Gertler, P. J., & Boyce, S. (2001). An experiment in incentive-based welfare: The impact of PROGESA on Health in Mexico. Gutiérrez, J. P., Leroy, J., López Ridaura, R., DeMaria, L., Walker, D., Campuzano, J. C., & Bertozzi, S. (2008). Evaluación de la calidad de los servicios de atención a la salud asignados a la población beneficiaria de Oportunidades. In Evaluación externa del Programa Oportunidades 2008. A diez años de intervención en zonas rurales (1997–2007). Tomo II, El reto de la calidad de los servicios: resultados en salud y nutrición. Secretaría de Desarrollo Social. Hagen-Zanker, J., McCord, A., & Holmes, R. (2011). Systematic review of the impact of employment guarantee schemes and cash transfers on the poor (p. 96). Overseas Development Institute. Retrieved from https://www.odi.org/sites/ odi.org.uk/files/odi-assets/publications-opinion-files/7161.pdf Handa, S., Martorano, B., Halpern, C., Pettifor, A., & Thirumurthy, H. (2014a). The impact of the Kenya CT – OVC on parents’ well-being and their children. UNICEF.

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Handa, S., Martorano, B., Halpern, C., & Thirumurthy, H. (2014b). Subjective well-being, risk perceptions and time discounting: Evidence from a large-scale cash transfer program. UNICEF. Hoddinott, J. (2010). Nutrition and conditional cash transfer programs. In M. Adato & J. Hoddinott (Eds.), Conditional cash transfers in Latin America. Johns Hopkins University Press. Hoddinott, J., & Wiesmann, D. (2010). The impact of conditional cash transfer programs on food consumption. In M. Adato & J. Hoddinott (Eds.), Conditional cash transfers in Latin America. Johns Hopkins University Press. International Food Policy Research Institute (IFPRI). 2002. Mexico PROGRESA: Breaking the cycle of poverty. International Food Policy Research Institute (IFPRI). Kilburn, K., Thirumurthy, H., Halpern, C. T., Pettifor, A., & Handa, S. (2016). Effects of a large-scale unconditional cash transfer program on mental health outcomes of young people in Kenya. Journal of Adolescent Health, 58(2), 223–229. https://doi.org/10.1016/j.jadohealth.2015.09.023 Ladhani, S., & Sitter, K. C. (2018). Conditional cash transfers: A critical review. Development Policy Review, 38, 29–41. Levy, S. (1991). Poverty alleviation in Mexico. The World Bank. Levy, S. (2006). Progress against poverty: Sustaining Mexico’s ProgresaOportunidades program. Brookings Institution Press. MacAuslan, I., & Riemenschneider, N. (2011). Richer but resented: What do cash transfers do to social relations? IDS Bulletin, 42(6), 60–66. https://doi. org/10.1111/j.1759-5436.2011.00274.x Martínez Martínez, Ó. A. (2011). La influencia de la condicionalidad de recursos de un programa social en la asistencia a consultas médicas. el caso del programa Oportunidades de México. Revista de Ciencias Sociales de La Universidad Iberoamericana, 11, 83–97. Molyneux, M. (2006). Mothers at the service of the new poverty agenda: Progresa/Oportunidades, Mexico’s conditional transfer program. Social Policy & Administration, 40(4), 425–449. Molyneux, M., & Thomson, M. (2011). CCT programs and women’s empowerment in Peru, Bolivia and Ecuador. CARE. Morris, S. S. (2010). Conditional cash transfer programs and health. In M. Adato & J. Hoddinott (Eds.), Conditional cash transfers in Latin America. Johns Hopkins University Press. Organisation for Economic Co-operation and Development (OECD). (2014). Estadísticas de la OCDE sobre la salud 2014 México en comparación. OECD. Palomar-Lever, J., & Victorio-Estrada, A. (2014). Determinants of subjective well-being in adolescent children of recipients of the Oportunidades human development program in Mexico. Social Indicators Research, 118(1), 103– 124.

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Rivera, J. A., Sotres-Alvarez, D., Habicht, J.-P., Shamah, T., & Villalpando, S. (2004). Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: A randomized Effectiveness study. JAMA, 291(21), 2563. http://doi.org/10. 1001/jama.291.21.2563 Rocha Menocal, A. (2001). Do old habits die hard? A statistical exploration of the politicisation of Progresa, Mexico’s latest federal poverty-alleviation program, under the Zedillo administration. Journal of Latin American Studies, 33(3). http://doi.org/10.1017/S0022216X01006113 Roelen, K. (2014). Sticks or carrots? Conditional cash transfers and their effect on child abuse and neglect: Researchers observe both benefits and harms of CCT programs. Child Abuse & Neglect, 38, 372–382. https://doi.org/10. 1016/j.chiabu.2014.01.014 Rubio, M. (2002). The impact of Progresa on household time allocation. Mimeo. Samuels, F., & Stavropoulou, M. (2016). “Being able to breathe again”: The effects of cash transfer programs on psychosocial well-being. Journal of Development Studies, 52(8), 1099–1114. https://doi.org/10.1080/002 20388.2015.1134773 Sánchez López, G. (2009). Living in poverty: An analysis of health, disease and care processes among rural indigenous households. In External evaluation of Oportunidades 2008. 1997–2007: 10 years of intervention in rural areas (Vol. 2). Secretaría de Desarrollo Social. Saucedo, O. A. (2013). The gendered reading of conditionality in antipoverty programs: Unintended effects on Mexican rural households’ Interactions with public health institutions. Bulletin of Latin American Research, 32(1), 61–77. https://doi.org/10.1111/j.1470-9856.2011.00694.x Schultz, T. P. (2000). The impact of PROGRESA on school enrolments. International Food Policy Research Institute (IFPRI). Secretaría de Desarrollo Social (SEDESOL). (2016). Conoce todo sobre Prospera. Retrieved from http://www.gob.mx/sedesol/articulos/conoce-todosobre-prospera Skoufias, E. (2005). PORGRESA y sus efectos sobre el bienestar de las familias rurales en México (Informe de investigación No. 39). International Food Policy Research Institute (IFPRI). Skoufias, E., Davis, B., & De la Vega, S. (1999). Targeting the poor in Mexico: An evaluation of the selection of households for PROGRESA. International Food Policy Research Institute (IFPRI). Skoufias, E., & McClafferty, B. (2001). Is PROGRESA working? Summary of the results of an evaluation by IFPRI (Discussion Paper No. 118). International Food Policy Research Institute (IFPRI). Skoufias, E., & Parker, S. W. (2001). Conditional cash transfers and their impact on child work and schooling: Evidence from the PROGRESA program in Mexico

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(Discussion paper No. 123). Washington, D.C.: International Food Policy Research Institute (IFPRI). Smith-Oka, V. (2013). Shaping the motherhood of indigenous Mexico. Vanderbilt University Press. Smith-Oka, V. (2014). Fallen uterus: Social suffering, bodily vigor, and social support among women in rural Mexico: Fallen uterus in Mexico. Medical Anthropology Quarterly, 28(1), 105–121. https://doi.org/10.1111/maq. 12064 Smith-Oka, V. (2015). Microaggressions and the reproduction of social inequalities in medical encounters in Mexico. Social Science & Medicine, 143, 9–16. https://doi.org/10.1016/j.socscimed.2015.08.039 Ulrichs, M., & Roelen, K. (2012). Equal opportunities for all? A critical analysis of Mexico’s Oportunidades. Institute of Development Studies (IDS). Retrieved from http://www.ids.ac.uk/files/dmfile/Wp413.pdf United Nations Development Programme (UNDP). (2003). Human Development Report 2003. Oxford University Press.

CHAPTER 4

Street-Level Bureaucrats: From Obedience to Participation

The health clinics of Cualcan and Nexpan were located just a few blocks from the center of the towns. As I arrived to these small, modest, onestory buildings for the first time, I could see mainly women, young and old, sitting in the waiting room. These rooms were furnished with simple plastic chairs and a few posters with health information about vaccinations, contraception, and other announcements. Often, the front desk was empty, and the soft voices of physicians could be heard from the inside of the consultation rooms. This setting was where frontline officers and program participants constantly encountered each other. The question this book tries to answer is to what extent these interactions generated a relationship that is potentially vital for the success of the program’s aims and for the ability of Oportunidades-Prospera to improve the well-being of its participant families. To understand the effects of officer–recipient relationships on well-being, it is valuable to get a sense of this relationship from the perspectives of both actors involved. This chapter focuses on the narratives, experiences, and attitudes of the health officers during the delivery of the program in the clinics of Nexpan and Cualcan. It is based on interviews with officers and observations of the delivery of the compulsory workshops of Oportunidades and of interactions at the waiting room. These explored the ways officers talked about

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the recipient families, their relationship with them, and their roles in the program and in the clinic.1

The Context of Implementation: Between the Program’s Discourse and the Officer’s Job Position One of the most salient results was that the officers’ relationship with recipients was unavoidably one of authority and power. Yet, the strength of this authority and the effects of this power on the quality of the relationship was influenced by three distinguishing factors present in both localities. First, the language of conditionality embedded in Oportunidades; second, the professional and socioeconomic identities of officers and recipients; and third, the officer’s job position in the clinic. These structures did not constitute direct behaviors of officers during their exchanges with recipients, but certainly influenced how these took place. Oportunidades-Prospera’s Discourse of Conditionality Conditional CTs are based on the idea that poverty relief will be more successful if the poor demonstrate their commitment to lift themselves out of poverty. Hence, programs like Oportunidades-Prospera provide poor families with monetary transfers only if they commit to adopting actions that promote their human capital in the form of health and education. In the health clinics where Oportunidades was delivered in Nexpan and Cualcan, the conditionalities dictated the (minimum) frequency and the terms in which the officer–recipient interaction occurred. Families, but primarily mothers, needed to attend the clinic at least once a month for their compulsory workshops, although many turned up more frequently because of their involvement in the health committee, their role as vocal or because chronic illness or pregnancy required attendance every two months. These activities were mediated by the health officers and thus, this discourse of conditionality constantly framed how the health officers talked about the implementation process, the recipients, and their roles within the clinic.

1 Fragments of this chapter are published in Ramírez (2020).

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We call it ‘captive population’ in the sense that it is compulsory. We have to schedule their medical appointments and if they do not comply they get an absence [in their attendance record]. If they do not want to get an absence, then [they have to comply]. Permanent Doctor, Nexpan

As mentioned earlier, the health officers regulated the official conditionalities of the program through an attendance record. Therefore, when recipients did not comply with an activity, they got an absence on it. This happened for the official conditions of the program. Yet, in the case of the unofficial conditions, recipients were led to believe that they also got an absence if they did not participate in the health committee, for example. The officers constantly used words like compulsory in the previous quote, as well as obligation, compliance, and obedience when describing the conditions. Rather than recognizing the services they provided as an entitlement of recipients, the language of conditionality transformed it into an obligation, which of course changed the way physicians delivered the medical attention and their expectations of recipients’ behaviors as they received it. For instance, the physicians recognized their capacity to use their discretion to decide if a ‘proof’ of absence from a recipient was sufficient to justify it or not. Of course, many of the reasons for an absence were not verifiable, such as not being able to leave work. Although others were verifiable, like missing a consultation because of an activity at school, physicians still had the last word to consider it or not. In some cases, physicians interpreted absences as laziness or forgetfulness, and did not take the word of the recipient. The discourse of conditionality was so intertwined with the way physicians delivered the services that they believed that participants only attended the clinic because the services were compulsory. Hence, they used this in most of their interactions with recipients. A lot of people do not come because “oh, I forgot”, or because “I was lazy to come early so I didn’t”. Obviously, if they come with a sick note or proof that something urgent happened, you (officer) decide if you justify their absence or not. Because as they receive the [cash transfer], they also acquire an obligation. Temporary Doctor, Nexpan We tell them how they have to participate, that they always have to come to their health check-ups, what documents they have to bring. And with the aim of getting them to attend, I tell them that whoever does not come to their consultations or their vaccinations, they get an absence from Oportunidades. This is the only way they come. Temporary Nurse, Cualcan

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Indeed, the discourse of conditionality set the terms of the relationship through the strategies officers used to encourage participation, their expectations from recipients, and their understanding of their own roles in the delivery of the program. Officers had the perception and expectation that the recipients’ part was to obey and comply, and in contrast, the officer’s part was to enforce, regulate, and mediate the services offered. Together these created what could be considered a disciplinary relationship in which the attendance record was an authoritative tool officers could use at their discretion. Identities and Intersectionality The accounts of officers also suggested that their own identities and their reading of the identities of recipients were central frames of their interactions. Of these identities, their status as Oportunidades’ officers and their identity as a particular kind of officer, physicians or nurses, was particularly important. The officers understood this institutional relationship mainly as one between medical staff and patients. The prominence of the professional identity over the managerial identity of the frontline officer is documented elsewhere in the case of social workers implementing health care policies (Evans, 2011). In both localities, Oportunidades’ recipients were a large group of the population (in Cualcan it was half of the total population) and unquestionably the group that used the clinic the most. In spite of this, the officers talked about them far more frequently as patients than as policy participants. The program is applied at the national level and is implemented [in the clinic] through the health ministry. What happens is that the pa… no, not patients, they are called… the beneficiaries register to the program (…) and when they are accepted they come here so we can generate their annual schedule of medical appointments. Temporary Doctor, Nexpan

In the day-to-day practice, the line between recipient and patient was blurry. In contrast, officers clearly labeled themselves as doctors or nurses rather than as public officials or program providers. Even when describing their roles in the delivery of the program, they never spoke of themselves as officers. This is probably because, as the following quote suggests, Oportunidades is only part of the work they do in the clinic; but also because they are not the direct employees of the program.

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(Researcher: What is your main role in the clinic?) I am the director of the clinic. I am a doctor. (Researcher: And what does that imply?) Oh! Well, everything (laughs). Starting from giving medical consultations. We are doctors but we focus on prevention. So, the greater number of healthy consultations we have, the more impact our service is having. We cover at least 15 programs, Oportunidades is one of them. Permanent Doctor, Nexpan

The patient–doctor duo was probably the most important identity influencing the relationship between these actors. Socioeconomic status also differentiated officers from recipients. In contrast to the urban, educated, and middle-class image of themselves, officers often identified beneficiaries as poor, uneducated, farmers, and even backwards. A differentiation that lead to discriminatory treatment. Oportunidades is given to families that have greater economic needs. The program includes that you have to check them every 6 months, they have to come in for a medical consultation, and us in the dental area take advantage of this because they would never come for dental consultation on their own will. (Researcher: Why do you think so?) Well, because even though Nexpan is close to a city, I feel that is a region that… since they are farmers, they don’t have the… how can I put it? They do not value their dental health. They do not have the knowledge or the education. They are a little backwards in that regard. Permanent Dentist, Nexpan Imagine how she (the director of the clinic) would talk about a person who… I mean, many beneficiaries cannot read or write. So the treatment is not good, no. Temporary Doctor, Nexpan

Ethnicity was mentioned by officers in the indigenous locality of Cualcan primarily as an important barrier for successful communication with recipients. Language was perceived as a challenge during consultations. The health officers in Cualcan at the time did not speak Nahuatl, and thus they provided their workshops and consultations in Spanish. Recipients tried to solve this by bringing a family member that could translate, but if this was not the case, doctors reported difficulty explaining their patients their condition and the use of medications. One would think it would also be the case for the effective delivery of workshops, although this was more difficult to detect by the physician carrying it out to 20 or 30 women at a time. Especially because workshops were primarily organized as a lecture from physicians rather than as a space where women could actively participate. The influence of gender was not readily visible in this study because most participants—physicians and recipients—were women. However, we

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cannot disregard its significance. While this study was not able to observe gender differences directly, both officers and recipients recounted negative interactions with former male officers. At the same time, previous research has found that recipients felt less comfortable during consultations with male doctors (Adato et al., 2000). Nevertheless, what was obvious in this setting is that overlapping or intersecting identities relating to gender, socioeconomic status, educational achievement, ethnicity, and geographic location were relevant for the quality of the interactions and the ways officers provided the service. Officers were aware that their clients were mostly female, indigenous, uneducated, and recipients of a poverty relief program, a perception that was inseparable from their attitudes toward them. Temporary Officer Versus Permanent Officer Naturally, the relationship with recipients varies between officers and localities. However, in this sample, the officer’s job title as temporary or permanent was the most salient distinguishing factor. Despite the complexity of the job positions established by the National Health Ministry in Mexico, in these two localities there was a clear difference in the narratives of officers based on their employment status as permanent or contract-based, and as temporary or student-based. In the case of Cualcan, the officers interviewed were students (one physician and one nurse) working in the locality for a year as part of their final year training before finishing medical school. In some countries, this is called an internship and therefore is an ‘unpaid’ service they provide to the community. The medical intern in Cualcan was the current director of the clinic since the Ministry did not assign a permanent doctor for the duration of her placement. In Nexpan, only one of the four officers interviewed was a medical student or intern and the remaining three were certified clinicians (one doctor and the director of the clinic for the last three years, one dentist and one nurse) who received payment for their services. Interestingly, while the position as nurse or doctor did entail a hierarchy in the clinic, there was a consistent and clear distinction in the way officers described their relationship with recipients depending on the permanency of their position and not their training as nurses or doctors. Permanent officers established a more authoritarian and power-based relationship compared to temporary officers which were more responsive to women and their needs. The temporary officers corroborated these

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observations by describing the attitudes of previous or current permanent officers as authoritarian, confrontational, and even abusing, and because of this, they consciously took a different approach. A previous nurse trained me and I observed her and learned how she treated people. So I got an idea of how to work. But there were some things that I changed because sometimes people said she had a very bad temper so I try to be kinder to people because some say, “I rather not go (to the clinic)”. Others say that the [former permanent doctor] was constantly scolding them, so they didn’t want to come to their consultations. So, I try to be better. Temporary Nurse, Cualcan There are some staff who, since they already hold a position and they get paid, they take advantage of the power that this gives them. (Researcher: And do you feel that this happens in this clinic?) (Laughs) Yes, yes it happens. Temporary Doctor, Nexpan

These accounts problematize the exercise of power and abuse from permanent officers and recognize the effects these could have on the outlook of recipients to the clinic and to complying with the conditions of the program. These contrasting attitudes and type of relationships created by temporary and permanent officers were present in all themes that emerged from the interviews as well as in the many observations in the health centers. At the same time, the fact that the clinic in Cualcan was mainly led by temporary officers, whereas in Nexpan most officers were permanent, resulted in these localities witnessing two contrasting officer–recipient relationships.

The Officer–Recipient Relationship: From Obedience to Empathy The chief objective of interviewing the health officers was to understand their perspectives about their relationship with recipients during the delivery of the consultations and workshops of the OportunidadesProspera program. During the interviews, this was explored in two ways. Firstly, a direct account of the relationship was obtained by asking officers to describe their relationship to recipients. Secondly, to avoid any biases in the findings because of the way officers chose to narrate the relationship, an indirect account was obtained from the stories they used to explain the process of policy delivery, their challenges during this process, and their overall experiences in their job and the localities. The narratives of officers showed that these localities by and large witnessed two

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contrasting officer–recipient relationships. In Nexpan, the relationship with the permanent officers was hierarchical, mostly characterized as one of obedience, power, and disengagement. In Cualcan, in turn, the relationship with the temporary officers was more horizontal, and could be described as one of reciprocity, communication, and empathy. Authority through Power and Obedience: Permanent Officers In response to the question, ‘how would you describe your relationship with the recipients,’ the permanent officers in Nexpan started by describing a moderately positive relationship and denying any conflict with recipients. However, the tones and words used suggested an ambivalent relationship that easily moved from the positive to the negative. Good, you have to have a good [relationship] because if you don’t they don’t obey you. There needs to be empathy and respect, but also authority because they are too many [recipients] and all behave like children, “I arrived first, why her and not me?” (Imitating a ‘recipient’ with a childish tone). And they are only looking [what to complain about]. So you have to treat them all at the same level. Permanent Doctor, Nexpan Apparently [the relationship] is calm and normal (laughs sarcastically). There is the one who gets upset because there is no consultation or whatever, but you try not to be affected by it (laughs) because there are some [recipients] who are quite insolent (she conjugated the word in Spanish in a way that is usually used in a degrading manner or with a superiority tone: ‘groseronas’). Permanent Dentist, Nexpan

These quotes provide numerous insights into the character of the relationship between the recipients and the permanent officers. First, they suggest an expectation from the officer that recipients behave obediently and compliantly, and officers assumed that an authoritarian relationship was necessary to maintain control. Secondly, they also suggest that the relationship was in constant tension because, while recipients exponentially increased the officers’ workloads, recipients also permitted officers to achieve most of their performance targets expected from the Health Ministry. Therefore, the most important purpose of having a ‘good’ relationship with recipients was the benefit obtained from their participation.

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I rely a lot on Oportunidades. We call it captive population in the sense that it is compulsory. We have to give them appointments [and] it is there where we apply all our programs, we examine them based on all our programs. In that way, I have productivity in my own programs and we have Oportunidades completely covered. Permanent Doctor, Nexpan

An important part of the officers’ job was to achieve certain monthly quotas in the health programs set by the Health Ministry (e.g., vaccination, pap smears, detection of diabetes, etc.), programs that in some cases were external to Oportunidades. If these performance quotas were not achieved, the health professional feared receiving some form of penalty. In the interviews, officers reported that there were no formal penalties if they did not reach the quotas. Yet, they felt constant pressure from the Ministry and, permanent officers specially, feared not having their contracts renovated (see also Campos & Peeters, 2021). Hence, recipients were instrumental for officers in pursuing their duties and keeping their jobs. Thanks to the recipients’ condition as ‘captive population,’ officers were able to satisfy the Ministry’s quotas.2 This also reflects how the language of conditionality of Oportunidades was used during the delivery of the services. The existence of a hierarchical relationship was visible in many ways in the narratives of permanent officers in Nexpan. One way was in the use of sarcasm, and offensive or superiority tones as officers talked about recipients. While it is difficult to communicate paralinguistic expressions in a written form, the next quotes try to illustrate how these were used to dismiss, reject, or disengage from the recipients and their needs. (Researcher: What have you liked about working in this clinic and in this town?) Well… I have liked that they do obey as long as you explain things to them and talk to them right, because they don’t like that (long laugh)… We have to treat them well. Permanent Doctor, Nexpan [About working] in the town? (laughs) The town… the town… Who knows (laughs sarcastically), I don’t know the town (laughs)… Well… I don’t really leave the clinic, but one works with the people… There are some grateful people

2 Research published after the elimination of Prospera confirms this. In a study conducted by Campos and Peeters (2021), the health professionals that remained in the clinics that formerly implemented the program, reported the sudden loss of easy access to clients that allowed them to meet their performance quotas.

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and others are rude, we have of all types. There are people who do understand you, but they are very few. Permanent Dentist, Nexpan

The last quote from the interview with the permanent dentist is rather illuminating. She starts denying any relationship with the town, as a way of separating herself from the people (‘I do not know the town’). Yet, she then seems to reassess this by suddenly realizing that she has daily contact with its population during dental consultations and when she helps with the program’s procedures. Next, instead of talking about her experiences as a dentist or performing her tasks in the clinic, she focuses primarily on ‘the people.’ This focus on recipients and their attitudes (‘there are some grateful people and others are rude, we have of all types’) underlines the centrality of relationships in the officers’ own accounts of their work. The particular personality of one officer did not necessarily caused this. Rather, in most of the accounts of current or previous permanent officers, there was a focus on their interactions with patients and at the same time a constant disengagement from them. There was a differentiation between ‘us and them’ and a need to make clear this difference through tones of superiority and degrading characterizations of recipients. People here are quite close-minded. Well, (long pause) it is not that they do not have the knowledge, what they don’t have is the willingness to learn. (…) People do not have much education because even though you explain things to them they do not understand. I think it requires a lot of effort from them, because of their customs and [because of] what one is telling them. Permanent Nurse, Nexpan

This negative way of characterizing an entire town by permanent officers (as backward, unwilling to learn, and uneducated) was recognized by the only temporary doctor in the locality when contemplating the way the director of the clinic talked about and to recipients. There are some staff who, since they already hold a position and they get paid, they take advantage of the power that this gives them. (Researcher: And do you feel that this happens in this clinic?) (Laughs) Yes, yes it happens. But you will see it yourself. I could tell you things but don’t tape them (…) The doctor [director] discriminates [recipients] a lot. Temporary Doctor, Nexpan

In her interview, the director of the clinic confirmed this attitude.

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I don’t like to antagonize with the people, why? Because if I do, they stop obeying you and the tables turn around! They are aggressive, they all gang up, they are liars. They say you mistreated them or that you didn’t want to give them consultations or that you talked to them badly. I mean, they start talking about mistreatment, wrongful charges, or things like that. (…) So you think I will be risking being bad to people seeing how they are? Permanent Doctor, Nexpan.

This passage supports the negative characterizations of recipients and the relationship of power and authority created in Nexpan, especially by permanent officers. Yet, it also speaks about the ambivalence of power and its uncertainty. The officer feels she has to comply with ‘being nice’ to recipients, and has a sense that her power could be easily taken away if recipients allege wrongful charges or mistreatment. This uncertainty could also influence on her need to misuse her authority. Additionally, the quote describes the tendency of redirecting the focus toward the recipients as sources of any conflict that emerged in their relationship and in the implementation of the program. In the interviews, officers were asked about the strengths and challenges of the clinic during the implementation of the program to try to understand how they perceived their own roles and those of recipients in it. When discussing the strengths, all officers concentrated on their own roles and activities such as their effective organization and how they followed procedures. Their motivations or aims for doing so were, however, rather different. The permanent officers in Nexpan considered that their organization allowed them to apply all the health programs that the clinic was expected to apply by the Health Ministry. When asked about what were the difficulties the clinic faced during delivery, however, recipients were frequently at the spotlight. There was an expectation that recipients abide to the rules and recognized their duties in the clinic and in the program for it to be successful. (Researcher: What difficulties do you think the clinic faces in the implementation of the program?) Well that [recipients] support us. [The difficulty] is that people do not want to support us or comply. There are certain rules, [for example], that they have to arrive at a certain time. But [although] they know, they arrive late. (…) They have rights but also duties and rules, don’t they? But often the people does not educate themselves to arrive at a certain time, sometimes they want to come whenever they... But

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we (officers) not only have to attend to them, we have to do other activities! Permanent Dentist, Nexpan

Even though officers were expecting recipients to comply with their duties, there was a clear tension in Nexpan around the provision of consultations. Although the clinic’s official opening hours were between 8:00 and 17:00, the real working hours were hazy. To receive the compulsory consultation of Oportunidades, recipients were asked to arrive at 7:00 to start making a queue. In this clinic, the consultations to the general population were combined with the compulsory consultations of the clients of Oportunidades. Therefore, the queues could be long and tiring. The consultations would be delivered between 8:00 (or when the doctor arrived, which not always happened), until 14:00 (before the Oportunidades workshop started). Therefore, people could be waiting seven hours to be called. These long waiting times forced many recipients to forgo that day of work—and possibly that day’s income. This, together with the uncertainty of when and if the consultation will take place, generated frustration in both recipients and doctors. As will be seen in the next chapter, the recipients were upset and unsatisfied with this delivery format, and the officers felt irritated by the cumulative demands from recipients, patients, and their other work responsibilities. Yet, at the same time, this form of organizing the consultations was the choice of the director of the clinic, and reflected a disregard for the time and needs of recipients and general patients alike. In sum, the relationship between officers and recipients in Nexpan could be characterized as one of hierarchies, mistreatment, and an expectation of obedience from recipients. In many ways, officers tried to exert their power over recipients, it was rare they showed empathy toward them and their situation, and they sometimes talked about recipients in derogative tones. Officers were aware of the potential collective power of recipients and this was referred to in a negative way and even as a threat they wanted to restrain through (ab)use of power. Officers did not reflect upon their own role in the quality of the relationship. Instead, recipients were often depicted negatively, conferring to them and their attitudes the responsibility of a good/bad relationship and of the outcomes of the program. This type of relationship was salient in my observations of the only permanent officer in the clinic in Cualcan (a nurse). Despite not being able to interview her, as she refused, my observations during the workshops suggested that she addressed the groups in

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a rude and authoritarian manner, to which recipients reacted by avoiding her and approaching another officer with questions. Yet, by and large, the accounts of (temporary) officers in Cualcan echoed a very different relationship with recipients. Authority through Communication and Support: Temporary Officers In Cualcan, the tone of temporary officers was unlike that of permanent officers in Nexpan. Despite the unavoidable hierarchies created by the program’s discourse of conditionality and the differences in socioeconomic identities, in their narratives and attitudes, officers described a more positive and less hierarchical relationship with recipients. [The relationship] is very good, they participate in anything we ask because we try to talk to them kindly. Some just can’t [participate] and others don’t like to, but they are a minority. They are united and when they are organised they do it well. With nurse X [permanent nurse] they do not have a good relationship because her treatment is rude, aggressive; but with me, they participate well and support the clinic. They come and ask, ‘do you need anything doctor?’. Temporary Doctor, Cualcan There is a good relationship. If any [problem] escalates, we talk to them, have a conversation with them. For example, if the number of consultations given now is less than what was before, we let them know so that they understand the situation and the reasons. We try to communicate with them. Temporary Nurse, Cualcan

These storylines have rich information about the distinctive approach temporary officers in Cualcan took toward recipients and toward their job. On the one hand, they presented recipients in a positive tone, as participative, organized, and supportive during the delivery of the program. On the other hand—and in contrast to permanent officers—,the strategies used to enforce the conditions of Oportunidades were primarily good treatment and communication. To promote participation, they used hierarchies less frequently and instead underlined their shared responsibility in the procurement of the chores that recipients helped with in the clinic in their character of health committee members or vocales . Sometimes I deliver the workshop and what you do is converse with them in a way they understand what I am telling them. And, I also help organise the chores [of the health committee] and I team up with [recipients] so that there

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is a good result [in the work]. Because if I only go and tell them ‘do this and do that’ and I come back in to do my own work, well, they are going to say ‘she only comes to command and does not help’. Temporary Nurse, Cualcan I feel that [recipients], at least unlike with the previous doctor, have a little more confidence when approaching me. They are not afraid anymore, they do not get angry, they do not think that they will come only to get into a fight or get reprimanded. So yes, is nice that the people themselves say they receive a better attention. Temporary Doctor, Cualcan

Officers reflected on their own role in constructing a positive relationship by using kindness and respect, and providing clear information to recipients. They recognized that their forms of engagement with recipients could have effects on the recipients’ participation, attendance to consultations and attitudes toward the program in general. Yet, this recognition goes further, as the officers were aware of the effects they could have over the recipients’ confidence and emotional well-being during policy delivery. Interestingly, temporary officers coupled quality of medical attention with quality of relationship in many instances, which was something that permanent officers did not do. In this locality, the interest of officers in constructing a positive environment around the clinic and of providing a better treatment was not only to meet the Ministry’s expected quotas, but also to improve the recipients’ participation and attendance to the program’s activities. They recognized the profit recipients obtained from better public health and from participating in the activities of Oportunidades. Hence, the focus moved away from the officer’s own benefit, to those of recipients and the larger population. When the environment is nice, everything comes together: you build a relationship with people, they vaccinate their pets, and they comply with their Oportunidades workshop. You kill two birds with one stone. Temporary Doctor, Cualcan

The consideration for the needs of beneficiaries was also visible in the way the conditions of the program were organized in this clinic. In juxtaposition to Nexpan—where the compulsory consultations of Oportunidades were combined with the consultations provided to the general population—, in Cualcan officers chose to concentrate the consultations of the program to two hours every day, from 12:00 to 14:00. At these times, physicians only received recipients of Oportunidades and, therefore, the

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latter could plan their days better and not miss a whole day of work to comply with the program. These accounts of the process of implementation of Oportunidades reinforce the description of this relationship not as one in which power is absent but one in which officers manage their power in a different way. They use it not to force obedience, but to promote participation, one that benefits both recipients and them. However, the fact that the officers’ accounts suggest that hierarchies did not rule the relationship does not mean that there were not conflicts or an exercise of authority from temporary officers. The interviewees did acknowledge the existence of conflict, yet, instead of identifying recipients as the guilty party in the conflict, they focused on the causes and their attempts to solve the conflict. In most cases, the temporary officers in Cualcan used communication as a tool to resolve conflict with recipients. However, in some of their accounts the word reprimand was employed in a particularly interesting way. This is illustrated in the following quote where the officer is expressing her bewilderment about why some recipients are more interested in the cash transfer than in their health. She gives the example of a recipient who constantly comes to the clinic for duties related to the program. Still, for months she did not get her blood sugar checked out, resulting in dangerous levels of glucose in her blood. I talked to her about this. I reprimanded her, no, I lectured her so she can reflect on this. I explained the consequences this might bring [to her health]. (…) The kind of situation that I like to create is that if they are not complying (with Oportunidades), I try to give them orientation. To tell them in a way that, it is not a nice way because we are talking about a situation with which you cannot play around. It is a situation in which their health is at risk and they have to be aware that they need to be regularly checked out. So, I reprimand them in a direct way but without being disrespectful. Without yelling, scolding, humiliating, without any of that. Instead, creating awareness about the importance of taking care of themselves. Temporary Doctor, Cualcan

In this community and in general, the temporary officers did mention what can be considered the hierarchical concept of ‘reprimand’ (as in a parent–child relationship). Nonetheless, in the way they used it, the ultimate benefit was for the recipient and not their need to maintain a disproportionate level of authority. In this case, it was about the risks to the recipient’s health because of her lack of compliance. In other cases, the officers in Cualcan and the temporary officer in Nexpan, used the

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word reprimand to make recipients aware that they were about to lose the program if they did not comply with the conditionalities. Finally, often when talking about reprimand, the temporary officers showed awareness that this word was loaded with issues of power, and annotated that, even though they considered it necessary, it was always done in a respectful way. Overall, the tone of the officers in Cualcan and of temporary officers in general was of empathy and engagement with their work and their clients. Their strategies of implementing the program were less hierarchical, and during which the perspectives and feelings of recipients were taken into account. The authority of officers in this context was not enforced through power or discrimination, but through trust, communication, and respect. Indeed, there was a striking difference between the attitudes of permanent officers and those of temporary officers, resulting in important disparities in the terms of their relationship with recipients. In the following section, these contrasts are explored in more depth by analyzing two topics, the officers’ outlooks on their roles in the clinic (and thus of the recipients’ roles) and their narratives of the recipients in general. The Good and the Bad Recipient The assumptions officers had about what was a positive attitude from recipients and those that were frowned upon or conflictual were salient in the interviews. In many situations, both temporary and permanent staff described the recipients as demanding. Yet, the contexts in which these words were used and how they were interpreted also reflects the contrasting relationships built by the two kinds of officers. For permanent doctors in Nexpan, people demanding their rights or defending their position was interpreted as aggressive or dissenting. It was definitely an attitude that was not well regarded and even considered a threat. In contrast, a good recipient was one who was docile and obedient. [Vocales] are more demanding. They think of themselves as having more rights. Some are fussy. Permanent Dentist, Nexpan Some (recipients) have an aggressive attitude, they are dissenters! Permanent Doctor, Nexpan As long as the people are calm when they talk to you, well, then you stay calm too. I mean, that they let you do your work. Permanent Dentist, Nexpan

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In Cualcan, being demanding was not narrated as a negative attitude in itself since, for the temporary officers, recipients were entitled to fight for their rights and also their attitudes were a sign of historical mistreatment from other physicians. Still this defensiveness made their interactions more complex, and officers consider it a challenge in their relationship with recipients. Officers recognized that because of this attitudes they needed to treat recipients and take decisions in a way that was explicitly transparent and considerate, to avoid any conflicts with the population. In general the population is good, but difficult if you don’t know how to work with them, if you don’t know how to comply with their needs. They are no longer the people who did not react, who were repressed. (Researcher: Why do you think they changed?) In the clinic because they did not like the mistreatment from previous doctors (…) I mean, before the people was more peaceful. Now they treat you the way they are treated by you. Temporary Doctor, Cualcan Everything is done in a way that everyone knows and everyone agrees, because if you don’t, they think that we imposing things and they don’t like that at all. Temporary Nurse, Cualcan

In sum, in the case of the permanent officers in Nexpan, there was what could be considered an idea of the good and bad recipient. The good recipient was one who had a docile attitude and followed orders. The bad recipient was one who demanded rights they were not entitled to from the officers’ perspectives. Temporary officers did not follow this dichotomous interpretation. They held a more positive understanding of recipients as participative, organized, and helpful; and narrated their demand for respect as their entitlement. This use of agency was recognized as difficult in certain contexts.

Explaining Opposing Relationships A subject that is left unresolved is why permanent and temporary officers showed such striking differences in their encounters with recipients. To understand better these differences, they must be viewed within the broader context in which they took place, such as the difficulties officers faced in the execution of their tasks, broader relational processes and environment within the clinic, and cultural factors. The observations in Nexpan and Cualcan give interesting clues to these factors.

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Having a Contract The most evident difference between permanent and temporary officers is that the former worked on a contract and received payment for their services while the latter did not. Working under a contract, gave permanent officers greater authority and therefore more power within the clinic. This was particularly the case for the directors of the clinics. It was obvious that the directors were the main authority in the clinic, managing and providing the consultations and workshops of the program, applying other health programs, allocating responsibilities, and supervising the staff. They also had the main role in monitoring the recipients’ compliance of the conditions of Oportunidades. The rest of the staff, largely followed the director’s orders, and thus the working environment created in the clinic was heavily reliant on them. As such, the contract conferred permanent officers greater authority and power in the clinic, it also increased the responsibilities and challenges that come with them. For temporary officers, their time in the locality and holding that position was only transitory. Their internship would last one year and their professional career could move elsewhere in the future. Therefore, their encounters with the challenges and routines of the job were brief and this novelty could explain their positive attitude toward it. Permanent officers, on the contrary, had a relatively stable position and with it greater obligations in the clinic and with the Health Ministry, which increased their stress and tiredness toward their duties. A study with nursing students in the United Kingdom found similar attitudes from senior health professionals compared to students in which the latter perceived that senior officers had developed disengagement, exhaustion, and disillusionment toward the job (Hughes & Condon, 2016). In Mexico, the Health Ministry is quite flexible and constantly changes frontline officers from one locality or position to another. In these localities, some of the permanent officers had spent less time in that clinic than temporary officers had. However, there is something about the stability of the work and the responsibility that came with it that can explain the attitudes of permanent officers even though they had spent just a few months in a locality. Most permanent officers were older and had worked in the health system for longer, causing that the tiredness of the job increased. As Lipsky (2010) recognized, officers could take with them the weariness from one position to another and from one community to another. In my conversations with the director of the clinic in Nexpan, I

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found that she transferred to this locality the uneasy relationship she had with the population in her previous station. A bond that seemed to be repeating itself in Nexpan. The Health Ministry When discussing the clinic’s challenges in implementing Oportunidades, temporary and permanent officers raised three themes. Firstly, despite the differences in type of contract and seniority between permanent and temporary officers, both temporary and permanent officers considered the recipients’ participation central to the effective delivery of the program. Secondly, only temporary officers reflected on the need to improve their organization in terms of consultations and paperwork as well as better communication among staff. Finally, the topic that officers mentioned with greater concern was the constant failure of the Health Ministry to provide the necessary resources and staff, which limited the effective functioning of the clinic. This role of the Health Ministry in the operations also had a direct influence on the attitudes of officers toward their work. The Health Ministry regulated all the procedures of the clinic, the rotation of staff, and the provision of medical instruments and medicines. In both localities, the officers expressed their difficulties due to a recurrent lack of support from this institution. For example, while the Ministry set certain quotas in different health programs like vaccinations and pap smears, they often did not provide the necessary instruments and the staff to attend the target population or even to meet the requirements of the Ministry itself. For tuberculosis, they (Health Ministry) ask me to do 100 tests but do not give me the instruments. In the case of chronic patients, they ask me to take 70 to 100 tests and they send the instruments but only to do 10. And at least I have 104 patients! And woe be unto you if you do not do them. Permanent Doctor, Nexpan To be honest we really need a permanent doctor because sometimes we have too many people expecting a consultation. From Oportunidades, we are asking recipients to come for their (compulsory) consultation but we cannot give it to them. And [they worry] they will get an absence in their attendance record. So yes, the amount of staff influences a lot. Temporary Nurse, Cualcan

This had an effect on the quality of the medical care provided and as requested by the conditions of Oportunidades. The lack of support from

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the Ministry in the provision of staff increased the pressures officers endured as well as their workload in paperwork and consultations. We are supposed to give a full check-up to the elderly, their body mass index, glucose, everything. But we do not have the instruments to perform them. (…) Many people only come twice a year for their consultations, and if we do not have the tools for detection, they leave without being checked, and we will see them only until the next semester. Also, the lack of staff implies you cannot focus too much in each of the many recipients that come for their compulsory consultation because outside you have other 20 ill people waiting. Temporary Doctor, Nexpan

At the same time, the lack of staff and of medical instruments obstructed officers from fulfilling the minimum requirements that the Oportunidades program established itself for the health conditionality. Officers perceived this as a contradictory discourse from the Health Ministry’s expectations, procedures, and values. In the central offices there is one coordinator for each program so, each month I go to deliver my reports they start asking, “why didn’t you do this or that?” And for the programs [I had greater output in] they say “Oh no, but in this one you did more, I am going to erase some here because they should be 50, not 100”. So you think, what about my productivity in these other programs? This is the type of logistics I do not agree with. Permanent Officer, Nexpan I’ve been reprimanded because I delivered 447 consultations this month and they (Health Ministry) told me that I have to reduce it to half. And I asked them “Why is it wrong that I am giving so many consultations?” And they answered, “Because when the next (permanent) doctor arrives ‘he’ will not want to give as many consultations as you and ‘he’ will not be liked by the town”. I don’t understand the way the ministry thinks, their norms. It is not possible that they are denying the service. I want to work, I am not complaining, on the contrary. I happily delivered them a good productivity and they tell me this. (R: Do you think that other doctors would not be able to do what you are doing?) With organization yes, we have enough time, and giving quality consultations to people. Temporary Doctor, Cualcan

In Nexpan, the director of the clinic expressed how the Health Ministry was only interested in obtaining the exact quotas requested. Instead of reinforcing any other achievements, they erased them from the officer’s reports. In Cualcan, the Health Ministry also reprimanded the officer for giving a larger number of consultations. According to the officer’s

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account, this was not because of a concern with the quality of each consultation, but a concern that the next officers will not be willing to give the same amount of consultations and the town would notice. The discourse and procedures of the Health Ministry risked prioritizing filling up quotas and numbers over the health of the patients. This incongruous approach could have had an influence on the attitudes that medical staff, especially permanent, develop over time. The pressures of the work setting of frontline officers and their influence in the effective delivery of the program is in line with the street-level bureaucracy literature that identifies lack of support, ambiguous demands and policy goals, and inadequate resources as part of the daily challenges of policy delivery. Similarly, officers often found themselves in a tension between their professional responsibilities as physicians and the increasing bureaucratic demands of policy-making (Ellis, 2011). During my observations at the clinics, there were days in which the physicians, especially the directors of the clinics, were virtually unavailable to patients because they needed to fill in forms for their monthly reports to the ministry and to Oportunidades. An interesting consequence of this finding is that the relationship between frontline health officers and their superiors at the health ministry is yet another relational context implicated in the outcomes of the program in people’s lives. The hierarchical relationship perhaps too usual in this kind of institutions, the amount of pressure imposed over frontline officers, and their expected obedience to rules that sometimes are blind to the challenges of implementation, can indeed have critical consequences on the terms of a relationship further down the chain: the relationship between frontline officers and their clients. Relationships Among Staff Another reason for the opposing approaches by permanent and temporary officers seen in the two communities was the quality of the relationships among staff. This was particularly evident in Nexpan where both recipients and medical staff characterized the director of the clinic as very ‘strict’ and with a ‘difficult personality.’ This translated into an exercise of power and authority that could have had an effect on the approach that the medical staff needed to have toward her and toward recipients. Hughes and Condon (2016) study of nursing students support the importance of relationships at work particularly for temporary staff as it finds

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that trainees experienced greater satisfaction with their work when their working environment and supervisors were supportive and flexible (see also Halliday et al., 2009). The next quotes come from conversations with the medical staff working under the director of the health center in Nexpan (Maria). (R: How do you feel about working here?) I have liked it… I mean, the doctor has a very strong character, not everyone adapts to her so each person needs to find a way of coping with working here. Temporary Officer, Nexpan (R: When there are tensions because of the workload, can you easily talk to the clinic’s director?) It is a little difficult (laughs) because she has a very strong character. When she is stressed and has a lot of pressure, she has a very strong character. But once her tension is relieved, maybe you can go talk to her and try to reach an agreement. I think one needs to give in because if you don’t the problems keep growing. Permanent Dentist, Nexpan

These testimonies depict a low communication with Maria and tension between the staff. By highlighting the strong personality of Maria, both officers imply that her exercise of power makes the relationship between staff more arduous. Thus, in order to have a better relationship with Maria the officers needed to abide with her way of approaching things (‘one needs to give in’). Indeed, an interviewee suggested I take this approach if I wanted to conduct my research in the clinic. The following quote comes from a point in the conversation where she is explaining to me what happens during a consultation of Oportunidades. (R: Do you think it would be possible for me to observe a consultation?) Well, unless you ask the patient for permission… but do not even dream that [Maria] will let you. To be honest I don’t think that she will allow you to have much access to the clinic. I think that if you want to see anything you would have to become her ally, because if you don’t it will be very difficult for you. She is not very open. Perhaps because is not convenient for her, there are many things that… you will notice yourself. Also, a permanent officer will not be able to tell you much because maybe the doctor could do something [to them], you know? Temporary Officer, Nexpan

This relational dynamic in the clinic might have led officers to find ways of coping with the working environment including accepting and reproducing the attitudes that the director had toward them, the work, and the recipients. This was clear to me since the first day I arrived to the clinic to

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introduce myself to the staff and to the director, Maria. As I introduced myself to her, she asked very detailed questions about me with an authoritarian and annoyed attitude and then she abruptly asked me to come back at 14:00 with a list of documents to prove my identity (including my official ID, degree certificate, and proof of address). Later that day I came back and Maria was in her office accompanied by a temporary doctor (who finished her internship that week) and the permanent dentist. After I was called into the room, as I came in, Maria pointed at a stool and, without looking at me, asked me to sit there. Then, she extended her arm requesting the documents I was carrying in a folder and introduced me to her assistants. She asked me to explain what I was researching. A few seconds after I started to explain, she interrupted saying that she was very busy and I had better be clear about what I was doing and what I wanted there. I started again and mentioned that I wanted to be able to attend the Oportunidades workshops to get to know the recipients and that I would be happy to help in the clinic in any way she considered appropriate. To this, Maria laughed and said, ‘But you are an economist aren’t you? You don’t know anything about medicine, so there is very little you can do here, except buying us breakfast or something (laughs).’ Ana (permanent dentist) gave chorus to Maria’s sarcastic laugh. The temporary officer, on the other hand, had an expression of amazement and discomfort. At the end of what was probably a five minute meeting she mentioned that if she was not around the only person that would have the authority of letting me in the clinic and sharing information was Ana, and that ‘she would share things at her discretion.’ Even though my relationship with Maria improved with time as she realized I was not a direct threat to her or her job, the consequences of her personality were visible in her relationships. Particularly, this scene clearly shows a relational phenomenon between the officers that could affect interactions with recipients. In this scene, Ana was the only one explicitly supporting Maria’s sarcastic attitude toward me, which in the end proved to give her privileges that no other staff had, being her right hand. This makes it possible that the hierarchical relationship observed in the officer’s accounts of recipients also happened in the relationship between staff. In order to avoid being at the lowest steps of the hierarchy, the staff needed to reaffirm and support the attitude of Maria toward me (in this case) but more importantly toward recipients on a daily basis.

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Relationships Within Localities In contrast to relationships among staff, another relational sphere that could influence interactions between officers and recipients was the ability of recipients as a group to organize themselves to voice their opinion or complain about any wrongful treatment received or inadequate procedure conducted in the clinic. Although this will be explored more deeply in the next chapter, it is worth mentioning here briefly. In Cualcan, the people were known for their collective strength against cases of injustice. This reputation transcended the locality itself. When I was choosing the fieldwork contexts for the research, I had meetings with researchers and government officers in the city of Puebla to find out more about this locality. More often than not, they warned me of the ‘political’ and ‘aggressive’ attitude of the population in Cualcan, trying to dissuade me from going there. They recounted previous instances where the population got together outside the clinic to demand the current permanent doctor to leave the town, and one mentioned that they constantly came into the clinic with their machetes (the tool they use in the field to harvest). Even though I never witnessed this kind of behavior and it was evident that people came into the clinic with their machetes because they were coming from or to work, the people in this community did transpire a personal dignity and collective unity that is uncommon in the eyes of middle class Mexicans. In contrast, in Nexpan, participants displayed more frequently attitudes and feelings of defeat, submission, and powerlessness against mistreatment. Recipients themselves recognized feeling impotent about the attitude of the officers and frustrated by their lack of organization to change their situation. Nexpan was a larger town than Cualcan and more accustomed to life in the city, thus people seemed to be less supportive and close to each other, and thus probably also had less ability to organize. These contrasting attitudes from recipients might have an influence on the kind of relationship created between them and the officers. The Wider Culture of Discrimination in Mexico The street-level bureaucracy literature often highlights the importance of organizational factors in the way officers use discretion, but recent studies also emphasize that culture is key in determining the nature and how

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deep-rooted the practice of discretion can be (e.g., Cohen, 2018). Therefore, the larger culture of discrimination and stratification in Mexico could also have a role in shaping these relational phenomena. Discrimination is highly pervasive, entrenched in the culture, traditions, and family and social practices of the nation. According to Székely (2006), being indigenous (1st) and having a low economic position (3rd) are major causes of discrimination, categories that clearly describe the situation of recipients in Cualcan and Nexpan. Additionally, the National Council for the Prevention of Discrimination (CONAPRED in Spanish) finds that while 64.6% of people in Mexico report having a darker skin (morena), 54.8% accepts that people are highly discriminated against by their skin color (CONAPRED, 2011). At the same time, national data suggests that public hospitals are one of the spaces in which people perceive greater discrimination (Székely, 2006). This places the attitudes of frontline officers at the core of the reproduction of discrimination and inequality in the nation, especially those at first-level health centers in indigenous and rural localities implementing Oportunidades and other social policies. Indeed, if these broader cultural, political, and social aspects are not taken into account, social policies like CCTs can reproduce and produce many unintended by-products over society. One of these byproducts occur through the influence of social stratification in the quality of the interactions between officers and recipients seen in these localities.

Summary In the provision of Oportunidades-Prospera, the attitudes of physicians and their relationships with recipients were complex and influenced by a number of factors. In these two health clinics, the identity of officers as health professionals and their contrasting socioeconomic characteristics to those of recipients shaped their relationship in important ways. Their medical knowledge and expertise, as well as their levels of income and education created a barrier from recipients, limiting their capacity to communicate and increasing the formation of stereotypical conceptions of the ‘other.’ However, in these localities, the effect of these were intensified by the discourse of conditionality of Oportunidades-Prospera and the officer’s job position. Firstly, the characteristics of Oportunidades-Prospera as a conditional program magnified the officers’ perceived authority to monitor and regulate the behaviors of recipients. Conditionality made recipients a captive

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population for officers to achieve the various public health quotas they needed to fulfil for the Ministry of Health. This contributed to validating a disciplinary relationship in which the recipients’ role was to obey and comply with the activities of the program, instead of using a service they were entitled to receive. Hence, the form of the program by design and the way the discourse of conditionality was reinterpreted at the grass roots influenced the relationship of officers with recipients. These findings problematize how policy language can shape delivery. The narratives of officers in these localities of Mexico suggest that conditionality can transform officer–recipient interactions, increasing the power of officers during the delivery of the program and over the participant’s actions and access to health services. Secondly, permanent officers and temporary officers used their discretion differently, fostering two opposite styles of relationship. In these localities, permanent officers mostly promoted a relationship of obedience and hierarchies. This was evident by their hostile verbal descriptions of recipients and authoritarian forms of policy delivery. Permanent officers (primarily in Nexpan) considered it necessary to exert control and power over recipients, expected them to comply and behave in certain ways that facilitated their jobs. These officers expressed greater disengagement from the recipients’ needs and the pressures of their jobs compelled them to be primarily concerned of meeting the quotas set by the Health Ministry. Temporary officers, in contrast, usually promoted a relationship of reciprocity, exerting their authority not through power but through communication and empathy. Temporary officers focused on the positive aspects of the relationship, recognizing the challenges they encountered and their strategies for solving them. Neither their narratives nor their schemes of delivery showed disengagement from recipients. Rather, they constantly reflected on the recipients’ needs in terms of medical care and the economic support received from Oportunidades. They showed an interest in helping recipients boost their fulfilment of the conditions. Finally, in contrast to permanent officers, they were aware that the way they engaged with recipients affected the recipient’s outlooks of the program and the clinic, as well as their general well-being. The officers interviewed recalled similar experiences with previous officers indicating that these differences are not only true for the participants of this study, but part of the larger structure of health care provision in Mexico and perhaps connected to the training of health professionals at large. In Mexico, this medical training has been anchored to the use of

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hierarchies, inequality, and punishment between peers, which then shapes the interactions of doctors and nurses with their patients, especially in the public sector (Castro, 2014). Although Lipsky (2010) recognized that negative styles of service delivery could be a structural issue reproduced from officer to officer, these findings suggest that the officers’ job position is key in explaining these differences. Interestingly, these results also highlight the overarching significance of relationality at different levels of policy delivery. In this setting the wider culture of discrimination, the relationships between the Health Ministry and physicians at first-level health clinics, the interactions between staff, and the relationships among the local population can shape the actions of frontline officers during program delivery and their relationship with recipients. As such, a relationship in one context can become a structure in another relationship (officers–recipients).

Bibliography Adato, M., Coady, D., & Ruel, M. (2000). An operations evaluation of PROGRESA from the perspective of beneficiaries, promotoras, school directors, and health staff . International Food Policy Research Institute (IFPRI). Campos, S. A., & Peeters, R. (2021). Policy improvisation: How frontline workers cope with public service gaps in developing countries—The case of Mexico’s Prospera program. Public Administration Development, 1–11. https://doi.org/10.1002/pad.1907 Castro, R. (2014). Génesis y práctica del habitus médico autoritario en México. Revista mexicana de Sociología, 76(2), 167–197. Cohen, N. (2018). How culture affects street-level bureaucrats’ bending the rules in the context of informal payments for health care: The Israeli case. The American Review of Public Administration, 48(2), 175–187. Consejo Nacional para Prevenir la Discriminación (CONAPRED). (2011). National survey on discrimination in Mexico. Enadis 2010 Overall Results. Consejo Nacional para Prevenir la Discriminación (CONAPRED). Ellis, K. (2011). Street-level bureaucracy’ revisited: The changing face of frontline discretion in adult social care in England. Social Policy and Administration, 45(3), 221–244. Evans, T. (2011). Professionals, managers and discretion: Critiquing street-level bureaucracy. British Journal of Social Work, 41, 368–386. Halliday, S., Burns, N., Hutton, N., McNeill, F., & Tata, C. (2009). Streetlevel bureaucracy, interprofessional relations, and coping mechanisms: A study of criminal justice social workers in the sentencing process. Law and Policy, 31(4), 405–427.

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Hughes, A., & Condon, L. (2016). Street-level bureaucracy and policy implementation in community public health nursing: A qualitative study of the experiences of student and novice health visitors. Primary Health Care Research & Development, 17 , 586–598. Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services (30th anniversary expanded ed.). Russell Sage. Ramírez, V. (2020). Relationships in the implementation of conditional cash transfers: The provision of health in Oportunidades-Prospera. Social Policy and Society (First View), 1–18. https://doi.org/10.1017/S1474746420000445 Székely Pardo, M. (2006). Un nuevo rostro en el espejo: percepciones sobre la discriminación y la cohesión social en México. Naciones Unidas, CEPAL, Div. de Desarrollo Social.

CHAPTER 5

Recipients: Between Medical Attention and Mistreatment

My conversations with the female (mostly) recipients of OportunidadesProspera commenced in the local clinics during a health workshop. At the end of the workshop, I introduced myself and my research to the 40 recipients present. I announced I was doing research on the role of Oportunidades in their lives and their well-being, and I was looking for volunteers interested in talking to me about their experiences in the program. In the days that followed, as I walked through the streets of the localities looking for the homes of the voluntary interviewees, I could observe the surroundings. Nexpan is a semi-rural community located in a valley at the foothills of one of the most imposing and active volcanos in Mexico, Popocatepetl. It was spring and thus the environment was dry and dusty. Most streets were straight paved roads surrounded with small houses most of which were built of concrete and brick. Cualcan, in contrast, is a rural community located in a humid and mountainous forest. Most streets were steep, some paved with rocks and others were dirt roads. Those houses closer to the city center were in better conditions, compared to most houses which had floors of dirt, walls made of wood, and many others fully built with waste materials. The first house I visited in Cualcan was one of the latter houses. As I entered the home, I could not avoid thinking of an event that occurred a week before when a downpour swept through the town. It lasted hours © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 V. Ramírez, Relational Well-Being in Policy Implementation in Mexico, https://doi.org/10.1007/978-3-030-74705-3_5

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and the house where I was staying was flooded. I spent a few hours trying to stop the flooding with three more people. Back in the home of my interviewee, Lorena received me with interest and invited me to sit down in the only chair I could see. The house was small, only one room and a simple double bed made of wood, with no mattress. As I sat in that chair, I looked at the holes and crannies in the walls and the fragility of the ceiling. I could not help but imagine the weariness and worry that this family went through each long rainy season. As Lorena handed me a cup of regional coffee, she told me that they entered the program recently and that she was looking forward to be able to save a little to make some improvements to their home. To me, the importance of the cash transfer was never as clear as in that moment. In fact, the centrality of Oportunidades in the life of recipients was a predominant theme in my conversations with them. Receiving the cash was crucial to improve their well-being and their attitudes toward the program and its health conditions were generally positive. Yet, their perceptions of their relationships with physicians in the health centers were more intricate and dense. This chapter explores the recipients’ narratives of their experiences in Oportunidades. The differences between localities identified in the accounts of the health officers persisted. However, the conversations with recipients provided a comprehensive picture of the nature of their relationship as well as the channels through which it influenced well-being.

The Centrality of Oportunidades-Prospera for Well-Being The program was vital to improve the lives of recipients and those of their children. Although many interviewees recognized that the cash transfer was small in relation to their needs, Oportunidades was primarily important as an economic security net, especially at an older age and for young families with children in school age. When describing their management of the transfer, recipients reported using it for the purposes intended in the program’s design—to buy healthy food and school supplies for their children. More importantly, however, the transfer allowed them to live better in times of crisis. It was a central source of stable income as most

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families relied on informal and insecure forms of employment, such as agricultural work and house cleaning. They also used it to invest for the future, particularly buying construction materials to improve their house, at least ‘brick by brick’ as someone said. We (husband and her) rely on the support (cash transfer) of Oportunidades because with it we can buy school supplies for our children, shoes, and uniforms. And what I get for myself I use it for food and kitchen utensils. This has allowed us to use everything my husband earns to save and with time we were able to build this house. Recipient, Cualcan

When our support (cash transfer) arrives, I always save it. Whatever I earn from my (intermittent) jobs, I use it for the week. But, when I cannot get work, I am not earning anything. That is why I save my support, because then is when I use it. Just a small part because the rest is for my children. Recipient, Cualcan

Many recipients expressed how the economic support was not only important to buy material assets, improve their sources of food, and saving for the future or coping with shocks, it was also central for their subjective and relational well-being. Among other things, having greater economic stability and access to material sources, reduced feelings of shame and increased feelings of self-worth and belongingness to their communities. Recipients mentioned this particularly in relation to their pasts since, compared to their own childhood, they felt they fared better today. Yet, it was also relevant for their children’s quality of life. They reported that with the support of the transfer, their children were happier, had better opportunities at present—access to school, clothing, and food—and potentially better futures. My family (children) was very excited when we got into Oportunidades because they saw that other children already receiving it dressed better and took snacks to school. They also wanted to buy those snacks but before I did not have money for that. Now I can afford it, it is not much but these little things are something, I save every week so they have those little things. Recipient, Cualcan Today with the support (transfer) you can buy school supplies for your children, shoes, uniforms. In my times, there was no uniforms, you just went to school

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with your own clothes. But there was a lot of discrimination because many children wore old clothing and were mocked. I wore that kind of clothes, traditional clothing, and they offended me! And it makes you feel bad! Recipient, Cualcan

In addition to the positive effects of the transfer, the health and education conditionalities also contributed to their well-being, although sometimes in contradicting ways. The opinions and attitudes of participants toward the conditions of the program (health and education) were generally positive. Many recognized the responsibility they had acquired and showed interest in complying. However, home and work duties often made it challenging, especially for women who had a conflictive relationship with their husbands or those who had to stop working for the day in order to observe the program’s requirements. The workshops are every month and we already know the dates we must attend. We just need to get organized to arrive on time. The same happens with the yearly consultations. It is easy to get the whole family organized because we know from the start of the year when is our turn. So, we have time to prepare. Recipient, Cualcan Since I entered the program, I have to hurry up with my chores at home so I can arrive to my workshops in the clinic. (Researcher: How has your family reacted to these changes?) (Lowers voice) At first, my husband did not like it. I explained that the program was helping us; it is giving us back a little bit of what we pay in taxes and electricity. But, now I just have to ask him (permission) when I have to leave (home) for the program. Recipient, Nexpan

Women often juggled between their personal duties as mothers and housewives, their jobs, and the activities of the program. For instance, in both localities, the workshops were scheduled at 14:00 on a weekday, which assumes that women either do not work or are able to leave work to attend their meetings without economic repercussion. Yet, this was usually not the case, especially in Nexpan. Many women worked in informal jobs like domestic cleaning or farming where their salary is earned by the day and/or the number of crops collected. If they miss a day of work, they forgo a day of salary (see also Álvarez et al., 2008). Hence, complying with the conditions sometimes entailed adapting their lives to have the flexibility the program required. Therefore, complying with

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Oportunidades’ conditions often required adapting their own lives to the needs of the program. Attending the monthly workshops was, however, only part of the activities recipients needed to conduct. They also had to attend the clinic for the compulsory consultations that took place at least twice a year (consultations for pregnant, hypertensive, or diabetic people happened every two months). Payday also occurred every two months, requiring women to line up in the town center for a whole day to receive the cash. Finally, those women that collaborated in the health committee conducting cleaning work and those that acted as vocales partook in many more activities that often made it impossible for working women to observe. Therefore, some recipient women needed to forgo many days of work in a year. This could have been problematic for some employers, reducing the possibility of women finding formal employment that offered access to social security, stable income, and other benefits that are fundamental to get out of poverty. This is part of the contradictory gendered bias in the design of Oportunidades identified by Molyneux (2006) and others. Whereas Oportunidades sought to include women more directly in the program—giving them direct control over the transfer and access to services—at the same time it assumed that women are exclusively mothers whose schedule is at the disposal of the State. The only problem [about the conditionalities] is that, as my fellow recipients say, they summon us very often. But, we have to work and we have to ask for permission (to miss a day of work) every time they call us. In some [jobs], they give you permission but you stop earning (the income of the day). But, sometimes if they (boss) see that it is repeatedly they stop allowing you [to miss work]. Besides, every time I go to the clinic, if I want to take a bus it is 12 pesos return, and with that, I could buy at least 1 kilo of tortillas. So instead of spending it on the bus I rather walk (it took her one hour walking one way to arrive to the clinic). Recipient, Nexpan When you are recipient, you only go to the training sessions when the promotor ask you to. You know leave two hours and then come back. You do your activities at home, you sweep, you cook, you feed your children and so on. But, when you are a vocal it is something else, because you give your training to recipients and at the end recipients talk to you about their problems and you need to help them. It takes more time. It is a waste of time, more so when you have to leave such copies, you have to go to the office, you have to go see such

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a person because they are ill or I don’t know. Then it is more complicated because I was always thinking about my children: are they hungry, what are they doing, if they have done their homework. So, while you comply in one place, you do not comply in the other. One cannot attend to two things at the same time. Vocal, Cualcan

In addition to the third shift that the program conditions entailed for women (on top of formal work and household duties), the extra costs for transportation and lost salary behind complying with the conditions could reduce the real economic benefit of the program (also Escobar Latapí, 2000). Sometimes interviewees did not feel that the size of transfer compensated the costs, especially for those that lived at the outskirts of town. Indeed, if not weighted in the calculations of the size of the benefit, this could reduce the intended income effect of the program over poverty. Despite this, participating in the activities of the program could contribute to the subjective and relational well-being of recipients in positive ways. Continuing the education of their children, and sometimes their own education with the support of Oportunidades, contributed not only to improving their expected future opportunities, but also their feelings of self-esteem, and the acquisition of competence and empowerment. At the same time, attending the health workshops, the meetings with recipients and promotores, and the other activities outside the home, helped many women feel better informed, and with better capabilities to make decisions about their own health and their families’. This knowledge also helped them improve their personal relationships, especially with their families. I do not see the workshops as an obligation or as if it implied a huge effort to attend because we learn a lot from them. We get information about diseases, how to treat them, and what are the symptoms. We do not understand many things about illnesses and this knowledge can help us know what to do. The workshops are very important. Vocal, Cualcan I talk a lot with my daughters and they talk to me too. I get my experience from them because they study and have more capacity to understand. I just have secondary school. The workshops also help me understand what my daughters explain to me. I also tell them what I learned in the workshops and that is how we get on talking sometimes. Recipient, Nexpan

Therefore, the knowledge and experience acquired through the activities of the program contributed to improving the family dynamics from the

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perspective of recipients. Participants reported feeling more self-confident when interacting with their families, have better communication with their partners and children, and better capacity to share information and knowledge. This reinforced the quality of close relationships. Unfortunately, in those families where gender roles were especially entrenched, these benefits on family relationships were not so visible. As the interviewees expressed that their participation in Oportunidades improved their close relationships, they also recognized how the program enhanced their social connections beyond the home. In concert with the findings of Adato (2000), the participants of this study expressed that their entrance to Oportunidades increased interactions with fellow recipients during health workshops and other meetings of the program. This was especially relevant to many women that moved to town when they married and thus had little relations with neighbors and the community. It was also important for those women whose husbands were controlling and limited their mobility, allowing wives to leave home to comply with the conditions of Oportunidades. Recipients who had the role of vocal often recognized that even though their responsibilities increased significantly with the role, they learned much from interacting with fellow recipients, speaking in public and building new relationships. The moment I entered Oportunidades my life changed completely because before I had contact with no one, I had no friends and talked to no one. The program helped me a lot. I have been a vocal for four years and I am very thankful it arrived in my life. I feel taken into account by recipients and other vocales. I feel important, respected. Many good people came into my life thanks to the program. Vocal, Nexpan

Indeed, many vocales perceived the whole experience was empowering and expanding their capabilities and well-being in different ways. They especially felt recognized by their fellow recipients, their communities and local authorities as being people of influence and whose voice should be listened to and respected. Yet, while the program strengthens social connections between recipients, they felt the program had created new divisions within their communities. For example, interviewees mentioned that being a recipient of Oportunidades caused that the community felt that they ought to take full charge of traditional community activities like cleaning the town streets or keeping the health clinic. These results were reported by Adato (2000) in the early years of the program. The findings of this study, 15 years later, suggest that these community divisions linger.

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Because we are recipients of Oportunidades we have to sweep the streets, pick up the garbage. Sure! I know I have to pick up my garbage, sweep my street, but I do not have to go out to the streets of the whole town to clean them up. Why us? There are several programs in this town! Why do not they call all recipients of all programs so we can support each other and do things well? Vocal, Cualcan

In sum, Oportunidades was essential for the recipients’ lives and the lives of their families in multiple aspects of their well-being. The cash transfer and the activities of the program had a direct effect on the recipients’ access to resources, information and services. Yet, they also contributed to the subjective and relational well-being of these women by promoting self-confidence, competence, social connections and recognition, and better family relationships. Although sometimes this happened in contradictory ways. Despite the clear centrality of the program as a whole in their lives, when talking about the health conditions, recipients in both localities repetitively mentioned their complex relationship with doctors and nurses, as well as the elaborate ways in which the conditions of the program emerged in such relationships. This is explored next.

From Medical Attention to Mistreatment Having a good relationship with officers was important to recipients for two reasons: to receive adequate and timely medical attention and because officers were seen as having significant power over their stay in the program. On the one hand, the local health clinic was often the only, most direct and accessible provider of medical attention to these families. The services offered were free and some medicines could be obtained at this clinic. Yet, despite this service was officially an entitlement, only a couple of recipients perceived them as such. Those recipients were vocales who tended to have more knowledge about the program and the clinic’s roles. However, most recipients expressed the belief that getting a consultation or a referral to a hospital was a favor physicians could decide to do or not to do, rather than their responsibility. Sara: I do think it is important to have a good relationship with the medical staff because the clinic is the first place we would go if we have an ill (family

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member). Especially families like us who have scarce resources, and if we do not have a good relationship with them, they will not treat us. Gloria: I also think it is important because that way whenever we need a favour they (health officers) will not say no. Researcher: What kind of favour would you ask them? Julia: Yes, for example, if we have [someone] ill and we do not have a way of bringing him/her to the clinic, you can ask the doctor the favour of doing a house visit or to refer him/her to the hospital. Carola: I think it is important because receiving Oportunidades depends on them. I mean, they fill in the S1 formats (attendance records). Focus Group, Cualcan (…) because the doctor is the only one who signs (the attendance record), the only one who authorises anything. Recipient, Nexpan

On the other hand, recipients perceived officers as strong figures of authority in the delivery of the conditions, especially the directors of the clinic since they controlled the procedures and the monitoring of the conditionalities. The attendance record retained at the clinic—or S1 formats—and the appointment booklet that the family kept to monitor their own appointments—‘carnet ’ or ‘cartilla familiar’- were the most important tools physicians had to oversee recipients’ compliance. In these sort of report cards, physicians recorded each turnout to the medical appointments. However, as will be seen next, the criteria physicians used to record compliance often were blurry to recipients and were dependent on certain behaviors physicians expected from recipients, behaviors that lay beyond simply reaching the consultation room at the time/date established. In addition to the role of health officers as key mediums to benefit from the program, recipients frequently evaluated their interactions with officers beyond the quality of the medical attention provided. Their concerns focused on the treatment received during the consultations and workshops of Oportunidades, which related to the perceived attitudes and behaviors of doctors and nurses during service delivery. (Researcher: Can you describe your experiences during a compulsory consultation of Oportunidades ?) Well, it depends on the doctors’ treatment. Because Dr. Maria (chief doctor and permanent officer) never conducts a check-up, she only kind of listens to you, she does not examine you and just

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gives you medication. But, the intern (temporary officer) is nice and attentive… we always trust interns more. With her (current intern) we can talk, tell her how we feel, she listens, and she conducts a check-up. She asks where it hurts or what is going on. Dr. Maria does not do that. Vocal, Nexpan I really like going with Dr. Lorena (chief doctor and temporary officer) because she is a good doctor, a good person, she is very kind. (Researcher: What makes her a good doctor?) She never scolds, she greets us kindly and talks to us nicely. She does not say bad things to us. Recipient, Cualcan

Recipients had a difficult time separating the quality of the medical attention provided by health officers from the quality of the relationship with them. In many ways, both the personal and professional aspect of this relationship was essential for participants to feel their interactions were positive. As a result, many passages captured both aspects of this relationship, the personal associated more directly with the attitudes of the staff, and the professional associated with their roles as providers of medical attention and as supervisors of the conditions of the program. A deeper analysis of the ways recipients characterized positive and negative interactions with doctors and nurses in both localities suggest that the most important aspect of the relationship was feeling respected. In these contexts, respect materialized in the way physicians handled the consultations and administrative procedures around them. Many participants emphasized that the compulsory medical consultations were brief and often required considerable waiting time. In some cases, they perceived the waiting time was unnecessary and the doctors were not prioritizing the consultations during the time officially allocated to this activity. This was mostly mentioned in Nexpan where the times for the consultations of Oportunidades were not separate from the consultations to the general public, which in practice started at 9:00 (not at 8:00 as officially stipulated). Hence, to get one of the 20 consultations offered in a day, recipients (and general patients) had to queue from 7:00 and sometimes the last recipient/patient to arrive left the clinic at 13:00. In Cualcan, in contrast, the clinic had two hours reserved every day for the compulsory consultations of Oportunidades (between 12:00 and 14:00, right before the workshop). Therefore, recipients spent less time waiting for their turn. This simple change in the delivery mechanisms significantly reduced the economic, social and physical costs of the program to recipients in Cualcan compared to Nexpan. At the same time, unnecessary

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waiting time was perceived as disrespectful and compelled some recipients to see a private physician when ill, and thus attend the public health center only to comply with the activities of Oportunidades. Jara: They (health officers) want us to be punctual at 8 a.m. to get in the queue, but sometimes they are just standing there chatting away instead of hurrying up with the consultations so that they don’t have us there waiting… Bere: (interrupts) until 1 p.m. (laughs) Judith: We haven’t even had breakfast and we are waiting. Apparently, we have to wait (for the consultations to start) until more people arrive, but they shouldn’t do that. That is why I don’t go there anymore, I prefer to pay for a private doctor. Brenda: Yes, we go because we are forced to! (6 participants nod in agreement). Focus Group, Nexpan

Recipients also mentioned concerns about respect to privacy and the confidentiality of the medical records. Testimonies of the strategies to promote implementation that violated confidentiality included being yelled at in the consultation room so as to everyone in the waiting room hear, as well as using the workshops to publicly put pressure on recipients to attend the consultation for a particular treatment. This not only violated medical confidentiality, but also could threaten the health and well-being of the recipient if family members, neighbors, or the community got information about issues that could be taboo, for example, the use of contraception. The nurse is always ventilating [information] during the workshops and the reasons why recipients need to report to the clinic. She says, ‘X person needs to come for Y reason, and Z person has many months since she last came to check for this illness’. But these things are confidential! There was the case of a woman who was using contraceptives but her husband didn’t know. Through the workshop the nurse asked to let her know that she needed to come check her contraceptive device and another recipient told her husband. When the woman arrived home, the husband beat her very badly. A few days after, she asked me to talk to the doctor. Vocal, Cualcan

Due to these problems and others, interviewees repeatedly focused on the quality of the communication with physicians during the activities of Oportunidades. For recipients in both localities, a positive dialogue

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entailed that the doctors and nurses took the time and effort to explain things appropriately during the consultations and workshops, but also that they paid attention when recipients are explaining their symptoms and feelings. The importance of having good communication with physicians was also associated with the extent recipients felt they could express their complaints and needs related to the activities of Oportunidades, their compliance and their absences to workshops and consultations. Therefore, the attitudes of physicians were central to promote the effective exchange of information but also trust in the physicians, in the medical attention received and in the program. Despite this, recipients expressed not feeling listened to by officers. This was such a recurring theme that many passages of this chapter show it, here is one example of a recipient recounting her experiences with a former male permanent doctor. The doctor did not listen. He was always on a hurry, stressed out. He did not want to understand us, to listen to us, nor allowed us to express ourselves about what we were going through or what we were feeling. He was very close-minded and this affected us because we could not understand each other nor trust him. Vocal, Cualcan.

A more personal aspect of the interaction with doctors and nurses related to the importance given to receiving a caring medical attention. This was narrated in many different ways that conflated also attributes such as positive communication and respect. It involved being treated with courtesy, kindness and consideration. They focused on whether the staff demonstrated sensitivity and empathy, as well as the extent to which they provided personalized care. The opposite of respectful and caring interactions was expressed as feeling shamed, yelled at, scolded, ridiculed, mistreated and even humiliated, especially when this was conducted in front of others. The doctor is agreeable. She gives us information, asks how I am feeling, is concerned about whether I took my medication or not, and even compels me to take it because I often forget. But she does not say so as a scold, but because she cares. Recipient, Cualcan The doctor we have now takes much care of us. Now if you cannot go to the clinic because you are pregnant or ill, she sends the nurses to look for you and see how you are. She really cares about how we are doing. Recipient, Cualcan

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The way officers (ab)used their power to compel recipients to comply with the conditions also influenced experiences of program delivery. In Nexpan recipients frequently described officers’ attitudes as authoritative, demanding, and sometimes aggressive. They especially expressed feeling used and pressured during the compulsory consultations to undergo certain medical treatments. As mentioned in Chapter 4, physicians had to fulfill treatment quotas every month. These were part of the larger agenda of the National Health Ministry and were a way to evaluate the performance of first-level physicians. Yet, Oportunidades’ recipients were instrumental in the accomplishment of such quotas. On the ground, rather than using information to convince a person of the need of a medical treatment, recipients reported the use of coercion to undergo treatments that were not a requirement of Oportunidades. On some occasions, recipients commented being threatened with program expulsion if they did not accept the medical treatments. This is, of course, highly problematic. Forcing recipients to undertake medical procedures is against the freedoms and rights of every person to decide over their own lives and their health. The health officers constantly blackmail us. They need to apply their own procedures and just because we have Oportunidades we are required to accept them. For example, doctors have certain goals they have to achieve. But then, they think: ‘since the women in Oportunidades have to come to the clinic, let’s do the procedures on them, fill our quotas with them’. The procedures are good for us, but some people do not want to receive them and they feel pressured. The doctors use the program to pressure us. Vocal, Cualcan

Recipients who participated in the faenas , the informal condition of the program, expressed a similar feeling. Even though they were aware that attending the consultations and workshops was compulsory, to them, officers abused their power when they forced them to conduct activities not clearly linked to the program or when they treated them as employees. [What I like about Oportunidades] is the support (cash) and the workshops. The workshops teach us about diseases and self-esteem, to be a better person. What I do not like is that people take advantage of us as recipients. For example, we are the only ones in town who take part in the health committee of the clinic. (Researcher: Who takes advantage of this?) The (chief) doctor, of course (laughs). She promotes it. She says that because we receive the cash and the workshops we have to support her whenever she needs something in the

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clinic. It is compulsory for us, she demands it. Health committee member, Nexpan

As mentioned earlier, faenas were not set in the design nor was their implementation monitored by program officials. Still, in both localities faenas were central for the functioning of the clinic. In Nexpan, the members of the health committee—the group of recipients carrying out the faenas —rotated once every year following the list of recipients by surname. In Cualcan, they rotated every two months based on voluntary participation. The members conducted work in the clinic every day and thus the economic and relational burden of these activities was high. Often, recipients needed to stop working when they became part of the committee. They also needed to negotiate with their families the time spent outside the home and the activities they had to miss because of this—such as cooking for the family or doing the house chores. Their daughters or other women in the family took over these activities, although this was not always possible. Women also needed to negotiate with their fellow recipients to stand in for them those days they could not attend or even if they could not be part of the committee at all even though it was their turn in the list. Everyone was expected to participate in the faenas. Both physicians and recipients had this expectation. At the same time, recipients felt that the demands of the program were contradictory. On the one hand, the program asked recipients to do work for the clinic and, on the other, they were shamed if they did not keep their homes clean and organized. This discourse reproduced by physicians also permeated into the recipients’ convictions, making the inability to participate in the committee costly. It could result in intricate and contradictory forms of social disgrace. Therefore, in addition to the possible consequences over their stay in the program, there were considerable social costs of not participating. Finally, discrimination was also a salient theme in both localities, in Nexpan toward recipients in general and in Cualcan toward indigenous recipients in particular. An activity in the focus group in Nexpan asked recipients to choose three words to describe positive and negative interactions. Only one recipient wrote the word discrimination in the negative list. Yet, during the collective ranking and discussion of the words, all participants agreed that discrimination was the most important. Recipients considered discrimination the main cause of the other

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negative aspects listed, which included mistreatment, yelling, humiliating, scolding, rudeness, aggression, and threats. As a vocal I have to interact with the local president, the government authorities, the school director and the director of the clinic, and discrimination is always there. For peasants like us, sometimes they do not even look at us, they do not greet us, they do not pay attention to us, they are not kind and treat us as if we were ignorant. They discriminate us. It is getting to the point of bullying, because even the director of the clinic tells us that she is sick of us. She is sick that us, the recipients of Oportunidades, are always asking for her signature (in the attendance record, a requirement of the program). So they are gradually turning against us. They also discriminate us because if they see us with good clothes they treat us well, if they think that we did not brush our hair, took a bath or have dirty shoes, then they mistreat us. One deserves respect because of who she is, not because of what she has or is wearing (others say: Of course!). Focus group, Nexpan Sometimes we think that if we had money or if we had education they would treat people better, or if I had money I would have visited another doctor that, even though he charges me more, he treats me well. Recipient, Cualcan

Ambivalent Interactions with Officers The accounts of officers and recipients described above corroborate that relationships with certain officers (temporary) were better than with other officers (permanent), and that recipients could identify the features of a positive and a negative relationship with them. Nonetheless, in both localities there was a noticeable ambivalence in the recipients’ characterization of this relationship in the sense that both positive and negative aspects could appear in a single interaction and with the same officer. Generating a type of impredictability that had consequences for the way recipients experienced program implementation. (Researcher: How do you feel during the consultations of Oportunidades ?) Well, there are good days and bad days. I think when the doctors are in a good mood they are laughing with you, ‘Tell me, how are you feeling?’ But when they are in a bad mood! I don’t know what happens to them. For example, one day I went to the Oportunidades [compulsory consultation] and my baby was ill. But the doctor made me choose between getting the Oportunidades consultation and taking my attendance or looking at my baby’s illness. Recipient, Cualcan

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Mia: The first time you go to a consultation, and if you are lucky, she treats you well and you leave satisfied. But next time she treats you as if you were [nothing]… So we think, ‘what is going on? How are they like in reality?’ Bere: Do you want to know what I think when I go to a consultation? I think I hope I find them in a good mood! (laughs). (Many laugh) Focus Group, Nexpan

The inconsistencies, changeability, and unpredictability in the mood or attitudes of doctors and nurses, made it difficult for recipients to easily categorize a relationship as positive or negative. This underscores the fluidity and coexistence of both good and bad phases within one single relationship. This coexistence also denotes how relationships often involve an active negotiation between the actors. The outcome of such negotiation, however, can easily depend on the most powerful actor in the relationship. In this context, the officer usually took this position, but not always or at least not absolutely. It was interesting to identify very few participants, especially vocales and men, who reported having less negative interactions with those officers usually portrayed by recipients as hierarchical and abusive. This prompted further analysis on the reasons behind this. The most relevant finding was that those recipients who felt/were more empowered and related to officers in a relatively assertive way, were those who narrated better interactions. The next couple of quotes illustrate this in each locality. The first excerpt originates from a conversation with Carlos, a male recipient in Nexpan who is remembering a conflict he partook in that involved a number of recipients and the physicians. The conflict appeared because recipients collected money among them to make expensive repairs in the clinic. The repairs were completed and the clinic needed to pay, but part of the money was missing. A group of recipients claimed they handed the money to a physician, but physicians said that they never received it. More money was necessary and this generated conflict between recipients outside the clinic one afternoon. Where was the money?, they were asking. The doctor approached saying, ‘So you are saying that we (officers) stole the money? (Imitating a superiority and aggressive tone, almost yelling) But say it! Because I can sue you of defamation!’ Everybody is afraid of that. With that (assertion) everybody shuts up. And then, I started talking. I thought, now I am going to play her own cards. I said, ‘Doctor, you said to be

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respectful, to allow people to talk. So now I ask with all that respect, allow me to talk. Doctor, how could you sue us?’ And I told my fellow recipients, ‘No one should intimidate you, if we all stick together, no one can intimidate us because we are united’ (…) So then she (doctor) saw my strength. What does she prefer, to have a friend or an enemy? A friend of course! So, she does not mess with me. I arrive to the clinic and she is like, ‘Mr Carlos, how are you? Good morning’. But, she does not treat everyone the same. Health committee member, Nexpan

Carlos acknowledged in the interview that he received differential treatment because he stood up for himself and he was able to generate social leverage for or against the physician as he was actively involved in negotiations with fellow recipients when a conflict emerged. A similar phenomenon occurred in Cualcan, where Sonia the leader of the vocales recurrently expressed similar experiences. She had an authoritative presence and, as she described herself, she was a woman ‘who stands up for herself, who speaks loudly, but with good reason.’ [The former permanent] doctor was very difficult. He was difficult to talk to because he always was stressed out, in a hurry. When you (anyone) arrived (to the clinic), he asked, ‘What do you feel?’ and as you were telling him he was writing a prescription without explaining anything. But he never treated me like this, probably because he knew how I am (laughs), or who knows. But there were many cases, very special cases of mistreatment in this community. Vocal, Cualcan

Recipients associated this ambivalence and inconsistencies in the officer– recipient relationship to ‘luck,’ the ‘mood’ of the officer, and the personal characteristics of the doctor/recipient involved in the interaction. Indeed, the quality of this relationship fluctuated, was negotiated, and transformed depending on various internal and external circumstances. Despite the changing nature of interactions with officers, recipients also confirmed the disparity in their quality between temporary and permanent staff, a disparity that was also visible in the interviews with health officers. In both localities, the participants of this study usually perceived relationships with temporary staff more positively compared to that with permanent staff. This also entailed that the experiences of recipients in Cualcan and Nexpan were strikingly different given the characteristics of the health officers working at the clinics at the time.1 1 As mentioned, in Cualcan the health officers were mostly temporary (interns) while in Nexpan the officers were mostly permanent (contract-based).

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Communication, Kindness, and Dedication: Relationships with (Temporary) Officers in Cualcan Cualcan is a rural locality with a predominantly indigenous population. Following the findings of previous empirical research on the quality of health care in Mexico (e.g., Campos Bolaño, 2012; Smith-Oka, 2015), one would expect that in this locality the quality of the medical attention is lower and the relationships with physicians influenced by inequality and discrimination. Yet, the interviewees in Cualcan tended to portray their interactions with current officers in positive tones. They described the relationship as one of communication, dedication, and empathy. The (chief) doctor we have now is very kind. She treats you very well, listens and is approachable. Besides, if you ask her something she gives good explanations. Yes, because the previous doctor was very rude, if you asked him anything he yelled at you from the start. Health committee member, Cualcan

Recipients in both localities particularly valued officers that were kind, listened to them, explained the procedures and medications they were prescribing and were patient when recipients asked questions. When the relationship was perceived as such, recipients conveyed greater trust in the clinic and feeling more confident about approaching the doctors and nurses to discuss issues of the program and of their own health. There is good communication with the doctor and with the nurse. I knock on the clinic at any time (of the day) and the doctor treats my child. Yes, at any time. She even tells me, ‘I am available if you need me. I am here to treat you.’ Recipient, Cualcan

Participants particularly appreciated officers were flexible with the timetables of the consultations and listened to the reasons recipients gave when they arrived late or were unable to attend because of work or family issues. However, most recipients were also accepting when the officers needed to place boundaries, for example, by not receiving a patient with mild respiratory symptoms in the middle of the night and asking them to reach the clinic the next day. The key was the way officers approached them and dealt with these tensions.

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Vocales and members of the health committee had frequent contact with physicians and nurses, and could give testimony of their own experiences complying with the conditions of the program, but also of their observations of the way physicians worked and engaged with their patients on a daily basis. These recipients were particularly positive about the treatment received at the time, as well as the way the conditions of the program were supervised. They emphasized transparency in the process of recording attendance to the consultations and workshops. Recipients felt they could understand when they had an absence in their attendance record as officers explained the reasons and often gave them a second chance to comply. This consideration from officers in the administration of the program was visible through the strategies officers used to communicate with recipients. I like being in the health committee because I have seen how the doctor is very kind; she treats her patients very well. She used to give 30 or 40 consultations every day but recently she explained us (recipients) during the [Oportunidades] workshop that her bosses asked her to cut down to 20 consultations. And we understand. I really like how she explains things to us. Also, when you arrive late for some reason and ask her if you still can get a consultation she says yes but if you wait after the people who arrived first get their check-up. Health committee, Cualcan

The astonishment of recipients about the responsiveness and availability of the current physicians stemmed from their previous negative experiences with permanent officers. Most interview participants felt comfortable with the current temporary doctor (chief of the clinic) and nurse. Most of their discomfort occurred during their interactions with the only permanent nurse currently working at the center and from previous experiences with former permanent physicians. Overall, their recollections emphasized attitudes of rudeness, disrespect and verbal aggression. I have nothing against the (current) physicians. I just did not like the previous doctor because he often got angry and took it out on us. The whole town was unhappy with him. Recipient, Cualcan I get on very well with Dr. Lorena and nurse Andrea, but not with nurse X (permanent nurse) because she has a very strong temper and the same way of

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working as the former doctor. She yells at people! Health committee member, Cualcan

Recipients narrated the way the discourse of conditionality of the program influenced how physicians—especially permanent—monitored the program’s consultations and workshops. In Cualcan, recipients recalled former permanent physicians stigmatizing them as opportunists, self-seeking or profit-seekers. If they missed an appointment, permanent physicians interpreted this as a symptom of the ‘real’ interest of recipients in the cash transfer and not in the benefits of the workshops or the consultations in their health. Recipients felt shamed by this interpretation especially when officers claimed this in public spaces. They also felt this was unfair especially when officers disregarded the explanation recipient offered for their absence, which often involved the inability to miss work, illness or family matters. The doctor was always saying (bad) things to us. He said we were opportunists (self-seeking)! That we are only interested in the cash transfer and we do not want to participate in our workshops and other activities! But, you cannot say that! Recipient, Cualcan

Relationships with officers were particularly problematic for those whose first language was not Spanish. Indigenous recipients in Cualcan recollected experiencing a lack of empathy and patience from previous permanent health officers when they could not speak or understand Spanish. To avoid this, when it was possible recipients went to the consultation or workshop with someone who could translate. In contrast, physicians had no training in Nahuatl nor access to translators form the Ministry of Health. Yet, they responded to this limitation in different ways: some former permanent officers acted dismissively, whereas current temporary officers sought support from the community itself, especially from members of the health committee who were readily available in the clinic when they were engaged in the faenas. Since officers are treating people who speak an indigenous language, I think that they should make an effort to understand us. Sometimes they get in a bad mood because people only speak Nahuatl and doctors do not understand them and they say, ‘It is better if you leave!’ That happened in front of me, which is why I am telling you. I understand that there are many people in

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the clinic, much stress and all. But this is no way of treating people. Vocal, Cualcan The (former) doctor’s treatment affected me because you could not even talk to him, ask him a question or any information because he would yell at you or say things to you. Many people were afraid of him… Sometimes I thought about those who do not speak Spanish, especially the elderly, like my mother. Imagine if my mom went (to the clinic) by herself? How would he treat her? He would probably send her off without healing her. Health committee member, Cualcan

In sum, in Cualcan recipients consistently reported having a positive relationship with most physicians at the time. Recipients characterized this relationship as one of communication, respect and dedication. Participants perceived that the current temporary officers managed the conditions of the program in a fair way, although maintaining adequate control of their attendance to the formal and informal activities. Recipients felt listened, they were not afraid of approaching officers, and felt comfortable in the clinic and complying with the conditions. However, despite having an overall positive relationship with the officers at that moment, recipients problematized interactions with former and current permanent officers. It was interesting that many recipients attributed the positive environment in the clinic to the leadership of the current director—a temporary officer. The director helped manage or reduce conflict between recipients and the only permanent officer, which highlights the role of good leadership in the adequate management of the provision of health and social policy in health centers.

Mistreatment, Humiliation, and Abuse of Power: Relationships with (Permanent) Officers in Nexpan In contrast to Cualcan, participants in Nexpan conveyed negative encounters with health officers considerably more frequently than positive encounters. Nonetheless, as in Cualcan, when participants perceived the relationship as negative, they described being mistreated, yelled at, and publicly humiliated. The most problematic encounters narrated by the interviewees were with the director of the clinic, Dr. Maria, who was a strong figure of authority both for recipients and for the rest of the staff.

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Therefore, the dynamics within the clinic as a whole seemed to follow a similar approach to that of the clinic’s director. Sometimes [the chief doctor] explodes with the first who crosses her way. That time when she yelled at me, I felt very embarrassed because the clinic was full. I expected her to understand and to listen to the reasons why my daughter missed the (compulsory) appointment (she had a school exam). She has yelled at many beneficiaries! Many! … I did not receive the cash transfer this time, so I will just wait and if I do not receive it again, oh well... The vocal told me to talk to the doctor about it and to bring her a form, but no way! If I go to the clinic, she will yell at me! (Researcher: Not talking to her could mean you are expelled from the program, right?) I would rather wait and see, if I do not get it again I might bring the forms or I (might) just stay like this. Recipient, Nexpan (…) there are ways of expressing yourself, ‘I apologise but I cannot treat everyone’ (kind tone) But no, she (chief doctor, permanent) says ‘I do not want you telling me that you want your little prescription, or whatever. I have told you that I cannot treat you all, I can only treat 18 [patients], and I don’t want to know anything else about it, ok?!’ And there she is mistreating us! (…) She also said that we should not ask her any question, that we are not children. Recipient, Nexpan

These testimonies also depict a way of managing the conditions in Nexpan that was not transparent. Recipients perceived that physicians did not take the time and effort to explain decisions taken in the clinic about the number of consultations available or the long waiting times. Instead, they remembered many instances in which officers used yelling, derogatory tones and negative representations of recipients to suppress any complaint. This treatment prompted some recipients to decide to leave the program to avoid the humiliation from physicians. Yet, in this locality, the interactions with permanent officers were described in even stronger hierarchical terms, including threats and abuse of power during the supervision of the health conditions. Maybe is wrong for me to say this, but... the doctor abuses her position a lot. She puts conditions to signing the attendance record depending on whether she likes you or not, or sometimes she might simply find an excuse not to sign it. And she forces us to do things! Health committee member, Nexpan

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I kindly asked her (chief doctor) to come home to see my son, because he could not move and I did not have a way of taking him, no one to help me.2 She said she did not have the time, that she was not at the disposal of the people, that she was there to work in the clinic and not to treat people in their homes. I did get upset and I told her that I thought that this was the reason she was sent here. I told her, “So, if I am dying, you will treat me only if I am able to get to the clinic?” From there on, she started telling me things, she started telling me that she will not treat me and even that she will expel me from the program. Vocal, Nexpan

The supervision of the program’s conditions in Nexpan seemed more influenced by relational processes than by the formal rules of the program. Recipients felt that the physicians used the attendance record as an authoritative tool based on their mood, their likeness of the recipient or their interpretation of the behaviors of recipients. Recipients felt forced to do things especially when officers did not take the time to explain the connection between the activities required and the program. If recipients stand up for themselves when feeling mistreated, the officers took an aggressive approach with the intention of obtaining compliance and submission again. This process facilitated the abuse of power on the part of physicians as well as the use of the program as a tool to assert their power over recipients. Discrimination was also habitual in this clinic. There was an event at the clinic that struck me as a faithful illustration of this. One morning during my observations, I asked a woman waiting for her consultation where the toilet was. She pointed toward a room whose entrance was covered by a large ply of wood and in front a big table to keep it in its place. She explained that the toilets have not been working for a while, although she was suspicious that this was true. Another day, early in the morning with the clinic almost empty, I asked the nurse (permanent) if there was a toilet I could use. The nurse showed me the way toward the same toilets the woman and I talked about days before. As the nurse and I were moving the ply of wood for me to get in, I asked her whether the toilets were working, to which she replied, “(laugh) they do work, we just don’t want the people to use them because they don’t know how to use a toilet”. Even though no one else heard this statement, I felt rather uncomfortable because the small number of people who were in the waiting room at the 2 Unfortunately, her son died a month after this interview took place.

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time appeared to realize the situation: I was allowed to use the toilet but they were not. The issue of the toilets was not minor. In the interviews and focus group with recipients, the toilets came up and their inability to use them was perceived as sign of their lack of rights in the clinic. Paula: So many people come (to the clinic) and we are all willing to donate 5 pesos for the toilets to work, because they do not work! Apparently because there is no money! Bere: They do work! I just became part of the health committee and they (officers) always say the toilets do not work, but they do! Some of us came inside to check (laughs). Because, believe it or not, for example I am pregnant and I need to use the toilet fast. And any person who is ill or older, they need it fast. Brenda: And we (recipients) are (waiting) in the clinic since 7:00 a.m. for us to get a consultation. And there are some people that get to leave the clinic until 1 or 2 p.m., where can they go to the bathroom? Laura: They (officers) say that the [toilets] do not work because it smells bad… I mean, they say… ‘We (officers) have no reason to be in our workspace smelling your things’. Focus Group, Nexpan We do not have rights in the clinic, we do not even have the right to use the toilets. Health committee, Nexpan

In a way, physicians had the authority to structure many aspects of the behavior of recipients around the clinic and the health conditions: from the time of day they had to arrive to the clinic, the hours they waited to be seen, and even the most fundamental needs like using the toilet. Participants had different reactions toward this treatment. In the attitudes detected during the observations and their personal declarations in the interviews, many recipients in Nexpan showed feelings of disempowerment and often took a submissive behavior to avoid conflicts with officers. Whereas in the interviews they expressed frustration and anger, in my observations of interactions, recipients were compelled to become submissive if they wanted to get their situation sorted out. I cannot complain about the clinic. Yes, sometimes doctors have a bad temper for random reasons, but as the (chief) doctor has told us, “as long as you do not protest or contradict me when I tell you something, I will assist you”.

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But sometimes the doctor has such a mood that no one can stand her. Just a month ago, she had a problem with other beneficiaries in the waiting room and I was there. The beneficiaries were talking to each other and laughing, but between them. And the (chief) doctor thought they were laughing at her and started to yell and swear at the beneficiaries! (Researcher: What did you do?) Nothing, I just sat there. We cannot say anything to her. Vocal, Nexpan

Recipients often expressed a contradictory relationship with physicians. As the previous quote shows, some of them unconsciously endorsed the authoritarian attitude of the doctor by partly reporting satisfaction with the clinic’s services (‘I cannot complain about the clinic’) and accepting the doctor’s statement of superiority over recipients. This was further demonstrated by her feelings of being unable to react to this treatment despite being against it and being a vocal of the program. Other recipients were well aware that these negative attitudes of health officers were an act of discrimination and abuse of power, although in the interviews it was not clear how they would react to a direct conflict with an officer. They (physicians) act as if they always have the right to talk… people who are in power always think they have the right to have an opinion, the right to everything. Oh, but they are wrong, I could be humble and poor and whatever you want, but I am against this kind of discrimination. Health committee member, Nexpan

In the clinic of this semi-rural locality, recipients felt discriminated against not only because of their inability to use the facilities, the authoritarian attitudes of officers, the direct expressions of disdain or use of derogatory tones and words like portraying them as ‘child-like.’ Recipients also felt discriminated against based on their education level and their profession, as they recounted officers degrading them for being peasants, poor or uneducated. These cumulative forms of discrimination contributed to the feelings of recipients as unable to ‘fight back.’ In the following quote, a vocal and I were talking about what she described as the ‘strict’ personality of the chief doctor in terms of the procedures for monitoring the compulsory consultations and her way of coordinating the vocales and ‘telling them off.’ (Researcher: How do you feel when she treats you like that?) Bad. No one likes to be yelled at all the time. Besides, I hate injustices. But I cannot fight

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back even though I am upset. We cannot fight back because she has said it herself, ‘I am the doctor and none of you will tell me what I have to do, that is why I studied’. And unfortunately, what can we reply to that? Vocal, Nexpan

Overall, the narratives of recipients in Nexpan embody an extreme case of a negative relationship between recipients and officers. This relationship included more power-laden encounters that involved threats, abuse of power, discrimination, and violation of rights. In reaction to this, the narratives of recipients expressed feelings of fear, disempowerment, and mistreatment. In general, the data suggested that the threats and humiliating actions of officers caused recipients to prefer not to react directly or indirectly to the mistreatment. Many were afraid of losing the program and of other forms of retaliation if they reported officers to the larger authorities in the health ministry or in Oportunidades.

Narratives of Well-Being During Policy Delivery The data presented earlier suggested that the quality of the officer– recipient relationships had an influence on the attitudes of recipients toward the clinic and the program in both localities. Positive relationships improved the recipients’ perception of the quality of the medical attention received. Having good interactions also increased the recipients’ trust in the clinic and willingness to attend and comply with the conditions of the program. However, when interactions were negative, recipients preferred avoiding those physicians perceived as disrespectful or authoritative, and even to minimize their reliance on the clinic as much as possible. This entailed a real risk of losing the program if it involved not complying with the attendance expected by Oportunidades. In addition, if recipients or a family member fell ill, being mistreated in the clinic compelled them to seek other sources of health care such as private medical attention or traditional healers. Although avoiding the clinic for non-compulsory consultations does not risk losing the program, these are potentially harmful for their health—given the difficulty of identifying legitimate physicians—and for their economic situation—due to the costs of private care. However, for other recipients, negative encounters with officers were sufficient to dissuade them to remain in the program altogether.

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In addition to the influence on recipients’ attitudes toward the program, the quotes presented so far indicate other ways in which the terms of the relationship influenced inner well-being3 . This was more palpable when recipients perceived interactions as increasingly negative. No well-being approach was used to frame the discussions in the interviews and focus groups with participants. Yet, the recipients’ accounts still pointed out channels through which their encounters with officers influenced different aspects of their lives and well-being. It was in the analysis of these conversations that the Inner Well-being approach was used and the main findings are presented here. In general, feeling mistreated by doctors and nurses caused discomfort, distress and negative emotions in the participants who reported these interactions. If I go to the clinic in pain, and they do not assist me, they tell me off or yell at me, well, if I am already feeling bad, then I feel worse. That is why some people look for other options... But people do not say anything because of fear... yes is mainly fear that if I say something the doctor will not take my attendance (of Oportunidades). Vocal, Cualcan She (doctor) always mistreats us. She never treats us right. Imagine, if you are sad because something happened at home, a problem or something, you arrive to the clinic hoping to find her in a good mood. But if you find her in a bad mood, she treats you worse and that aggravates the whole situation. You leave (the clinic) feeling much worse. It affects your self-esteem. Recipient, Nexpan

Probably the most salient effect of negative and positive interactions on well-being was on the recipients’ economic confidence. Indeed, many recipients mentioned that they were concerned about their relationship with officers primarily because officers monitored their compliance with Oportunidades. However, when the relationships were more hierarchical, the recipients’ fear of losing the program and the cash transfer was much higher. (Researcher: In what ways do you think the relationship with health officers could affect you?) In many ways, primarily because they sign the attendance record and put conditions on everything. For example, they could decide not 3 Part of these findings were published in the Journal of Social Policy and Society (see Ramírez, 2016).

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to sign my attendance record even though I attend, and just by not signing, they can justify that I did not comply. Without the signature, I can be expelled from the program and then I cannot attend my workshops and I don’t get my support (cash transfer) either. Recipient, Cualcan

Recipients in both localities perceived that remaining in the program was determined by their own actions fulfilling the conditionalities, but especially by the officers’ discretion to decide when to sign the attendance record or to accept proofs of absence. Hence, even if the monitoring role of officers is necessary for the implementation and regulation of Oportunidades, when the quality of this relationship is poor it could also endorse arbitrary decisions that ultimately have the opposite effect to what a cash transfer is intended to do: increase the economic confidence of the poor. Moreover, many quotes presented so far in this chapter point toward feelings of fear. As the relationship with officers became more hierarchical and power-heavy, recipients felt more discouraged to approach them to talk about any issues associated with the program. Recipients also felt fearful of raising their voices when they disagreed with a decision made in the clinic, a procedure they felt forced to undertake or when they felt mistreated by officers. Therefore, the quality of this relationship also influenced the sense of agency of participants. When the doctor’s boss visited the town, he (doctor) showed off! Yes! And no one said anything; no one said how he was mistreating us. Everybody just stood there quietly! I told my sister-in-law, ‘He mistreated you, tell his boss now and in front of him’. ‘No’, she said. And I think that is why we are in this situation, because we don’t talk! (Researcher: Why do you think you don’t talk?) Because of fear! Because people think that he is the doctor and that we are poor, so they think he will win. Recipient, Cualcan One has to agree with her (chief doctor) in everything, be compliant. Because, for example, if she were to find out [that she is complaining of her in the interview] she would take it against me, and she can even take me out of the program. We have tried to issue a complaint before, but we don’t know how but she finds out and asks who was complaining and why. So you believe in her threats. And we think, what can we do then? It is even worse when she threatens that she can sue us of defamation. How could we defend ourselves from that? Health committee member, Nexpan

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The previous quotes also show how identity comes into play in the interaction and its well-being effects. Recipients had internalized a ‘hierarchical’ difference between their identities and those of physicians, often used by officers to assert their authority. This permeated in their individual and collective agency and empowerment as recipients found it very difficult to get organized to discuss, deliberate, and ultimately change a situation in the health centers. These quotes also start to point out how this relationship could influence people’s sense of self-worth and competence. The next excerpt comes from a discussion with the participants of the focus group in Nexpan after they performed a short play. The 10 recipients in the focus group gathered in pairs, one would take the role of a ‘physician,’ and the other of a ‘recipient.’ They had to enact a short scene in the consultation room illustrating what happened while receiving medical attention. After the five pairs had performed their act, I asked them to analyze the plot and the attitudes of each scene and each performer. This is partly what they said when analyzing the performance of the ‘recipient’: Jara: She is very submissive! Because she… because we have no other choice. Mia: Yes! Once I was in the clinic and a woman that was seven months pregnant was with the doctor. When I was coming in and she was leaving, the woman asked the doctor: ‘will you sign my attendance record?’ And the doctor said: ‘No, you will get an absence! I cannot believe that you have seven children and you didn’t know you were pregnant! Please, even the stupidest woman knows that!’ I was shocked… Researcher: What do you think about this situation? (Ask all) Uma: She thinks that because she is educated she can… Brenda: Trodden on us! (Others agree) Yes! Sometimes she says, ‘How can you think you can tell me what to do? If I am the doctor, I studied. How could you give me orders if you are just peasants!’ Focus Group, Nexpan

Feeling ‘trodden on’ by officers is a strong visual representation of how continuous negative and authoritarian interactions with officers can influence the sense of personal worth of these women. Moreover, the passion and emotion through which recipients voiced these personal experiences reflected the weight of these negative interactions in their well-being. These emotions were not referring to casual encounters but to systematic patterns of events with cumulative implications for well-being.

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Positive interactions with officers had the opposite effect on the sense of competence and self-worth of recipients. A few recipients in Nexpan and Cualcan suggested how having a good relationship with doctors and nurses not only enhanced their self-confidence during their encounters but also their self-confidence to cope with other relationships and events in their lives. For example, one recipient mentioned that having good communication and support from the doctor helped her feel more confident when discussing issues of family planning with her husband who was against using any contraceptive method. Similarly, the next quote presents the end of a conversation with another woman who is reflecting on the reasons why she feels more able to handle conflict with her husband. I told (my husband), ‘if I had a place to live, you wouldn’t enter my house again, because I am a woman and I respect and love myself.’ (Researcher: What has helped you feel so confident?) I think it is thanks to the workshops from Oportunidades, especially with Dr. Y [former doctor]. She gave us talks about self-esteem, female diseases and the like. She talked to us openly. At the beginning, we were shy because we weren’t used to talk about those things. But when we started trusting her and talking to her constantly, we were more open. I don’t know why they took her away from us. But yes, it was through her talks that I started saying, ‘I will give it a try.’ Recipient, Nexpan

Indeed, the extent to which the activities of Oportunidades can promote the well-being of recipients is not only associated with the knowledge provided, but also with how officers relate to recipients in the process of providing that knowledge. For this woman, this promoted her physical health and confidence about health-related issues, it increased her selfesteem and improved her ability to deal with the difficulties in her close relationships, particularly her marriage. It was, nonetheless, the negative interactions, which had the strongest and most overarching influence on inner well-being. Another quote from the focus group in Nexpan illuminates this. The play helped break the ice in relation to discussing issues at the clinic and create trust within the group and with me. After this, the participants naturally started to share their personal experiences during the compulsory medical consultations of Oportunidades. Paula: I’ll tell you what I felt during an appointment. Imagine that as soon as the doctor arrives (at the consultation room) she tells me not to get close to her. She tells me, ‘Ma’am, move over there’.

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Brenda: Yes, she doesn’t want you to get close. Researcher: Why do you think she doesn’t want you to get close? Paula: Well, because maybe she thinks that we have something [inherently] contagious. (Others agree) Researcher: And how does that make you feel? (Asks all) Paula: We feel she is undermining us... as if I was worth nothing to her. sLina: One feels like ... Bere: (Interrupts) Like you are worth nothing. (Uma: Yes) Ana: It affects your self-esteem! Paty: It’s like if she feels very tall and we are very small. Paula: I thought so because that is how she said it, ‘no, move, don’t get close’. And I am sitting there thinking, ‘The town worked for this? For [her] to be lazy and arrogant? (Many laugh) So [she] can talk to me any way [she] want[s] and treat us like that? No, that is not fair’. But I am not saying it aloud, only in my head. Researcher: Why don’t you say it aloud? Elena: Because of fear. (Others agree) Bere: As I was saying, she (doctor) tells us, ‘If I want I can erase you from here and you will be out (from Oportunidades) quickly!’ And that’s it. She might even say, ‘I will not sign your attendance record.’ (Many agree) Focus group, Nexpan

This powerful conversation between recipients of Oportunidades captures a shared experience of a relationship based on power, devaluation and discrimination that influences a number of well-being domains. It demonstrates the feelings of powerlessness of recipients as they realize the control officers have over the resources they can have (material well-being) and how they feel and think about what they can do and be (subjective well-being). The officers are the direct gatekeepers of their cash transfer and the health benefits and knowledge they receive from Oportunidades consultations and workshops. In the way officers treat recipients, they are also mediators of more personal and subjective aspects of well-being such as their sense of competence and self-worth and their ability to use their agency to improve their lives in other dimensions—even the quality of their close and personal relationships. Finally, as mentioned before, recipients were also wary that the quality of their relationship with officers had an impact on the quality and effectiveness of the medical attention received. This has been widely heard of the public health system in Mexico, in relation to Oportunidades as well as in relation to obstetric care in general (Smith-Oka, 2009, 2012,

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2014, 2015). In recent years, newspapers have published numerous cases of women giving birth outside hospitals or who lose a child or their lives because of medical negligence (see e.g., Proceso, 2016). This was mentioned a few times in Cualcan by women who lost their babies because they did not receive timely medical attention due to the carelessness (as they perceive it) of the medical staff, many of which are part of the implementation of Oportunidades. A recipient in Nexpan had a similar experience just a week before our interview. After seeking care numerous times at the Oportunidades clinic for weakness and other symptoms, a private physician detected she had severe anemia (in women, anemia is diagnosed when the levels of hemoglobin are less than 12.0 gram/100 ml. Laura had 2.8 gram/100 ml) when seven months pregnant. The doctors in the Oportunidades clinic dismissed her symptoms several times. (Researcher: Just to conclude this interview, could you please share with me what is important for you to live well?) Well, after what just happened, for me the first thing is health. Yes, because if we do not have health we cannot do anything else. Having health does not mean that we want [physicians] to send us flowers, having health is that they give us a good care. (Researcher: What do you mean by a good care?) As I was telling you, sometimes they do not even touch you, or ask, ‘what do you feel here or there?’ ‘Explain to me what you are feeling’. No! They only kind of look at you and kind of listen to you and just like that they write a prescription. What I mean by good care is that they explore you well, that they listen to you, that they listen carefully to what you are feeling. When I am at a consultation, I want to be able to explain well where it hurts and what am I feeling. Also, they need to talk to you appropriately. That is enough. They usually talk harshly, they not even look at you, and diminish how you feel. ‘No, these are only symptoms of your pregnancy, you are just exaggerating!’ (…) So this is why I think that Oportunidades needs to pay attention to everything, is not enough to send staff or give money away, they need to look at the kind treatment [that is provided] and the extortions that lie behind it. Even the private doctor said that she could identify [my anemia] by my pale countenance and they (Oportunidades physicians) made me think it was all in my head! So I think, if they are educated, why didn’t they see it before? Why didn’t they stop for just a moment? What is the need that someone is lost (dies), that a family is lost because of this? Because, God forbids, but if I die, my children will not be well. Who will care for my baby? So, it is not about undertaking a quasi-medical revision but about doing a proper revision. Doctors should also receive workshops about how to treat people! Recipient, Nexpan

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This is a compelling quote on the importance of health and appropriate medical care for well-being. However, this quote also convincingly depicts that in this context being healthy is not only something that you have or don’t have, being healthy is something that is highly mediated by the relationship with physicians in the local clinics and the quality of the treatment and care received. This is a powerful statement about the urgency to pay attention to the relationships that are created during policy delivery and their effects on subjective, material, and relational well-being.

Summary Oportunidades had multiple benefits on the well-being of recipients beyond the provision of the cash transfer. Indeed, for participants of this study, Oportunidades was a program that improved their economic confidence; the state of their health; their sense of competence and selfworth—through the knowledge obtained in the workshops; and their sense of social connectedness—through the increased social status offered by the cash transfer and the social relationships the activities of the program promoted. Yet, in the conversations about their experiences complying with the health conditions, the part played by health officers was unescapable. Having a good relationship with health officers was important to recipients based on two key roles of officers in the clinic: the provision of medical care and their policing of the conditionalities. More importantly, however, recipients’ evaluations of their relationship with officers often coupled the medical attention with their personal relationship. Recipients valued more those officers with whom they had kind, open, and empathic interactions than those who might have medical proficiency but rough manners and attitudes. Their experiences suggested that the personal relationship and attitudes of health officers can indeed reduce the quality of the workshops and the medical attention provided. The nature and quality of this relationship as experienced by recipients also varied between localities and health staff, confirming the differences found in Chapter 4 between temporary and permanent staff. When a relationship was considered positive, recipients emphasized aspects such as respect, communication, care, and dedication. Negative relationships were characterized as those that involved disengagement, mistreatment, verbal abuse, personal or public humiliation, abuse of power, and discrimination.

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Despite the clear positive and negative attributes of this relationship from the recipients’ perspectives, their narratives also suggested the dynamic and ambiguous nature of relationships in practice. This created unpredictability in the experience they would have in the clinic, as it was dependent on the mood of the officer, the level of empowerment and assertiveness of the recipient, and the negotiation capacity of the actors involved. Beyond this fluidity, the nature of this relationship and how it unfolded start to point toward their far-reaching effects on how policy participants feel and think about what they can do and be. In the two localities, a negative relationship with health officers was associated with lower economic confidence due to the perceived power of officers over the recipients’ stay in the program; lower self-worth and competence because of experiences of mistreatment, discrimination, and shaming; and reduced agency as this treatment promoted feelings of being incapable of transforming the terms of the relationship and of the service received. Relationships characterized by shared authority and empathy, on the other hand, had opposite effects on well-being. The breath and strength in the role of negative relationships with Oportunidades officials on the well-being of recipients was clear from these interviews. Whereas there were also indications that positive relationships were significant for well-being, recipients did not underline these as intensely as they did when interactions were negative. This could be because negative experiences are more consequential and meaningful for people than positive experiences. These results, though, do not test the statistical significance of these results. This is the purpose of the next chapter.

Bibliography Adato, M. (2000). The impact of PROGRESA on community social relationships. Washington, DC: International Food Policy Research Institute (IFPRI). Álvarez, C., Devoto, F., & Winters, P. (2008). Why do beneficiaries leave the safety net in Mexico? A study of the effects of conditionality on dropouts. World Development, 36(4), 641–658. https://doi.org/10.1016/j.worlddev. 2007.04.014 Campos Bolaño, P. (2012). Documento compilatorio de la Evaluación Externa 2007–2008 del Programa Oportunidades. Secretaría de Desarrollo Social Coordinación Nacional del Programa de Desarrollo Humano Oportunidades.

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Escobar Latapí, A. (2000). Progresa y el bienestar de las familias. Los hallazgos. In A. Escobar Latapí & M. González de la Rocha (Eds.), Logros y retos: Una evaluación cualitativa de Progresa en México. Secretaría de Desarrollo Social. Molyneux, M. (2006). Mothers at the service of the new poverty agenda: Progresa/Oportunidades, Mexico’s conditional transfer program. Social Policy & Administration, 40(4), 425–449. Proceso. (2016). Médico del IMSS incurre en actos de violencia sexual contra una paciente: CNDH. La Redacción, Proceso. http://www.proceso.com.mx/448 160/medico-del-imss-incurre-en-actos-violencia-sexual-contra-una-paciente. Ramírez, V. (2016). CCTs through a wellbeing lens: The importance of the relationship between front-line officers and participants in the Oportunidades/Prospera programme in Mexico. Social Policy and Society, 15(3), 451–464. https://doi.org/10.1017/S1474746416000129 Smith-Oka, V. (2009). Unintended consequences: Exploring the tensions between development programs and indigenous women in Mexico in the context of reproductive health. Social Science & Medicine, 68(11), 2069– 2077. https://doi.org/10.1016/j.socscimed.2009.03.026 Smith-Oka, V. (2012). Bodies of risk: Constructing motherhood in a Mexican public hospital. Social Science & Medicine, 75(12), 2275–2282. https://doi. org/10.1016/j.socscimed.2012.08.029 Smith-Oka, V. (2014). Fallen uterus: Social suffering, bodily vigor, and social support among women in rural Mexico: Fallen uterus in Mexico. Medical Anthropology Quarterly, 28(1), 105–121. https://doi.org/10.1111/maq. 12064 Smith-Oka, V. (2015). Microaggressions and the reproduction of social inequalities in medical encounters in Mexico. Social Science & Medicine, 143, 9–16. https://doi.org/10.1016/j.socscimed.2015.08.039

CHAPTER 6

The Well-Being Impacts of Officer–Recipient Relations: A Quantitative Perspective

As this book is based on a mixed-method study, previous chapters focused on the qualitative phase exploring the nature and well-being consequences of the encounters between recipients and frontline officers using the narratives and observed interactions of these actors. This chapter, in contrast, centers on the quantitative phase. This phase consisted on the application of a survey to the recipients of the program assessing (1) their socioeconomic characteristics and affiliation to Oportunidades, (2) the quality of their relationships with health officers, and (3) their subjective and psychosocial well-being evaluations. As explained in the methodological notes of this book, three scales were used to measure well-being and quality of officer–recipient relationship. To briefly recapitulate, the instruments used to measure well-being were obtained from the internationally renowned global questions of happiness and life satisfaction of the Subjective Well-being approach (SWB) and from the multidimensional and psychosocial model of inner well-being (White et al., 2014). In the interest to move away from solely western conceptions of wellbeing, the inner well-being (IWB) model was used and went through a process of contextualization during the piloting and analysis phases. During piloting, the original questions of the model were translated and adapted to the context and tested through in-depth interviews with local recipients. During the analysis, as seen next, the model was tested © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 V. Ramírez, Relational Well-Being in Policy Implementation in Mexico, https://doi.org/10.1007/978-3-030-74705-3_6

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through exploratory statistical tools to allow the domains to arrange in a way that was meaningful for the empirical data collected. Therefore, the IWB model that resulted from the statistical analysis (presented here) took the form of the well-being of the Oportunidades recipients in these localities of Mexico. To measure the quality of the relationship between health officers and recipients, a scale was designed particularly for this study. A 14-item scale (the QoR scale) was created based on the narratives of recipients on what constituted a positive and a negative relationship with officers obtained from the qualitative interviews and focus groups. The items used the wording of the recipients’ accounts in both localities with the objective of remaining as faithful as possible to their own experiences and perspectives. This scale measured aspects such as respect, trust, communication, and quality of medical attention during program implementation. The chapter presents first the sample and methods of the quantitative study. Second, explains the construction of the IWB and QoR scales through factor analytic procedures. And third, uses the resulting set of indicators to evaluate the statistical association between well-being and this policy-engendered relationship through variance, correlation and regression analyzes. This involves scrutinizing the differences between participants and localities in their reports of the quality of relationships with officers (QoR) and of well-being (SWB and IWB), and finally testing if officer–recipient relationships have significant effects on the well-being of recipients, and if so, through which channels (domains) it does so.

Participants In total, three hundred and twelve (n = 312) recipients completed the surveys, 142 in Cualcan and 170 in Nexpan. The target population of Oportunidades is mainly mothers, therefore, the sample of this study is mostly composed of female recipients, accounting for 96.2% of the sample (only 12 (3.8%) men completed the survey). The distribution of the sample in terms of ethnicity was almost completely determined by the locality. In Cualcan 97.9% of participants self-identified as speaking an indigenous language compared to only 5.3% in Nexpan. Similarly, approximately 80% of the sample in each locality reported being married or living with a partner, whereas the rest were widows, divorced, or never married (Table 6.1).

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Table 6.1 Demographics Total sample Variable Gender

Categories

Cualcan

Percent N

Nexpan

Percent N

Percent

300 12

96.2 3.8

136 6

95.80 4.20

164 6

96.5 3.5

Indigenous 148 Non-Indigenous 164

47.4 52.6

139 3

97.90 2.10

9 161

5.3 94.7

With Partner 245 Without Partner 67

78.5 21.5

113 29

79.60 20.40

132 38

77.6 22.4

Role in Recipient 202 Oportunidades Vocal or Health 110 Committee

64.7 35.3

116 26

81.70 18.30

86 84

50.6 49.4

Ethnicity

Marital Status

Female Male

N

In relation to the association with Oportunidades, 35.3% of all participants reported having acted or currently acting as vocales or health committee members. This proportion was, however, different in each locality as 18.3% of Cualcan’s and 49.4% of Nexpan’s recipients took part in either role. The process of selection and rotation of the members in each health center caused this difference between localities. In Cualcan, the health officers applied a selection process based on voluntary participation whereas in Nexpan the officers rotated recipients every year based on a list ordered by surname. The logical result is that in Nexpan more recipients had performed this role in the past than in Cualcan. Vocales and committee members spent more time at the clinic, therefore, it could be expected that these roles are significant for the terms of the relationship with officers and their influence on well-being.

Measures The model of inner well-being (IWB) originally comprised of seven domains measured through 36 items (Table 6.2) and the Quality of Relationships with Officers scale (QoR) comprised of 14 items (Table 6.3).1

1 The stars on the item names in both tables indicate that these are reversed coded questions.

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Table 6.2 Inner well-being Indicators Item EC1 EC2 EC3 EC4 EC5 AP1 AP2 AP3 AP4 AP5 SC1 SC2 SC3 SC4 SC5 CR1 CR2 CR3 CR4 CR5 CR6 PMH1 PMH2 PMH3 PMH4 PMH5 CSW1 CSW2 CSW3

Question How do you feel about your economic situation? How well could you manage economically if something bad were to happen (e.g. illness in the family)? Your economic worries affect your participation in the town celebrations? Do you feel people around you have done better economically than you? How often do you feel worried about money? In a town meeting, can you give your opinion freely? If an authority makes a decision that affects you directly, do you feel you can protest against it? How often you feel others do not care about what you have to say? How confident do you feel that the community can get together to take action? How often do you feel that you have the freedom to make your own decisions? If you need something (find a job, talk to an authority) do you know the kind of people who knows how to help you? Do you have friends or acquaintances in which you can count on during difficult times? Do you feel included in your community? Do you feel people in your community are helpful to you? Are you affected by gossip in your community? When you need to talk about something important to you, is there someone you can go to? How often do you feel harmony in your home? Do you feel that your family cares about you? Do you feel that your family supports you in important decisions you make? How worried are you about the amount of violence in your home? Do you like the way your family treats you? How often do you sleep well? Do you suffer from tension? How often do you feel sad? Do you have the strength you need for your daily work? In the last months, how much have you worried about your health? How far do you feel you are able to help other people? How confident are you that you are able to achieve the things that matter to you? How well do you feel you can perform your daily tasks?

(continued)

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Table 6.2 (continued) Item CSW4 CSW5 VM1 VM2 VM3 VM4 VM5

Question Do people around you make you feel that you are not capable of doing things? How often do you feel as if you were ignorant? Do you feel that life has been good to you? Do you feel that God is with you? Do you feel that your life has been worthwhile? Do you feel at peace at the end of the day? Do you feel that your life is meaningful?

Table 6.3 QoR indicators Item qor1 qor2 qor3 qor4 qor5 qor6 qor7 qor8 qor9 qor10 qor11 qor12 qor13 qor14

Question The way physicians ask you to comply with the conditions of the program is appropriate? Thinking about your experience in general, do you feel the physicians pay attention to your needs? Do you feel physicians treat you with kindness and respect? During consultations and workshops, physicians explain things clearly? Do you feel physicians abuse of their position? When physicians say or do something that makes you uncomfortable, can you say or do something about it? Have you felt discriminated during a consultation or workshop of Oportunidades? Have you been scolded by a physician in front of others? Have you been insulted or humiliated by a physician? Do you feel that everybody finds out about the reasons for your visit when you go for a consultation at the clinic? Is the waiting time for a consultation is worthwhile? When you go to the clinic, do you receive an adequate medical revision? Do you receive the best medical attention from physicians? Are physicians sensitive to you and your needs?

To construct and validate the IWB and QoR scales, factor analytic procedures were used. Factor analysis has the objective of reducing a set of observed variables into a more manageable set of composite factors by assuming that they are linear combinations of an underlying factor that cannot be measured directly (Hair et al., 2010).

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In the broadest sense, the uses of factor analytic procedures can be divided into two. Exploratory Factor Analysis (EFA), as its name suggests, is used to explore the structure behind the data and to develop and evaluate scales. This procedure is recommended at early stages of scale development. Confirmatory Factor Analysis (CFA), in contrast, is employed to test a hypothesis or an underlying theory, and is recommended when a scale has been validated or when there are good theoretical grounds supporting an a priori hypothesis. Both techniques provide complementary pieces of information about the structure of the data. The EFA allows establishing the reliability and validity of the construct measurements of the models, whereas the CFA allows rigorous evaluation of their goodness of fit for this data. This research conducted both EFA and CFA using SPSS 22 and AMOS 22. The results are presented next.

The Inner Well-Being Scale The IWB model has been tested and validated in two contexts, India (White et al., 2014) and Zambia (Gaines, 2014), obtaining positive results in terms of construct validity and model fit for a 7-domain model. To examine the extent to which these domains emerge for this sample or if new domains are more appropriate an unconstrained EFA procedure was conducted using Principal Components (PC) as the extraction method2 and Promax as the rotation method.3 To ensure the quality of the data, prior to the EFA the dataset was cleaned up through procedures that inspected for issues that affect ordinal scales such as non-engaged responses, missing values, and variables with severe kurtosis. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy supported the decision of conducting a factor analysis with this data, offering a value of 0.798 greater than the threshold of 0.7 (Field, 2 A variety of factor extraction models exist. The Principal component analysis (PCA) approach was used since it reduces the number of variables by creating linear combinations that retains as much as possible of the variance in the original variables. 3 A Promax rotation is appropriate since it assumes that the factors are correlated with each other. This is consistent with the theory behind the IWB model that postulates these domains as constituting one model of well-being between them.

6

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Factor analysis of the IWB model Loadings

Items CR6 CR3 CR4 CR1 CR2 VM4 VM5 VM3 VM1 SC3 SC2 SC4 SC1 PMH2 PMH3 EC5 PMH1 CSW2 CSW3 CSW1 AP2 AP1 EC2 EC1 EC4 CSW5 CSW4 Variance Explained

F1

F2

F3

F4

F5

F6

F7

F8

0.78 0.77 0.73 0.68 0.46 0.77 0.74 0.72 0.41 0.82 0.58 0.53 0.36 0.74 0.70 0.55 0.44 0.72 0.72 0.66 0.85 0.79 0.81 0.68 0.43 0.8 0.75 19.6

7.74

7.03

5.21

4.99

4.35

4.21

3.72

2013). Similarly, Bartlett’s Test of sphericity was statistically significant (p < 0.0005) which corroborates that the data is suitable for factor analytic procedures. The EFA revealed an eight-factor solution with eigenvalues greater than 1 and yielding a Total Variance Explained of 56.85%4 (Table 6.4). 4 A regression method was used to calculate the factor score of each IWB domain extracted.

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Table 6.5 IWB model fit

Statistic

Model

Ideal threshold

CMIN/df CFI RMSEA SRMR

1.625 0.883 0.045 0.057

Between 1 and 5 > 0.90 < 0.07 < 0.08

As expected, all loadings were positive and significant using the 0.350 threshold recommended by Hair et al. (2010) for sample sizes greater than 250. Similarly, the loadings within each factor average above 0.600 for all factors except for Factor 3 (SC), which is just at the margin with a loading of 0.573.5 The CFA was conducted through Maximum Likelihood estimation to evaluate how well the measured variables represent the constructs found in the EFA (Hair et al., 2010). The goodness of fit indices evaluate how well the proposed model accounts for the correlations between the observed variables in the data. The fit indices for the final measurement model suggest that all thresholds are met following the recommendations of Hu and Bentler (1999) and Gaskin (2012) (Table 6.5). Interpreting the IWB Factors The eight domains of the IWB of this sample are close relationships (CR), values and meaning (VM), social connections (SC), mental health (MH), political participation (PP), social recognition (SR), and economic confidence (EC) (Table 6.6). The domain of Close Relationships (CR) relates to the quality of personal relationships that people enjoy. The items evaluate the level of harmony within the home and feelings of support and care from family members. The fact that this is the first factor that loads in the pattern matrix indicates that the quality of intimate and close relationships is a critical factor in the inner well-being of this sample, explaining for 19.59% 5 One characteristic of this model is that two factors (6 and 8) are composed of two

items. This can be a limitation of the scale because factors with less than three items could increase instability within the factors (Costello & Osborne, 2005) and cause the model to be under-identified (Hair et al., 2010). Yet, the study of Guadagnoli and Velicer (1988, p. 274) support the interpretation of these factors in sample sizes greater than 300 observations.

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Table 6.6 IWB factors and items Item 1

CR1 CR2 CR3 CR4

2

3

CR6 VM1 VM3 VM4 VM5 SC1 SC2

4

5

6

7

8

SC3 SC4 PMH1 PMH2 PMH3 EC5 CSW1 CSW2 CSW3 AP1 AP2 EC1 EC2 EC4 CSW4 CSW5

Question When you need to talk about something important to you, is there someone you can go to? How often do you feel harmony in your home? Do you feel that your family cares about you? Do you feel that your family supports you in important decisions you make? Do you like the way your family treats you? Do you feel that life has been good to you? Do you feel that your life has been worthwhile? Do you feel at peace at the end of the day? Do you feel that your life is meaningful? If you need something (find a job, talk to an authority) do you know the kind of people who knows how to help you? Do you have friends or acquaintances in which you can count on during difficult times? Do you feel included in your community? Do you feel people in your community are helpful to you? How often do you sleep well? Do you suffer from tension? How often do you feel sad? How often do you feel worried about money? How far do you feel you are able to help other people? How confident are you that you are able to achieve the things that matter to you? How well do you feel you can perform your daily tasks? In a town meeting, can you give your opinion freely? If an authority makes a decision that affects you directly, do you feel you can protest against it? How do you feel about your economic situation? How well could you manage economically if something bad were to happen (e.g. illness in the family)? Do you feel people around you have done better economically than you? Do people around you make you feel that you are not capable of doing things? How often do you feel as if you were ignorant?

of the variance in the model. The domain of Values and Meaning (VM) is loaded in factor two. This domain relates to a sense of meaning in life, such as feeling at peace with oneself and feeling that one’s life is worthwhile. This domain could relate to a general satisfaction-with-life evaluation. Factor three represents another relationship domain, Social

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Connections (SC). This domain conveys the quantity of one’s ties to others, as well as the perceived quality of one’s social environment and the level of connectedness to one’s community. White et al. (2014) suggest that this domain represents those less intimate and more political relationships that extensive research has shown to be important for well-being. In this sample, factor four captures Mental Health (MH). The underlying theme of the items that load in it tap on feelings of worry, tension, stress, and sadness. It is worth noting that one item capturing feelings of worry about money consistently loaded in this factor (EC4). This could suggest that one of the main sources of poor mental health in this sample was their poverty and the risks behind being economically poor. Previous research consistently underlines the connection between mental health and poverty (e.g., Hanandita & Tampubolon, 2014; Lund et al., 2010). In this sample, the two items intended to measure physical health showed problems of negative loading (PMH5) and cross-loading (PMH4) and thus were eliminated from the analysis. The domain of Competence and Self-worth (CSW) was captured in factor five as it measures people’s sense of being capable of helping others, as well as feeling able to achieve daily or more significant tasks or goals. Factor 6 alludes to people’s sense of being able to voice their opinions and participate in social and political events such as town meetings or in interactions with local authorities. Since these items are tapping on a particular experience of agency, it cannot be claimed that this factor is capturing the comprehensive understanding of the concept of Agency originally intended in the IWB model. For this reason, the domain does not retain the label used by the Well-being Pathways project and is changed to Political Participation (PP). It was deemed valuable to retain this domain since this book is interested in understanding the role of the quality of relationships with frontline officers who can be considered authorities in these localities. Factor seven represents the domain of Economic Confidence (EC) which captures people’s feelings about their economic situation overall and relative to others, and how well they feel they can manage economically. Finally, factor eight alludes to feelings of adequacy that are derived from other’s reactions toward oneself, perceptions of how one is recognized by others, feelings of being able to say or do things. The items of this factor separated from the original domain of Competence and SelfWorth. Despite having the theoretical expectation that all items of CSW load together, this was not possible for this sample. Therefore, the domain is labeled “Social Recognition” (SR).

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The domains obtained from the factor analytic procedures suggest that the structure of inner well-being of the recipients in these two localities of Mexico broadly resembles what was expected from previous studies that validated the IWB model in Zambia and India.6 The psychometric analysis showed that the IWB domains can be used for the objectives of this book. The CFA confirmed that this model fits the data and can be used to evaluate the well-being of this sample. Ultimately, the aim here is not to obtain a model of well-being that can be universalized or applied across contexts. Rather, the objective is to obtain a model that captures or approximates what well-being is and how it is experienced in these localities.

The Quality of Officer–Recipient Relationships Scale To fully explore the effect of the relationship with frontline officers in well-being, a section of the survey evaluated the subjective perceptions of the quality of this relationship through 14 questions. An unconstrained EFA procedure was conducted in SPSS using Principal Component Analysis as the extraction method and Promax as the rotation method. After exploring for any issues of cross-loading and low loadings, the model that explained the data best is the two-factor model presented in Table 6.7. In the inspection of sampling adequacy, the KMO measure suggested that the sample was factorable (KMO = 0.906). The two-factor model shown in Table 6.7 depicts a very clean structure and a strong convergent and discriminant validity through high loadings within factors and no cross-loadings using the 0.200 threshold accepted in the literature (Matsunaga 2010). All loadings were significant and above the 0.350 threshold for samples greater than 250 (Hair et al., 2010). Similarly, 6 The disparity between the original model of IWB and the model constructed for this sample generates questions about the success of the process of contextualization of the indicators to the research sites. Contextualization is a process that seeks to improve the relevance of the indicators used to the contexts in which they are applied. However, in these research contexts this process was not easy to conduct because of the low literacy levels in the sample, as well as issues in the translation of the items to Spanish and because this was the second language for some participants in the indigenous locality. Although more could be said about this, in the future and with more resources and time available, more sophisticated procedures such as cognitive interviewing are recommended (Camfield, 2016).

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Table 6.7 Factor analysis of QoR scale

Loading

Table 6.8 QoR Model Fit

Items

Factor 1

qor2 qor3 qor4 qor7 qor8 qor9 qor12 qor13 qor14

0.771 0.625 0.713

Variance Explained

0.546

Factor 2

0.632 0.942 0.894 0.833 0.878 0.853 0.125

Statistic

Model

Ideal threshold

CMIN/df CFI SRMR

3.323 0.956 0.048

Between 1 and 5 > 0.90 < 0.08

both factors have excellent average loadings of 0.779 and 0.823, respectively. Finally, the Total Variance Explained of this model was very good (67.142%). In terms of model fit, the CFA confirmed the factor structure of the previous exploratory analysis, as well as the validity and reliability of the model. The goodness of fit statistics of the final measurement model confirm that all thresholds are met based on Hu and Bentler (1999) and Hair et al. (2010) (Table 6.8). As a result, this confirms that the QoR scale is a valid and reliable measure to assess the relationship between officers and recipients of the Oportunidades program in these localities. Interpreting the QoR Factors This analysis suggests that the quality of relationships with officers is in fact reflecting two underlying constructs measuring positive relationships and negative relationships separately. On the one hand, the items that load onto the first factor clearly relate to a positive evaluation of the quality of

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this relationship, including aspects such as good medical attention, appropriate explanations, kindness, and respect (Table 6.9). On the other hand, all items that load onto the second factor related to negative aspects of the relationship, capturing issues of discrimination and verbal mistreatment. Given this clear duality in the evaluation of the relationship with officers, the factors were labeled as Positive Quality of the Relationship (PveQoR) and Negative Quality of the Relationship (NveQoR), respectively. The extent to which the PveQoR and NveQoR are measuring unrelated features of a relationship or opposite sides within a continuum (e.g., humiliation on one side, and respect on the other) is unclear. One indication that PveQoR and NveQoR are not isolated aspects of relationships comes from the narratives of recipients reported in Chapter 5 that revealed that both positive and negative characteristics could coexist within one relationship (for example depending on the mood of the officer, the actors involved in the interaction, etc.). Indeed, relationships can be both respectful and humiliating at different moments. This implies that positive and negative interactions could have differential effects and Table 6.9 QoR factors and items Factor

Item

Positive Interactions (PveQoR)

qor2

qor3 qor4 qor12 qor13 qor14 Negative Interactions (NveQoR)

qor7

qor8 qor9

Question Thinking about your experience in general, do you feel the physicians pay attention to your needs? Do you feel physicians treat you with kindness and respect? During consultations and workshops, physicians explain things clearly? When you go to the clinic, do you receive an adequate medical revision? Do you receive the best medical attention from physicians? Are physicians sensitive to you and your needs? Have you felt discriminated during a consultation or workshop of Oportunidades? Have you been scolded by a physician in front of others? Have you been insulted or humiliated by a physician?

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intensities of effects on people’s lives and well-being. Hence, this separation into two underlying constructs could allow exploring whether positive and negative aspects of the relationship with officers have differential roles on well-being. Namely, if positive aspects could influence certain well-being domains whereas negative aspects could affect others.

Mapping the Well-Being of Oportunidades-Prospera ’s Recipients The well-being of the recipients of Oportunidades in Cualcan and Nexpan was explored using the two global indicators of happiness and life satisfaction, and the composite indicators of IWB generated from the factor analytic procedures presented above. Happiness and life satisfaction remain ordinal indicators with a 5-point Likert scale that ranges from (1) very unhappy or unsatisfied to (5) very happy or satisfied. In contrast, the IWB domains extracted from the factor analysis are standardized and continuous variables with mean 0 and standard deviation 1. Yet, to ease interpretability and comparability these were re-scaled into a 1 to 5 metric. In terms of subjective well-being, the average levels of happiness and life satisfaction of recipients was above average (3.5), although one-way ANOVA tests prove that recipients in Nexpan experience significantly higher happiness (F(1,310) = 6.48, p = 0.011) and life satisfaction (F(1,310) = 4.41, p = 0.036) than recipients in Cualcan. Jointly, however, their average levels are lower than that for the nation as a whole. According to the BIARE questionnaire collected by INEGI in 2012, on average happiness and life satisfaction of Mexicans was 4 and 4.2, respectively (personal calculation). These results are very similar to the 2008–2012 data collected by World Happiness Report for a nationally representative sample in Mexico (4.2). However, the latest data of the 2020 World Happiness Report derived from a 2017–2019 series, suggests that Mexico suffered an important reduction in happiness compared to the 2008–2012 results (3.4; a reduction of 0.804 on a scale of 1–5).7

7 The original data is on a scale of 0 to 10. It was rescaled here to match that used for this study. Originally, Mexico obtained an average happiness of 6.465 on a scale of 0 to 10, and was the 24th happiest country in the world in 2020. This implies a reduction of 0.558 from 2008–2012 to 2017–2019.

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The lower average reports of this sample compared to the national average is not a surprising result since the participants of the study represent the most deprived and marginalized groups in the nation and of their communities. The main reason they are recipients of Oportunidades is that they experience deprivations in education, health, and income, which are strongly associated to subjective well-being. Research in Mexico and Latin America has found that while income is a weak predictor of SWB (Fuentes & Rojas, 2001; Rojas, 2009a, 2009b); other variables such as health (García et al., 2007), education (Rojas, 2007b; García et al., 2007), living conditions and access to basic services (Powell & Sanguinetti, 2010) are key explanatory variables. The IWB domains give us a richer picture of the well-being outcomes across the sample. The mean levels presented in Table 6.10 indicate that participants reported higher scores for the domains of social recognition (SR), values and meaning (VM), and close relationships (CR) compared to mental health (MH) and social connections (SC) (F(7,2488) = 21.851, p < 0.001). On the other hand, if we look at IWB scores by locality, we find that even though Nexpan reports higher SWB than Cualcan, the IWB domains show that this is not the case for all aspects of psychosocial well-being. The IWB in Cualcan and Nexpan is similar in Table 6.10 Descriptive statistics SWB and IWB Total

SWB Happiness Life Satisfaction IWB Close Relationships Values and Meaning Social Connections Mental Health Competence and Self-worth Political Participation Economic Confidence Social Recognition Observations

Cualcan

Nexpan

Mean

Std. Dev

Mean

Std. Dev

Mean

Std. Dev

3.5 3.5

0.885 0.870

3.3 3.4

0.963 0.844

3.6 3.6

0.798 0.883

3.4 3.4 3.0 2.9 3.3 3.2 3.1 3.5

0.833 0.860 0.757 0.583 0.793 0.717 0.691 0.668

3.4 3.1 3.1 3.0 3.4 3.4 3.1 3.5

0.761 0.850 0.778 0.620 0.788 0.753 0.672 0.639

3.4 3.7 3.0 2.9 3.2 3.1 3.2 3.5

0.890 0.775 0.738 0.547 0.796 0.660 0.708 0.694

312

142

170

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Table 6.11 Correlations IWB and SWB against demographics

Happiness Life Satisfaction Close Relationships Values and Meaning Social Connections Mental Health Competence and Self-worth Political Participation Economic Confidence Social Recognition

Age

Years of education

−0.147** −0.107†

0.118* 0.136*

−0.033

Years in oportunidades

Cash transfer (MXP)

Housing

−0.107 −0.074

−0.010 −0.007

0.078 0.042

0.152**

−0.003

0.009

0.195**

0.023

0.040

−0.106

0.048

0.138*

0.090

−0.085

0.062

0.030

0.081

−0.033 −0.102†

0.012 0.022

−0.092 0.014

−0.015 −0.027

−0.008 0.082

0.003

0.068

0.046

−0.002

−0.101†

0.071

−0.058

−0.013

−0.081

0.223**

−0.020

0.029

0.154**

0.137* 0.103

Pearson correlations (2-tailed). Significance levels: **p < 0.01, *p < 0.05, † p < 0.1

most domains except for values and meaning (VM) and political participation (PP). One-way ANOVA tests indicate that Nexpan experienced significantly higher levels of VM compared to Cualcan (F(1,310) = 39.87, p < 0.001), whereas Cualcan shows significantly higher levels of PP compared to Nexpan (F(1,310) = 12.65, p < 0.001). Who experiences greater levels of SWB and IWB in the sample? For the case of SWB, happiness and life satisfaction only correlate with age and years of education.8 In other words, being younger and having more education is associated with higher SWB, a common finding in the literature (Table 6.11). One-way ANOVA tests (F(2,309) = 3.59, p = 0.029) and Tukey’s HSD post hoc analysis further attest that participants of 33 years old or less were significantly happier than participants of 45 years

8 Well-being also correlated with age-squared as found in the literature showing that the relationship between age and well-being takes the form of an inverted U-shape. Yet, in this sample, the results obtained with age and age-squared were equivalent.

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old or more9 (p = 0.021). Similarly, a One-way ANOVA test (F(2,309) = 4.57, p = 0.011) and post hoc Tukey’s tests confirmed that those who completed high school were significantly happier compared to those who only completed junior high (p = 0.017) or primary school (p = 0.022). The IWB domains indicate that the positive association between education and well-being in this sample occurred through the domains of close relationships and social recognition (Table 6.11). This was supported by a one-way ANOVA test and post hoc Tukey’s tests showing that recipients with a high school degree had a significantly better sense of recognition from others compared to recipients who did not have any schooling (F(2,309) = 4.42, p < 0.05).10 Similarly, the negative relationship between age and inner wellbeing occurred through the domains of competence and self-worth and economic confidence. This is no surprise since the recipients in both localities often secured their income from labor that was physically intensive, such as farm work. In the qualitative interviews elderly participants suggested that their age implies that they are more dependent on their children and that their capacity to work decreased importantly. Hence, their confidence in securing enough income to meet their daily needs was even more compromised at this stage of life. In contrast, although mental health was not correlated to any demographic indicator, a oneway ANOVA (F(2,309) = 8.54, p < 0.001) and Tukey’s HSD tests suggested that the youngest (33 years or less) and oldest (45 or more) recipients in the sample experienced significantly higher levels of mental health compared to recipients between the ages of 34 and 44 (p < 0.001). Another result consistent with well established findings in the well-being literature. If we evaluate the relationship between the program and the recipients’ well-being outcomes, the number of years of adherence to Oportunidades and the size of the cash transfer were not associated with any well-being domain, including economic confidence. The only exception was political participation. The length participants had been part of the Oportunidades

9 In this sample, the age groups were constructed from a quintile approach (the division of the distribution in equal groups). Three age groups were created: 33 or less, 34 to 44, and 45 or more. 10 This result could be over-determined, however, since one item of the Social Recognition indicator taps on people’s feelings of being ignorant.

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program related to higher feelings of being able to express opinions and protest within their localities.11 Not finding a relationship between the size of the cash transfer and perceived well-being was not completely expected since, during the qualitative interviews, recipients constantly described the cash transfer as a vital security net. In many cases, the cash transfer was the only secure income they obtained and important expenditure decisions were taken around the dates that the transfer was made. These decisions affected their immediate needs such as food expenditure, as well as investments in children’s clothing and education, improvements in housing conditions, and even debt relief. However, recipients did recognize that the size of the transfer was not enough to meet their basic necessities. These results could be a sign that this dependence on the cash transfer might not improve the recipients economic confidence overall. Moreover, the quality of people’s housing was a proxy of economic position and wealth. The housing indicator was measured at the household level and constructed from questions about the quality of dwelling and infrastructure (i.e., sources of water, sanitation facilities, type of flooring, and overall house construction materials).12 The correlation analysis with all well-being measures indicated that housing was not associated with happiness or life satisfaction; yet, the quality of people’s close relationships, their sense of meaning in life, and their economic confidence correlated positively and significantly with the quality of their housing conditions. The previous descriptive analyses reveal that IWB and SWB do not always concur on the connection between people’s personal and economic characteristics and their well-being outcomes. While this could be interpreted as initially pointing towards the different characteristics

11 There is a possible two-way causation in this result. That is, in addition to the previous direction of causality, it is also possible that people with greater sense of political participation used it to enter and remain in Oportunidades. 12 These variables were assigned an incremental weight based on the conceptual quality of the indicator (e.g., the water indicator was coded as (1) no piped water, (2) piped water from neighbor/other, (3) piped water into residence). Despite the limitations of constructing a proxy of relative economic position based on these indicators, recent studies have validated and recommended the use of this approach in contexts like Cualcan and Nexpan. That is, contexts in which measuring income and consumption expenditure is challenging due to the variability and diversity of the income sources, to give an example (e.g., Moser & Felton, 2007).

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of these approaches, it does not clarify what is the specific relationship between SWB and IWB.13 SWB and IWB have distinct ontological and epistemological stances. SWB understands well-being as an experiential phenomenon, focusing on people’s cognitive and emotional responses toward their lives as a whole. IWB, in contrast, looks at well-being from a more substantive perspective, defining the constituents of wellbeing based on theory and empirical research, evaluating their quality directly and looking at each domain from a more relational perspective. Even though we know about these differences conceptually, the statistical relationship between SWB and IWB needs exploring. Assessing the association between these approaches can give us two different kinds of information that are relevant to understand the wellbeing of social program recipients. First, analyzing the extent to which the IWB domains explain happiness and life satisfaction can indicate whether the quantitative data corroborates that these (IWB and SWB) are two different constructs of well-being. This can also give support to the earlier assessment of the construct validity of IWB as a model of well-being in itself, since some positive association between the two approaches is expected. Yet, having in mind that they have conceptually different stances toward well-being, an exact match between them is not likely. Second, since the global indicators of SWB only tell us a summary indicator of how people are feeling about their lives, the IWB domains can shed light into their meaning in these localities. Namely, by identifying which IWB domains explain and have greater weight on the experience of happiness and life satisfaction for this sample. Overall, the analysis of the association between IWB as a substantive approach and SWB as an empirical approach to well-being is carried out through correlation and regression analysis. Table 6.12 presents the pattern of Pearson’s correlations between the two indicators of SWB, happiness and life satisfaction, and all domains of IWB constructed for this sample. As expected, most domains of IWB depict a significant and positive relationship with happiness and life satisfaction (except for the domain of political participation which is not

13 The analysis of the relationship between IWB and SWB was explored initially using the sample as a whole. As shown in the previous section, the samples in Nexpan and Cualcan do not show large or consistent well-being differences. For this reason, hereafter the analysis is conducted collapsing the data across locality (it is nonetheless advisable to test for differences across contexts in any new sample).

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Table 6.12 Pearson correlation IWB and SWB

IWB Close Relationships Values and Meaning Social Connections Mental Health Competence and Self-worth Political Participation Economic Confidence Social Recognition

Happiness

Life Satisfaction

0.36** 0.22** 0.27** 0.11†

0.39** 0.35** 0.27** 0.19** 0.20**

0.01 0.22** 0.14*

0.08 0.25** 0.10†

0.25**

Significance levels: **p < 0.001, *p < 0.05, †p < 0.1 Observations: 312

significant). While correlation does not imply causation, it confirms that the higher the IWB of participants, the higher their happiness and life satisfaction (and vice versa). The results also reveal that although the sizes of the correlations are moderate, not all are equally important.14 The highest correlation is with the domain of close relationships (CR) with a coefficient of approximately 0.4. This is consistent with several studies conducted in Mexico (e.g., Rojas, 2004, 2007a, 2018) and internationally (Helliwell et al., 2012, 2017) that attest that family relationships are the greatest source of happiness and life satisfaction. In the case of happiness, the correlation with close relationships (CR) is followed by the domain of mental health (MH), whereas for life satisfaction is values and meaning (VM), proving the more emotional and evaluative nature of the indicators of SWB, respectively. The domain of social connections lies in third place for life satisfaction and fourth for happiness, both closely followed by the domain of economic confidence. Mental health (MH) is more strongly associated with happiness than with life satisfaction, whereas with competence and self-worth (CSW) the opposite occurs. In turn, in both SWB indicators, correlations with the domain of Social Recognition (SR) are positive but low, and correlations with Political Participation (PP) are non-significant.

14 The results of this analysis concur with those by Fernandez et al. (2014) who found significant but slightly stronger relationships between the IWB indicators and happiness.

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These findings indicate two things. First, whereas IWB and SWB are measuring well-being, they are not capturing the same thing. As expected, the direction of the association between SWB and IWB domains is consistently positive. Nonetheless, the strength of their association varies with each domain of IWB. Second, this analysis of linear relationship also confirms the centrality of social relationships for the SWB of this sample. It shows that CR is the domain most strongly associated with happiness and life satisfaction, with the domain of SC positioned a few places behind. It is nonetheless important to go beyond correlation analysis to find the relative association of each IWB domain with the happiness and life satisfaction of the Oportunidades recipients in this sample. The regression analyses15 conducted here is not based on the assumption that IWB domains are either determinants or components of happiness. For this book IWB and SWB are simply different approaches to well-being, they measure distinct constructs or understandings of well-being. The aim is simply to understand which domains of IWB are linked to how participants responded to the SWB questions. For this cross-sectional study using ordinal dependent variables (the SWB items are ordinal and measured in a 5-point Likert scale), OLS models were conducted to explore the relationship between IWB and SWB.16 The model specification is thus a linear regression model based on the following general model: SWBi = IWBi (IWB1 . . . IWBn, γi ), n = 8 Where SWBi represents the happiness or life satisfaction of each i participant in the sample and IWBi stands for her inner well-being 15 Regression analysis is a commonly used method within well-being research to evaluate

the nature of relationships between indicators. This statistical tool explores functional relationships between variables (Gujarati & Porter, 2009). In the happiness and domain satisfaction literatures, regressions are often used to understand which variables explain SWB and what is their relative explanatory power (how important they are) taking into account other variables (e.g., Rojas, 2006). 16 For this type of data, well-being researchers usually opt either for Ordinal Least

Square (OLS) models or Ordered Probit models. There is debate about which is the best model to use. However, in recent years many SWB scholars have opted for OLS models for their easier interpretability but also because it has been found that they deliver equivalent results. Similarly, Garson (2012) supports the use of ordinal dependent variables in OLS estimation as long as the variable has at least 5 response categories.

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outcomes in each of the eight domains. A normally distributed error term is represented by γi . More specifically two regressions were conducted: Hi = δ0 + δ1 CRi + δ2 VMi + δ3 SCi + δ4 MHi + δ5 CSWi + δ6 ECi + δ7 PPi + δ8 SRi + μi LSi = β0 + β1 CRi + β2 VMi + β3 SCi + β4 MHi + β5 CSWi + β6 ECi + β7 PPi + β8 SRi + ei where: Hi : Happiness of person i, in a 1 to 5 scale. LSi : Life satisfaction of person i, in a 1 to 5 scale. CRi : the quality of Close Relationships of person i, in a 1 to 5 scale. VMi : the Values and Meaning of person i, in a 1 to 5 scale. SCi : the quality of Social Connections of person i, in a 1 to 5 scale. MHi : the Mental Health of person i, in a 1 to 5 scale. CSWi : the Competence of person i, in a 1 to 5 scale. ECi : the Economic Confidence of person i, in a 1 to 5 scale. PPi : the Political Participation of person i, in a 1 to 5 scale. SRi : the Social Recognition of person i, in a 1 to 5 scale. μi and e i : error term of person i for each regression. δ j and β j : the parameters to be estimated in each regression, j = 0 to 7. The regressions and the assumptions they need to satisfy were explored using Stata version 13.0.17

17 The residuals of these regressions are homoscedastic. Homoscedasticity signifies that the residuals are equally distributed over the predicted values for all dependent variables in the regression. This was evaluated using the Breusch-Pagan/Cook-Weisberg test confirming that the models present constant variance. The results for the Happiness regression are: Chi-squared(1) = 1.17, prob > chi2 = 0.28. The results for the Life satisfaction regression are: Chi-squared(1) = 2.29, prob > chi2 = 0.13. Similarly, for the regression results to be valid, the independent variables in the models need to not be highly

6

Table 6.13 Linear regression analysis of SWBi over IWBi

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Happiness Constant Close Relationships Values and Meaning Social Connections Mental Health Competence and Self-worth Political Participation Economic Confidence Social Recognition R-squared

215

Life satisfaction 0.704† 0.206** 0.224** 0.130* 0.087 0.069

1.045* 0.248** 0.121* 0.083 0.232* 0.001 −0.077 0.158* −0.006

−0.009 0.207** −0.058

0.197

0.244

Significance levels: **p < 0.001, *p < 0.05, †p < 0.1 Observations: 312

The IWB model predicts both happiness and life satisfaction (Table 6.13). The R-squared—which describes the explanatory power of all independent variables over the dependent variable—shows that IWB explains 20% of the variation of happiness and 25% of the variation of life satisfaction. Despite this, not all domains are equally strong or significant for both indicators of SWB. The regression analyses mainly reflect the results of the correlation statistics with the exception that the domains of competence and self-worth (CSW), political participation (PP), and social recognition (SR) are not significant either for happiness or life satisfaction. Whereas some connection between IWB and SWB was expected, the conceptual differences between the two were reflected in the moderate explanatory power of the IWB model in the regressions. Their links are primarily through economic confidence, a subjective evaluation of income and a common determinant of SWB; and also through the more internaloriented domains of IWB, mental health and values and meaning. In contrast, IWB includes the domains of CSW, SR, and PP not accounted correlated with each other to avoid problems understanding which variable contributes to the variance explained by the model. For this, the Variance Inflation Factor test was conducted. The mean coefficient of 1.24 for both models (since the same independent variables are introduced in both regressions) giving consistent evidence that these models did not suffer from a collinearity problem. These post-estimation results and the satisfaction of these assumptions justify the interpretation of the results of these regression models.

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for in the variation of happiness or life satisfaction—at least not in this sample. However, the significance of these domains on well-being is not only justified by the results of the factor analysis of the IWB model, but also supported by the qualitative findings of this research. Indeed, in addition to being central aspects of the participant’s well-being narratives, their sense of competence and self-worth, political participation, and social recognition were influenced by the quality of their relationships with the medical staff in the clinic, the focus of this book. One interpretation of these results could be that, while the IWB model is indeed associated with SWB, it includes aspects of well-being not captured by either happiness or life satisfaction. Therefore, the multidimensional and psychosocial model of IWB could be offering a distinctive picture of the experience of well-being. So far the descriptive analysis of well-being depicted which recipients were better off and what aspects of well-being were associated with different demographic indicators, with the Oportunidades program, and with each other. This analysis also showed that through the IWB domains the well-being experiences of participants can be evaluated more profoundly. Whereas the SWB indicators suggested that the happiest and most satisfied people in the sample are the younger and more educated recipients, the IWB model allowed a deeper analysis into the pathways through which these demographic indicators influence well-being. Being able to disaggregate in different domains, therefore, uncovers interesting relationships that could be explored more deeply in the future. Finally, this analysis also provides interesting insights about the relationship between a hedonic approach to well-being (SWB) and a psychosocial approach (IWB), as well as the value of taking a substantive (psychosocial) and multidimensional model of well-being such as IWB. IWB can explain people’s happiness and life satisfaction reports and allows for the deconstruction of well-being into different domains or aspects that are central for people’s lives. In this sample, this analysis confirms that close relationships, economic confidence, and values and meaning are essential for the subjective well-being (happiness and life satisfaction) of recipients of Oportunidades.

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Relationships in Policy Implementation and Their Well-Being Impacts This section explores the quality of officer-recipient relationships in both localities and their impact in the well-being of recipients. This is investigated through descriptive, correlation and regression analyses of the association between the quality of the relationship with Oportunidades health officers (QoR) and the subjective and inner well-being outcomes of recipients. The variables used are the two indicators of SWB, the eight composite indicators of IWB and the two composite indicators of QoR (PveQoR and NveQoR) generated through the factor analytic procedures. These were standardized and re-scaled to a 5-point Likert scale to simplify interpretation. The demographic variables used are well-known drivers of well-being (e.g., Dugain & Olaberriá, 2015), they include locality, age, years of education, living with partner, being employed, amount of cash transfer received, household size, and quality of housing as proxy of wealth. The Quality of the Relationship with Officers in Nexpan and Cualcan The quality of the relationship with officers in both localities are relatively high (Table 6.14). Yet, on average Nexpan reported a significantly worse relationship compared to Cualcan in PveQoR (F(1,310) = 27.27, p < 0.001) and NveQoR (F(1,310) = 11.76, p = 0.001) following a one-way ANOVA test. To be clear, on average, participants in Nexpan reported lower levels of positive interactions (3.3) and higher levels of negative interactions with the health staff (2.2) than participants in Cualcan (with average scores of 3.8 and 1.9, respectively). Table 6.14 Descriptive statistics PveQoR and NveQoR Total sample

PveQoR NveQoR Observations

Cualcan

Nexpan

Mean

Std. Dev

Mean

Std. Dev

Mean

Std. Dev

3.6 2.1

0.864 0.852

3.8 1.9

0.721 0.711

3.3 2.2

0.911 0.930

312

142

170

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Table 6.15 Descriptive analysis of QoR by affiliation to Oportunidades Total Variable

Categories

Cualcan

Nexpan

PveQoR NveQoR PveQoR NveQoR PveQoR

NveQoR

Role in Recipient Oportunidades Other roles

3.6 3.4

2.1 2.1

3.9 3.6

1.9 2.0

3.3 3.3

2.3 2.2

Choice of source of medical attention

3.7

1.9

3.9

1.8

3.6

2.0

3.2

2.4

3.7

2.2

3.1

2.5

Local Clinic Other

Differences in the reported quality of the relationship with officers were explored based on the roles of recipients in the activities of Oportunidades (vocales and health committee members versus just recipients) and those who reported having the local clinic or other suppliers as their first choice to seek medical attention (Table 6.15). The latter variable, tried to capture those people who, despite the gratuity of the medical service in the Oportunidades clinic, chose a different source when seeking medical attention for reasons not included in the compulsory services of the program. Those recipients who had direct contact with the health staff due to their role as vocales or as committee workers,18 experienced significantly lower levels of positive interactions with staff compared to those who only acted as recipients (F(1,310) = 6.332, p = 0.012). This difference appears to be driven by the locality of Cualcan in which vocales and health committee members report lower positive interactions (3.6) compared to those who are only recipients (3.9) (F(1,140) = 4.336, p = 0.039). In Nexpan, even though on average they experienced lower levels of PveQoR, no significant differences were found between these

18 In this data set, no differentiation was made between vocales and health committee

members since some participants reported acting in either role in the recent past (a month before the fieldwork was conducted the members of the health committees in both localities changed). This indicated that it was not going to be possible to discern between present and previous experience. Thus, this variable captures those recipients that had acted or were currently acting in either role.

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two groups of recipients. Overall, these results could indicate that those recipients who had frequent contact with the officers due to their role (practically acting as unpaid employees in addition to clients) experienced a less positive interaction with the health staff. A relatively bad interaction with the health officers implementing Oportunidades could also have implications in the attitudes recipients took toward the clinic. This was explored by asking participants about the first place they would resort to when requiring medical attention (particularly non-compulsory medical attention). Analysis of variance shows that people who did not choose the local clinic as their first option, reported significantly lower positive interactions (F(1,310) = 27.163, p < 0.001) and higher negative interactions (F(1,310) = 23.534, p < 0.001) with the health staff. If we evaluate differences by localities, recipients in Cualcan only reported significantly worse negative interactions (F(1,140) = 6.065, p = 0.015), whereas in Nexpan they declared both significantly lower positive interactions (F(1,168) = 14.883, p < 0.001) and higher negative interactions (F(1,168) = 9.933, p = 0.002). Although further research is required, these results could suggest that a relatively worse relationship drives recipients to choose other health care options (including private doctors or traditional healers) when needing medical attention for their ailments. Overall, consistently with the qualitative findings, these results indicate that Nexpan is the locality that experienced a worse relationship with health officers. Yet, participants evaluated the relationship less negatively in the surveys than would be expected from the negative reports found in the qualitative analysis presented in previous chapters. This incongruence between how relationships are evaluated in the qualitative and quantitative studies could have two interpretations. One possible explanation is that participants in these contexts could have experienced a positive bias or social desirability bias when faced with the precise and tangible essence of survey questions. A similar experience has been reported in other countries when measuring quality of relationships. In Zambia (White & Jha, 2014) and India (Jha & White, 2016), the Well-being Pathways research group found that participants tended to evaluate their close relationships more positively in the survey questions than they did in the qualitative interviews. In the face of these results, White and Jha (2014) emphasized the need to further examine the implications of wording in the measurement of quality of relationships.

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Whereas close relations are a different kind of relationship, the literature on client-provider interactions in the context of health (Merkouris et al., 2004; Simmons & Elias, 1994) has also problematized the measurement of clients’ subjective evaluations of their interactions with physicians. Simmons and Elias (1994) highlight a number of findings in countries from the Global North and the Global South where quantitative and qualitative results are in contradiction. Quantitative indicators typically revealed high levels of client satisfaction while qualitative studies show extensive evidence of dissatisfaction. A possible reason for this contradiction according to Simmons and Elias (1994) are issues of ‘courtesy’ biases in people’s responses to quantitative indicators since ‘people are often unwilling to reveal their views to someone with whom they have not established extensive rapport and trust’ (p. 9). In contrast, Merkouris and colleagues (2004, p. 356) suggest that other possible explanations are patient’s ‘social conformity and/or dependence’ on health staff as well as a difficulty of discerning between the quality of care received and other aspects of health provision. This last explanation was visible in the interviews with recipients who constantly merged the quality of medical attention with the quality of care received. A merge that in fact does not seem farfetched as the human aspect of medical provision is increasingly recognized. Additionally, participants in this study might have felt that their answers to such questions could have real repercussions in the future, either for them or for the health staff. Indeed, for this sample this positive bias might have been higher because of a fear of retaliation that recipients expressed during the qualitative interviews. The fear voiced was that if officers find out how recipients were evaluating them, they could act against recipients by, for example, taking them out of the program. This fear could have been more acute in the surveys than in the interviews since the former were applied in the clinics themselves (though without the health staff present).19 Finally, these results could suggest a limitation of surveys to capture certain aspects of relationships observed in qualitative data. For example, Simmons and Elias (1994) argue that ‘surveys cannot assess adequately such factors as the technical quality of care provided, nor can they reflect 19 The recipients were consistently reassured that their responses to the survey questions were anonymous and their identity would be safeguarded. Similarly, the health staff did not have any involvement with the survey neither before, during or after it was applied.

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easily the complex feelings and perspectives of clients or the underlying dynamics of power and status’ (p. 9). While the former evidence points toward the difficulty of measuring relationships quantitatively, another interpretation of the contradictory results of qualitative and quantitative data is that during qualitative commentary people could tend to privilege negative experiences while taking for granted the positive experiences with health officers. In other words, in a conversation, negative interactions could be more immediately available in their recollections of their interactions with officers or can more easily turn into an interesting discussion among participants (e.g., in focus groups), than positive interactions. Yet, since this book takes the position that neither form of elicitation provides the ‘real’ or ‘single truth’ about the nature of the relationship between officers and recipients, both need to be contrasted and analyzed to understand better what is happening in these interactions. Even though more research is necessary, these divergent results give additional support to the need of taking a mixed-methods perspective in the study of such complex issues like the quality of relationships. Yet, beyond this broader discussion about different forms of elicitation, these findings start to point out toward the possible implications of the quality of the relationship with officers for the health and well-being of recipients. The Well-Being Effects of Frontline Officers The pathways through which this policy-engendered relationship impacted the well-being of recipients was explored through correlation and regression analysis between QoR and well-being. The Pearson’s correlations of PveQoR and NveQoR with all IWB domains show interesting results (Table 6.16). First, all significant correlations are positive and low. A low score was expected as the quality of the relationship with the health officers was not likely to be a large determinant of people’s well-being since there are many other aspects of their lives (including other relationships) that could be more relevant to each domain. Despite the low coefficients, the overall assessment shows that having a positive relationship with officers (measured by positive indicators such as respect, kindness and the like through PveQoR), is significantly associated with well-being outcomes in the domains of close relationships (CR), social connections (SC), political participation (PP), economic confidence (EC) and social recognition (SR). On the other hand, having a more negative relationship (measured by indicators such as feeling scolded, insulted

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Table 6.16 Correlation QoR scales and IWB domains

Close Relationships Values and Meaning Social Connections Mental Health Competence and Self-worth Political Participation Economic Confidence Social Recognition

PveQoR

NveQoR

0.113* 0.060 0.115* 0.090 0.035 0.142* 0.103† 0.121*

−0.025 0.012 −0.009 −0.071 0.071 −0.037 −0.045 −0.131*

Significance levels: **p < 0.001, *p < 0.05, † p < 0.1 Observations: 312

and discriminated through NveQoR) significantly correlated with lower well-being outcomes in the domain of social recognition (SR). If we take a closer look, the link between CR and SC with PveQoR might be capturing three things. First, the three are measures of quality of relationships, therefore, the correlation might be capturing personal characteristics of the participant concerning relationships such as the participant’s tendency to construct positive or negative relationships with others all together (either with their family, their locality, or the health officers). Secondly, the significant correlation with SC could indicate that the relationship with the health officers is one part of the social connections domain of recipients. Since the relationship with the health officers has become a constant and important interaction in the life of recipients due to the part officers play in the regulation of the conditions of Oportunidades, it could have become one part of a better quality of social connections within the inner well-being of recipients. Thirdly, these significant coefficients could indicate legitimate effects of the relationship over the participants’ close relationships and social connections. The qualitative data indicated that health officers sometimes influenced people’s personal relationships by creating conflict between recipients or between recipients and their families (like the case of the woman who was beaten by her husband because a nurse publicly exposed her use of contraceptives, which was subsequently filtered to the husband by a fellow recipient). Hence, as interactions with physicians are more positive, participants could have avoided some conflicts with their other relationships.

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On the other hand, the political participation domain measures the extent to which people feel that they can use their agency in their town and when interacting with an authority. Therefore, the association between PveQoR and PP can indicate that if the relationship with the health officers is more positive, this is associated with a higher ability to express a complaint and an opinion in social scenarios but also in interaction with authorities such as the health staff themselves. A number of passages from conversations with recipients in the qualitative interviews illustrated this as well. The positive and significant relationship between EC and PveQoR is also an interesting finding. The health officers were in charge of regulating the conditions of Oportunidades and therefore were key for the recipients’ stay in the program. In this context, a positive and significant correlation between the PveQoR and the recipients’ economic confidence is no surprise. The more positive the relationship with the health officers might imply that recipients were less afraid of losing the cash transfer. Many participants in the interviews declared this, as well as the centrality of the cash transfer as a security net during their (constant) times of economic hardship. Finally the domain of SR is associated both with PveQoR and NveQoR, showing that more expressions of respect and fewer expressions of insults and discrimination in their interactions with health officers were linked to recipients having a greater sense of worth or recognition from others. So far, the descriptive analysis shows that recipients in Cualcan have a better QoR with health officers measured by both PveQoR and NveQoR. Furthermore, it showed that QoR—positively and negatively measured— is linked to IWB principally through the domains of CR, SC, PP, EC and SR. These results largely confirm the qualitative findings so far. However to explore whether the association between QoR and IWB outcomes remains after controlling for the personal characteristics of participants and by locality, regression analyzes were undertaken. The regression analyzes were conducted in two stages. First, to isolate the effect of QoR over IWB, a set of eight regressions were conducted with each domain of IWB as dependent variables and only the two indicators of QoR as independent variables (model 1). Second, another set of eight regressions were conducted to explore whether PveQoR and NveQoR remained significant when demographic characteristics are accounted for (model 2). The main variables used were: as dependent variables, each of the eight standardized composite factors of the IWB

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Table 6.17 Descriptive statistics independent variables

Total sample Demographics Role in programme Age Years of education Living with partner Working Cash Transfer (MXP) Household Size Housing

Mean

Std. Dev

0.35 40 8.2 0.79 0.74 1,133.04 5.57 0.61

0.479 12.58 4 0.411 0.441 615.66 2.551 0.216

Observations: 312

domains; namely, CR, VM, SC, MH, CSW, PP, EC, and SR. The independent variables comprise the two standardized composite factors of quality of relationships with the health officers PveQoR and NveQoR and data on demographic characteristics (Table 6.17). The subsequent equation expresses the general form of Model 1 IWBi j = β0 + β1 PveQoRi + β2 NveQoRi + μi where: IWBij : the inner well-being of person i measured by each of the j domains of the IWB model (CR, VM, SC, MH, CSW, EC, PP, and SR, with j = 1 to 8). All dependent variables are in a 1 to 5 scale. PveQoRi : the positive interactions with the health officers reported by person i, in a standardized scale.20 NveQoRi : the negative interactions with the health officers reported by person i, in a standardized scale.21 μi : the error term of person i for each regression. β: the parameters to be estimated in each regression.

20 The QoR indicators used were the standardized scores obtained from the factor analysis to avoid any issues of multicollinearity in the regression analysis due to the interaction effects introduced. 21 The NveQoR indicator remained in its original reverse code to ease interpretability (i.e., the higher the score, the more negative the interaction with officers).

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The results denote that the interactions with the health officers show a significant and positive effect on the IWB of recipients only when measured by positively phrased questions (PveQoR) (Table 6.18). Moreover, PveQoR explains the well-being outcomes for the domains of close relationships (CR), social connections (SC), economic confidence (EC), and political participation (PP). In sum, these findings imply that as participants experience more positive interactions with the health officers, their well-being improves in the IWB domains mentioned. In contrast, the quality of the interactions with officers do not have a significant effect in the domains of values and meaning, mental health, and competence and self-worth. If we compare these results with the correlation analysis previously conducted, we can see that in the regressions the explanatory power of QoR on SR drops. Model 2 presents the same group of eight regressions but now controlling for demographic variables known to be key drivers of well-being (e.g., Dugain & Olaberriá, 2015). Hereafter, the regressions take into account most of the relevant characteristics of the individual in order to elicit whether those relationships between QoR and IWB still hold. This model also includes an interaction effect with the variable Drole. This dummy variable separates the sample between those who act only Table 6.18 Regressions IWBi over PveQoR and NveQoR 22

PveQoR NveQOR Constant R-square

CR

VM

SC

MH

CSW

PP

0.123* 0.05 3.38** 0.015

0.086 0.06 3.43** 0.007

0.124* 0.064 3.03** 0.018

0.043 −0.017 2.92** 0.009

0.089 0.107 3.30** 0.014

0.129** 0.048 3.225** 0.023

EC

SR

0.079† 0.046 0.015 −0.062 3.14** 3.47** 0.011 0.02

Significance levels: **p < 0.001, *p < 0.05, †p < 0.1 Observations: 312 22 In model 1 assumptions were tested, finding that the residuals of all regressions are homoscedastic (have constant variance) using the Breusch-Pagan/Cook-Weisberg test, except for regressions with MH and PP as dependent variables. On the other hand, no collinearity was present between the independent variables in the models according to the Variance Inflation Factor test that offered a mean coefficient of 1.49 for all models since the same independent variables are introduced. The satisfaction of these assumptions justifies the interpretation of the results, although the regressions of MH and PP should be interpreted with caution due to possible heteroscedasticity present.

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as recipients and those who have acted as vocales or members of the health committee within Oportunidades and the clinic. This variable and its interaction with both indicators of QoR (PveQoR i Drole i ; NveQoR i Drole i ) were introduced to the regressions given the results that this group of recipients reported significantly worse interactions with officers. These variables test whether having closer and more frequent interactions with officers is linked with a stronger effect on well-being. If the coefficient is positive, the effect of QoR on well-being is stronger for those recipients who have a role in Oportunidades than for those who are only recipients. On the other hand, if the coefficient is negative, the effect of QoR on well-being is lower for vocales and health committee members than for the average recipient. The generic model can be expressed as follows. IWBi = βo + β1 PveQoRi + β2 NveQoRi + β3 PveQoRi Drolei + β4 NveQoRi Drolei + β5 Drolei + β6 zi + μi where zi represents a vector of the control variables in the regression: zi = α1 Dlocality + α2 agei + α3 educi + α4 Dpartneri + α5 Dworkingi + α6 cttotali + α7 hhsizei + α8 housingi + εi where: IWBij : the inner well-being of person i measured by each of the j domains of the IWB model (CR, VM, SC, MH, CSW, EC, PP, and SR, with j = 1 to 8). All dependent variables are in a 1 to 5 scale. PveQoRi : the positive interactions with health officers reported by person i, in a standardized scale. NveQoRi : the negative interactions with health officers reported by person i, in a standardized scale. Drolei : binary (dummy) variable on the role of person i in the program, where 0 = recipient only and 1 = vocales and/or health committee members. PveQoRi Drolei : interaction effect about the impact of PveQoR given the role of person i in Oportunidades.

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NveQoRi Drolei : interaction effect about the impact of NveQoR given the role of person i in Oportunidades. Dlocalityi : binary variable of the locality of person i, where 0 = Cualcan and 1 = Nexpan. agei : the age of person i measured in years. Dpartneri : binary variable of the marital status of person i, where 0 = no partner (single, divorced, widowed) and 1 = living with partner (married or cohabitating). Dworkingi : binary variable about the employment status of person i, where 0 = not working and 1 = working in formal or informal employment. cttotali : proxy of the amount of cash transfer received by person i. hhsizei : household size of person i. housingi : quality of dwelling and housing of person i. μi and εi : error term of person i for each regression. β i and α j : the parameters to be estimated in each regression. The regression outputs indicate that, even after controlling for personal characteristics, positive interactions with health officers (PveQoR) have a significant and positive association with the well-being of all recipients for the domains of values and meaning (VM), social connections (SC), economic confidence (EC) and social recognition (SR), as well as for overall happiness (Table 6.19). The positive and significant effect of PveQoR on social connections (SC) indicate that, as the relationship with health officers improves, people feel more supported by their social networks within their localities. These might include health officers themselves, but also other authorities in the community and influential people like teachers, school principals, and promotores —the other frontline officers coordinating Oportunidades at the municipal level. The significant and positive association with economic confidence (EC), in turn, reinforces the importance of the relationship on the recipients’ possibility of securing the cash transfer every two months. The better interactions with physicians are, the less dangerous these actors are perceived for securing the recipient’s stay in the program. Positive interactions with officers were also significant for increasing the sense of social recognition (SR) of participants and decreasing feelings of not being a capable person in the eyes of others. Although this is significant only at 1% (p < 0–1), this is consistent with the findings in the

0.195* [0.092] −0.123 [0.093] −0.024 [0.103] 0.041 [0.150] 0.08 [0.152]

0.671** [0.106] 0.002 [0.004] 0.01 [0.014]

0.073 [0.107] 0.005 [0.005] 0.036** [0.014]

VM

0.117 [0.093] 0.107 [0.480] 0.018 [0.094] −0.014 [0.897] −0.284† [0.153]

CR

0.005 [0.066] 0.014 [0.067] −0.108 [0.074] 0.104 [0.108] 0.008 [0.109] −0.038 [0.076] −0.002 [0.003] −0.001 [0.010]

−0.027 [0.099] 0.005 [0.004] −0.008 [0.013]

MH

0.170* [0.086] −0.066 [0.087] −0.024 [0.097] −0.1 [0.141] −0.115 [0.142]

SC

Regressions IWBi over QoR 23

−0.082 [0.104] −0.007 [0.004] −0.004 [0.014]

0.075 [0.091] −0.076 [0.092] −0.022 [0.102] −0.015 [0.148] −0.106 [0.150]

CSW

−0.303** [0.091] 0.005 [0.004] 0.022 [0.012]

0.055 [0.079] −0.073 [0.080] 0.086 [0.089] 0.217† [0.129] −0.054 [0.131]

PP

0.146 [0.090] −0.004 [0.004] 0.004 [0.012]

0.198* [0.078] −0.082 [0.079] −0.052 [0.088] −0.232† [0.128] −0.11 [0.129]

EC

0.016 [0.085] −0.001 [0.004] 0.037** [0.011]

0.121* [0.074] −0.045 [0.074] 0.103 [0.083] −0.207† [0.120] 0.308* [0.122]

SR

0.383** [0.113] −0.008 [0.005] 0.013 [0.015]

0.238* [0.098] −0.108 [0.099] −0.147 [0.110] −0.054 [0.160] −0.154 [0.162]

Happiness

0.275* [0.112] −0.004 [0.005] 0.026† [0.015]

0.125 [0.098] −0.068 [0.099] 0.013 [0.110] 0.288† [0.160] −0.308† [0.162]

Life Satisfaction

23 The residuals of all regressions are homoscedastic (have constant variance) according to the Breusch-Pagan/Cook-Weisberg test and no collinearity was present according to the Variance Inflation Factor test that offered a mean coefficient of 1.58 for all models with the highest individual VIF of 2.49. These post-estimation results and the satisfaction of these assumptions justify the interpretation of the results of these regression models following OLS estimation.

Years of education

Age

PveQoR* Role NveQoR* Role Control Variables Locality (Nexpan)

Role

NveQoR

PveQoR

Relations with officers

Table 6.19

228 V. RAMÍREZ

0.09

0.145 [0.119] 0.035 [0.138] 0 [0.000] 0.005 [0.021] 0.660** [0.218] 2.3** [0.349] 0.17

0.083 [0.118] −0.055 [0.105] 0 [0.000] −0.012 [0.021] 0.456* [0.215] 2.7** [0.345]

VM

SC

0.06

0.169 [0.110] 0.001 [0.099] 0 [0.000] −0.017 [0.019] 0.244 [0.202] 2.6** [0.323]

Significance levels: **p< 0.01, *p< 0.05, †p< 0.1 Observations: 312

R-squared

Constant

Housing

Household size

Cash Transfer

Employed

Living with a partner

CR

0.06

0.124 [0.085] −0.167* [0.076] 0 [0.000] 0.079 [0.015] −0.054 [0.155] 3.1** [0.248]

MH

0.04

0.003 [0.117] 0.071 [0.104] 0 [0.000] −0.025 [0.020] 0.314 [0.213] 3.6** [0.341]

CSW

0.11

0.14 [0.102] 0.264** [0.091] 0 [0.000] −0.004 [0.018] 0.031 [0.186] 2.6** [0.298]

PP

0.06

0.103 [0.101] −0.056 [0.090] 0 [0.000] −0.012 [0.018] 0.357† [0.184] 3.0** [0.294]

EC

0.10

0.147 [0.126] −0.233 [0.112] 0.000 [0.000] −0.006 [0.022] 0.186 [0.230] 3.44** [0.368]

−0.094 [0.095] −0.048 [0.084] 0 [0.000] −0.013 [0.016] 0.237 [0.173] 3.1** [0.277] 0.11

Happiness

SR

0.08

0.092 [0.126] −0.010 [0.112] 0.000 [0.000] −0.019 [0.022] 0.117 [0.229] 3.24** [0.367]

Life Satisfaction

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qualitative data in which recipients describe how the public humiliation, yelling, and threats of doctors and nurses influenced their self-esteem and sense of personal worth. Finally, good relationships with physicians related positively with recipients’ values and meanings (VM) which measure an overall sense of having a peaceful, worthwhile, and meaningful life. This is complemented by the significant coefficient with happiness that denotes that good interactions during policy implementation contribute to positive emotions and feelings of happiness overall. Interestingly, the NveQoR indicator in isolation was not significant for any well-being indicator. This is at odds with the qualitative results that showed that recipients gave a much greater importance to negative interactions with officers on their well-being experiences. Despite this incongruity, NveQoR was significant for close relationships (CR), social recognition (SR) and life satisfaction when interacting with the role of recipients in the program. This interaction variable evaluates to what extent having a role in Oportunidades as vocal or member of the health committee mediates the effect of the relationship on well-being. The interpretation of this coefficient goes as follows: when the sign of the coefficient is positive, the quality of the relationship is more significant for the well-being of vocales and committee members than for the average recipient. In contrast, when the sign is negative, the relationship is less significant for the well-being of this group than for the average recipient. The most interesting result here is the positive coefficient (NveQoR*Role = 0.308**) of this interaction effect in the domain of Social Recognition (SR), which denotes that for vocales and committee members having negative interactions with officers has a greater effect than for an average recipient on how much they feel recognized and valued by others. This is possibly due to the constant and more frequent interactions these recipients have with officers and the fact that they receive direct orders from them - whether to summon other recipients, collect signatures or reports, or clean the clinic. Yet, although with a lower significant level (p < 0.1), negative interactions with officers had a lower effect on the quality of personal relations and overall life satisfaction of vocales and committee members compared to an average recipient. Having a role in Oportunidades and in the clinic also mediated the effect of positive interactions with officers (PveQoR*Role) on well-being although at a lower significance level (p < 0.1). On the one hand, this

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variable exhibited a significant and negative coefficient (–0.207*) with Social Recognition (SR). Namely, positive interactions with officers had a lower effect on the social recognition of vocales and committee members compared to an average recipient. On the other hand, the positive coefficient in Political Participation (PP) (PveQoR*Role = 0.217*) indicates that for vocales and committee members a positive interaction with staff had a stronger effect in their sense of political participation and agency than it had for the average recipient. This could relate to the particular function of vocales to act as intermediaries between the program, the clinic, and the recipients. Their function was as administrative as it was political. In front of physicians, they advocated the needs of individual women and their families, and the collective needs of the community of recipients. Therefore, positive interactions with physicians could facilitate the execution of this responsibility as well as the vocales’ well-being outcomes in this domain. Finally, the effect of a positive interaction is less strong for the economic confidence of those with a role (PveQoR*Role = –0.232*). This result could relate to the reduced knowledge of the average recipient about the power of health officers over their stay in the program. Thanks to the training vocales obtained, they were better informed about the procedures of the program and about the position health officers took in them. They were more certain that physicians could not carry out their threats of taking recipients out of the program if they did not comply with activities unrelated to the official conditions of Oportunidades (attending the consultations and workshops). Therefore, their relationship with officers could influence their economic confidence less. Inspecting the R-squared coefficients of these regressions make evident that the explanatory variables are not strong predictors of the well-being of recipients in any indicator. Although the R-squared coefficients are not very high, they are not smaller than what is usually found in similar studies in the well-being literature. It is also important to note that the objective of this analysis was not to maximize the explanation of the determinants of inner well-being. Specifically, the objective was to explore the statistical significance of the relationships with health officers in different domains of the inner well-being of recipients.24 24 Issues of causality are not explicitly investigated here. This book is only exploring the association between the quality of relationships with health officers and the well-being of recipients. Nonetheless, it is important to have in mind that a possible reversed causality

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Summary This chapter examined the shape of the inner well-being of Oportunidades recipients, the quality of officer–recipient relationships and their association from a quantitative perspective. The results indicate, on the one hand, that the well-being of the Oportunidades recipients in this sample was relatively low. The highest-ranking indicators were happiness, life satisfaction and social recognition, whereas the lowest were mental health, social connections, political participation and economic confidence. There were no significant differences between localities except for the domains of values and meaning and political participation. In terms of the role of Oportunidades on the well-being of recipients, it was noteworthy that being in the program for longer was associated with a greater sense of political participation. Surprisingly, the size of the cash transfer was not associated with any indicator of well-being. On the other hand, as expected, recipients in Nexpan experienced significantly higher levels of negative interactions with physicians and lower levels of positive interactions than Cualcan. Similarly, recipients who had a role in the program reported significantly lower positive interactions with health officers compared to recipients who met officers less frequently and only interacted with them as clients. Overall, this is consistent with the qualitative findings. However, the average QoR evaluation was higher than expected from the experiences and perspectives of recipients obtained in the qualitative study. As discussed, this might have been caused by a number of issues such as social desirability biases, the difficulty of capturing certain aspects of relationships quantitatively, or participants’ fear of retaliation from officers. The most important results were obtained from the regression analyzes scrutinizing the association of officer–recipient relationships with each domain of the inner well-being of this sample. The results indicate that five of the eight domains of inner well-being are at play during interactions with officers. These are values and meaning (VM), social connections (SC), economic confidence (EC), political participation (PP) and social recognition (SR). In contrast to the narratives of recipients in chapter five, these results incorporate the domains of VM and SC and exclude the domain of competence and self-worth (CSW)—although could exist in which recipients who experience high well-being could influence the quality of their relationships with the health officers.

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arguably they can be substituted with the results related to the domain of social recognition which includes indicators of CSW. As discussed in this chapter, there could be a number of reasons behind the small inconsistencies between the qualitative and quantitative findings. However, on the whole, the qualitative and quantitative studies point toward the same direction: program-engendered relationships such as those created between frontline officers and recipients in the delivery of the health conditionalities of Oportunidades are non-negligible for the well-being experiences of recipients. Ultimately, these findings have important implications for well-being and policy research, as well as for policy making, implementation and evaluation.

Bibliography Camfield, L. (2016). Enquiries into well-being: How could qualitative data be used to improve the reliability of survey data? In S. C. White & C. Blackmore (Eds.), Cultures of well-being (pp. 47–65). Palgrave Macmillan UK. https:// link.springer.com/chapter/10.1057/9781137536457_2 Costello, A. B., & Osborne, J. W. (2005). Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical Assessment, Research and Evaluation, 10(7). Dugain, V., & Olaberriá. (2015). What makes Mexicans happy? OECD Economics Department Working Papers No. 1196. OECD. http://www. oecd-ilibrary.org/economics/what-makes-mexicans-happy_5js4h5qp6l0w-en Fernandez, A., White, S. C., & Jha, S. (2014). Well-being pathways report: India round 2. Well-being and poverty pathways. University of Bath. http://www.well-beingpathways.org/images/stories/pdfs/working_p apers/India_T2_report_FINAL_whole.pdf Field, A. P. (2013). Discovering statistics using IBM SPSS statistics: And sex and drugs and rock “n” roll (4th ed.). Sage. Fuentes, N., & Rojas, M. (2001). Economic theory and subjective well-being: Mexico. Social Indicators Research, 53(3), 289–314. https://doi.org/10. 1023/A:1007189429153 Gaines, S. O. (2014). Evaluation of the inner well-being model in Zambia. Psychology of Well-Being, 4(1). https://doi.org/10.1186/s13612-014-0016-5 García, J. de J., Fuentes, N., Borrego, S. A., Tapia, A., & Gutiérrez, M. D. (2007). Values and happiness in Mexico: The case of the metropolitan city of Monterrey. In L. Bruni & P. L. Porta (Eds.), Handbook on the economics of happiness. Edward Elgar. Garson, G. D. (2012). Testing statistical assumptions. Statistical Associates Publishing.

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Gaskin, J. (2012). Confirmatory Factor Analysis (CFA). http://statwiki.kolobk reations.com Guadagnoli, E., & Velicer, W. F. (1988). Relation of Sample Size to the Stability of Component Patterns, 103(2), 265–275. Gujarati, D. N., & Porter, D. C. (2009). Basic econometrics (5th ed.). McGrawHill Irwin. Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R. E. (Eds.). (2010). Multivariate data analysis (7th ed.). Prentice Hall. Hanandita, W., & Tampubolon, G. (2014). Does poverty reduce mental health? An instrumental variable analysis. Social Science & Medicine, 113, 59–67. https://doi.org/10.1016/j.socscimed.2014.05.005 Helliwell, John F., Huang, H., & Want, S. (2017). The social foundations of world happiness. In J. F. Helliwell, R. Layard, & J. Sachs (Eds.), World Happiness Report 2017. UN Sustainable Development Solutions Network. Helliwell, J. F., Layard, R., & Sachs, J. (Eds.). (2012). World happiness Report 2012. UN Sustainable Development Solutions Network. Hu, L., & Bentler, P. M. (1999). Cut-off criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi. org/10.1080/10705519909540118 Jha, S., & White, S. C. (2016). The weight falls on my shoulders: Close relationships and women´s well-being in India. In Culture of well-being: Method, place, policy (pp. 144–174). Palgrave Macmillan. Lund, C., Breen, A., Flisher, A. J., Kakuma, R., Corrigall, J., Joska, J. A., Patel, V. tver. (2010). Poverty and common mental disorders in low and middle income countries: A systematic review. Social Science & Medicine, 71(3), 517–528. https://www.sciencedirect.com/science/article/ abs/pii/S0277953610003576?via%3Dihub Merkouris, A., Papathanassoglou, E. D. E., & Lemonidou, C. (2004). Evaluation of patient satisfaction with nursing care: Quantitative or qualitative approach? International Journal of Nursing Studies, 41(4), 355–367. https://doi.org/ 10.1016/j.ijnurstu.2003.10.006 Moser, C. O. N., Felton, A., & Chronic Poverty Research Centre. (2007). The construction of an asset index measuring asset accumulation in Ecuador. Chronic Poverty Research Centre. Powell, A., & Sanguinnetti, P. (2010). Measuring quality of life in Latin America’s urban neighborhoods: A summary of results from the city case studies. In Eduardo Lora, World Bank, A. Powell, B. M. S. Van Praag, & P. Sanguinnetti, (Eds.), The quality of life in Latin American cities: Markets and perception (pp. 31–64). Inter-American Development Bank: World Bank.

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Rojas, M. (2004). Well-being and the complexity of poverty: A subjective wellbeing approach (Research Paper No. 2004/29). United Nations UniversityWIDER. http://www.wider.unu.edu/publications/rps/rps2004/rp2004029. pdf Rojas, M. (2006). Life satisfaction and satisfaction in domains of life: Is it a simple relationship? Journal of Happiness Studies, 7 (4), 467–497. https:// doi.org/10.1007/s10902-006-9009-2 Rojas, M. (2007a). A subjective well-being equivalence scale for Mexico: Estimation and poverty and income-distribution implications. Oxford Development Studies, 35(3), 273–293. https://doi.org/10.1080/13600810701514845 Rojas, M. (2007b). Enhancing poverty-abatement programs: A subjective wellbeing contribution. Working Paper 37, Well-being in Developing Countries ESRC Research Group (WeD), University of Bath. Rojas, M. (2009a). Enhancing poverty-abatement programs: A subjective wellbeing contribution. Applied Research in Quality of Life, 4(2), 179–199. https://doi.org/10.1007/s11482-009-9071-0 Rojas, M. (2009b). Economía de la felicidad: hallazgos relevantes respecto al ingreso y el bienestar. El Trimestre Económico, LXXVI (3), 303, 532–573. Rojas, M. (2018). Well-being in Latin America has social foundations. In John F. Helliwell, Richard Layard, and Jeffrey Sachs (Eds.), World Happiness Report 2018. UN Sustainable Development Solutions Network. Simmons, R., & Elias, C. (1994). The study of client-provider interactions: A review of methodological issues. Studies in Family Planning, 25(1), 1. https://doi.org/10.2307/2137985 White, S. C., & Jha, S. (2014). The ethical imperative of qualitative methods: Developing measures of subjective dimensions of well-being in Zambia and India. Ethics and Social Welfare, 8(3), 262–276. https://doi.org/10.1080/ 17496535.2014.932416 White, S. C., Gaines, S. O., & Jha, S. (2014). Inner well-being: Concept and validation of a new approach to subjective perceptions of well-being—India. Social Indicators Research, 119(2), 723–746. https://doi.org/10.1007/s11 205-013-0504-7

CHAPTER 7

Conclusion

This book set out to explore the role of the relationships with health officers in the well-being of the recipients of Oportunidades-Prospera, the conditional cash transfer program in Mexico. This has important links with two larger discussions. First, with discussions about the significance of relationships in the implementation of social policy and programs, especially those that are of conditional nature and that have proliferated around the world in the last decades. Second, this book also contributes to deepen understanding about the practical implications of a well-being perspective in policy analysis at the frontline level (McGregor et al., 2015, White & Abeyasekera, 2014). Relationships generated through policy implementation are a largely neglected area for both mainstream wellbeing and public policy literatures. The first has primarily focused on close and intimate relationships, while the second has seldom used a wellbeing lens to analyze the outcomes of social programs in general and the effects of the social interactions that occur during policy implementation in particular. This book meets these gaps by presenting a mixed-methods study of the delivery of the health component of Oportunidades-Prospera. To do so, the journey of the book commenced by bringing together the literatures on well-being and policy. Chapter two analyzed how well-being approaches have been employed in public policy, and specifically, their relevance for assessing the effectiveness of social policies and programs at the practical level. Then, the chapter moved on to © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 V. Ramírez, Relational Well-Being in Policy Implementation in Mexico, https://doi.org/10.1007/978-3-030-74705-3_7

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the study of social relationships and relationality in the well-being literatures. There are different ways in which subjective well-being approaches have been used to study relationships, yet until now they were not used in scrutinizing those relationships created during policy implementation. This chapter ends by arguing that in this task, however, psychosocial approaches are better suited to explore officer–recipient interactions because they offer a relational understanding of well-being that can observe the complex processes through which relationships influence people’s lives. The book then traveled into a discussion of policy implementation and street-level bureaucracy, before introducing the context and implementation processes of the health component of Oportunidades-Prospera in chapter three. The empirical evidence so far suggested that frontline officers have a central role in the implementation processes and outcomes of social programs—especially of conditional programs. Still, their effects over well-being has not been sufficiently studied. The major argument developed here was that looking at officer–recipient relationships through a well-being lens is necessary if we are to improve the design, implementation, and analysis of policies as well as to understand better the contributions of a well-being approach in public policy. After looking at the state of the literature, chapters four, five, and six recounted the empirical analysis conducted in two localities of the state of Puebla in Mexico using mixed methodologies. Together, these findings illuminate on the nature of interactions between frontline health workers and recipients of the Mexican conditional cash transfer program, as well as their effects over the well-being of recipients. To end this journey, this final chapter discusses the larger connections between the quantitative and qualitative findings and engages with their potential conceptual, policy, and methodological contributions.

The Characteristics and Quality of Officer–Recipient Relationships One of the most salient discoveries of this book was the importance recipients conferred to the quality of their personal relationship with health officers and their perceived attitudes and behaviors toward them. Their narratives repeatedly confirmed previous evidence (Merkouris et al., 2004) that what patients’ value is not only the doctor’s professional proficiency or the simple reception of service. Instead, even though recipients

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cared much about the quality of the medical attention received, they constantly linked it to the way it was provided. In this respect, the quality of officer–recipient relationships were opposites in each locality. In Cualcan (rural and indigenous recipients), although participants recalled negative experiences with former officers, they tended to describe their present interactions more positively, underlining trust, kindness, empathy, care, respect, and communication. In Nexpan, however, negative experiences were routine. Despite these differences, when participants in both localities described a negative interaction, they tended to emphasize aspects like mistreatment, verbal abuse, and personal and public humiliation. Nevertheless, in Nexpan (semi-rural and non-indigenous recipients), these negative experiences were more extreme, including discrimination and abuse of power. These results were further confirmed in the quantitative analysis, as the factor analytic procedures employed to construct the QoR scale confirmed the separation of the scale into two constructs: positive (PveQoR) and negative (NveQoR) interactions. The average QoR reports verified the disparity in the experiences across localities. Nexpan reported significantly higher levels of negative interactions and lower levels of positive interactions (2.2 > 1.9) than Cualcan (3.3 < 3.8) (see Table 6.14). Although with cross-sectional data is not possible to statistically test whether these results were associated with a lower set-point expectation in Nexpan, in the interviews there was no difference that stand out between what people expected or described as a positive and negative interaction in both localities. Similarly, no significant discrepancies were found in the well-being reports of recipients among localities that could suggest different biases in responding to survey questions. Hence, these results could indeed indicate true differences in the quality of interactions in communities. Finally, the implementation procedures of the program and previous findings suggested that recipients had two key roles in the program that could lead to a distinctive interaction with officers and different effects of the relationship on their well-being. Regular recipients on the one hand, and recipients who acted or had acted as vocales and/or members of the health committee on the other. The difference being that the latter had more frequent interactions with the officers than the former. The quantitative data confirmed the hypotheses. In the first case, vocales and health committee members reported lower positive interactions (3.4) compared to an average recipient (3.6), but there was no difference

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in negative interactions reports (2.1 for both). Moreover, as emphasized below, this differentiated relationship based on the recipient’s role influenced well-being differently as well. Factors Mediating the Officer–Recipient Relationship The nature of the relationship between officers and recipients was unavoidably one of power and authority. The narratives of officers (Chapter four) and of recipients (Chapter five) provided an explanation of the different factors that explained the (mis)uses of this authority and their effects on the quality of the officer–recipient relationship across localities. Previous evidence indicated that interactions in Oportunidades-Prospera were especially critical in indigenous and rural localities where reports of discrimination, mistreatment, abuse of power, and lower quality of health care were more frequent (Campos, 2012, Gutiérrez et al., 2008, Smith-Oka, 2014, Escobar Latapí, 2000, Agudo Sanchiz, 2012). In these research sites, however, neither the rural/urban divide nor ethnic identity explained the nature of this relationship and the overall differences between localities. Although in Cualcan some recipients did describe rougher encounters with officers when indigenous recipients had difficulties speaking or understanding Spanish. Instead, the salient distinguishing factors were the socioeconomic and professional identity of officers, their job title within the clinic, and the discourse of conditionality of the program. Officers often used their professional and socioeconomic identities to underline their power and to differentiate themselves from recipients. The category of ‘doctor’ justified the understanding of officers as knowledgeable and educated, in contrast to recipients who were conflated to the category of ‘patients,’ conceived as individuals with little knowledge and backward thinking. It was clear to officers that their training was inaccessible to recipients and this permitted controlling the format in which the health services of the program were provided. In addition, the socioeconomic status of officers—which were usually middle class, of urban origin and educated—contrasted with the stereotypical labels used for recipients such as ‘lazy,’ ‘uneducated,’ and the stigmatized view of their profession, ‘peasants.’ These labels also had the function of reinforcing the power of officers and the powerlessness of recipients, as suggested by the development literature (Wood, 1985; Eyben, 2006). Similarly, although the interviews

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with recipients focused on present experiences, they repeatedly recounted past experiences of this kind of treatment with former health officers indicating that these interactions were part of the larger structure of health care provision (Lipsky, 2010) in Mexico and not only of the interviewees in this research. These results are consistent with the studies that emphasize the influence of the professional (Mandlik et al., 2014) and institutional (Lipsky, 2010) authority granted to health officers in the way they delivered the services, as well as those that underline how power and identity shape relationships in the policy arena (Eyben, 2006; Wood, 1985). However, this book shows that the officer’ job position within the clinic and the discourse of conditionality of Oportunidades-Prospera intensified their effect over the delivery processes and the officer–recipient relationship. First, although the limited resources provided by health system in Mexico and the cumbersome administrative procedures of Oportunidades did not facilitate implementation, in the face of such adverse conditions permanent and temporary officers used their discretion differently, fostering opposite styles of interactions with recipients. Permanent officers, were direct employees of the public health system, they tended to be middle aged and had spent more time dealing with the institutional structure of the Mexican health system. These officers characterised by promoting a hierarchical relationship that used authoritarian methods of delivery, were primarily concerned in meeting the quotas set by the Ministry and were inflexible in the control over the procedures of the program. Permanent officers also exhibited a dichotomous understanding of the ‘good’ and ‘bad’ recipient in which obedience was a desirable trait. Sometimes, this promoted the surveillance of the behaviors of recipients beyond what was stipulated in the program, including body hygiene, clothing and house cleanliness. Permanent officers were a majority in Nexpan. In contrast, temporary officers were medical or nursing interns with a short-term position in the health clinics. They tended to be younger than permanent officers and their stay in the locality was transitory, which could reduce their tiredness with the challenges of the job. Possibly influenced by this, these officers exercised their authority in the monitoring of the conditionalities through communication, trust, and support. Stereotypical representations of recipients were less salient in their narratives and in their interactions with recipients, and they recognized their own responsibility in stimulating the recipients’ participation in the program

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and in promoting public health in the community at large. As such, temporary officers, who were a majority in Cualcan, tended to promote a relationship of reciprocity and empathic authority with the recipients of Oportunidades-Prospera. Finally, the relationship between officers and recipients in the localities of this study was also influenced by the characteristics of the program itself, especially the discourse of conditionality of Oportunidades-Prospera. Making the program conditional magnified the officers’ authority to monitor and regulate the behaviors of recipients around the formal and informal activities of the program. This validated a disciplinary relationship in which officers used their discretion to decide how to provide the services and how to control the behavior of recipients. It also endorsed a view of recipients as a captive population whose responsibility was to comply and behave according to the expectations of the health staff, rather than use a service they had the right to access. These differential interactions were also encouraged by the contradictory demands of the Health Ministry in the evaluation of the officer’s outputs in terms of large procedure quotas and strict deadlines. These specially pressured permanent officers because of the nature of their rank. As permanent officers had rising responsibilities in the clinic, they also were increasingly worried about meeting such deadlines and quotas. Together, these compelled them to prioritize numbers and outputs, rather than the quality of service delivery, inhibiting any concern for the well-being of recipients. This book also confirmed what Eyben (2010) noted in the context of development agencies, that the power and hierarchies used during interactions with recipients were noticeable in interactions between staff themselves. In Nexpan, hierarchical relationships also happened among staff, which inhibited nonconforming subordinate/junior staff (usually temporary officers) from improving or criticizing the way services were provided. Moreover, the strong community relations that were more prominent in Cualcan than in Nexpan, were also instrumental for recipient families in their attempts to counteract negative interactions with officers because of social cohesion, community empowerment, and their ability to organize. Overall, officers—both temporary and permanent—showed a legitimate interest in promoting public health in the populations in which they worked, yet at the same time, they held negative stereotypes and labels of recipients that reduced the quality of their interactions. Moreover, it

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was evident that relationships at different levels also altered the interactions between officers and program participants including relationships between officers themselves, and between officers and the community, the program’s discourse of conditionality, and the Health Ministry. The Implications of Relationship Quality Over the Program’s Outcomes Characterizing the nature of this relationship and the factors that explain differences across localities and officers was relevant to understand their consequences over the attitudes of recipients toward the program and the conditions. The quality of the relationship with officers was especially relevant for recipients since it was perceived as a key means for receiving better medical attention and for complying with the conditions of the program more smoothly. Yet, the attitudes of the health staff toward the recipients affected the quality of the workshops and the medical attention provided as part of the program, as well as the outlooks recipients had about the program and the clinic. When interactions were perceived as positive, recipients expressed having more trust in the clinic, more willingness to seek medical attention there and evaluated the quality of the medical attention more positively. In contrast, when interactions were perceived as negative, recipients preferred avoiding certain officers or even minimized their involvement in the clinic. The quantitative data confirmed these results. Those who reported not choosing the local clinic as their first option to receive medical attention, also reported significantly lower positive interactions (3.2, versus an average of 3.7 for those who chose the local clinic) and higher negative interactions (2.4, versus an average of 1.9 for those who chose the local clinic) with health officers. This double effect was stronger for Nexpan than for Cualcan, also confirming the results from the interviews with recipients and physicians about differences between localities. The effects of negative interactions over the decision to reach the clinic for medical attention is non-negligible. Looking for other sources of health care in private physicians or traditional healers is not only potentially harmful for the recipients’ economic security because of the greater cost of private care, but also for their health given the difficulty of identifying legitimate physicians. In some cases, this also entailed losing the benefits of the program if the recipient chose to stop complying with the minimum attendance required. These results have important policy

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implications since not addressing or discouraging negative officer–recipient interactions could reduce the program’s ability to achieve its primary goals such as improving health, but more importantly to have a positive influence in the overall well-being of recipients, as discussed next.

Well-Being and Policy-Engendered Relationships The quantitative and qualitative evidence of this book sought to explore the shape of the well-being of recipients and the differential role of officer–recipient interactions on it. In broad terms, the results of both approaches and methodologies corroborated each other, although the qualitative data uncovered different forms of association not observed through the quantitative data. This section discusses these findings together, analyzing some of the similarities between them and the causes behind their differences. The Shape of the Well-Being of Oportunidades-Prospera Recipients in Nexpan and Cualcan The subjective well-being of recipients were lower than the average levels of happiness and life satisfaction nation-wide, and Cualcan reported lower well-being compared to Nexpan. Yet, the IWB model shows that this difference was not consistent across all domains since both localities reported similar average levels across all domains except two. Namely, Cualcan reported significantly higher political participation (PP) and Nexpan significantly higher levels of values and meaning (VM). Being able to disaggregate in different domains through the IWB model also permitted observing other relationships with demographic variables. While the SWB approach suggested that the happiest and most satisfied participants were the younger and more educated, the IWB model showed that these and other demographic variables were relatedwith certain domains and not others. For example, being educated was associated with a higher sense of social recognition and better quality of close relationships; while better housing conditions was associated with higher economic confidence, quality of close relationships, and a general sense of meaning in life. The former results reveal that SWB and IWB do not always concur. Hence, it was decided to clarify the empirical association between them through correlation and regression analysis. This exploration has only

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been done once before (Fernandez et al., 2014), and so, little knowledge exists of the association between a psychosocial and a hedonic approach to well-being. In this sample, a significant but moderate relationship was found between the IWB domains and the global questions of happiness and life satisfaction. While the domains of close relationships, economic confidence and values and meaning explained the variation of happiness and life satisfaction, the domains of competence and self-worth, social recognition, and political participation did not. These results expose possible conceptual and methodological differences between the two approaches that should be further investigated. For example, it is likely that in this study people understood happiness and life satisfaction more in relation to immediate circumstances such as their family and their economic hardships; whereas political participation, social recognition, and competence and self-worth were secondary aspects for SWB in their circumstances. Yet, as the qualitative data showed, this does not imply that these domains are not relevant for their experiences of a good life nor for the possible pathways through which anti-poverty programs like Oportunidades-Prospera could influence the life of their participants. The Significance of Oportunidades-Prospera in the IWB of Recipients Oportunidades-Prospera was clearly central in the lives of the recipient families, yet, sometimes the qualitative and quantitative data showed different results concerning its well-being effects. The interviews with recipients supported that the benefits and services of the program—the cash transfer, medical attention, and the knowledge obtained through the health workshops—were essential for their well-being, confirming some previous results (Molyneux, 2006; Adato, 2000). Participants particularly described how the benefits of the program moderated feelings of shame associated with their poverty and increased their psychosocial well-being and overall happiness. However, the size of the cash transfer was not important for well-being, in fact, it was not significant for any domain of IWB in the regression analyzes. The qualitative data suggests that this happened because the size of the transfer was usually insufficient for sustaining all their needs and it not always compensated the costs of complying with the conditions of the program (e.g., transportation, lost salary, and time invested in the formal and informal activities of the program). Instead, that it was the certainty of receiving a

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benefit what made it important for well-being. Even though the transfer was small, it constituted a safety net for recipient families to cope with times of crises and save for the future. The amount of time a participant had been a member of the program also received mixed results in terms of its implications for well-being. The quantitative analysis did not show any statistical association between length of participation in the program and happiness or life satisfaction. However, scores for the IWB domain reflecting participants’ sense of political participation did increase with the years of being recipient. That is, as recipients remained longer in the program, they felt that they were more capable of voicing their opinions in different social and political contexts. The activities and degree of involvement that the program required from recipients could be driving this result. In the interviews, many participants emphasized that the workshops and meetings of the program provided information about health and community concerns; linked them to local authorities such as promotores, teachers, and physicians; and provided spaces to gather and discuss common issues with fellow recipients. The effect of the program on political participation undoubtedly was higher for recipients with an additional role in the program, especially vocales . Vocales obtained more information about the program, attended additional meetings, had a closer contact with local and policy authorities, and gained a prominent position relative to their fellow recipients. Vocales obtained the responsibility, but also the possibility, to voice the needs and concerns of recipients to local and policy authorities (and vice versa), increasing their sense of having a valuable political role in their localities. Yet, as featured by previous research (Molyneux, 2006), the program had contradictory consequences on the personal relationships of recipients. On the one hand, recipients confirmed the rise in tensions between the personal responsibilities of female recipients to their families and their duties to the program. On the other hand, because of the constant interactions with fellow recipients during health workshops and other activities, the program helped boost the social connectedness of all recipients, especially in the case of vocales (Adato, 2000). Therefore, while the duties of the program affected family relationships negatively, they enhanced women’s social interactions outside the household. For some recipients the latter was an important benefit of the program, as they developed networks of support that were not available before. However, the benefits of the program on social connectedness were tempered by

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the tensions between recipients and non-recipients in relation to who was responsible for traditional community activities (see also Adato, [2000], Escobar Latapí & González de la Rocha, [2004]). Overall, an important finding here is that for recipients complying with a conditional program had both positive and negative consequences over their subjective and psychosocial well-being. The information their received in the workshops and consultations helped recipients make better decisions about their health, improve their personal relationships and have a greater sense of competence, self-worth, and social recognition from their communities. Nonetheless, the time it took them to comply with the conditions was in tension with their own control of their time, their responsibilities within the household, and their relationship with their husbands and children as well as the broader community. These contrasting effects were particularly experienced by vocales and health committee members who derived much satisfaction and experience from their roles in the program, but had many additional—formal and informal—responsibilities that aggravated the negative effects. These results give a broader outlook of the pathways through which conditioning programs could influence the lives of targeted populations. The effects of the implementation of conditionalities, however, can be better observed by looking at the relationships created during this process. Inner Well-Being and the Relationship Between Officers and Recipients A central contribution of this book is quantifying the association between officer–recipient interactions and different dimensions of well-being. This involved two distinct achievements. First, the generation of both positive (PveQoR) and negative (NveQoR) indicators permitted accounting for the negative dimensions of social relationships that are usually excluded from mainstream well-being research. Second, this and the multidimensional model of IWB also facilitated accounting for asymmetries in the impact of positive and negative interactions across diverse aspects of well-being. This approach contrasts with the dominance of the global questions of SWB, which has restricted previous research in incorporating this kind of examination.1

1 One exception comes from the Theory of Self-Determination, see La Guardia and Patrick (2008).

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Positive (PveQoR) and negative (NveQoR) interactions had significant effects on different domains of IWB, even after controlling for personal characteristics. As recipients experienced more positive and less negative interactions with health officers, their inner well-being improved in different domains. More specifically, having more positive relationships (PveQoR) with officers was significantly associated with greater feelings of connectedness to others in their communities and the quality of that connection (SC), more confidence in managing economically (EC), greater feelings of social recognition (SR), and greater feelings of having a meaningful life overall (VM). In contrast, in isolation, negative interactions (NveQoR) were not significant for any domain. An interesting finding was that neither PveQoR nor NveQoR were statistically significant for the domains of mental health (MH) and competence and self-worth (CSW). Although issues of heteroscedasticity in the regression with mental health (MH) advise that these results are interpreted with caution, they could also be pointing to the possibility that this relationship is not relevant given the personal nature of these domains. These indicators of IWB are tapping on very personal aspects of wellbeing such as feelings of worry, tension, stress, and sadness (MH), and one’s ability to help others or to achieve personal goals or tasks (CSW). Therefore, these domains could be explained by other factors and not by this less personal kind of relationship. Indeed, when recipients talked about these domains in the interviews, they did so in relation to the family context. For example, one of their main source of worry and sadness was the health or well-being of family members, while their need to feel capable of conducting certain tasks related to childcare or to being competent in the eyes of their children. Yet, this was not explored in this book but is worth pursuing in future research. Moreover, disaggregating by the role the recipient played in the program (participant or vocal /health committee member) showed that certain domains were more associated with the quality of the relationship with officers than others were. Compared to the average recipient, for vocales and health committee members positive interactions with officers had greater effects on their sense of political participation (PP) and social recognition (SR), while negative interactions also had greater negative effects on their sense of social recognition (SR). That is, when their relationship with officers was positive, their confidence to voice their opinions was more strongly promoted; but if they experienced negative interactions, their ability to voice opinions and their feelings of

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personal adequacy and of being recognized by others were more negatively affected than for the average recipient. These results have interesting policy implications for programs that involve recipients beyond a basic role. It indicates that these programs should be particularly attentive on the quality of the relationship with frontline officers, especially if the additional roles of recipients involve some form of subordinate position like conducting additional tasks and chores under the command of officers. In contrast, compared to the average recipient, having positive interactions with officers had lesser effects on the economic confidence (EC) of vocales and health committee members. As seen above, the voices of recipients evoked that an important part of their economic confidence was the certainty of receiving the cash transfer, which closely relates to the perceived authority of health officers over recipients’ stay in the program. At the same time, through the training vocales received when taking on the role, they obtained more knowledge about program procedures and the function (power) of health officers on these. Similarly, health committee members were better informed about these issues as well, in their compliance of this informal task they had de opportunity to observe the inner doings of the health centers. This could explain the lower impacts of the relationship on this domain for recipients with these roles. Indeed, in the interviews, vocales and committee members demonstrated being aware that health officers did not have absolute power over decisions about their stay or expulsion from the programme and that there were other channels in place through which recipients could appeal any unfair decision in this regard. The policy implications of these findings are also noticeable since, while these indicate that the program could indirectly reduce the impact of negative forms of policy implementation on well-being by expanding the available information about the program procedures to recipients. This alone could only counteract the negative effects on economic confidence but not necessarily on every domain of well-being. Indeed, as seen above, despite vocales and committee members having greater knowledge about the program, the relationship affected their sense of political participation and social recognition more than for a lay recipient. Therefore, programs should aim at directly addressing the ways in which officers can manifest their authority over recipients during their encounters and the surveillance of the conditions, formal or informal. As the quantitative data confirmed that officer–recipient relationships had significant effects on the aforementioned domains of well-being, the

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qualitative data permitted observing some of the processes through which these associations were produced. The recipients’ accounts constantly emphasized the complex interlinkages between their inner well-being and these interactions in the policy arena. Positive encounters with officers in the health centers were highly valued by recipients. When they recounted feeling supported, understood, and treated with kindness and respect by officers, this improved their sense of self-worth, confidence, overall meaning in life. Yet, negative interactions and feelings of mistreatment, disrespect, shaming, and discrimination were more intensely expressed and lived by recipients. These conversations confirmed, as mentioned above, that the economic confidence of all recipients (but especially of lay recipients) was highly influenced by negative relationships. Attitudes of authoritativeness, strictness, and sometimes instances of misuse of power from officers caused recipients to perceive that remaining in the program (and thus receiving the cash transfer) was less determined by their own compliance and more by the officer’s discretion to decide when to sign the attendance record or to accept some form of proofs of absence. This generated a constant fear of losing entitlements, which reduced the recipients’ sense of agency and participation. Permanent officers, especially, could discourage individual or collective agency by differentiating themselves from recipients in terms of various sets of identities, but also by using threats of expulsion, public humiliation, scolding, and other forms of mistreatment. As the relationship became more hierarchical, recipients were less confident about being able to solve any issues about the program or their health and were discouraged to approach officers or raise their voices when they disagreed about how they were treated or about the procedures in the clinic. In this process, the recipients’ sense of self-worth and competence could be diminished, generating feelings of submissiveness, oppression, devaluation, and discrimination. The frequent mention of these experiences exposed the repeated manifestation of these encounters and their weight on the well-being of recipients. Feelings of frustration about their inability to change recurrent negative encounters with officers were manifest in both localities, but especially in Nexpan. These results are in line with the few qualitative studies that have found, mostly indirectly, evidence of the well-being consequences of this relationship (Molyneux & Thomson, 2011; Agudo Sanchiz, 2012, Samuels & Stavropoulou, 2016 and Attah et al., 2016). For instance, this study confirmed the claim of Agudo Sanchiz (2012) that the power

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relations between officers and recipients could reduce the capacity of the program of promoting the agency, participation, and empowerment of recipients. Similarly, these results resonate with the findings of Molyneux and Thompson (2011) that negative interactions with health officers reduced the sense of self-worth, agency and empowerment of program recipients in Peru. Samuels and Stavropoulou (2016) further confirmed this using the IWB model in the context of Middle East and Sub-Saharan Africa for the domain of competence and self-worth. To my knowledge, this issue has not been explored quantitatively until now. The results also corroborate the evidence about the role of power in the course and results of this relationship (e.g., PADHI, 2009). In these localities, those recipients that felt more confident beacuse of their role in the program (vocales ) or their social status in their communities or the larger society (men) also expressed feeling better equipped to negotiate their interactions with officers. However, they were not necessarily in a position of empowerment in this relationship. Notwithstanding the consistent findings about the differential roles of positive and negative interactions in well-being, the qualitative study also captured the ambivalent nature of these relationships. Indeed, sometimes even for recipients themselves it was difficult to classify a relationship with an officer in either pole, positive or negative. Sometimes good and bad features coexisted in one relationship or interaction, for example, when the quality of an interaction was dependent on mood, circumstances, or on the identities of the persons involved. This does not necessarily suggest inconsistencies in people’s subjective evaluations of a relationship, but instead could reflect inherent tensions in all social relationships. However, when these arise in the interactions created during policy delivery, these tensions need to be understood and dealt with in policy-making.

Academic, Methodological, and Policy Implications In the analysis of the interactions of health personnel and recipients during the delivery of one of the most important CCT program in the world, Oportunidades-Prospera, this book is connecting two large research areas—well-being and public policy—through a mixed-methods perspective. This permits integrating new claims to each literature at different levels.

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The first claim points to the well-being literature by emphasizing the need to take a broader outlook toward relationships and well-being to better understand their intricate association. The second relates to the methodological approach taken, the benefits of mixed-methods and critical realism for uncovering the complex connections between inner well-being and officer–recipient relationships, and some reflections about the challenges of the integration of these methodologies. The third is about the value of a well-being lens in policy, by showing the contribution of incorporating the assessment of the relationships created during policy delivery and their role on the well-being of recipients. The Need for a Broader Outlook Toward Relationships and Well-Being In analyzing relationships created in the policy arena during implementation, this book seeks to contribute to the well-being literature by conceptually and empirically demonstrating that a broader outlook toward relationships and well-being could uncover important associations between them that can be unaccounted for by traditional approaches. All well-being approaches recognize the importance of relationships, still, mainstream research has mainly concentrated on the well-being outcomes of close relationships. It also has tended to assume that relationships are positive for well-being, failing to admit more complex and ambivalent forms of association. This has limited its ability to recognize the full impact of social relationships. Hence, this book took a broader tack by, firstly, evaluating the importance of relationships created by social policies during program implementation, and secondly, using a psychosocial and multi-domain approach to well-being and mixing methodologies. This permitted observing two forms of association between wellbeing and officer–recipient relationships: (1) the outcomes of the quality of the interaction on different domains of well-being and (2) some processes through which they co-constructed the well-being experiences of recipients. In relation to the first point, rather than solely assessing whether relationships had an effect on an overall measure of subjective well-being, this book traced which domains were at play during officer–recipient interactions. This demonstrated that relationships can indeed support or thwart certain aspects of well-being more than others depending on the type of relationship, the personal characteristics of the actors involved, and whether positive and negative features of the relationship arise during

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interactions. Thus, future research should try to further decompose its analysis to better understand the pathways through which relationships can transform well-being. In addition to analyzing the impact of relationships in different domains of subjective well-being separately, distinguishing between positive and negative aspects of relationships was useful to observe that not all domains of inner well-being are similarly influenced by positive and negative encounters. Therefore, simply assessing the amount of social contact people have or the positive aspects of relationships, as it tends to occur in well-being scholarship, is not enough to capture the complex interrelationships between social interactions and well-being. In relation to the second point, qualitative analysis of officer–recipient relationship illuminated not just the outcomes but also some of the processes that underlie this association. It uncovered the institutional and cultural factors as well as the power dynamics that mediated the quality of officer–recipient relationships and thus the well-being of recipients during program encounters within the health clinics delivering OportunidadesProspera. These results ultimately indicate that relationships should not be understood as static external effects on an individually construed wellbeing. Rather, as dynamically and intricately linked to different aspects of well-being, as proposed by the development and psychosocial well-being literature. Methodological Contributions As we consider improving the quality of interactions between policy recipients and frontline officers because of their non-negligible well-being impacts, this book offers reflections on how we may know whether we are making progress. The mixed-methods and critical realist approach taken here offered a number of benefits and lessons for well-being and mixed-methods research. Firstly, this book advanced from the conventional studies that either take a quantitative or qualitative approach by employing a mixed-method perspective. Quantitative methods enabled this study to speak in a language that is common for policy-makers and mainstream well-being literature, while qualitative methods and locally generated indicators permitted observing well-being and social relationships through the voice, perspectives, and experiences of the participants. Mixing the two narrowed the distance between research, policy-making and the actual

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experiences program participants have of both on the ground. In the long run, this could simplify the translation of these (and future) research findings into practical changes in the design and implementation of social programs. Changes that could be more effective as they are built over the experiences of recipients themselves. Secondly, taking a critical realist perspective permitted being congruent with the understanding of well-being taken by this book, one that places relationships at the center and rejects an individualistic understanding of the construction of well-being and subjectivity. It also allowed constant reflection about the way each method illuminated the association between relationships and well-being. Mixing methods allowed concluding that officer–recipient relationships not only have static impacts on well-being, rather this relationship is also vulnerable to the larger political and cultural contexts in which they develop. This more complex understanding of relationships and well-being would have been hard to obtain using quantitative methodologies in isolation. However, mixing methodologies should be more than simply recognizing the contributions of each method, enabling a dialogue between the different shapes that relationships and well-being take when looked at from the unique lenses each methodology offers. This book tried to do so by identifying, throughout the analysis, the tensions in mixing methodologies and of transforming qualitative constructs into quantitative indicators, as well as the contradictions and paths for communication between the findings of each. For instance, this permitted identifying contradictions in the way recipients evaluated the relationship with officers in the interviews and the surveys. In this book, although the items were constructed with the words recipients used to describe their interactions in the qualitative study, the results suggested that participants tended to evaluate relationships more positively in the surveys than the interviews, and that relationships were better evaluated when answering to positively phrased survey questions than to negatively phrased. This methodological concern about the presence of biases in the quantitative assessment of relationships has been raised before (e.g., Simmons & Elias, 1994; Merkouris et al., 2004; White & Jha, 2014, Jha & White, 2016) and can complicate the interpretation of the results. For example, it is yet unclear whether the two underlying constructs in the QoR scale (PveQoR and NveQoR) are capturing different features of relationships as it has been argued in previous research (e.g., Goswami, 2012) or whether they simply reflect

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response biases toward positively and negatively worded questions. The scale, however, was developed through people’s own understandings of the quality of their interactions with health officers and proved to be statistically valid according to the factor analytic (FA) procedures. This raises the question as to which perspective should be prioritized in mixed-methods research when the languages of qualitative and quantitative methods are not easily reconciled. The former permits observing the complex interlinkages between domains and dimensions, while the latter needs to simplify and compartmentalize them to observe the general patterns behind. Mixing methods thus requires an ability to speak across the languages of each methodology to obtain solid quantitative indicators and models according to the terms that statistical tools require without oversimplifying the richness of qualitative data. This is especially relevant in the study of sophisticated social phenomena like well-being and relationships, and so it strongly defies the exclusive reliance on statistical techniques in well-being research and policy evaluation. Therefore, without an ample understanding of the terms of each methodology and of the tools to maximize their communication, mixing methods could result in simply applying two different approaches to the study of one phenomenon, rather than prompting deeper discussions about their implications in the results obtained. This is what this book set out to do. The Value of a Well-Being Lens in Public Policy in Practice Finally, the heart of this book lies on exploring the merit of a well-being lens in public policy. So far, most well-being research has intended to influence policy at the macro level by assessing the well-being of societies as a whole, comparing results across countries and drawing conclusions about which societies are doing better and what are the economic and policy structures that underline the results. These have been the focus of international indicators like the OECD’s Better Life Index and the World Happiness Reports. In contrast to this approach, this book looked at the contribution of well-being in public policy (see also McGregor et al., 2015) by focusing on the last link of the policy process: its implementation through officers at the street-level. This was done in two ways. On the one hand, by evaluating the subjective well-being of the recipients of a specific CCT program (Oportunidades-Prospera), this book

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showed the effects of the program on broader outcomes to those stipulated in the design. For instance, this conditional program could improve and deteriorate different aspects of people’s lives at the same time (e.g. improve social connections among recipients by involving them in the program’s activities, but deteriorate relationships with non-recipients by creating a differentiation from them; improve the recipients’ sense of competence and self-worth with the knowledge acquired from the health workshops, but deteriorate family relationships as the time lost complying with the conditions increased). Hence, assessing the subjective well-being of recipients can help detect problems that reduce the efficacy of program implementation and the overall achievement of original program objectives. On the other hand, evaluating the links between well-being and the relationships created during policy delivery, demonstrated the broad consequences of policy implementation. Indeed, policy implementation is not only about delivering a service or a benefit effectively; it is about the relational processes through which it is delivered. The narratives and survey reports of recipients’ encounters with officers showed that providing the services of a program through abuses of power, mistreatment, and public humiliation, or through care, dedication, respect, and empathy create important discrepancies in the way a program works. More importantly, however, this book strongly emphasized that analyzing these relationships beyond their effects on direct program outcomes is crucial, focusing instead on their capacity to transform the well-being of recipients. This directly speaks to the CCT and street-level bureaucracy literatures, which have been primarily concerned with the effects of this relationship on the adequate management of welfare delivery or on the achievement of the program’s chief goals (health, education, consumption, etc.). In contrast, using a wellbeing lens shows that the relationship between officer and recipient is not only important for achieving direct outputs, like improving health through preventive medical care and informational workshops. They are important because these encounters can have wider impacts on the life of those the program is ultimately trying to benefit, recipients. This is particularly significant for social protection programs and conditional cash transfers that make their benefits conditional to certain behaviors that are directly monitored by frontline officers. Policy implementation in these types of programs is strongly relational.

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Policy Implications of the Well-Being Impacts of Officer–Recipient Interactions The global consensus to ‘leave no one behind’ set in the Sustainable Development Goals, has propelled numerous social protection programs and conditional cash transfers to accomplish this. Even without considering the expected negative effects of the global pandemic occurring as I write these lines, the results of these programs are rather mixed. While we have been successful in increasing literacy and reducing the education gender gap in regions like Africa and Latin America, successes in terms of health care and poverty have been slower than planned. Still, CCTs have been the preferred tool to tackle poverty in many contexts given the large consensus of their various merits and achievements. Making transfers conditional is praised for their capacity to change individual behavior toward attitudes and actions that benefit quality of life more holistically. It also boosted the legitimacy of the programs to the eye of the ordinary citizen: the cash is not simply given away to ‘inadvertent’ recipients. For 20 years, academics, governments and private agencies evaluated the Oportunidades-Prospera program. It is arguably on the most evaluated program of this sort in the world, certainly the most evaluated program in Mexico. Governments and academics have used these evaluations as evidence for designing and implementing twin programs elsewhere. Yet, albeit these numerous evaluations attest positive results in objective terms like income, health, and education, the findings of this book show that looking at the subjective well-being of recipients and the relational processes of implementation unveil important unintended and overlooked consequences over people’s lives that need to be more systematically included in policy design, implementation, and evaluation. Interactions with street-level officers are significant for the attitudes that people have about the program. Their confidence in the service received, their interest in attending the clinic, and even their degree of compliance of the conditionalities. More importantly, however, these interactions are significant for their subjective and psychosocial wellbeing. These policy-engendered interactions can influence people’s sense of self-worth, competence, agency, political participation, and social recognition. Moreover, these effects can be amplified the greater the number of activities required from recipients and the higher the degree of surveillance from officers. Given the centrality of relationships for wellbeing, these relational processes of implementation are potentially more

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relevant for subjective and psychosocial well-being than the cash transfer itself. These findings do not necessarily challenge conditional programs altogether. If properly implemented, conditionalities can increase government spending in the infrastructure needed to deliver them (e.g., schools and health centers), and can signal participants of the availability and value of exercising such entitlements. Nonetheless, these findings do problematize the possible reinterpretation of conditionality by frontline officers during the execution of their work. This reinterpretation can transform their relationship with recipients into one between superiors and subordinates, increasing the discretionary power of officers over program procedures, but more importantly, over the well-being of recipients. As such, we can derive from this some significant lessons for policymaking. A practical policy recommendation is establishing effective accountability mechanisms that permit obtaining timely and confidential feedback from the final recipients about the quality of service provision and their experiences during implementation. Although the health centers had suggestion boxes available, in many cases, recipients doubted the confidentiality of their submissions. From their perspective, the health officers themselves opened and sent them up the system at their discretion. Thus, officers could use it as a tool to punish recipients as a group. A possible way to avoid this is installing a more direct mechanism. One that reduces bureaucracy and reaches a fixer with sufficient authority to make decisions in relation to the complaints. Oportunidades-Prospera had a figure that took this role - in theory - the promotor. Unfortunately, this study did not explore the relationship promotor-recipient. However, in the conversations with officers or recipients, promotores did not sufficiently came up as key mediators of the issues raised by recipients, nor they were identified by the participants as crucial in recognizing issues around the quality of service provision and/or generating positive changes in it. This could happen for various reasons. One could be for communication flaws between promotores and recipients or between promotores, program executives and the health ministry. These flaws thwart the possibility of positive feedback loops. More importantly, promotores worked for the program while health officers for the Ministry of Health. Therefore, the real instruments for rewards and penalties behind the work of officers came from the Ministry of Health, and thus the program could not fire or sanction physicians. This reduced the authority of promotores to monitor,

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mediate, and counter balance the relationships between recipients and officers. In these circumstances, promotores cannot fully serve as ombudsman, representing the interests of recipients by investigating complaints and trying to resolve them through arbitration or recommendations. Hence, facilitating promotores in performing such a role or incorporating another actor for this purpose could be beneficial. Of course, introducing a new relationship in the already complex structure of implementation of CCTs like Oportunidades-Prospera could face similar challenges to those of health officers, and thus should be monitored as well. In a country like Mexico with highly entrenched discrimination and exclusion, listening to the voices of program recipients through alternative mechanisms of accountability is vital. Not only to improve and detect issues during policy delivery, it is essential because it conveys a powerful message to the whole government structure of the dignity, worth, and significance of these groups for the better functioning of public institutions, policies, and society at large. A second way to promote better service delivery could be by addressing it at the level of the frontline officer—the physician in this case. As a participant of this study suggested, offering continuous training to clinical staff about how to deal with patients in a respectful way could help generate an implementation environment where mistreatment, abuse of power and discrimination are discouraged. Instead, an environment of respect, communication and the exercise of empathic authority could be promoted through these workshops. Hence, workshops carried out early in their careers and continuously could train staff in dealing with people and not only with bodies, and could prevent inadequate treatment. This is a central area for improvement in health services, especially since their quality closely relates to the way it is provided. Yet, staff training is useful for any type of frontline officer, not only health care providers. They can extend to social workers, practitioners, bureaucrats, teachers, and so on. Implementation can improve by making them aware of the circumstances and particular needs of their clients, reducing any misinterpretation of the identities, and focusing on avoiding incidences of discrimination and mistreatment. It is important however not to mark out frontline officers as the sole culpable of inadequate forms of implementation in social policy. Following the lessons of the street-level bureaucracy literature, it is also important to take into account the pressures and stresses in which

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they work. In the implementation of Oportunidades-Prospera, these partly explained the quality of officer–recipient interactions. This book confirmed what many have said before, workers at the last link of policy implementation in developing countries tend to work in contexts of limited resources, inadequate training, and understaffed workplaces. It would be naïve to propose adding to the workload of officers who already are overburden by the ever-increasing bureaucracy in government institutions. Therefore, policies and governments need to take seriously the necessity of improving working conditions of frontline officers, especially permanent officers. Whereas more research is necessary to understand the role of the type of contract in officer’s attitudes, delivery strategies, and relationships with recipients, the findings here reinforce the need to develop and improve contract schemes that permit permanent officers to deal better with the weaknesses of the job. The fact that temporality was better for relationships with recipients does not justify the increasing precariousness of permanent employment. Instead, it indicates the need to improve the quality of the working conditions for all workers, especially permanent employees. If officers are not trained to provide well-being support to recipients, they are unable to move away from the traditional top-down, controlling, and authoritative structure of government institutions. Yet, the role of program and institutional management in this cannot be ignored. The health officers of this study faced a constant tension between the contrasting expectations of their superiors and the needs of Oportunidades-Prospera and of recipients. This not only promoted negative uses of discretion, but also had negative impacts on the well-being of citizens. To avoid this, there needs to be coherence between program design and implementation. Setting forth clear expectations about the work of frontline officers, more consistency between the needs of the policy and the resources available to achieve them, as well as coherent and more holistic mechanisms to monitor their accomplishments. The whole structure of public institutions delivering street-level policies must introduce an approach focused on the promotion of well-being. One way to start could be by monitoring multidimensional outcomes that include subjective well-being and quality of interactions during service delivery. If well-being and relationships are at the heart of policy-making, this can

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assist governments and policy-makers to recognize the humanity of all those involved in the process. Ultimately, the findings of this book seek to start a conversation about the centrality of officer–recipient relationships in well-being and their possible policy implications. To generate a more nuanced understanding, however, more research is needed across localities, contexts, and social programs, as well as with larger and more diverse samples. For example, to corroborate the function of the job position in the quality of the interaction, it would be useful to conduct this investigation in more localities and localities where both permanent and temporary health officers are employed. Similarly, gender could be an important explanatory factor of the quality of this relationship and its well-being outcomes. Unfortunately, differences based on gender were not properly investigated here primarily because of the program’s central focus on female recipients, but also because in the research localities all health officers were female at the time. Even though these findings are derived from the case of Oportunidades-Prospera, these are potentially relevant to other conditional programs as well as social policies that require the monitoring of recipients’ behaviors through frontline officers. To reach stronger conclusions about how making programs conditional could influence the nature of officer–recipient relationships, future research in other CCTs is necessary. For example, recipients’ relationships with frontline officers delivering other components of the programs like promotores or teachers could show further interesting results. Additionally, a comparison of conditional and unconditional cash transfer programs could help observe more clearly differences in this relationship depending on whether the transfer is provided with or without conditions. Finally, with the elimination of Oportunidades-Prospera in 2019 and its substitution with largely unconditional scholarship programs, future research should scrutinize how former recipients are experiencing this transition and whether they continue attending to the health clinics voluntarily and the reasons behind their decision. Already some studies are suggesting that with the elimination of the conditionality, families stopped attending the clinics to receive medical attention and other routine treatments like vaccines or pap-smears (Campos & Peeters, 2021). Their estimates indicate an 80% decrease in attendance to the local health centers. Hence, it seems that 20 years of investing in primary health care and information workshops were not sufficient to compel recipients to

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continue using the services they have the right to receive. The findings of this book give some indications of the relational mechanisms and its well-being consequences that operated for this to occur. In a context where conditionality has been placed under scrutiny in academia (e.g. Hagen-Zanker et al., 2011) and in politics (following the decision of the new presidential administration in Mexico to eliminate Prospera), understanding better the relational aspects construed in the implementation of conditional programs and their well-being impacts could be useful to this debate. In the interactions between officers and recipients, policies generate new social scenarios that can reproduce wider hierarchical structures that keep people vulnerable. Potentially reducing— rather than increasing as is assumed—the program’s ability to achieve its primary goals such as improving health and reducing poverty, but more importantly, improving well-being more holistically. Therefore, the incorporation of a subjective and relational understanding of well-being in policy is essential to uncover program processes and unintended effects that are usually unaccounted for in policy evaluations. This needs to go past an analysis of program procedures and efficiency and of the resources recipients can have and use. Evaluations need to include a view of how recipients feel about what they can do and be as a result of passing through processes of service provision.

Bibliography Adato, M. (2000). The impact of PROGRESA on community social relationships. International Food Policy Research Institute (IFPRI). Agudo Sanchíz, A. (2012). The social production of conditional cash transfers’ impacts. International Policy Centre for Inclusive Growth, No. 172. Attah, R., Barca, V., Kardan, A., MacAuslan, I., Merttens, F., & Pellerano, L. (2016). Can social protection affect psychosocial well-being and why does this matter? Lessons from cash transfers in Sub-Saharan Africa. The Journal of Development Studies, 52(8), 1115–1131. https://doi.org/10.1080/002 20388.2015.1134777 Campos Bolaño, P. (2012). Documento compilatorio de la Evaluación Externa 2007–2008 del Programa Oportunidades. Secretaría de Desarrollo Social Coordinación Nacional del Programa de Desarrollo Humano Oportunidades. Escobar Latapí, A. (2000). Progresa y el bienestar de las familias. Los hallazgos. In A. Escobar Latapí, & M. González de la Rocha (Eds.), Logros y retos: Una evaluación cualitativa de Progresa en México. Secretaría de Desarrollo Social.

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Eyben, R. (2006). The power of labelling in development practice. Institute of Development Studies, (28). Eyben, R. (2010). Hiding relations: The irony of “Effective Aid.” European Journal of Development Research, 22(3), 382–397. https://doi.org/10.1057/ ejdr.2010.10 Fernandez, A., White, S. C., & Jha, S. (2014). Well-being Pathways Report: India Round 2. Well-being and Poverty Pathways: University of Bath. http://www.well-beingpathways.org/images/stories/pdfs/wor king_papers/India_T2_report_FINAL_whole.pdf. Goswami, H. (2012). Social relationships and children’s subjective well-being. Social Indicators Research, 107 (3), 575–588. https://doi.org/10.1007/s11 205-011-9864-z Gutiérrez, J. P., Leroy, J., López Ridaura, R., DeMaria, L., Walker, D., Campuzano, J. C., & Bertozzi, S. (2008). Evaluación de la calidad de los servicios de atención a la salud asignados a la población beneficiaria de Oportunidades. In Evaluación externa del Programa Oportunidades 2008. A diez años de intervención en zonas rurales (1997–2007). Tomo II, El reto de la calidad de los servicios: resultados en salud y nutrición. Secretaría de Desarrollo Social. Hagen-Zanker, J., McCord, A., & Holmes, R. (2011). Systematic review of the impact of employment guarantee schemes and cash transfers on the poor. Overseas Development Institute. https://www.odi.org/sites/odi.org. uk/files/odi-assets/publications-opinion-files/7161.pdf Jha, S., & White, S. C. (2016). The weight falls on my shoulders´: Close relationships and women´s well-being in India. Culture of Well-being: Method, Place, Policy (pp. 144–174). Palgrave Macmillan. La Guardia, J. G., & Patrick, H. (2008). Self-determination theory as a fundamental theory of close relationships. Canadian Psychology/psychologie Canadienne, 49(3), 201–209. https://doi.org/10.1037/a0012760 Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services (30th anniversary ed.). Russell Sage Foundation. Mandlik, M. A., Glynn, M., & Hyde, K. (2014). Client contribution to professional service delivery: Implications for relationship quality. New Zealand Journal of Applied Business Research, 12(1), 19–34. McGregor, A., Coulthard, S., & Camfield, L. (2015). Measuring what matters: The role of well-being methods in development policy and practice. Overseas Development Institute. Merkouris, A., Papathanassoglou, E. D. E., & Lemonidou, C. (2004). Evaluation of patient satisfaction with nursing care: Quantitative or qualitative approach? International Journal of Nursing Studies, 41(4), 355–367. https://doi.org/ 10.1016/j.ijnurstu.2003.10.006

264

V. RAMÍREZ

Molyneux, M. (2006). Mothers at the service of the new poverty agenda: Progresa/oportunidades, Mexico’s conditional transfer program. Social Policy & Administration, 40(4), 425–449. Molyneux, M., & Thomson, M. (2011). CCT Programs and Women’s Empowerment in Peru, Bolivia and Ecuador. CARE. PADHI. (2009). A tool, a guide and a framework: Introduction to a psychosocial approach to development. Social Policy Analysis and Research Centre. Samuels, F., & Stavropoulou, M. (2016). “Being able to breathe again”: The effects of cash transfer programs on psychosocial well-being. The Journal of Development Studies, 52(8), 1099–1114. https://doi.org/10.1080/002 20388.2015.1134773 Simmons, R., & Elias, C. (1994). The study of client-provider interactions: A review of methodological issues. Studies in Family Planning, 25(1), 1. https://doi.org/10.2307/2137985 Smith-Oka, V. (2014). Fallen uterus: Social suffering, bodily vigor, and social support among women in rural Mexico: Fallen uterus in Mexico. Medical Anthropology Quarterly, 28(1), 105–121. https://doi.org/10.1111/maq. 12064 White, S. (2016). Introduction: The many faces of well-being. In Cultures of well-being: method, place, policy. Palgrave Macmillan. White, S. C., & Abeyasekera, A. (Eds.). (2014). Well-being and quality of life assessment: A practical guide. Practical Action Publishing. White, S. C., & Jha, S. (2014). The ethical imperative of qualitative methods: Developing measures of subjective dimensions of well-being in Zambia and India. Ethics and Social Welfare, 8(3), 262–276. https://doi.org/10.1080/ 17496535.2014.932416 Wood, G. D. (Ed.). (1985). Labelling in development policy: Essays in honour of Bernard Schaffer. The Hague: Sage Publications; Institute of Social Studies.

Index

A Accountability mechanisms, 258, 259 Adaptive preferences, 5

B Bartlett’s Test of sphericity, 199

C Cash transfer programs, 96 Communication, 141, 143, 167, 174 Conditional cash transfers, 3, 11, 13, 95, 96, 158, 237, 251, 255–257 Conditionality, 13, 102, 112, 258, 262 compliance, 13, 15, 99, 113, 131, 146, 257 conditional programs, 261 conditions, 113, 146 discourse of, 130, 141, 154, 176, 240–242 education impacts, 160 faenas , 114, 118, 169 formal conditions, 14

gender perspective, 13 goals, 13, 75 health impacts, 13–15, 22, 80, 98, 115, 116, 121, 148, 158, 164, 178, 180, 189, 233 income impacts, 11, 112, 153 informal conditions, 14, 113, 169 language of, 130 official conditions, 131 unofficial conditions, 131 vs. unconditional cash transfers, 11, 96, 261 well-being impacts, 262 Confidentiality, 167 Confirmatory Factor Analysis (CFA), 198, 200, 204 Co-responsibility, 95, 97, 102, 118, 122 COVID-19, 12, 96, 257 Critical realism, 21, 253 Cross-cultural applicability, 49 Cualcan, 28, 29, 129, 133–136, 141, 145, 152, 157, 166, 170, 174, 217, 219, 232, 239, 244

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 V. Ramírez, Relational Well-Being in Policy Implementation in Mexico, https://doi.org/10.1007/978-3-030-74705-3

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INDEX

D Deci, Edward, 4, 7, 49, 54, 57, 59 Diener, Edward, 4, 6, 18, 46, 48, 50, 54, 55, 64 Discretion, 73, 80, 118, 131, 184, 241, 260 Discrimination, 69, 118, 120, 122, 133, 152, 170, 179 Domestic violence, 108

E Ethnicity, 28, 133, 194 indigenous, 28, 29 Nahuatl, 29 Evidence-based policy, 2 Exploratory Factor Analysis (EFA), 198, 199, 203

F Factor analysis, 197, 239, 255 Fieldwork, 28 Cualcan, 28–30 ethnicity, 28 health clinics, 30 Nexpan, 28–30 sample participants, 30 urbanization, 28 Frontline officers, 8, 12, 13, 70–73, 111 access encounters, 78 administrative rules, 75 discretion, 73–75 frequency of interactions, 13, 78, 115 identities, 76, 77, 119 in well-being, 15, 45, 71 labelling, 76, 120 professional knowledge, 77, 132 psychological sanctions, 78 public service gap, 74

G Gender, 133 Goodness-of-fit, 198, 204 H Health care health centers, 30, 100, 108, 135, 150, 153, 158, 167, 177, 185, 195, 249, 250, 258 health clinics, 22, 74, 98, 105, 107, 116, 118, 130, 153, 155, 163, 164, 241, 253, 261 meetings, 32, 100, 105, 114, 154, 162, 163, 246 opening hours, 140 providers, 61 reproductive, 99 services, 115 staff, 112, 118 structure, 154, 180, 241 Health committee members, 31, 113, 115, 141, 161, 175, 195, 218, 226, 230 Health component, 112 administrative deficiencies, 116, 117 appointment booklet, 113, 165 attendance record, 113, 131 ‘carnet ’ or ‘cartilla familiar’, 113, 165 failure to comply, 113 health check-ups, 99, 113 health conditionality, 13, 113 health workshops, 99, 113 lack of resources, 147 medical attention, 164 monthly quotas, 137 private medical attention, 116, 165, 239 quality of health services, 117 S1 form, 113, 165 Health officers, 31, 77, 129 administrative procedures, 166, 241

INDEX

compulsory medical consultations, 166, 169 dentist, 134 director of clinic, 134, 140, 146, 165 doctor, 30, 112, 134 intern, 134 nurse, 134 permanent officers, 31, 134–136, 139, 241 physician, 167 relationships among officers, 141, 149, 166 temporary officers, 31, 134, 135, 146, 241 Health professionals, 13 healthcare professionals and subjective well-being, 77 Hierarchical relationship, 137 I Inner well-being (IWB), 10, 24, 62, 120, 183, 193, 195, 198, 206, 207, 210, 211, 221, 232, 244 agency and participation (AP), 184 close relationships (CR), 221, 225, 230 competence and self-worth (CSW), 185–187, 245, 248, 250 domains, 24, 26 economic confidence (EC), 183, 184, 221, 223, 225, 227, 231, 232, 248–250 factor analysis, 199, 200 model fit, 200 origins, 195 physical and mental health (PMH), 232 political participation (PP), 221, 223, 225, 231, 232, 246, 248, 249 psychosocial model of, 110

267

relational framework, 24 social connections (SC), 221, 225, 227, 232, 246, 248 social recognition (SR), 221, 223, 227, 230–232, 248, 249 values and meaning (VM), 227, 232, 248 Intergenerational transmission of poverty, 12, 97, 99 International Monetary Fund, 95

K Kaiser-Meyer-Olkin (KMO), 198

L Latin America, 53, 96, 207 Lipsky, Michael, 8, 72

M Medical sociology, 9 Mexican Social Security Institute (IMSS-Prospera), 99 Mexico, 54, 56, 65, 96, 97, 206, 207, 237, 257, 259 Micro-aggressions, 119 Millennium Development Goals (MDGs), 11, 95 Ministry of Education, 99 Ministry of Health, 99, 258 Ministry of Social Development, 99 Mistreatment, 119, 122, 139, 140, 145, 164, 177 Mixed methods, 18, 20–22, 237, 251–253 Molyneux, Maxine, 45, 105, 108, 110, 119, 161, 245, 246, 250, 251

268

INDEX

N National Health Ministry, 99, 134, 137, 139, 146, 147, 169, 242 contradictory discourse, 148 workloads, 148 Nexpan, 28, 29, 129, 134–136, 139, 140, 152, 157, 160, 166, 170, 177, 217, 219, 232, 239, 244

O Obligation, compliance, obedience, entitlement, 131, 132 Officer–recipient relationships, 8, 9, 11, 13, 72, 73, 80, 112, 114, 115, 119, 121, 135, 238, 239, 247 client–agent, 71 client-provider, 71 doctor–patient, 133 negative, 182 officer-beneficiary, 71 positive, 182, 240 quality of, 117 Oportunidades-Prospera, 3, 11, 12, 16, 97, 238, 251, 255, 257, 258 affiliation to, 218 aims, 97 and well-being, 3, 11, 14, 15, 26, 109–111, 121, 158 attendance record, 98 captive population, 137 cash transfers, 103 community relationships, 109, 121 components, 97 compulsory consultations, 142, 161 conditionality, 137 domestic violence, 108 education component, 98 education transfers, 103 evaluations from a well-being perspective, 109

female heads of households, 105 health component, 98 husband-wife relations, 108, 163 intergenerational transmission of poverty, 12, 97, 99 nutritional component, 98 nutrition transfers, 103 on women’s empowerment, 108, 120 Oportunidades , 100 payday, 161 Progresa, 100, 107 Prospera, 100 provision of health, 112 qualitative evaluations, 108 quantitative evaluations, 106 size of cash transfer, 103, 209, 210, 245 size of scholarships, 98, 103 targeting criteria, 101 years of adherence, 209 Ordered Probit models, 213 Ordinal Least Square (OLS) models, 213 Organization for Economic Cooperation and Development (OECD), 44, 96

P Permanent officers, 31, 146, 250 Policy implementation, 72, 73, 121, 237, 238, 249 Policy implications, 249, 251, 257 Positive and negative emotions, 47 Poverty, 1 Power abuse, 122 Principal component analysis (PCA), 198, 203 Principal Components (PC), 198 Privacy, 167 Professional identities, 130, 240

INDEX

Program implementation, 252 Promax, 198, 203 Promotor(es), 99, 100, 227, 258 Psychological Well-being (PWB), 48, 49, 59 eudaimonic well-being domains, 4, 49, 56 meaning, 49 philosophical standpoint, 4 purpose, 4, 49 Self-Determination Theory (SDT), 49 Psychosocial Assessment for Humanitarian Interventions (PADHI), 25, 69 Psychosocial programs, 68 Psychosocial well-being, 5, 10, 48, 50, 69, 111, 121, 238, 252, 257 Puebla, 28, 100, 101

Q Qualitative methods, 19, 20 Quality of Relationships with Officers scale (QoR), 27, 61, 194, 195, 217, 239 kindness and respect, 142 model fit, 204 Negative Quality of the Relationship (NveQoR), 205, 217, 221, 223, 230, 239, 247, 248 Positive Quality of the Relationship (PveQoR), 205, 217, 221, 223, 225, 227, 239, 247, 248 quality of medical attention, 142 Quantitative methods, 18 measurement limitations, 18

R Recipients, 30 good and bad, 144

269

health committee members, 113, 115, 130, 141, 161, 175, 195, 218, 226, 230 indigenous, 117, 170, 176, 239, 240 vocales , 31, 99, 105, 115, 130, 141, 161, 163, 164, 172, 175, 195, 218, 226, 230, 246 Regression analysis, 194, 213 Relational well-being, 11, 48, 62, 67, 68, 111 relational spaces, 67 Research design, 22 focus group, 32 interviews with health officers, 32 interviews with recipients, 31 quantitative study, 33 scales, 26 IWB, 26 NveQoR, 205, 217 PveQoR, 205, 217 QoR, 27 SWB, 27 Ryan, Richard, 4, 7, 49, 54, 57, 59 Ryff, Carol, 4, 49, 56, 57

S Self-report indicators, 46 Sen, Amartya, 1 Smith-Oka, Vania, 9, 29, 113, 118, 119, 174, 187, 240 Social protection programs, 11, 95, 96, 256, 257 3Ps, 96 Social relationships, 7, 52 close relationships, 60 instrumental and intrinsic value, 53 Latin America, 12, 53, 96, 207, 257 negative relationships, 58, 66, 171, 250

270

INDEX

positive relationships, 58, 66, 171 power, 66, 119, 130, 139, 240 quality of, 55, 56 quantity of social connections, 55 relationality, 11, 14, 54, 155 satisfaction with, 56 social contact, 54, 57, 253 the cultural construction of well-being, 62 Socioeconomic identities, 130, 141, 240 Stiglitz-Sen-Fitoussi Commission, 43 Street level bureaucracy, 8, 149, 259 bureaucrats, 8, 73 Subjective well-being (SWB), 4, 27, 46, 47, 59, 206, 207, 210, 211, 238, 252, 255, 257 affect, 48 cognition, 48 happiness, 48, 193, 206, 227, 232, 244 hedonic well-being, 4, 48, 216 life satisfaction, 48, 193, 206, 230, 232, 244 measuring, 47

Sustainable Development Goals (SDGs), 11, 44, 95, 257

W Washington Consensus, 95 Well-being and Poverty Pathways (WPP), 24, 47 Well-being in Developing Countries (WeD), 10, 25, 62 3D well-being framework, 62 material dimension, 69, 187, 189 relational dimension, 63, 69, 187, 189 subjective dimension, 69, 187, 189 Well-being in policy, 4, 5, 46, 69 well-being at the frontline level, 3, 45, 237 well-being at the national level, 45 White, Sarah C., 3–5, 8, 10, 18, 20, 24–27, 44, 45, 51, 59, 62–67, 69, 193, 198, 202, 219, 237, 254 World Bank, 95 World Happiness Report, 44