Introduction
A significant aspect of programme success is determined at the lowest stage of the process, the implementation. In fact, the policy implementation literature is founded upon the idea that, during this stage, usually a dissonance appears between what is stated in the design and how programmes look on the ground. The street-level bureaucracy literature has attributed this implementation gap to how front-line officers execute their work (Hupe and Buffat, Reference Hupe and Buffat2014). Front-line officers are the actors responsible for policy delivery. They represent the direct interface of the policy with society as they are in charge of engaging with citizens on a daily basis during the provision of services, resources or information, as well as of the policing of recipients’ behaviours (Lipsky, Reference Lipsky1980).
In a global milieu where social policies remain reliant on the important work of front-line officers, an in-depth analysis of how officers experience implementation and relate to recipients is fundamental. The role of front-line officers has been the focus of a growing literature on street-level bureaucracy since the 1970s. This literature has concentrated primarily on how officers alter programme’s procedures and direct outputs and outcomes in a changing environment of public administration (Ellis, Reference Ellis2011; Erasmus, Reference Erasmus2014). Yet, this level of analysis often ignores the relational processes of implementation materialised in the relationships between front-line officers and recipients (Johannessen, Reference Johannessen2019), and how these can be influenced by the programme’s discourse and implementation methods, but also by the wider social and institutional context in which the policy is situated. Additionally, although the analysis of front-line workers has rapidly expanded in the global North (e.g. the UK, Finlay and Sandall, Reference Finlay and Sandall2009), more research in the global South and particularly with officers interacting with vulnerable populations is necessary to broaden our understanding of the role of front-line officers in policy implementation and the way recipients experience it.
Hence, the main goal of this article is scrutinising officer-recipient relationships during the provision of the health services of the conditional cash transfer (CCT) programme in Mexico, Oportunidades-Prospera. It does so by looking at officers’ everyday attitudes and practices during interactions with recipients, and analysing their causes and effects in the type of relationship created and the programme delivery. In doing so, this article contributes both to street-level bureaucracy and to the analysis of the implementation of CCTs in the global South.
In what follows, this article surveys literature of street-level bureaucracy, justifies analysing officer-recipient relationships in CCT programmes like Oportunidades-Prospera, presents the qualitative methodology used, and analyses the findings. The article ends with a discussion of the implications of officer-recipient relationships for policy implementation and practice.
Policy implementation and officer-recipient interactions
Michael Lipsky’s (Reference Lipsky1980) seminal work on US bureaucracies was the first to conduct a thorough analysis of the role of front-line officers in policy implementation, identifying a series of behaviours that characterise these actors and the contexts in which they work. Front-line officers constitute the immediate link through which a social policy achieves its goals. Their roles can include public servants and bureaucrats in charge of administrative tasks, as well as professionals with specialised knowledge associated with the services the policies provide (e.g. teachers). Interestingly, empirical research has revealed that social interactions are at the core of officers’ own narratives of their work, defining it more in terms of relationships than of the rules or procedures that demarcate their tasks (Maynard-Moody and Musheno, Reference Maynard-Moody and Musheno2003). Of these relationships, their interaction with policy recipients is particularly relevant.
A number of characteristics of front-line officers and the features of 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. The institutional architecture where they work grants significant power to front-line officers by making them the official gatekeepers to a recipient’s valuable resources and services. This formal power gains relevance in a background where recipients usually are non-voluntary clients with limited alternatives to access such services and resources elsewhere (Checkland, Reference Checkland2004).
The specialised training of some officers intensifies the authority they convey. Habitually officers are trained health practitioners, counsellors, development workers, social workers, or other professionals. The higher the level of technical knowledge and skills, the more inaccessible this is to recipients and the greater control officers have over the procedures deployed. This is particularly problematised in the health sector where the professional training of physicians is significantly higher than that of their clients (Mandlik et al., Reference Mandlik, Glynn and Hyde2014). Yet, evidence demonstrates that in conditions of institutional failure, high demand and lack of resources, professional expertise can generate forms of paternalism that authorise some officers to have abusive practices and use discretion (Ellis, Reference Ellis2011).
The concept of discretion is central to understand front-line officers’ protagonism during implementation (Carausan, Reference Carausan and Boldea2015). Lipsky (Reference Lipsky1980) points out that discretion is a coping mechanism officers use to make programmes operational. Discretion can take the form of arbitrary decisions about how to allocate resources or services, structure the circumstances in which interactions with participants take place, their frequency, the time spent on each case and the quality of what is provided (Moncrieffe and Eyben, Reference Moncrieffe and Eyben2007).
Although a number of factors influence the use of discretion (Kaler and Watkins, Reference Kaler and Watkins2001; Walker and Gilson, Reference Walker and Gilson2004), the uncertain and complex circumstances in which officers work is central. It is not rare that officers face what Hupe and Buffat (Reference Hupe and Buffat2014) call a public service gap which involves working under unclear rules and insufficient resources in a context of increasing demands for service, large caseloads, and the non-typical situations not outlined in programme’s procedures (Crook and Ayee, Reference Crook and Ayee2006; Gaede, Reference Gaede2016). These challenging working environments, coupled with the difficulty to monitor and control the routine activities of front-line officers (Brodkin, Reference Brodkin2008), make discretion necessary but potentially prone to negative uses. For this reason, Brodkin (Reference Brodkin2008: 326) has described discretion as ‘the wild card of policy delivery’.
In addition to the influence of formal rules and of the (predictable and unpredictable) circumstances of the job in shaping the behaviours of officers, the surrounding cultural setting also plays a role in their interactions with recipients (Henderson and Pandey, Reference Henderson and Pandey2013). At the grassroots level, this is materialised in the politics of identity (Eyben, Reference Eyben2006). The identity asymmetries between officers and recipients in terms of gender, class, race and education tend to be striking, especially in conditions of scarcity and deep social stratification. Officers are usually part of (relative) social elites, while recipients of such conditional social policies tend to hold identities that are structurally marginalised in their societies. The fact that policy implementation requires interactions between people not among either’s reference groups could facilitate the reproduction of hierarchical relationships and stereotypical conceptions of the other. This is particularly problematic for the most vulnerable recipients because, as Lipsky (Reference Lipsky1980: 6) recognises, ‘the poorer people are, the greater the influence street-level bureaucrats tend to have over them’.
The formal labels in social policy can exacerbate these differences (Wood, Reference Wood1985; Eyben, Reference Eyben2006; Moncrieffe and Eyben, Reference Moncrieffe and Eyben2007). The State uses labels to classify the target population in simpler categories and to ease targeting and implementation. However, these can represent participants negatively, leading to stereotyping, and reinforcing prejudices and stigma associated with that label. At the street-level, the apparent reality of these labels can become a tool to officers to justify inappropriate actions or middling accomplishments of their own and of the programme’s performance (see e.g. Goetz, Reference Goetz1997). As such, officer-recipient interactions have been rightly characterised as ‘micropolitical situations that parallel relations in society at large’ (Simmons and Elias, Reference Simmons and Elias1994: 4).
As seen above, the behaviours and attitudes of front-line officers towards their work and recipients can be shaped by their position of power within programmes, their uncertain working conditions, their capacity to use discretion over policy administration and procedures, and the sociocultural and institutional contexts in which the programme is delivered. This article is concerned about how these power-heavy forms of engagement construct different narratives of recipients and types of relationships between officers and recipients.
This study takes the case of Oportunidades-Prospera and the provision of its health services. A programme that, because it was implemented for two decades, allows observing the long-lasting and complex effects of these processes over officer-recipient relationships. Additionally, since the nature of health care services is exceptionally personal, inadequate officer-recipient interactions could result in lasting (and life-threatening) consequences for the individual (Fochsen et al., Reference Fochsen, Deshpande and Thorson2006), making the analysis of these interactions particularly relevant. The next section presents the programme and the existing empirical evidence about the implementation of its health conditionalities.
Oportunidades-Prospera: the provision of the health conditionality
Conditional cash transfer (CCTs) programmes are direct non-contributory payments that require certain behaviours and actions from recipients (Arnold et al., Reference Arnold, Conway and Greenslade2011). Over the last few decades, CCTs have become a popular social protection programme (Adato and Hoddinott, Reference Adato and Hoddinott2007; Bastagli et al., Reference Bastagli, Hagen-Zanker, Harman, Barca, Sturge and Schmidt2019); and Mexico is a pioneer, launching Oportunidades-Prospera Footnote 1 in different guises from 1997 to 2018. Its aims were to reduce the intergenerational transmission of poverty through investment in three basic components: education, nutrition and health. In practice, the programme provided bimonthly transfers on the condition that families (primarily mothers) send their children to school, attend preventive health workshops and comply with regular medical check-ups (Skoufias, Reference Skoufias2005).
Before the decision by the newly elected President Andrés Manuel López Obrador to suspend the programme in December 2018, Oportunidades-Prospera was praised internationally, becoming a model for the creation of other CCTs around the world (Barber and Gertler, Reference Barber and Gertler2010). It was also the biggest anti-poverty programme in the country. In 2018, reached 6.5 million families – approximately one out of every five Mexicans was a recipient of the programme.
CCTs are ideal scenarios to examine officer-recipient relationships. Theoretically, conditionalities aim at transforming recipients from passive receptors of benefits to empowered agents of their own progress by following specific ‘socially desirable behaviours’ (Levy, Reference Levy2006; Martínez Martínez, Reference Martínez Martínez2011). These behaviours demand continuous supervision and long-term interactions with front-line officers at different stages such as targeting, payment, delivery and monitoring of services. The centrality of officer-recipient interactions in CCT programme delivery calls for ‘reconceptualising cash transfers as ongoing processes of intervention in a complex system of social relations’ (MacAuslan and Riemenschneider, Reference MacAuslan and Riemenschneider2011: 60). Probably the most complex and significant interaction generated by Oportunidades-Prospera was during health care provision.
The health component of the programme was rigorously enforced and required complex management. In 2005, the programme provided 42.5 million consultations (Levy, Reference Levy2006). To achieve this, collaboration with the largest health institutions in Mexico was necessary: the Ministry of Health (Secretaría de Salud) and the Social Security Institute (Instituto Mexicano del Seguro Social). The health officers – doctors, nurses, dentists and interns – implementing Oportunidades-Prospera were primarily accountable to these institutions and not the direct employees of the programme.
The family’s stay in the programme depended on the compliance of specific health activities monitored by health professionals. The regulations stipulated two official activities. The first was attending medical check-ups scheduled twice a year for all family members enrolled. The second official conditionality, health workshops, involved monthly talks about illnesses and preventive health measures delivered by the medical staff directly to mothers. For the programme, the strict observance of these activities, some of which are directed to all family members, was the responsibility of female heads of households (typically mothers). This gendered outlook, although upheld by the programme, has been challenged for potentially reinforcing stereotypes of women within and outside the household (Molyneux, Reference Molyneux2006; Cookson, Reference Cookson2018).
The health staff strictly and constantly monitored people’s yearly compliance through an attendance record (Adato et al., Reference Adato, Coady and Ruel2000). Health officers signed each turnout from the recipient in the attendance record and documented this in the programme’s system electronically. Not complying with one appointment entailed an economic penalisation, but not complying for four consecutive or six non-consecutive months caused permanent expulsion (Adato, Reference Adato2000). Therefore, the signature of the health officer in the attendance record was critical for recipients.
Faenas comprised a third but unofficial and unwritten conditionality of the programme. These occupied recipients in 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 around their communities. The lack of official information about these activities strikingly contrasts with their significance to programme implementation. Although faenas have been reported as ‘volunteer’ activities (Adato, Reference Adato2000), in practice, recipients had little say in their degree of involvement. For women recipients and health professionals, these unofficial activities were part and parcel of the programme’s conditions, and recipients were constantly reminded that they could lose their benefits if not complying with them (Agudo Sanchíz, Reference Agudo Sanchíz2012; Ramírez, Reference Ramírez2016). By not formalising these activities, the programme potentially transformed them into requirements that implicated recipients in unpaid jobs under the strict supervision of health officers.
Ultimately, the (official and unofficial) health conditionalities of Oportunidades-Prospera created repeated and long-lasting interactions between health officers and participants that could influence the power dynamics that occur during their interactions, the nature and quality of the relationship, and the effects of the programme on people’s lives in non-negligible ways. However, little research was found exploring directly the attitudes of officers during delivery and their relationships with the recipients of Oportunidades-Prospera. Instead, most empirical evaluations focus on the quality of healthcare, suggesting that the actual conditions of health provision were a major obstacle to programme effectiveness (CONEVAL, 2011).
Indeed, evidence suggests that serious deficiencies in quantity and quality of health care services endured. These included lack of resources, insufficient staff, reduced applications of health procedures, and deficient improvements in health indicators (OECD, 2014). Yet, beyond administrative and resource deficiencies, a few studies find that health officers’ attitudes had a central role in these disappointing achievements (Escobar Latapí and González de la Rocha, Reference Escobar Latapí and González de la Rocha2000). Gutiérrez and colleagues (Reference Gutiérrez, Leroy, López Ridaura, DeMaria, Walker, Campuzano and Bertozzi2008) showed that 59 per cent of the omissions to perform routine procedures and tests occurred not because of resource deficiencies, but because staff did not consider it necessary. This capacity to deny a service hides attitudes of officers that can be at play during service provision and that affects the quality of relationships with recipients.
Recipients have been reported to recognise the poor health services received, yet most of their complaints relate to the lack of courtesy experienced during check-ups (Saucedo, Reference Saucedo2013). These were especially critical in rural areas (Sánchez López, Reference Sánchez López2009; Smith-Oka, Reference Smith-Oka2014) and for indigenous recipients, who reported lower quality of medical care, mistreatment, abuse, and discrimination (Campos, Reference Campos2012). Abuses of power are also documented. Escobar Latapí (Reference Escobar Latapí, Escobar Latapí and González de la Rocha2000) noted health staff using threats of expulsion (and carried them out) to force women recipients to accept undergoing pap smears. In rural localities, doctors imposed illegal fees to recipients and supervised faenas as ‘duties’, requiring recipients to grant certain amount of work hours or threaten with reporting them (Agudo Sanchíz, Reference Agudo Sanchíz2012).
Psychological sanctions and microaggressions are also potentially part of these encounters. In public hospitals in Puebla, Mexico, Smith-Oka (Reference Smith-Oka2015) identified various forms of ‘microaggressions’ during obstetric procedures, such as verbal aggressions, reprimands, physical mistreatment, and passive aggressive teasing that reflected the physician’s negative stereotypes and labels towards patients and had the purpose to cause shame and a submissive and compliant behaviour. Additionally, Ramírez (Reference Ramírez2016) found that these systematic acts of mistreatment, aggression and power struggles occur in Oportunidades-Prospera’s health services according to recipients’ experiences and that these are significant for their psychosocial wellbeing.
Despite being a well-studied programme, there is a small body of literature exploring the health delivery procedures of Oportunidades-Prospera and the existing evidence on the quality of officer-recipient relationships and the factors that determine it is scarce. Yet, they do commence to show that this relationship is potentially relevant not only because of the control officers can have over the implementation procedures of the programme. These forms of engagement can affect people’s objective circumstances (by restricting access to resources and services, for example) as well as recipients’ thoughts and feelings about their life and themselves. This makes the analysis of these interactions ever more necessary. The next section turns to delineating the methodology used by this study to explore the nature of these interactions through the narratives of health professionals who deliver Oportunidades-Prospera.
Methodology
The empirical data for this article derives from a larger mixed-methods research project that included thirty interviews with recipients and 371 surveys on quality of officer-recipient relationships and psychosocial wellbeing outcomes (part of the findings are published in Ramírez, Reference Ramírez2016 and Ramírez, Reference Ramírezforthcoming). The findings presented here are closely informed by these data but particularly come from semi-structured interviews with six female health officers and observations during the provision of the health workshops in two localities of the State of Puebla named Nexpan and Cualcan for anonymity reasonsFootnote 2 . The fieldwork took place between 2013 and 2014.
The localities partaking in this study were selected based on their socio-demographic characteristics following previous research that documented lower quality of health services in rural localities (Sánchez López, Reference Sánchez López2009; Campos, Reference Campos2012). Nexpan is a semi-rural, non-indigenous locality at the outskirts of Puebla, the capital city of the state. Cualcan, in contrast, is a rural, indigenous locality situated four hours away from the capital city in the mountain range of the state.
The selection of the interview participants was constrained by the number and type of health officers working at the clinics at the time. Six out of the ten health officers in both localities (all female, six in Nexpan and four in Cualcan) were interviewed. Four officers were not interviewed: either because they refused to participate (one permanent officer in Cualcan); or because they were not based at the clinics, their interactions with recipients were sporadic (for example, they were in charge of the vaccination campaign only), and thus setting the interviews became challenging and ultimately unattainable. Despite this, my observations of the activities at the clinics allowed me to witness their behaviours and interactions with recipients. These observations largely confirmed the information provided in the interviews.
The health officers involved had three types of roles, doctors (three), nurses (two), and dentists (one). However, in the analysis of the interviews it was obvious that a more relevant way to categorise the interviewees was in terms of their job position within the clinic, either as permanent or contract-based (three, all in Nexpan) and temporary or student-based (three, two in Cualcan and one in Nexpan). Both groups included doctors and nurses. Yet, the main difference between these was that permanent officers were the direct employees of the Ministry of Health and thus had more responsibilities and authority within the clinic, whereas temporary officers were non-paid medical trainees conducting their one-year internship in the locality.
The interviews’ rationale was to understand the way officers narrated recipients and their relationship, as well as their interpretation of their own roles and those of recipients in the health clinic and in the implementation of the conditionalities. Given that relationships are difficult to discuss directly, the opening statement focused on officers’ working experiences at the clinic. The stories officers used to explain the process of policy delivery, their challenges, and their overall experiences in the job and the localities, offered an indirect account of the relationship. The follow-up questions asked officers to describe the relationship with recipients, offering a direct account of the relationship. Both forms of enquiry provided insights into the assumptions, attitudes, and the use of language associated to the topic understudy.
In accordance with the purpose of scrutinising the relational experiences of officers with recipients during programme delivery, the analysis of the interviews was based on a discourse analysis approach. This approach gives greater relevance to the use of language and emphasises that, through it, the interrelationship between the context, the others and the self emerges. It permits not just categorising the surface content of what was said but also the underlying structures and assumptions (the discursive framing) (see Tannen, Reference Tannen2012).
In practice, this involved several steps. First, in addition to recording the interviews, detailed notes of the interviewees’ nonverbal reactions were taken. Second, the interviews and notes where transcribed verbatim into NVivo the day they were conducted. Third, all interviews were read at once and coded line-by-line paying attention not only to what was said, but also to how officers used language to represent themselves in relation to the recipient, the tones used to express it and the context of the conversation in which it was said. Finally, the initial codes were reconfigured into larger categories and themes.
Results
The interviews consistently indicated that the nature of the relationship between officers and recipients in Oportunidades was unavoidably one of authority and power. Three distinguishing factors explained the strength of this authority and the effects of this power on the quality of the relationship 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. The latter, as will be seen below, was the most important factor to explain the differences between localities.
Oportunidades-Prospera’s discourse of conditionality
The discourse of conditionality set the terms of the relationship through the strategies officers used to promote participation, their expectations from recipients, and their understanding of their own roles in monitoring and delivering the programme. Beyond having an impact on the procedures of the programme, conditionality transformed the understanding of the service provided from entitlements to obligations. Officers had the perception (and expectation) that the recipients’ role was to obey and the officers’ role to regulate, enforce and mediate the services offered by Oportunidades. Together these created a disciplinary relationship in which the attendance record was an authoritative tool officers used to their discretion.
We call it ‘captive population’ in the sense that it is compulsory. We schedule their appointments and if they do not comply they get an absence [in their attendance record]. (Permanent Doctor, Nexpan)
You (officer) decide if you justify their absence or not, because, as they receive the [transfer], they also acquire an obligation. (Temporary Doctor, Nexpan)
Identity: professional and socioeconomic
Officers’ professional identity as health practitioners shaped their narratives and interactions with recipients. In both localities, recipients were a large group and unquestionably the group that used the clinic the most. Despite this, officers talked about them more frequently as patients. It was clear to officers that their professional knowledge and training as physicians was inaccessible to recipients and that they were able to control the format in which it was provided. Socioeconomic status also differentiated officers from recipients. In contrast to the knowledgeable, urban and middle-class image of themselves, officers identified the ‘beneficiary’ as poor, uneducated, and backwards, categories that often lead to discriminatory treatment.
(Recipients) never come for consultation on their own will (…) because even though Nexpan is close to the city, is an area that, since they are farmers, they don’t value their health. They don’t have the knowledge or the education. They are backwards. (Permanent Dentist, Nexpan)
Imagine how [the clinic’s director] would talk about a person who… I mean, many beneficiaries cannot read or write. The treatment is not good. (Temporary Doctor, Nexpan)
Discrimination in Mexico is highly pervasive. Economic status (Székely, Reference Székely2006) and skin colour (CONAPRED, 2011) are mayor causes of discrimination. In addition, public hospitals are a common space in which people report discrimination (ENADIS, 2017). In these clinics, this broader social context permeated into the attitudes of officers towards recipients, increasing their need to distinguish themselves from recipients by imposing hierarchies and having attitudes of superiority.
Permanent versus temporary officers: contrasting officer-recipient relationships
Naturally, the relationship with recipients varied between officers and localities. However, in this sample, the officer’s job title as temporary or permanent was the salient distinguishing factor. At the time of the fieldwork, the clinic in Cualcan (rural/indigenous) was mainly lead by temporary staff, whereas in Nexpan (semi-rural/non-indigenous) most staff were permanent. As a result, these localities witnessed two contrasting officer-recipient relationships (recipients confirmed the quality and characteristics of these relationships, these findings are reported in Ramírez, Reference Ramírez2016). In Nexpan, the relationship with permanent officers was hierarchical, characterised by obedience, power and disengagement. In Cualcan, in turn, the relationship with temporary officers was more horizontal, and based on shared responsibility, communication and empathy.
A relationship of obedience: permanent officers
Permanent officers commenced describing their relationships with recipients relatively positively and denying conflict. However, the tones and words used implicitly suggested an ambivalent relationship that easily became negative. Additionally, officers had an expectation that recipients should behave obediently and that an authoritarian approach was necessary to maintain control over them.
Good, you have to have a good [relationship] because if you do not they don’t obey you. There needs to be empathy and respect, but also authority because they are too many and all behave like children. (Permanent Doctor, Nexpan)
The interest permanent officers had behind this control was the benefit they obtained from recipients’ participation, particularly fulfilling monthly quotas set by the Ministry of Health.
I rely a lot on Oportunidades to have productivity in my own programmes. (Permanent Doctor, Nexpan)
Permanent officers also had a tendency of redirecting the focus towards the recipients as sources of conflict, even though the data collected during observations of health workshops and interviews with recipients (see Ramírez, Reference Ramírez2016; Ramírez, Reference Ramírezforthcoming) indicated recipients’ attitudes were primarily calm and even submissive.
I don’t like to antagonise 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, that you didn’t want to give consultations or that you talked to them badly. I mean, they start talking about mistreatment, wrongful charges, or things like that. (Permanent Doctor, Nexpan)
A dichotomous view of the recipient was common in permanent officers, who repeatedly used labels to represent the good and the bad recipient, although the latter dominated. For them, the good recipient should be docile, grateful, and obedient; the bad recipient was rude, backward, unwilling to learn, and uneducated. For permanent officers in the sample, people defending their views or their rights was interpreted as aggressive or dissenter, attitudes not well regarded and even considered a threat.
In most of the accounts, officers purposefully distanced or disengaged from the recipients and their needs, making a differentiation between ‘us and them’ through tones of superiority and degrading characterisations of recipients.
People here are close-minded. It is not that they don’t have the knowledge, what they don’t have is the willingness to learn. People do not have much education, and even though you explain things to them, they don’t 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 way of characterising recipients and the exercise of power by permanent officers was recognised and problematised by temporary officers in both localities. This hierarchical form of engagement was salient in the officers’ recollections of the implementation strategies used by former permanent physicians in both localities, and was visible in the observations of the only permanent officer in Cualcan who refused to be interviewed.
Some staff, since they already hold a position and get paid, take advantage of the power this gives them. (Researcher: Do you feel this happens in this clinic?) Yes, it happens. I could tell you but stop recording. The clinic director often makes discriminatory comments to [recipients] during consultations. (Temporary Doctor, Nexpan)
A previous (permanent) nurse trained me, but I changed some things because (recipients) said she had a very bad temper. Others said 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)
Overall, the relationship permanent officers created with recipients was characterised by hierarchies, mistreatment and an expectation of obedience. In the many ways officers talked about recipients, it was rare they showed empathy, and frequently used derogative tones. Officers were aware of the potential collective strength of recipients but this was referred to in a negative way and even as a threat they wanted to restrain through the (ab)use of power. Finally, officers did not reflect upon their own role in the quality of the relationship. Instead, negative representations of recipients were used to attribute to recipients and their attitudes the responsibility of a good/bad relationship and the outcomes of the programme.
A relationship of empathy and reciprocity: temporary officers
The tone of temporary officers in Cualcan was unlike that of permanent officers in Nexpan. In their narratives and attitudes, temporary officers described a more horizontal interaction with recipients, despite the unavoidable hierarchies created by the programme’s discourse of conditionality and the differences in their socioeconomic identities. They presented recipients as participative, organised and supportive during programme implementation.
[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 get organised, they work well. With [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. (Temporary Doctor, Cualcan)
The strategies used to enforce the conditionalities of the programme were primarily communication and good treatment. To promote participation, temporary officers used hierarchies less frequently and, instead, underlined shared responsibility and reflected on their own duty in constructing a positive relationship by providing clear information to recipients. They were aware of the effects they could have on the recipients’ feelings, wellbeing, and on their attitudes towards the programme. Against permanent staff, temporary officers coupled the quality of the medical attention with the quality of their relationship with recipients.
We have a good relationship. If any [problem] escalates, we try to communicate with them. For example, now we had to decrease the number of consultations, so we explained the situation and the reasons to recipients in a way they understand. (Temporary Nurse, Cualcan)
[Recipients] have more confidence approaching me compared to the previous (permanent) doctor. They are not afraid anymore, they do not get angry, do not think that they will get into a fight or be reprimanded. Is nice people say they receive a better treatment. (Temporary Doctor, Cualcan)
This interest in constructing a positive environment around the clinic and of providing a better treatment was not only to meet the Ministry’s expected health quotas, but also with the purpose of improving the recipients’ participation and attendance to the programme’s activities. They recognised the profit recipients obtained from better public health and from gaining one more signature in their Oportunidades’ attendance record.
When the environment is nice, everything comes together: you build a relationship with people, they vaccinate their pets, and comply with their Oportunidades workshop. You kill two birds with one stone. (Temporary Nurse, Cualcan)
In this relationship, power and conflict were present, yet managed differently. In terms of conflict, temporary officers recognised the community’s ability to take action against bad treatment. However, they narrated this as an entitlement and as a sign of historical mistreatment. Although this was a challenge in their own work environment, rather than using power to force obedience or maintain a disproportionate level of authority, temporary officers identified the causes of conflict, solved it through communication and promoted recipients’ involvement.
The community is good, but difficult if you do not know how to work with them. They are no longer the people who did not react, who were repressed. In the clinic, they demand their rights nowadays because they did not like the mistreatment from previous doctors. (Temporary Nurse, Cualcan)
The environment I like to create is that, if they are not complying (with Oportunidades), I give them orientation. Since we are talking about their health, I do reprimand them in a direct way but without being disrespectful. Without yelling, scolding, humiliating. Instead, creating awareness about the importance of taking care of themselves. (Temporary Doctor, Cualcan)
Overall, the tone used by officers in Cualcan and by temporary officers in general was of empathy and engagement. Their implementation strategies consciously diverted from permanent officers’, taking into account the perspectives and feelings of recipients. Authority was enforced 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 their relationship with recipients.
Explaining the differences between front-line officers
Overall, the previous sections noted that the officers’ narratives of recipients and their understanding of the conditions of the programme influenced the way they interacted with recipients and the treatment recipients received while complying with Oportunidades. However, permanent and temporary officers showed significant differences in the way they used their discretion in their personal engagement with recipients. The data also suggested possible reasons behind these differences.
The most evident is the fact that permanent officers work on a contract-basis and receive payment for their services while temporary officers do not. This had two effects supported by the empirical data of this study. The first is that working under a contract gave officers greater authority and power within the clinic. This was particularly the case for the directors of the clinic. In the observations and interviews with officers, it was obvious that the directors were the main authority in the clinic, organising and delivering the consultations and workshops of the programme, assigning responsibilities and managing the staff, as well as interacting with recipients and supervising their compliance of the conditionalities. The staff largely followed the director’s orders, and thus the working environment created in the clinic was heavily reliant on them.
The second is associated to time. For temporary officers in the sample their time in the locality and holding that position was potentially transitory – as the internship would last one year and their professional career could move elsewhere in the future (additionally, all temporary staff were not originally from the localities they were working in). Therefore, their encounters with the challenges and routines of the job have not only been brief, but also this novelty could justify their positive attitude towards it. Permanent officers, conversely, had a stable position and greater responsibility with the Ministry of Health and the clinic, which increased their stress and tiredness towards their duties (see Hughes and Condon, Reference Hughes and Condon2016 for similar findings in a nursing setting in the UK). Additionally, although the health system in Mexico is flexible and can continuously change officers between localities, permanent officers could bring their frustrations with the job from one locality to the other. As Lipsky (Reference Lipsky1980) recognises, negative relationships in policy contexts might not be isolated events that disappear with the conclusion of one particular encounter. If built into the structure of policy institutions, these power relations can endure and have cumulative effects.
Despite the differences in type of contract and seniority between permanent and temporary officers, in both localities, all officers emphasised the constant failure of the Ministry of Health to provide the necessary resources and staff, which limited the effective functioning of the clinic. Officers perceived the Ministry had contradictory procedures and values, offering an inconsistent platform over which they could work. While the Ministry set quotas to be filled by officers in various health programmes, often it did not provide the necessary instruments and staff to attend all the population or even to meet its own requirements. Officers reported that the lack of support from the Ministry increased the pressures (particularly permanent) they endured as well as their workload in paperwork and consultations.
This had an effect on the quality of medical care as requested by Oportunidades. Officers recounted reprimands for delivering more consultations than required or surpassing the expected number of tests or procedures expected. From the officers’ perspectives, the Ministry was mainly interested in reaching statistical goals, instead of in offering quality consultations. The lack of resources, the pressures to satisfy quotas and the contradictory discourse of the institutions in which front-line officers work is a common finding in the street-level bureaucracy literature (e.g. Hupe and Buffat, Reference Hupe and Buffat2014). However, this research suggests that these also have an influence on the attitudes and relationships of medical staff, especially permanent.
The contrast in the quality of the relationship found in Nexpan and Cualcan provokes the question as to whether this was determined by the job position of the officers (primarily temporary in Cualcan and primarily permanent in Nexpan) or by the locality and the characteristics of the recipients in them. Based on the data, the response to this question is: both. Firstly, the positive relationship created by temporary officers was found in both localities, not only Cualcan. Therefore, temporary officers did have a particularly positive approach to recipients and to their work. Similarly, whereas the only permanent officer in Cualcan was not interviewed, my own observations and the accounts of other staff about her and about previous permanent officers suggest their profile was closer to that of permanent officers in Nexpan. Therefore, the type of contract officers have is significant for the quality of the relationship regardless of the characteristics of the community with which they work.
Secondly, the attitudes of recipients do seem to influence the terms of the relationship (see Ramírez, 2016, Reference Ramírezforthcoming). Indeed, in Cualcan the community proved to be empowered and prepared to use their agency to provoke change in their environments. Instead, in Nexpan, recipients felt impotent about the attitude of the officers and frustrated by their lack of organisation to change their situation. Following the concept of negotiated discretion proposed by Johannessen (Reference Johannessen2019), these contrasting attitudes of recipients across localities could negotiate differently the interpretations and actions of officers during service provision and, ultimately, affect the kind of relationship created – even if limited by the high social inequalities of the context.
Conclusion
The aim of this article was to understand front-line officers’ attitudes and relationships with recipients during the implementation of the Oportunidades-Prospera CCT programme and the factors that explained these. The findings corroborate previous research on the influence of professional (Ellis, Reference Ellis2011; Mandlik et al., Reference Mandlik, Glynn and Hyde2014) and institutional (Lipsky, Reference Lipsky2010) authority on the way health officers deliver services, and those on how power and identity shape relationships (Eyben, Reference Eyben2006). However, this study shows that the officer’s job position and the discourse of conditionality of the programme intensified their effect over the delivery processes and the officer-recipient relationship.
First, although the health care system and the administrative processes of Oportunidades did not facilitate programme implementation, in the face of such adverse conditions permanent officers and temporary officers in this sample used their discretion differently, fostering two opposite styles of interactions. The former promoted a hierarchical relationship that used authoritarian methods to policy delivery; exhibited a dichotomous understanding of the ‘good’ and ‘bad’ recipient, in which obedience was a desirable trait; and, in the process of delivery, they were primarily concerned in meeting the quotas set by the Ministry. In contrast, the latter used communication and trust to monitor compliance of the conditionalities, stereotypical understandings of the recipient were less salient in their narratives, and they recognised their own responsibility in stimulating recipient’s participation in the programme and promoting public health in the community.
Interviewees 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 (see Castro, Reference Castro2014). Although Lipsky (Reference Lipsky1980) recognised that negative styles of service delivery could be a structural issue reproduced from officer to officer, this article suggests that the officers’ job position is key in explaining these differences.
Whereas more research is necessary to understand the effect of the type of contract in officers’ 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 officer-recipient relationships does not justify the precarisation of permanent employment. Instead, it indicates the need to improve the quality of the working conditions for all workers, especially permanent employees.
Second, the officers’ relationship with recipients in this sample was influenced by the characteristics of the programme itself, particularly the discourse of conditionality. Making the programme conditional magnified the officers’ perceived authority to monitor and regulate the behaviours of recipients and validated a disciplinary relationship in which the role of the ‘good’ recipient was to obey and comply, rather than use a service they were entitled to. These findings do not challenge conditional programmes altogether, yet, they do problematise the possible reinterpretation of conditionality by front-line officers during the execution of their jobs. This reinterpretation can transform their relationship with recipients into one between superiors and subordinates, increasing the discretionary power of officers over programme’s procedures and over participants’ activities and wellbeing (Ramírez, Reference Ramírez2016).
Even though these findings are derived only from the case of Oportunidades-Prospera, these are potentially relevant to other conditional programmes as well as to any social policy that requires the monitoring of recipients’ behaviours through front-line officers. However, further research is needed to identify whether these forms of engagement are similar in other CCTs and whether non-conditional programmes show different results. Nevertheless, policies should consider this and establish mechanisms to dissuade and prevent using this discourse to endorse abuse of power during implementation.
Overall, these findings illuminate the practices of front-line officers delivering CCTs and underline that analysing the effectiveness of service provision and the following of programme procedures might not be enough for understanding the possible impacts of front-line officers on policy success. Beyond their influence over procedures, in this study, the experiences and interpretations of officers about the programme, their jobs and the recipients, fostered different kinds of interactions and uncovered important policy implications that can be unaccounted for by typical evaluation procedures.
In a context where conditionality has been placed under scrutiny in academia (Hagen-Zanker et al., Reference Hagen-Zanker, Bastagli, Harman, Barca, Sturge and Schmidt2016) 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 programmes could be useful to this debate. In the interactions between officers and recipients, policies and programmes generate new social scenarios that can reproduce wider hierarchical structures that keep people vulnerable, potentially reducing – rather than increasing as it was assumed – the programme’s ability to achieve its primary goals such as improving health, but more importantly, improving wellbeing more holistically.
Acknowledgements
The author is grateful to the National Council of Science and Technology (CONACyT) in Mexico and the University of Bath Research Studentship for providing financial support to this research as part of her Ph.D. dissertation project. The author is also indebted to the Cambridge-UDLAP Visiting Fellowship and extends her appreciations to the two anonymous reviewers, the managing editors, Ricardo Velázquez-Layer and other colleagues at UDLAP for their invaluable comments on earlier drafts of this article. The author certifies that she has no affiliations with or involvement in any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this article.
