Alexandra Bramsen
Geography 17
Professor Batra
March 13th, 2020
The Development of Cash Transfers and the Implications on “Third World” Women’s Bodies
Cash transfers have in a sense become the new microfinance in the discourse of development. They are considered promising for the resolution of many problems, one of which is the prevention of HIV (Human Immunodeficiency Virus), through controlled conditional cash transfer (CCT) programs. The demographic implementation of these programs has taken a concentration on women in developing nations, as development programs with microfinance previously did. Now whether cash transfers (CTs) are really a viable option for development is still up for debate, alongside the possible implications of its focus on women. How does this focus perpetuate the language of development as the progress of the “Third World” woman? It must be noted that the phrase “third world” women will be used throughout this paper, with the understanding that this is a critique of that kind of othering language that is often repeated in development rhetoric, and that the concept of the third world is inherently problematic. Going beyond this, what are other moral questions that come to light with using incentives to control women’s sexual behavior in the name of HIV prevention? Power dynamics in the space are important to recognize as while development programs have a will to act in the name of what is right for the people, it should not mean that the programs have the ability to control and bend the people participating in them to that will.
To completely understand the literature discussions on CT programs and their role in HIV prevention, we must look back to how microfinance was also similarly linked to HIV prevention. This movement was initiated alongside a shift from focusing on the individual and couples in HIV prevention to the broader group and structural issues that contribute to HIV prevalence (Dworkin & Blankenship, 2009). In this, programs drew on how microfinance could be used to address poverty and especially target women, promoting gender equality and empowerment through giving women access to credit and other business services (Dworkin & Blankenship, 2009). Essentially, women becoming more independent economically from their male counterparts could potentially lead to less domestic violence and women being able to have more of a voice, limiting the possibilities of risky sexual interactions, such as allowing for safer sex discussions as dominating power structures in the marriage are deconstructed (Dworkin & Blankenship, 2009). These trials over time have produced a mixture of results; both allowing for some growth and empowerment, but also not really guaranteeing that progress, as well as sinking some communities further and further into debt (Dworkin & Blankenship, 2009, Janet, 2015). Critiques addressed the discrimination of programs only helping the ‘not so poor’ and not really enacting social changes (Janet, 2015, p. 490). In this way CTs were believed to be the step up more innovative version of microfinance, where it would not have as many unforeseen consequences and would not leave participants trapped in debt.
CTs picked up in popularity across politics and development especially in the early 2000s after microfinance started to become unpopular because of the issues that were uncovered by discourses on the subject; misuse, debt cycles, and the objectification of the third world woman. Mexico’s Progresa, now Prospera, CT program’s success started a chain of copycats which spread to Sub Saharan Africa (SSA), this paper’s focus, as well as the rest of the developing world (Handa et al., 2018). CTs are a “form of social assistance” which had lots of renewed excitement surrounding their implementation, as they were thought by scholars to be the most affordable, more donor-dollar effective, and have a greater multiplier effect than previous programs, especially when combined with complementary programs, such as food aid (Farrington et al., 2007, p.6). With all the excitement, there were wisely words of caution; such as if it was truly affordable, considering that developing countries would have to find new funds to support the program if they were simply adding CTs to their list of programs, in comparison to if it was replacing older programs (Farrington et al., 2007). If program replacement was the resulting case, then politics became the means by which option would be selected for replacement, based upon opinions of importance (Farrington et al., 2007).
A common understanding is that for CTs to be successful they had to be adopted by their actuators under the political banner rather than the developmental. Under politics, there would be a rationale and certain blockades that would support the just, fair, even distribution and targeting of these programs, accounting for existing inequalities, rather than development’s one-sided approach that usually only views poverty as their target with little consideration of causal effects, for example segregation (Farrington et al., 2007). Other arguments have focused on whether to make CTs conditional or not, as there is potential that participants might misuse the grants resulting in poor effects on the intended target for aid (Farrington et al., 2007). On the other side, there are also issues of whether the program environments are suitable to the existing conditions, especially in Africa where public services, such as health and transportation, are often very limited and might impede participants ability to meet the preset conditions (Farrington et al., 2007). Upon further study, there have been very few points in research that have suggested that CTs have lasting effects on poverty reduction (Farrington et al., 2007). This issue may be a result of the programs aiming not to lift their participants above the poverty line, but rather decrease the asperity of their low-income status (Farrington et al., 2007). These benefits of programs, at least to some measure, have been proven by researchers as true in regard to aspects of the participant’s lives, such as domestic upkeep and protection of assets that have notably improved, although impacts have varied with the sizes of transfers (Farrington et al., 2007). Another approach to CTs has worked to set their participants up to “graduate” from that scheme of aid and move on to the next level of development and aid, which is often assumed to be small local loans that participants could now use efficiently and wisely to support their family or business (Farrington et al., 2007). Early discussions have worked to predict what the best authority, conditions, and possible effects of CT programs would be, but have been fairly inconclusive so it is important to move on and look at some specific case studies to assess what would be ideal (Farrington et al., 2007). Governments saw this new form of development as a means to a political platform or promotion, so CTs became quite popular with a lot of pilot programs starting up in the early 2000s (Farrington et al., 2007).
There have been mixed results of different CT programs, and for the purpose of this paper, the focus will be in Africa, specifically Eastern and Southern Africa. In general, CTs have been able to address and impact many different fields of life and its development, including but not limited to; education, health, nutrition, savings, investment, production, employment and empowerment (Bastalgi et al., 2016, p.266). Formats and application are huge factors in how programs impact a community as with more time, conditions and supplementary programming, CTs can have even broader and more profound impacts, both intentional and unintentional (Bastalgi et al., 2016). There are many current CT national programs in SSA acting as social protections, nevertheless this discussion will only address a few examples for contextualization. To start, in Zambia, there have been two randomized control trials for a Child Grant Program (CGP) and a Multiple Category Targeted Program (MCP) (Handa et al., 2018, p.43). These programs have been effective in fostering income multiplication, increased food stability and surprisingly there have been positive impacts on productivity (Handa et al., 2018). The real question in these trials addressed the longevity of effects and concluded that larger transfers, that were more regular and frequently given out, gave the best results, even with unconditional CTs as there was an observed filtration of benefits down to even the poorest households (Handa et al., 2018). Zambia’s current successes show how ideally CTs could be implemented and impactful, however, further assessments reveal unforeseen outcomes and impacts that are potentially harmful, but not mentioned in the Zambian study. This CT worked to the extent that it gave some poverty alleviation, though not eradication. However, it was a very economically focused study, and it would have been useful to also have a discussion on the emotional and empowering impacts of the programs on their respective participants.
The earlier buzz about CTs spouted from similar literature to that of the Zambian study, where there was much optimism in the potential of the programs especially when attached to conditions. This sparked the mass of randomized control trials (RCTs) of the programs testing the effectiveness of incentivizing certain actions. One early case that starts looking into the possibilities of CCTs and education of young women in developing countries was conducted in Malawi (Baird et al., 2010). The structure was set up to give about $10/month and pay for school fees of the female participants, as long as they met a school attendance quota or re-enrolled in school if they had dropped out (Baird et al., 2010). This Zomba CT Program’s RCT realized that a link existed between the education of women, its influence on their sexual behavior and thereby a reduced the risk of HIV infection (Baird et al., 2010). Results of this CCT program in Malawi showed self-reported decreases in early marriages, teen-pregnancies, and other sexual activity assumedly due to increased school attendance from monetary incentives (Baird et al., 2010). The idea was that by spending time in school there was less opportunity for “risky” sexual activity that could lead to the spread of HIV (Baird et al., 2010). By assuming that programs could contribute to HIV prevention, the paper, in turn, brought about and even demanded more studies and the expansion of CCT programs across SSA (Baird et al., 2010). It concluded that these programs could only have “win-win” effects with empowerment, education and reduced risk of HIV infection of young women (Baird et al., 2010, p.67). Education incentives for young women became a very important tool used by development agencies to reduce their risk of HIV infection.
With more discussion and research on this topic of CCTs in HIV prevention efforts, more questions and new concepts came to light. Malawi Incentives Project research began considering its cost-effectiveness, and the part that education incentivization had in HIV prevention as well as pursuing an understanding of unintended outcomes, such as violence, bullying, and jealousy between the intervention and control groups (Pettifor et al., 2012). There was a newfound agreement that structural factors of education played a big role as did context, but there was not a concluded ideal situation, only that programs needed to be as transparent as possible (Pettifor et al., 2012). These findings were further affirmed by other studies in Malawi and Tanzania and extended further, stating that CCTs needed to be integrated into an existing structural program, working in education and equality, to be most effective (Heise et al., 2013). It was clear that CTs working alone would stand no chance in combating the HIV epidemic in SSA (Heise et al., 2013). Despite the problems, discourse still emphasizes CCTs as a very important function in structural methods of HIV prevention. Another point of contention with these studies is that they always note that there is either very little evidence, support, or true determinants of CCT impacts on HIV, though there appeared to be widespread interest, conversation, and attention on the potentials of these programs. It seemed to continually exist as a preliminary assumption that CCTs worked, even when studies might have not reached that conclusion there was a compulsive need for more testing and trials. In the discourse on CT programs, a tension between the inconclusive suspicious results of trials and the former hope and optimism of this miracle development program arise.
The importance of context and size on program effects is more clearly observed in the case of South Africa’s Mpumalanga province that has had several CT program RCTs of varying scale. One was conducted with 29 girls in one school, where each was given a portion of a transfer every 2 months, with the remaining majority going to their caregiver upon following the condition of attending school (MacPhail et al., 2013). Program impacts on the wider community were assessed by integrating caregivers’, classmates’ and teachers’ feedbacks into the qualitative data that was collected (MacPhail et al., 2013). It concluded that the program was feasible and acceptable, despite tensions that arose with some community jealousy, there were no truly negative impacts on the relationships of participants (MacPhail et al., 2013). Participants used the cash wisely and accepted conditions despite resistance to having to split their grants, with their caregiver receiving most of it (MacPhail et al., 2013). These findings suggested that while participants felt that conditions could be improved; extended to more people including men, more fair splitting of the grant with the caregiver, and improved methods of attendance over the inconvenient fingerprinting task, there was generally positive and optimistic feedback to the program (MacPhail et al., 2013). Unlike this previous study a later trial in Mpumalanga, that observed 2537 young women, has since brought a discouraging note to the future of CCTs in HIV prevention (Pettifor et al., 2016). It discovered that there was in fact no effect on HIV incidence in their intervention group in comparison to their control group (Pettifor et al., 2016). It appeared to have little effect on school attendance, which was assumed to be a condition of choice participants already being in school (Pettifor et al., 2016). This discovery could be interpreted as a limit to how far educating girls can act as an HIV prevention strategy, as there is potentially a point where even if all participants are complying with the conditions of education their sexual behavior has not been altered so much that they are not susceptible to HIV infection. It is important to note that there is very strong evidence that increased school attendance does reduce the risk of infection, however discovering a limit to this effect means that the epidemic is still going to exist to some extent in systems where there is high attendance of females in secondary schools (Pettifor et al., 2016). Keeping girls in school is only reducing risk of infection but not able to eradicate HIV altogether as their sexual experiences can only be altered so much by attending school.
Now that there is a context of how conditional CTs have been focusing on preventing HIV infection of adolescent females in SSA, it is important to consider the biopolitical implications of such programs. These programs explicitly seek to control and influence these women’s actions in such a manner that it extends through the public sphere of education deeper into their private social and in this case sexual interactions. This manipulative approach is extremely diminutive as it asserts that these women do not have the capacity to make their own conscious correct decisions on education and sex, and so need to be influenced in the right direction. The concept of development enforcing the movement from “bare life” to the “good life” of these women, by manipulating their choices into a model that is deemed right be western standards (Parfitt, 2009). CCTs in part address structural inequalities that could create conditions where these women were not free to make those choices, because of limited finances or controlling, limiting and possibly abusive relationships, by slightly alleviating some of these issues with some financial support and with the small social protection education and money can give. Even so, CTs do not truly get to the causal effects, like completely eradicating poverty, gender inequalities, and imbalanced abusive power dynamics (Janet, 2015). In fact, it just asserts another power over the body of a third world woman. In a way it also explicitly dictates who is the ‘homo sacer’, the group that are allowed to die, by using conditions, such as attendance, that must be met in order to be considered deserving of the cash aid (Parfitt, 2009).
Problems that come up with this are how much geographical imaginations of developing nations, and the women in poor societies might influence and even negatively impact the implementation of these programs. Another is can programs really be empowering these women if at the core programs are only seeking to guide and protect them based upon an assumption that they are now powerless? These points bring up how orientalism is maintained in modern development discourse, placing those that exist in the developing world in the new Orient (Said, 1978). It asserts that the women that these programs focus on are subjected to be the lesser other, in that what modernity and progress in the West is, is everything that these women can never be on their own (Said, 1978). This is known to not be the case as assumptions of women in the developing world are usually not correct, and often their importance in development is misstated. Women can be very impactful in raising a nation out of poverty and chaos, as their agency can be very powerful. The problematic discourse that defunctionalizes this idea, is when the woman’s agency is only considered to exist when outside sources make it possible. This ignores self-actualization that can occur in these spaces.
In turn, there must be an understanding that RCTs themselves are just as explicitly unjust in their manipulation and division of participants. Program acceptability had a lot of focus on relationship impacts but seemingly brushed over the importance of participant feelings of selection being unfair and the tensions of jealousy (Pettifor et al., 2012). The biggest fear was always of violent physical and verbal retaliation over program designs, which did exist in some cases, but emotional conflict is just as valid of a negative consequence (Pettifor et al., 2012, Heise et al., 2010). Then when considering government control of trials, the obstacle of corruption is important, especially when working in a chaotic developing country, where the abuse of power over subjects and resources could give even more complicated detriments to the program (Farrington et al., 2007). Furthermore, despite conditions on certain aspects of the program, the money given could easily be misused for risky and even more harmful behavior, which would impair participants more than if they never went through the program (MacPhail et al., 2013, Heise et al., 2013). An example could be alcohol or other drugs being purchased and used in a manner that could lead to violence, addiction, and other harm. The reality is also that, despite so many different trials, results have not always been conclusive or even coherent with each other, suggesting that there needs to be a change or that something is missing and the situation of CCTs as a way to prevent HIV needs to be reassessed in a very critical manner.
It appears that just as microfinance sparked interests and then questioning, CCTs that have been set up for HIV prevention now need to be reanalyzed. This step in criticizing current impacts would need to be done alongside a slowing down of the implementation of RCTs, as despite having many previous trials, little conclusions have been made. The automatic response to these unclear results has been to conduct more studies, but this would appear to be the issue of the dog chasing his own tail, where the inconclusion is the conclusion. Programs need to be slowed and cross-compared to clearly understand what is working and what is not. This could lead to a reconstruction of better programs that could systematically be reintegrated into the scheme of development. It does not seem rational to keep pursuing a method of HIV prevention whose actual positive and negative impacts are not fully known or understood.
Finally, it must be understood how the programs themselves perpetuate the impetus of third world women as development, objectifying their status and progression, just as development also formulates and maneuvers the idea of poverty and who exists as poor to have a focus in the push for modernity. Development looks to help those it considers vulnerable, such as the “third world woman,” but in doing so it makes them visible. They are left exposed and even more vulnerable. CCT studies have not given much thought and attention to the human rights violations of their actions, as there are the elements of manipulation and exclusion that are underplayed and dismissed too easily. CTs in general have been critiqued, adjusted and rescaled with understandings of optimal benefits, and unconditional CTs appear to be the better choice with fewer negative social impacts. Taking everything into consideration, HIV prevention through the use of CCTs for young women’s education appears to have caused more structural and biopolitical issues than it has attempted to solve, though there is evidence that unconditional CT programs do still have working potential in the development sector for social protection. CTs have never been thought of as a singular means to an end, either for poverty or for the HIV epidemic. Unconditional CTs appear to be an important component to new development models, if they’re conducted in conjunction with other more targeted and lasting programs.
References
Baird, S., Chirwa, E., Mcintosh, C., & Özler, B. (2010). The short-term impacts of a schooling conditional cash transfer program on the sexual behavior of young women. Health Economics, 19(S1), 5568. doi: 10.1002/hec.1569
Bastagli, Francesca & Hagen-Zanker, Jessica & Harman, Luke & Barca, Valentina & Sturge, Georgina & Schmidt, Tanja & Pellerano, Luca. (2016). Cash transfers: What does the evidence say? A rigorous review of programme impact and of the role of design and implementation features. doi; 10.13140/RG.2.2.29336.39687.
Dworkin, S.L., Blankenship, K. Microfinance and HIV/AIDS Prevention: Assessing its Promise and Limitations. AIDS Behav 13, 462–469 (2009) https://doi.org/10.1007/s10461-009-9532-3
Farrington, J., Harvey, P., & Slater, R. (2007, July). Cash Transfers in development and relief contexts: A Review of recent Literature. Retrieved January 31, 2020, from https://www.odi.org/sites/odi.org.uk/files/odiassets/publications-opinionfiles/5737.pdf
Handa, S., Natali, L., Seidenfeld, D., Tembo, G., & Davis, B. (2018). Can unconditional cash transfers raise long-term living standards? Evidence from Zambia. Journal of Development Economics, 133, 4265. doi: 10.1016/j.jdeveco.2018.01.008
Heise, L., Lutz, B., Ranganathan, M., & Watts, C. (2013). Cash transfers for HIV prevention: considering their potential. Journal of the International AIDS Society, 16(1), 1–5. doi: 10.7448/ias.16.1.18615
Janet Seeley (2015) Microfinance and HIV prevention, Review of African Political Economy, 42:145, 488-496, DOI: 10.1080/03056244.2015.1064372
MacPhail, C., Adato, M., Kahn, K., Selin, A., Twine, R., Khoza, S., … Pettifor, A. (2013). Acceptability and Feasibility of Cash Transfers for HIV Prevention Among Adolescent South African Women. AIDS and Behavior, 17(7), 2301–2312. doi: 10.1007/s10461-0130433-0
Parfitt, T. (2009). Are the Third World Poor Homines Sacri? Biopolitics, Sovereignty, and Development. Alternatives, 34(1), 41–58 https://doi.org/10.1177/030437540903400103
Pettifor, A., MacPhail, C., Nguyen, N., & Rosenberg, M. (2012). Can Money Prevent the Spread of HIV? A Review of Cash Payments for HIV Prevention. AIDS and Behavior, 16(7), 17291738. doi: 10.1007/s10461-012-0240-z
Pettifor, A., MacPhail, C., Hughes, J. P., Selin, A., Wang, J., Gómez-Olivé, F. X., … Kahn, K. (2016). The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomized controlled trial. The Lancet Global Health, 4(12). doi: 10.1016/s2214-109x(16)30253-4
Said, Edward W. (1978). Orientalism. Vision Australia Personal Support.