The Oportunidades Human Development Program: lessons learned

1
The Oportunidades Human Development Program
lessons learned
José E. Urquieta
Tegucigalpa, Honduras October 09, 2006
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Presentation Structure

• The Oportunidades program today
• Primary health-related results
• Conclusions
• Challenges for the future

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The Oportunidades Program

• (Originally called Progresa). It is a program
• that targets the poorest families and
  communities in Mexico,
• based on conditional cash transfers,
• that is multi-sectoral, and one of the federal
  governments largest social development programs

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The Oportunidades Program

• Its mission is to promote the development of
  human capital among families living in extreme
  poverty, by improving educational, health and
  nutrition conditions, with the goal of
  interrupting the intergenerational transmission
  of poverty
• The Program began in 1997 in rural areas and
  expanded to semi-urban areas in 2001 and urban
  areas in 2002
• evaluation as an asset of the Program

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Growth of the Program
1997 2006
Beneficiary families 300,000 5,000,000
Rural localities 7,800 87,720
Semi-urban and urban localities -- 2,993
Municipalities 280 2,435
States 9 32
Annual budget (in millions of US ) 30 3,182
Total scholarship recipients 287,000 5,298,756
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Components of the Program

• Educational component
• Health component
• Nutrition component
• Patrimonial component Youth with Opportunities
• Component for older adults

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Inter-sectoral Collaboration
Health Sector
Secretary of Education

1. National Education Program
2. Support for schools and educational quality

Secretary of Social Development
General Coordinator for Oportunidades

1. National Social Development Program
2. Synergies with other programs

1. Analysis of targeting, administration of
   transfers, evaluation and accountability

SPSS Social Protection in Health System APV
Equal Chance in Life program
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Conditional Transfer Scheme
Co-responsibilities of the beneficiary families
Benefits

• Educational scholarships
• Other monetary transfers (youth, older adults,
  nutrition)
• Provides a Basic Package of Health Services
• Fortified nutritional complements
• Facilitates access to a broader social protection
  in health system (Popular insurance)

• Regular school attendance by children
• Attendance at preventive health services by
  family members
• Attendance at health promotion, nutrition and
  hygiene workshops

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Basic Package of Health Services

• Basic sanitation at the family level
• Family planning
• Prenatal, delivery, puerperal and newborn care
• Monitoring of nutrition and child growth
• Immunizations
• Management of diarrhea cases in the home
• Anti-parasite treatment in families
• Management of acute respiratory infections
• Prevention and control of pulmonary tuberculosis
• Prevention and control of arterial hypertension
  and diabetes mellitus
• Prevention of accidents and initial treatment of
  injuries
• Community training for self-care in health
• Prevention and detection of cervical cancer

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Oportunidades has great potential for improving
womens and childrens health

• Targets its activities on highly marginalized
  families and localities
• Priority groups for the health component
• Pregnant and breastfeeding women
• Children under 5 years old

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Results in child health and nutrition
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Impact of Oportunidades on the prevalence of
anemia in rural areas after 1 year of
implementation
Oportunidades has attained a decrease in the
prevalence of anemia in rural areas. Nevertheless
it remains high.
60
Source Rivera et al., JAMA 2004
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Impact of Oportunidades on the height of
children 6 in rural areas
The Program achieved an increase in height in
centimeters among children who were participants,
in comparison with non-participants
Adjusted for age and height in 1988, using a
linear random intercept model
Source Rivera et al., JAMA 2004
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Impact of Oportunidades on the increase in height
after 2 years of intervention in urban areas
Difference in height, Oportunidades-control in
2004 (cm)
n 206 plt0.05
n 96 p0.05
n 437 plt0.05
Age of child in 2002 (months)
Paired on propensity score, age, height in 2002,
sex and maternal height Source Neufeld et al,
In preparation
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Oportunidades does not have an effect on weight
for height in urban areas
plt0.10
Difference in weight for height,
Oportunidades-control in 2004
NS
NS
Age of child in 2002 (months)
Paired on propensity score, age, weight for
height in 2002, sex Source Neufeld et al, In
preparation
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Impact of the Program on the prevalence of
anemia in urban areas
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Other child health findings

• Significant increase in the average number of
  daily nutritional follow-up visits. Rural and
  urban
• Reduction in the number of days of illness for
  children 0 to 5 years old
• The Program does not appear to have an effect on
  the cognitive development of children in rural
  areas

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Other child health findings

• It was determined that children with
  Oportunidades in rural areas significantly
  improved their motor abilities, by 15
• There was no demonstrated effect of the Program
  on the duration of maternal breastfeeding
• The nutritional complement is well-accepted, but
  the quantities consumed are smaller than the
  desirable

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In rural and urban areas, the educational
component is weak

• Irregular sessions
• Insufficient information about nutritional
  complements
• Language barriers in rural areas
• Poor learning and teaching conditions

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Results in womens health and nutrition
21
Trend toward an increase in obesity among women
gt18 years old in urban areas
Source Neufeld et al, In preparation
22
Change in the BMI. Women gt18 years old in urban
areas
Change in BMI between 2002 and 2004 (kg/m2)
With overweight or obesity
Overweight
Obesity
Status at baseline (2002)
Source Neufeld et al, In preparation
Without Oportunidades
With Oportunidades
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Impact of Oportunidades on maternal and child
mortality

• Using data from the routine information systems
  (1995-2002), it was estimated that Oportunidades
  reduced the maternal mortality ratio by 11 and
  the child mortality rate by 2
• It is estimated that an average of 147 maternal
  deaths and 777 child deaths have been avoided
  annually
• The effects on maternal and child mortality were
  greater in highly marginalized areas

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Evolution of maternal mortality
Maternal mortality ratio, Mexico 1990-2005
Deaths x 100,000 live births
Millennium goal for Mexico

• The analysis of historical data on maternal
  mortality shows a reduction of
• 6.5 between 1990 and 1995
• 12.7 between 1995 and 2000,
• 12.8 between 2000 and 2005.

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Women that know about and use contraceptive
methods in rural areas, 2003
Incorporated in 1998
Incorporated in 2000
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Prenatal care in rural areas 2003
Incorporated in 1998
Incorporated in 2000
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Average number of procedures carried out in
relation to the NOM for prenatal and newborn
care in rural areas in 2003
NOM Official Mexican Norm
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Other womens health findings

• Positive effect on the number of women that get a
  Pap smear test
• The Program has had effects on the timely
  detection of diabetes however it has not been
  sufficient for improving control of this disease
• Increase in knowledge about modern family
  planning methods, although this knowledge has not
  translated into effective use of contraceptive
  methods
• There was no effect found on the concentration of
  hemoglobin and anemia among non-pregnant women
• The Program had no effect on skilled delivery
  care in urban or rural areas

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Percentage of women receiving care from a doctor
at the time of delivery
From 61.9 to 86.7 From 89.2 to 93.9 From 94.1
to 97.5 2 From 98.1 to 100
Source National Health and Nutrition Survey -
ENSANut 2006
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Access to a broader Social Protection in Health
System (Popular Insurance)
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Percentage of Oportunidades covered by the
Popular Insurance
Source ENSANut 2006
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Conclusions and challenges for the Program
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Conclusions

• Oportunidades has had an important effect on
  child health in rural areas (growth and anemia)
• Oportunidades has had a smaller effect on the
  health of the population in rural areas
• Oportunidades has had modest effects on womens
  health
• Oportunidades has had positive effects on the
  health indicators related to co-responsibilities
• Few or no impacts on hard health indicators

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Conclusions

• Oportunidades has no effect on obesity and
  overweight in women
• There is evidence of an important increase in the
  overall population
• Evidence that the health component needs overall
  improvement
• Undesirable quality of health services
• Weak educational sessions
• Limited access to Popular Insurance in the most
  vulnerable areas

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Challenges for the future

• Improve the quality of care of health services
• Empower the population regarding its rights to
  better care
• Improve the inter-sectoral coordination of the
  Program
• Establish a Governing Board with clear
  responsibilities for each sector and institution
• Define the co-responsibilities of the
  participating health institutions
• Make explicit the synergies or integration with
  programs in the health sector

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Challenges for the future

• Promote greater access to the Social Protection
  in Health System
• Efforts to improve quality are not aligned with
  Program coverage risk of greater inequity
• Strengthen the health education component
• Promotion of the consumption of healthy foods
• Promotion of physical activity
• Evaluate the intermediate- and long-term effects
  of the Program

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The evaluation documents, instruments and
databases are available at http//evaloportunidad
es.insp.mx
MANY THANKS