Instituto Nacional de Salud Pública
The Oportunidades Human Development Program: lessons learned
José E. Urquieta
Tegucigalpa, Honduras
October 09, 2006
Instituto Nacional de Salud Pública
Presentation Structure
The Oportunidades program today
Primary health-related results
Conclusions
Challenges for the future
Instituto Nacional de Salud Pública
(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 government’s largest social development programs
The Oportunidades Program
Instituto Nacional de Salud Pública
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
The Oportunidades Program
Instituto Nacional de Salud Pública
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
Growth of the Program
Instituto Nacional de Salud Pública
Educational component
Health component
Nutrition component
Patrimonial component “Youth with Opportunities”
Component for older adults
Components of the Program
Secretary of EducationHealth Sector
Secretary of Social Development
Operational scheme for
Oportunidades
1) National Health Program
2) Basic health and nutrition package
3) Synergies with other programs (SPSS and
APV)*
4) National Education Program
5) Support for schools and educational quality
6) National Social Development Program
7) Synergies with other programs
8) Analysis of targeting, administration of transfers, evaluation and accountability
General Coordinator for Oportunidades
Inter-sectoral Collaboration
SPSS: Social Protection in Health System; APV: Equal Chance in Life program
Instituto Nacional de Salud Pública
BenefitsBenefits
• Regular school attendance by children
• Attendance at preventive health services by family members
• Attendance at health promotion, nutrition and hygiene workshops
• 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)
Co-responsibilities of the beneficiary families
Co-responsibilities of the beneficiary families
Conditional Transfer Scheme
Instituto Nacional de Salud Pública
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
Instituto Nacional de Salud Pública
Oportunidades has great potential for improving women’s and children’s 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
Instituto Nacional de Salud Pública
60
* Children older than 12 months. Adjusted for age, using a GEE model** p < 0.05
%
**
54.9
44.3
0
10
20
30
40
50
Control group
Intervention group
Source: Rivera et al., JAMA 2004
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.
Instituto Nacional de Salud Pública
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
25.326.4
16.0
18.0
20.0
22.0
24.0
26.0
28.0
30.0
Poorest
Incr
ease
in h
eigh
t (c
m)
29.8
Growth without the program
Growth with the program
Potential growth
Source: Rivera et al., JAMA 2004
Instituto Nacional de Salud Pública
0
0.5
1
1.5
2
2.5
<24 <12 <6
Age of child in 2002 (months)
n = 437 p<0.05
n = 206p<0.05
n = 96p=0.05D
iffe
ren
ce in
hei
ght,
O
por
tuni
dade
s-co
ntr
ol in
200
4 (c
m)
Impact of Oportunidades on the increase in height after 2 years of intervention in urban areas
Paired on: propensity score, age, height in 2002, sex and maternal heightSource: Neufeld et al, In preparation
Instituto Nacional de Salud Pública
0
0.1
0.2
0.3
0.4
0.5
0.6
<24 <12 <6Age of child in 2002 (months)
NS
p<0.10
Dif
fere
nce
in w
eigh
t fo
r h
eigh
t,
Op
ortu
nida
des-
con
trol
in 2
004
NS
Paired on: propensity score, age, weight for height in 2002, sexSource: Neufeld et al, In preparation
Oportunidades does not have an effect on weight for height in urban areas
Instituto Nacional de Salud Pública
Impact of the Program on the prevalence of anemia in urban areas
16.817.4Anemia, %Children age 2-4 in 2004
With
OportunidadesMean ± SD (n=524)
Without Oportunidades
Mean ± SD (n=414)
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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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• Irregular sessions• Insufficient information
about nutritional complements
• Language barriers in rural areas
• Poor learning and teaching conditions
In rural and urban areas, the educational component is weak
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Results in women’s health and nutrition
Instituto Nacional de Salud Pública
Trend toward an increase in obesity among women >18 years old in urban areas
0
5
10
15
20
25
30
35
40
2002 2004
%
Overweight Obesity
Source: Neufeld et al, In preparation
Instituto Nacional de Salud Pública
Change in the BMI. Women >18 years old in urban areas
Source: Neufeld et al, In preparation
Status at baseline (2002)
With overweight or obesity
Overweight
Obesity
Without Oportunidades
With Oportunidades
Cha
nge
in B
MI b
etw
een
2002
and
200
4 (k
g/m
2 )
Instituto Nacional de Salud Pública
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
Instituto Nacional de Salud Pública
Evolution of maternal mortality
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.
Millennium goal for Mexico
Maternal mortality ratio, Mexico 1990-2005
Deaths x 100,000 live births
Instituto Nacional de Salud Pública
97.70
51.40
93.80
48.03
94.66
46.65
Know ledge of contraceptive methods Use of contraceptive methods (last sexualintercourse)
Per
cen
tag
e
Incorporados 1998 Incorporados 2000 control
Women that know about and use contraceptive methods in rural areas, 2003
Incorporated in 1998 Incorporated in 2000
Instituto Nacional de Salud Pública
3.07
5.97
3.19
5.62
3.36
5.58
Month that prenatal control began Average number of prenatal visits
Incorporados 1998 Incoporados 2000 Control
Prenatal care in rural areas 2003
Incorporated in 1998 Incorporated in 2000
Instituto Nacional de Salud Pública
10.07 9.78.73
0
2
4
6
8
10
12
14
Incorporated in 1998 Incorporated in 2000 Control in 2003
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
Instituto Nacional de Salud Pública
Other women’s 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
Instituto Nacional de Salud Pública
Percentage of women receiving care from a doctor at the time of delivery
Source: National Health and Nutrition Survey - ENSANut 2006
From 61.9 to 86.7%
From 89.2 to 93.9%
From 94.1 to 97.5%2
From 98.1 to 100%
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Access to a broader Social Protection in Health System (Popular Insurance)
Instituto Nacional de Salud Pública
From 50 to 75%
From 25 to 50%
From 0 to 25%
Percentage of Oportunidades covered by the Popular Insurance
Source: ENSANut 2006
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Conclusions and challenges for the Program
Instituto Nacional de Salud Pública
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 women’s health
Oportunidades has had positive effects on the health indicators related to co-responsibilities
Few or no impacts on “hard” health indicators
Conclusions
Instituto Nacional de Salud Pública
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
Conclusions
Instituto Nacional de Salud Pública
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
Instituto Nacional de Salud Pública
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
Instituto Nacional de Salud Pública
The evaluation documents, instruments and databases are available at:
http://evaloportunidades.insp.mx
MANY THANKS
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