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3 Center for Evaluation Research and Surveys and 4 Centre for Nutrition and Health Research, National Institute of Public Health, Col. Sta. María Ahuacatitlán, CP 62508, Cuernavaca, Morelos, Mexico
* To whom correspondence should be addressed. E-mail: jleroy{at}correo.insp.mx.
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ABSTRACT |
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 TOP ABSTRACT IntroductionDiscussionLITERATURE CITED |
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Introduction |
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TOPABSTRACTIntroductionDiscussionLITERATURE CITED |
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Oportunidades, Mexico's conditional cash transfer program with 5 million enrolled households across all regions of the country, provides an excellent opportunity to study the enrollment and utilization of a large-scale program. First, the program employs different recruitment strategies in rural and urban areas. A second interesting feature is the combination of obligatory and nonobligatory program components. Household members are obliged to participate in health education sessions and attend regular health check-ups to receive the program's monthly cash transfer. The regular and proper consumption of the nutrition supplement provided to children from 6 to 24 mo of age, on the other hand, is a program component that neither is nor could be enforced.
The objectives of this study were to analyze enrollment into the Oportunidades program and utilization of the different program components and to discuss ways it might affect the program's impact on childhood nutrition. The effectiveness of the program could be improved by minimizing both the size of the eligible, nonenrolled population and the size of the enrolled population not effectively utilizing the program's components (see Fig. 1). We first compared the rural program enrollment mechanism with that used in urban areas and identified household factors associated with enrollment. We specifically examined whether having a child entitled to receive the program's nutrition supplement (i.e., a child 6 to 24 mo of age) was positively associated with program enrollment. Second, we investigated the beneficiary households' utilization of program benefits, comparing the utilization rates of the obligatory program components (e.g., attending health education) with the nonobligatory consumption of the nutrition supplement.
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The Oportunidades program, program benefits, requirements, and impact
In 1997, the Mexican government launched PROGRESA (Program for Education, Health and Nutrition; now called Oportunidades), 1 of the world's largest conditional cash transfer programs. The program integrates interventions in health, education, and nutrition. Beneficiary families receive monthly cash transfers, medical care, scholarships for maintaining children in school, and depending on household demographics, nutritional supplements. The basic premise of this program is that by investing in human capital today the government can break the intergenerational transmission of poverty and guarantee a higher future standard of living for today's children (8,9). The received transfers constituted 25% of mean household income in rural areas and 15% to 20% in urban areas (10). All program benefits are received by the mother, a strategy designed to empower women in the program (8).
The monthly cash transfers are meant to improve the diet of the family and are given conditionally with several requirements. These include immunization of children, attendance at nutrition monitoring clinics for children 0–60 mo of age, prenatal and postpartum care visits, and preventive health check-ups for all family members. Household members 15 y and older need to attend monthly meetings at which health, hygiene, and nutrition issues are discussed (11,12). To receive the scholarship, school-aged children must be enrolled and attend at least 80% of the lessons. The scholarship increases in higher grades and is slightly higher for girls than for boys in secondary school (11,13). The nutrition supplements are provided to all children between 6 and 23 mo of age, to children between 2 and 5 y of age with low weight, and to pregnant and lactating women. The supplements are intended to be consumed daily (11).
The program has been shown to have positive impacts in health, education, and nutrition. The evaluation in urban areas showed that children younger than 6 mo in beneficiary families grew 1.5 cm (P < 0.05) more than children in comparison families. Similar effects were found in rural areas. Additionally, beneficiary families consumed healthier diets. The impact on anemia, however, has been modest (8,12–17).
Enrollment into the Oportunidades program
In rural towns (with up to 2500 inhabitants) the program employed a combination of geographic and household-level targeting. National census data were used to select localities with a high density of poor households and ready access to a school and a health facility. Households were targeted using a door-to-door census that evaluated socioeconomic status. The assessment primarily utilized household assets but also considered education and household composition. Oportunidades staff then returned to eligible households to invite them to enroll them in the program (18).
In urban areas (as in rural areas) the program was targeted to cities and neighborhoods within cities with a high density of poor households as identified by the national census. Because the poverty rates in urban areas are much lower than those in rural areas, it was considered too costly to conduct a door-to-door census to determine program eligibility. Mass media were used to advertise the program, invite families to visit the program recruitment office in the community, and solicit their economic evaluation. People thus needed to apply for the program before an evaluation of their eligibility took place. Based on an initial screening in the program office (using specific socioeconomic characteristics), applicants were informed of their possible eligibility. A program official then visited the household deemed eligible to validate the socioeconomic data. Applicants subsequently had to return to the program office to confirm eligibility and to register in the program (19).
Because of the greater complexity of the process in urban areas, lower enrollment was expected in urban areas. The difference, however, was surprisingly large. In rural areas, 97% of eligible households enrolled in the program (20), whereas only 51% of eligible households initially enrolled in urban areas. Based on their analyses of the urban baseline data, Coady and Parker concluded that, of the eligible households in urban areas, 24% were not aware of the program. Of the eligible households that knew about the program, 92% knew where the office was, and 92% of those actually went. Of those who applied, 80% completed the process and were registered as beneficiary households (19). In urban areas with high levels of poverty, the recruitment method was subsequently modified and is now using a census approach to reach a larger proportion of the poor.
We estimated the probability of enrollment of eligible urban households as a function of 1) having a child under 2 y (i.e., a child eligible to receive the nutrition supplement), 2) the potential monetary benefits the household could receive if enrolled, and 3) the interaction between 1) and 2). The models controlled for access to information (education level and parental literacy, having a TV or a radio, and participating in community activities), potential costs of participation (having children eligible for scholarships but currently working), the number of adults in the household, the number of children not yet eligible for scholarships, the autonomy of individuals making money to decide on how it is spent, and fixed community effects. We estimated an ordinary least-squares regression model using Stata 9.
Having a child entitled to the nutrition supplement was not associated with enrollment in urban areas (Fig. 2). The potential monetary transfer households could receive, however, was significantly and positively associated with enrollment. Households with potential transfers from 250 to 805 Mexican pesos (US$23 to US$75) and from 810 to 1550 Mexican pesos (US$75 to US$144) had a probability of enrollment that was 6.4 (P < 0.05) and 13.7 percentage points (P < 0.01) higher, respectively, than households with the basic transfer of 150 pesos (US$14). The interaction between the potential transfer and having a child of <2 y was not significant, indicating that the importance of the potential monetary transfer was not modified by having a child that age.
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50 Mexican pesos (US$4.67) per household per month. A different nutrition support program in Mexico provided households with foodstuffs that were sold on the open market. The local market price was 30% greater than the cost to the program. Applying this same factor to the Oportunidades supplement results in 65 Mexican pesos (US$6.07) per month, or within the range that would be observable, if the perceived value is commensurate with its equivalent market value. Utilization of the obligatory and nonobligatory program components
Utilization of the obligatory components of the program has been well above 90% (A. Macías Sánchez, personal communication, July 2007). It is below 100% because households are disenrolled only when they have missed 3 consecutive health visits or health education sessions. Utilization of the obligatory components is considerably higher than the use of the nutrition supplement. A number of studies showed that children did not consume the supplement daily as recommended. In rural areas, it was estimated that only 57% of the treatment group ingested the supplement 4 or more times a week (14). In urban areas, a mere 50% of the children between 6 and 23 mo consumed the supplement at least once a week, and only 66.4% of them consumed it regularly (4–6 times a week). Among those who consumed the supplement, mean intake was less then half of the recommended dose. Consequently, the mean daily intake was much lower than recommended (14). In both urban and rural areas, studies have shown problems including sharing with other family members and not properly preparing the supplement as well as not receiving the supplements (20,21).
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Discussion |
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TOPABSTRACTIntroductionDiscussionLITERATURE CITED |
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Notwithstanding the fact that one of Oportunidades' main objectives is improving child nutrition, initial enrollment in urban areas was clearly associated with the monetary transfers and not with the availability of nutrition supplements. The program could increase enrollment of families with children under 2 y of age through family planning clinics or prenatal care visits. Further, the program is evaluating a change in the subsidy pattern, reducing or eliminating the scholarships for years 3 and 4 of primary school (when almost all children are enrolled anyway) and redirecting the subsidy to households with young children.
The evidence with respect to utilization shows that the obligatory nature of part of the program did not drive the adequate utilization of the nutrition supplement in both urban and rural areas. The supplement is the program component with the highest potential to improve nutritional status. Important progress is being made, however, to improve this part of the program. A behavior change communication intervention in Chiapas and Veracruz successfully improved the appropriate use of the supplement in children (22). The materials developed in this study will be used at scale. A second solution is the use of micronutrient sprinkles or other micronutrient supplements that can be more easily targeted. They are currently being tested as an alternative to the existing supplement. Because of their perceived medicinal nature, sharing among family members is expected to be lower (23). A third alternative would be through active monitoring of the hemoglobin of individual children, identifying those with anemia and providing specialized attention to those children, both additional education to the household and supplemental iron until the deficiency is corrected. A similar approach could be followed for linear growth retardation. Finally, the program could consider an extension of the conditional nature of the program at the level of the Oportunidades clinics. Under a "pay-for-performance" scheme, clinics would be evaluated on changes in the prevalence of anemia and growth retardation and would receive (financial) rewards for improved performance. Experience with a pay-for-performance contract for family practitioners in the National Health Service in the UK showed that high levels of performance were attained but that monitoring was necessary to prevent gaming and abuse (24).
In conclusion, to achieve Oportunidades' full potential nutrition impact, new and creative approaches are needed to maximize the enrollment of eligible households in urban areas and to improve the utilization of the nutrition supplement in urban and rural areas. This finding is important for a number of other countries where conditional cash transfer programs similar to Oportunidades are being implemented. Key to the success of the program innovations is ongoing rigorous program evaluation. The consecutive Oportunidades evaluations have documented the program's impact to date, have identified the need for program improvements, and will be instrumental in evaluating the effectiveness of future program innovations.
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FOOTNOTES |
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2 Author disclosures: J. L. Leroy, H. Vermandere, L. M. Neufeld, and S. M. Bertozzi, no conflicts of interest.
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LITERATURE CITED |
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TOPABSTRACTIntroductionDiscussionLITERATURE CITED |
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1. Pelletier DL, Frongillo EA Jr, Habicht JP. Epidemiologic evidence for a potentiating effect of malnutrition on child mortality. Am J Public Health. 1993;83:1130–3.
2. Fishman SM, Caulfield LE, de Onis M, Blossner M, Hyder AA, Mullany L, Black RE. Childhood and maternal underweight. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: the global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2004. p. 39–161.
3. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet. 2003;362:65–71.[Medline]
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5. International Food Policy Research Institute (IFPRI) [homepage on the internet]. Washington, DC: IFPRI; 2007. Available from: http://www.ifpri.org/ [accessed 2007 May 1].
6. Secretaría de Desarrollo S (SEDESOL). México [homepage on the internet]. Mexico: SEDESOL; 2007. Available from: http://evaluacion.oportunidades.gob.mx/ [accessed 2007 May 1].
7. Hernández Avila M, Hernández Prado B, Urquieta Salomón JE, editors. Evaluación externa de impacto del Programa Oportunidades 2006. Cuernavaca, Mexico: Insitituto Nacional de Salud Pública; 2006.
8. Skoufias E. PROGRESA and its impacts on the welfare of rural households in Mexico. Washington, DC: International Food Policy Research Institute; 2005.
9. Cruz C, de la Torre R, Velázquez C. Evaluación externa de impacto del programa OPORTUNIDADES 2001–2006. Informe compilatorio. Cuernavaca, México: Instituto Nacional de Salud Publica; 2006.
10. Levy S. Progress against poverty: sustaining Mexico's Progresa-Oportunidades program. Washington, DC: Brookings Institution Press; 2006.
11. Programa de desarrollo humano oportunidades. Reglas de operación 2007. Mexico: Secretaría de desarollo Social (Programa Oportunidades); 2007.
12. Gertler P, Fernald L. The medium term impact of OPORTUNIDADES on child development in rural areas. Cuernavaca, Mexico: Instituto Nacional de Salud Publica; 2004.
13. Schultz P. School subsidies for the poor: evaluating a Mexcian strategy for reducing poverty. Washington, DC: International Food Policy Research Institute; 2000.
14. Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA. 2004;291:2563–70.
15. Gertler P. The impact of PROGRESA on health. Washington, DC: International Food Policy Research Institute (IFPRI); 2000.
16. Hoddinott J, Skoufias E. The impact of PROGRESA on food consumption. FCND Discussion Paper 150. Washington, DC: International Food Policy Research Institute (IFPRI); 2003.
17. Neufeld LM, García Guerra A, Leroy JL, de Lourdes Flores López M, Fernández Gaxiola AC, Rivera JA. Tomo II: Alimentación. Cuernavaca, México: Instituto Nacional de Salud Publica; 2006.
18. Skoufias E, Davis B, de la Vega S. An addendum to the final report: An evaluation of the selection of beneficiary households in the education, health and nutrition program (PROGRESA) of Mexico. Washington, DC: International Food Policy Research Institute (IFPRI); 1999.
19. Coady DP, Parker SW. Program participation under means-testing and self-selection targeting methods. FCDN Discussion Paper 117. Washington, DC: International Food Policy Research Institute (IFPRI); 2005.
20. Adato M, Coady DP, Ruel M. An operations evaluation of PROGRESA from the perspective of beneficiaries, promotoras, school directors, and health staff. Washington, DC: International Food Policy Research Institute (IFPRI); 2000.
21. Neufeld LM, Sotres-Alvarez D, Flores-Lopez M, Tolentino-Mayo L, Jiménez-Ruiz J, Rivera-Dommarco J. Estudio sobre el consumo de los suplementos alimenticios Nutrisano y Nutrivida en niños y mujeres de zonas urbanas beneficiarios de Oportunidades. Cuernavaca, México: Instituto Nacional de Salud Publica; 2004.
22. Bonvecchio A, Pelto GH, Escalante E, Monterrubio E, Habicht JP, Nava F, Villanueva MA, Safdie M, Rivera JA. Maternal knowledge and use of a micronutrient supplement was improved with a programmatically feasible intervention in Mexico. J Nutr. 2007;137:440–6.
23. Neufeld L. Efficacy of a fortified complementary food, sprinkles and a micronutrient syrup to prevent anemia in children under two years of age in urban Mexico. Micronutrient Forum. Instanbul, Turkey: Sight and Life; 2007.
24. Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med. 2006;355:375–84.
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