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

The Oportunidades Human Development Program: lessons learned

José E. Urquieta

Tegucigalpa, Honduras

October 09, 2006


Presentation Structure

The Oportunidades program today

Primary health-related results

Conclusions

Challenges for the future


(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


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


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


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


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


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


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


Results in child health and nutrition


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.


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


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


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


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)


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


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


• 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


Results in women’s health and nutrition


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


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 )


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


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


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


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


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


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


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%


Access to a broader Social Protection in Health System (Popular Insurance)


From 50 to 75%

From 25 to 50%

From 0 to 25%

Percentage of Oportunidades covered by the Popular Insurance

Source: ENSANut 2006


Conclusions and challenges for the Program


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


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


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


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


The evaluation documents, instruments and databases are available at:

http://evaloportunidades.insp.mx

MANY THANKS

Instituto Nacional de Salud Pública The Oportunidades Human Development Program: lessons learned José E. Urquieta Tegucigalpa, Honduras October 09, 2006.

Documents

oportunidades program

salud pblica oportunidades

national health program

nutrition slide

salud pblica results

salud pblica change

p instituto nacional

life program slide