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

2. Instituto Nacional de Salud Pública Presentation Structure The Oportunidades program today Primary health-related results Conclusions Challenges for the future

3. 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 governments largest social development programs The Oportunidades Program

4. 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

5. Instituto Nacional de Salud Pública 19972006 Beneficiary families300,0005,000,000 Rural localities7,80087,720 Semi-urban and urban localities--2,993 Municipalities2802,435 States9 32 Annual budget (in millions of US $) $ 30$3,182 Total scholarship recipients287,0005,298,756 Growth of the Program

6. Instituto Nacional de Salud Pública Educational component Health component Nutrition component Patrimonial component Youth with Opportunities Component for older adults Components of the Program

7. Secretary of Education Health 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

8. Instituto Nacional de Salud Pública Benefits 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 Conditional Transfer Scheme

9. 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

10. Instituto Nacional de Salud Pública 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

11. Instituto Nacional de Salud Pública Results in child health and nutrition

12. 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.

13. 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 25.3 26.4 16.0 18.0 20.0 22.0 24.0 26.0 28.0 30.0 Poorest Increase in height (cm) 29.8 Growth without the program Growth with the program Potential growth Source: Rivera et al., JAMA 2004

14. Instituto Nacional de Salud Pública Age of child in 2002 (months) n = 437 p<0.05 n = 206 p<0.05 n = 96 p=0.05 Difference in height, Oportunidades-control in 2004 (cm) 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 height Source: Neufeld et al, In preparation

15. Instituto Nacional de Salud Pública Age of child in 2002 (months) NS p<0.10 Difference in weight for height, Oportunidades-control in 2004 NS Paired on: propensity score, age, weight for height in 2002, sex Source: Neufeld et al, In preparation Oportunidades does not have an effect on weight for height in urban areas

16. Instituto Nacional de Salud Pública Impact of the Program on the prevalence of anemia in urban areas 16.817.4 Anemia, % Children age 2-4 in 2004 With Oportunidades Mean ± SD (n=524) Without Oportunidades Mean ± SD (n=414)

17. Instituto Nacional de Salud Pública 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

18. Instituto Nacional de Salud Pública 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

19. Instituto Nacional de Salud Pública 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

20. Instituto Nacional de Salud Pública Results in womens health and nutrition

21. Instituto Nacional de Salud Pública Trend toward an increase in obesity among women >18 years old in urban areas Source: Neufeld et al, In preparation

22. 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 obesityOverweightObesity Without Oportunidades With Oportunidades Change in BMI between 2002 and 2004 (kg/m 2 )

23. 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

24. 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

25. Instituto Nacional de Salud Pública Women that know about and use contraceptive methods in rural areas, 2003 Incorporated in 1998Incorporated in 2000

26. Instituto Nacional de Salud Pública Prenatal care in rural areas 2003 Incorporated in 1998Incorporated in 2000

27. Instituto Nacional de Salud Pública 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

28. Instituto Nacional de Salud Pública 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

29. 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%

30. Instituto Nacional de Salud Pública Access to a broader Social Protection in Health System (Popular Insurance)

31. 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

32. Instituto Nacional de Salud Pública Conclusions and challenges for the Program

33. 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 womens health Oportunidades has had positive effects on the health indicators related to co-responsibilities Few or no impacts on hard health indicators Conclusions

34. 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

35. 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

36. 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

37. Instituto Nacional de Salud Pública The evaluation documents, instruments and databases are available at: http://evaloportunidades.insp.mx MANY THANKS