Mexico's Conditional Cash Research Articles

Conditional Cash Transfers and Labor Market Conditions

Do local labor markets influence the effectiveness of educational policies? To answer this question, we focus on Mexico's conditional cash transfer program, PROGRESA, documented to have increased educational attainment. We show that PROGRESA's impact on schooling was smaller in areas with more export-oriented manufacturing jobs and argue this is because these jobs generate more convex opportunity costs of schooling. Consistent with this, the heterogeneity we document is strongest among those old enough to be working in factory jobs. In addition, this heterogeneity is primarily driven by jobs that directly influence schooling opportunity costs: low-wage jobs and jobs for school-aged workers.

Program Impact Pathways and Contexts: A Commentary on Theoretical Issues and Research Applications to Support the EsIAN Component of Mexico's Conditional Cash Transfer Program

ABSTRACTThis commentary on the Integrated Strategy for Attention to Nutrition (EsIAN) journal supplement begins with a discussion about the challenges that implementation researchers confront with respect to analyzing complex impact pathways. We note that the research on the implementation of the EsIAN component of Mexico's conditional cash transfer program was based implicitly or explicitly on a program impact pathway approach, which used both quantitative and qualitative methods to examine bottlenecks in program implementation. We then identify 5 categories of contexts that affect the impact, implementation, and survival of intervention programs: 1) biological, 2) social-cultural, 3) delivery modalities and platforms, 4) bureaucratic, and 5) political. Each of these contexts presents theoretical and methodological challenges for investigators. In this commentary, we focus primarily on biological and social-cultural contexts, discussing the theoretical and methodological challenges the investigators faced and the research strategies they used to address them, which have produced a unique compilation of “learning by doing” studies. We also touch briefly on the political context in which the Prospera program research was conducted. We conclude with statements that highlight the exceptional value of the journal supplement, not only with respect to the analysis of the interventions the studies cover and the sustained examination of a long-term program but also as a major contribution to the literature in implementation science in nutrition.

Closing the Nutrition Impact Gap Using Program Impact Pathway Analyses to Inform the Need for Program Modifications in Mexico's Conditional Cash Transfer Program

ABSTRACTBackgroundMexico's Prospera-Oportunidades-Progresa Conditional Cash Transfer Program (CCT-POP) included the distribution of fortified food supplements (FFS) for pregnant and lactating women and young children. Rigorous evaluations showed significant impacts on nutrition outcomes but also substantial gaps in addressing nutrition problems.ObjectivesTo highlight the program design-related and implementation-related gaps and challenges that motivated further research and the eventual design and roll-out of a modified nutrition component for CCT-POP.MethodsWe used a program impact pathway approach to highlight the extent and quality of implementation of CCT-POP, and its impact on nutrition outcomes. We drew on previously published and new primary data, organized into 3 sources: impact evaluations, studies to inform reformulation of the FFS, and a longitudinal follow-up study using qualitative and quantitative methods to document FFS use and the dietary intake of women and children.ResultsDespite positive impacts, a high prevalence of malnutrition persisted in the population. Coverage and use of health services improved, but quality of care was lacking. Consumption of FFS among lactating women was irregular. Micronutrient intake improved among children who consumed FFS, but the pattern of use limited frequency and quantity consumed. Substantial diversity in the prevalence of undernutrition was documented, as was an increased risk of overweight and obesity among women.ConclusionsThree key design and implementation challenges were identified. FFS, although well accepted for children, had limited potential to substantially modify the quality of children's diets because of the pattern of use in the home. The communications strategy was ineffective and ill-suited to its objective of motivating FFS use. Finally, the program with its common design across all regions of Mexico was not well adapted to the special needs of some subgroups, particularly indigenous populations. The studies reviewed in this paper motivated additional research and the eventual redesign of the nutrition component.

A Fortified Food Can Be Replaced by Micronutrient Supplements for Distribution in a Mexican Social Protection Program Based on Results of a Cluster-Randomized Trial and Costing Analysis

ABSTRACTBackgroundDespite positive nutrition impacts, the prevalence of malnutrition among beneficiaries of Mexico's conditional cash transfer (CCT) program remains high. Greater nutrition impact may have been constrained by the type of nutritional supplements provided.ObjectiveThe objective of this study was to inform a potential modification to the supplements distributed to pregnant and lactating women and children.MethodsImpact was assessed using 2 cluster-randomized trials (pregnant women, children) run simultaneously. Communities (n = 54) were randomly assigned to the fortified foods provided by the program (Nutrivida women, Nutrisano children) or alternatives: tablets (women), syrup (children), or micronutrient powders for women (MNP-W) and children (MNP-C). Each supplement for women/children contained the same micronutrients based on the formulations of Nutrivida and Nutrisano, respectively. Pregnant women (aged >18 y) were recruited before 25 weeks of gestation and followed to 3 mo postpartum. Children aged 6–12 mo were recruited and followed to age 24 mo. Primary outcomes were anemia for women and length growth for children. Statistical analyses appropriate for cluster-randomized designs were used, and structural equation modeling to estimate dose-response effects. Supplement costs per beneficiary (daily dose for 18 mo) were estimated for production and distribution.ResultsThere was no significant difference in change of anemia prevalence between supplement groups in women, or in length growth between groups in children. One daily dose of any supplement was associated with 0.8 cm greater length growth. From baseline to age 24 mo, the prevalence of anemia in the Nutrisano, syrup, and MNP-C groups decreased by 36.7, 40.8, and 37.9 percentage points, respectively (within-group, P < 0.05; between groups, P > 0.05). Costs per beneficiary ranged from $12.1 (MNP-C) to $94.8 (Nutrivida).ConclusionsThe CCT program could distribute alternative supplements at lower cost per beneficiary without compromising potential for impact. Acceptance among beneficiaries should also be considered in choice of alternatives. This trial was registered at www.clinicaltrials.gov as NCT00531674.

Sociocultural Influences on Poor Nutrition and Program Utilization of Mexico's Conditional Cash Transfer Program

The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze. We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program. We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions. Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions. Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.

Translating Evidence-Based Program Recommendations into Action: The Design, Testing, and Scaling Up of the Behavior Change Strategy EsIAN in Mexico

The Integrated Strategy for Attention to Nutrition (EsIAN in Spanish) is a national strategy within Mexico's conditional cash transfer program (initially Progresa, then Oportunidades, then Prospera, CCT-POP) designed to strengthen the health and nutrition component, address the nutrition transition, and improve the health and nutritional status of its beneficiaries, through 3 main components: 1) procurement of functioning equipment to primary health care (PHC) units; 2) providing free micronutrient supplements to beneficiary women and children; 3) implementing a behavior change communication (BCC) strategy and a training system for PHC providers (PHCPs). We aim to describe the iterative process and evidence-based approach used to design and roll-out the EsIAN at scale, by focusing on the BCC component. The BCC strategy was developed by following an iterative process through the following phases: situational analysis, formative research and design of the BCC strategy (using the socioecological framework and the social marketing approach), large-scale feasibility study, redesign, and national scale-up. The review and formative research revealed several barriers and issues that limited program coverage, utilization, and acceptance. These included misconceptions about pregnancy and infant feeding, nonalignment of practices with international recommendations, and lack of knowledge on nutrition and related topics, among others. These results were used to identify priority behaviors and elaborate key messages for mothers/caregivers and providers to develop the BCC strategy. The feasibility study resulted in significant improvements in PHCPs' knowledge, counseling (breastfeeding, and supplement use and consumption), and caregivers' complementary feeding behaviors, and highlighted several design and delivery aspects that needed strengthening. Based on these findings, the BCC strategy was adapted prior to a national scale-up. The theory-based iterative approach resulted in the identification of specific actions to target, and approaches to do so, as part of the design and roll-out of the BCC strategy at scale.

Promoting child development through group-based parent support within a cash transfer program: Experimental effects on children's outcomes.

We examined effects on child development of a group-based parenting support program (Educación Inicial - EI) when combined with Mexico's conditional cash transfer (CCT) program (Prospera, originally Oportunidades and Progresa). This cluster-randomized trial included 204 communities (n = 1,113 children in final sample), stratified by community indigenous status, and assigned to receive either: (T0) CCT only; (T1) CCT plus availability of EI in the community; or (T2) T1 plus promotion of the EI program by the CCT program. Interviews were conducted with the mother or primary caregiver of each child at baseline (2008, children 0-18 months old), and at follow-up (2012, children 3-5 years old); the intervention began after baseline and continued for all eligible households. Cognitive development was assessed with the Extended Ages and Stages Questionnaire (baseline) and the McCarthy Scales of Children's Development (follow-up); assessors were blinded to treatment. All analyses were intention to treat. There were significant effects on child development when EI received support and promotion from the CCT program (T₂ vs. T₀: General Cognitive Index, β = 3.90; 95% CI [0.51, 7.30], Verbal Score, β = 4.28; 95% CI [0.51, 8.05], and Memory Score, β = 4.14; 95% CI [0.62, 7.66]), effects equivalent to 0.26-0.29 SD. There were no significant benefits when the programs operated independently (T₁ vs. T₀). In stratified analyses, EI showed significant effects in indigenous communities only. We found consistent results in regressions controlling for covariates, with some reductions in magnitude of differences. Our findings suggest that group-based, parenting support programs can improve child outcomes within the context of a CCT, but only when the 2 programs are integrated and mutually supportive. (PsycINFO Database Record

The gender dynamics of conditional cash transfers and smallholder farming in Calakmul, Mexico

We explore how Oportunidades, Mexico's anti-poverty conditional cash transfer (CCT) program, impacts production and gender dynamics in the smallholder agricultural sector. A 2010 household survey in one southeastern municipality (Calakmul) captured data on Oportunidades receipt, land use and yields, as well as gendered patterns of asset control, decision-making, labor, and income receipt. Our analysis suggests that households with Oportunidades are more likely to engage in semi-subsistence maize cultivation and on average harvest more maize. Thus Oportunidades appears to support semi-subsistence production. We also document persistent gender gaps in land control, decision-making, labor, and income receipt. Nonetheless, we find that households with Oportunidades have on average smaller gaps of particular kinds: women receiving Oportunidades are more likely to hold de jure land rights and to share in income receipt from four main crops. These effects of Oportunidades on gendered smallholder production dynamics are important ones in smallholder women's lives.

Exploring the Differential Impact of Public Interventions on Indigenous People: Lessons from Mexico's Conditional Cash Transfer Program

This paper uses experimental panel data for Mexico from 1997 to 2000 in order to test assumptions on the impact of a conditional cash transfer (CCT) program on child labor and school attendance, adding to the literature by emphasizing the differential impact on indigenous households. Using data from the CCT program, PROGRESA (later on known as OPORTUNIDADES), we investigate the interaction between child labor, education and indigenous households. While indigenous children had a greater probability of working before the intervention, this probability is reversed after treatment in the program. Indigenous monolingual children also had lower school attainment compared with Spanish-speaking or indigenous bilingual children. After the program, school attainment among indigenous children increased, reducing the gap. In terms of child labor, the larger reduction is in the group of bilingual children.

Heterogeneous treatment effects in conditional cash transfer programmes: assessing the impact of Progresa on agricultural households

The success of Mexico's conditional cash transfer programme (Progresa) has sparked a wave of similar programmes across the developing world, and the highly successful social experiment in Progresa has created demand for experimental evaluations among development partners, multilateral agencies and governments as a way to assess development policy. But existing evaluations do not consider the possibility of heterogeneous treatment effects due to either multiple programme participation or the special circumstances of agricultural households when production and consumption decisions are not separable. This article shows that the impact of Progresa on health check-ups is significantly smaller among participants of Procampo, a programme that is linked to agricultural production. This differential impact may be due to Procampo conditionality or the fact that the shadow price of time is different between these households and other Progresa beneficiaries. The authors' conclusion is that conditional cash transfer programmes must consider multiple programme participation and non-separable agricultural households when designing programmes and assessing impacts

Empowering women: how Mexico's conditional cash transfer programme raised prenatal care quality and birth weight

Data from a controlled randomised trial are used to estimate the effect of Mexico's conditional cash transfer programme, Oportunidades, on birth outcomes, and to examine the pathways by which it works. Birth weights average 127.3 grams higher, and low birth weight incidence is 44.5 per cent lower among beneficiary mothers. Better birth outcomes are explained entirely by better quality prenatal care. Oportunidades affected quality through empowering women with information about adequate healthcare content to expect better care, and with skills and social support to negotiate better care. Efforts to empower the less well-off are necessary for public services to fully benefit the poor.

Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor.

Caesarean section rates are increasing in Mexico and Latin America. This study evaluates the impact of a large-scale, conditional cash transfer programme in Mexico on caesarean section rates. The programme provides cash transfers to participating low income, rural households in Mexico conditional on accepting health care and nutrition supplements. The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states. Using multivariate and instrumental variable analyses, we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting. Programme participation is measured by beneficiary status, programme months and cash transfers. More than two-thirds of poor rural women delivered in a health facility. Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for >or=6 months before delivery. Beneficiaries had significantly higher caesarean delivery rates in social security facilities (24.0 compared with 5.6% among non-beneficiaries) and in other government facilities (19.3 compared with 9.5%). The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities. This effect appears to be driven by the increases in disposable income from the cash transfer. These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements.

10-year effect of Oportunidades, Mexico's conditional cash transfer programme, on child growth, cognition, language, and behaviour: a longitudinal follow-up study

Mexico's conditional cash transfer programme, Oportunidades, was started to improve the lives of poor families through interventions in health, nutrition, and education. We investigated the effect of Oportunidades on children almost 10 years after the programme began. From April, 1998, to October, 1999, low-income communities were randomly assigned to be enrolled in Oportunidades immediately (early treatment, n=320) or 18 months later (late treatment, n=186). In 2007, when 1093 children receiving early treatment and 700 late treatment in these communities were aged 8-10 years, they were assessed for outcomes including physical growth, cognitive and language development, and socioemotional development. The primary objective was to investigate outcomes associated with an additional 18 months in the programme. We used cluster-adjusted t tests and multivariate regressions to compare effects of programme participation for height-for-age, body-mass index (BMI), and cognitive language and behavioural assessment scores in early versus late treatment groups. Early enrolment reduced behavioural problems for all children in the early versus late treatment group (mean behaviour problem score -0.09 [SD 0.97] vs 0.13 [1.03]; p=0.0024), but we identified no difference between groups for mean height-for-age Z scores (-1.12 [0.96] vs -1.14 [0.97]; p=0.88), BMI-for-age Z scores (0.14 [0.99] vs 0.17 [1.06]; p=0.58), or assessment scores for language (98.8 [13.8] vs 98.4 [14.6] p=0.90) or cognition (98.8 [12.9] vs 100.2 [13.2]; p=0.26). An additional 18 months of the programme before age 3 years for children aged 8-10 years whose mothers had no education resulted in improved child growth of about 1.5 cm assessed as height-for-age [corrected] Z score (beta 0.23 [0.023-0.44] p=0.029), independently of cash received. An additional 18 months in the Oportunidades programme has independent beneficial effects other than money, especially for women with no formal education. The money itself also has significant effects on most outcomes, adding to existing evidence for interventions in early childhood. Mexican Ministry of Social Development and the National Institutes of Child Health and Human Development.

Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme

To evaluate the impact of Mexico's conditional cash transfer programme on the quality of health care received by poor women. Quality is measured by maternal reports of prenatal care procedures received that correspond with clinical guidelines. The data describe retrospective reports of care received from 892 women in poor rural communities in seven Mexican states. The women were participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999. Eligible women accepted cash transfers conditional on obtaining health care and nutritional supplements, and participated in health education sessions. Oportunidades beneficiaries received 12.2% more prenatal procedures compared with non-beneficiaries (adjusted mean 78.9, 95% Confidence Interval (CI): 77.5-80.3; P < 0.001). The Oportunidades conditional cash transfer programme is associated with better quality of prenatal care for low-income, rural women in Mexico. This result is probably a manifestation of the programme's empowerment goal, by encouraging beneficiaries to be informed and active health consumers.

Providing a Healthier Start to Life: The Impact of Conditional Cash Transfers on Infant Mortality

In this paper, I evaluate the impact of Mexico's conditional cash transfer program, Progresa, on infant mortality. While studies on other aspects of Progresa make use of a randomized treatment and control evaluation database performed in 506 communities, this database lacks sufficient sample size to measure the effect on infant mortality. Instead, I use vital statistics data to determine municipality-level, rural infant mortality rates and create a panel dataset covering the period 1992-2001. I take advantage of the phasing-in of the program over time both between and within municipalities to identify the impact of the program. I find that Progresa led to an 11 percent decline in rural infant mortality among households treated in Progresa municipalities. Reductions are as high as 36 percent in those communities where, prior to program interventions, the population all spoke some Spanish and had better access to piped water.