International Conference

1. International Conference Evaluation of Financial Reforms Jaime SepúlvedaApril 21, 2004

2. E N S A 2000 ENEC - II ENEC ENSE - I I ENSE - I ENDEYO ENCOVA EMECADI -II EPPTRO ENN - I ENN - II ENSA - I ENSA - II ENSA - III ENA - I ENA - III ENA -II 2001 2002 2003 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Nutrición Progresa Rural Evaluación del programa Oportunidades, nivel suburbano Chronology of National Health Surveys and Program Evaluations Evaluación del programa Oportunidades, área urbana línea basal antes de incorporación

3. The Mexican Program Oportunidades Created in 1997 as “Progresa” Targeted to families in extreme poverty originally in rural areas (now includes urban areas) Two stage selection: poor communities and poor households Cash transfers as financial incentives for positive behaviours Families receive cash benefit if they attend health clinics, receive health education, and keep children attending school

4. The Mexican Program Oportunidades • Purpose: develop human capital through • Cash transfers • Health Services • Nutrition intervention (nutrition supplements and education) • Women, not men receive benefits • Coverage: 4.5 million families (20% of all families in Mexico) • Budget (2003): $2,250 million (US Dollars) • Incorporation of families staggered (from 0.3 to 4.5 mill in 6 y) • Evaluation component

5. Nutrition Component of Oportunidades • Nutritional supplements provided in Health Centers to: • All children 4-23 mo and underweight 2-4 y • Pregnant and lactating women • Ingredients whole dry milk, sugar, maltodextrin, vitamins, minerals, and flavors • 240 g packages of ready-to-eat food • Hydrated before consumption • Three flavors • Nutrition education sessions

6. Energy and nutrient content per supplement ration Ration (dry basis): papilla = 44 g, beverage = 52g

7. To evaluate the impact of Progresa on the linear growth and anemia prevalence in Mexican infants and young children Objective

8. States selected for impact evaluation

9. 506 localities randomized INTERVENTION320 localities CROSS-OVER INTERVENTION186 localities OverallEvaluation Cross-sectional baseline survey (children 0-60 mo) 2,396 children 205 localities 1,880 children 142 localities NutritionalEvaluation 461 infants 175 localities 334 infants 107 localities Panel (infants 0-12 mo) Flow diagram of study design

10. INTERVENTION 461 infants 175 localities CROSS-OVER INTERVENTION 334 infants 107 localities Age groups at baseline (1998) 0-5 mo 0-5 mo 6-12 mo 6-12 mo 232 infants124 localities 1998 229 infants133 localities 186 infants88 localities 148 infants73 localities 69 (30%) 103 (45%) 82 (44%) 50 (34%) 1999 163 children101 localities 126 children86 localities 104 children62 localities 98 children58 localities 24 (10%) 64 (28%) 43 (23%) 14 (10%) 2000 208 children117 localities 165 children105 localities 143 children75 localities 134 children73 localities Length of Exposure 2 yrs. 6-12 mo to 30-36 mo 2 yrs. 0-5 mo to 24-29 mo 1 yr. 12-17 mo to 24-29 mo 1 yr. 18-24 mo to 30-36 mo Age of Exposure Flow diagram of study design, cont

11. Selection bias due to attrition was assessed comparing lost to follow-up vs non-lost to follow-up by treatment in 1999 and 2000 The increment in height from baseline (1998) to 2000 was modeled as a random-intercept linear model to take into account that randomization was done at the community level and clustering within community. Independent variables : Height and age at baseline (1998) Treatment group (Intervention and cross-over intervention) Dichotomous SES (median was the cut-off point) Group of age at baseline1998 (0-5mo and 6-12mo) Two and three way interactions between the last three dichotomous variables. Statistical methods

12. The difference in anemia rates between intervention groups in 1999 and 2000 was tested using GEE, which takes into account clustering within community. Statistical methods

13. Descriptive statisticsat baseline (1998) for infants measured in 2000 by age group and intervention group Selection bias discarded in 1999 and 2000

14. Adjusted* increment in height (2000-1998) 29.8 22.7 n=79 n=76 n=55 n=71 n=53 n=89 n=72 n=100 < 6 months in 1998 6 - 12 months in 1998 ** * Adjusted by age and length in 1998, using a random-intercept linear model. ** P < 0.05

15. P=0.03 P=0.40 Prevalence of anemia* by year of survey and intervention group * Adjusted by age, using a GEE model.

16. This experimental study showed differences in height increments (1.1 cm) and in anemia rates (10 percentage points) associated with exposure to Progresa The randomized design of the study allowed us to attribute the biologically important differences between intervention groups to the effect of the program Progresa covered 2.6 million families by the end of evaluation and benefits currently 4.5 million families This evaluation is important because it is one of the few well controlled effectiveness evaluations of large scale programs that showed positive effects on nutrition and that also promises to support informed program improvements Conclusions

17. Fortification of the milk distributed by the government The Secretary of Social Development (SSD) runs a number of food distribution programs One of them is the distribution of milk to 4.6 million children Milk produced by Liconsa (a Government owned company) In several presentations of the Nutrition Survey results to SSD authorities, the addition of iron, zinc and other micronutrients to the milk distributed was recommended We worked in collaboration with the U. of Chile and came out with a formulation Ferrous sulfate is being used The milk is currently fortified as recommended We are currently conducting bioavaiolability studies as well as efficacy and effectiveness studies

18. Anemia prevalence was reduced in 26% in children 12-30 mo in a 6 mo period 6.I p.p (26%)