The ongoing Education, Health and Nutrition Programme (PROGRESA) 68 began in May 1997. By the end of 2001, PROGRESA was working in 68,282 localities (26.67 percent of the total number of localities in the country) in 2,166 municipalities in 31 states of Mexico. The approximate coverage at the end of 2001 was 3.2 million families, equivalent to about 14.4 million people.
The Programme is funded entirely by the Federal Government of Mexico. A total of about 14 billion pesos (US$ 1.4 million) was spent by the end of 2001.
Objectives of the programme
To support families living in extreme poverty in order to strengthen their ability and opportunities to improve their living standards.
PROGRESA is a programme well established at the central level and which has made an effort to cover all technical aspects that might jeopardize its implementation, including the quality of the product. By its nature, and perhaps owing to the financial investment that is being made, there has been limited space for more open and wider participation by the community or by the states and municipalities. Participation has largely been in the form of consultation, where views are sought from beneficiaries but there is no involvement in decision-making. All activities have been designed at the top, with community participation limited to passive participation for material incentives.
It is also worth noting that some specific aspects of local participation have been permitted and enabled, as in the role of the promotora. Some promotoras have had a more active role that has allowed them to strengthen the groups through their own initiatives.
Strengths, weaknesses, opportunities, constraints/threats (SWOC)
As a high profile programme, PROGRESA enjoys considerable political support which appears likely to continue. The Programme’s achievements in terms of coverage and impact are considerable. It is, however, an expensive programme and support may diminish if achievements and profile are not maintained. It is still unclear how sustainability will be achieved. With the limited participation of states, municipalities, communities and families and no apparent plan to increase their participation, the Programme is at risk should political support be withdrawn. This points to the urgent need to think through how to guarantee that once PROGRESA ends, the activities will be continued by the states, municipalities and localities.
Mexico is part of the North American continent, together with Canada and the USA. It has a surface area of 1,964,375 km2 and is the fourteenth largest country in the world. It borders the USA to the north and Guatemala and Belize to the south east.
The country is a representative democratic federal republic governed by three powers: executive, legislative and judicial. It is made up of 32 political-administrative entities, of which 31 are free sovereign states and one a federal district, seat of the federal executive power, wherein lies Mexico City, capital of the Mexican Republic. The official language is Spanish and there are, in addition, 62 indigenous languages with 30 dialect versions.
According to the results of the XII General Population and Household Census (INEGI, 2000) there were 97,483,412 inhabitants, of whom 10,040,401 were indigenous. The birth rate of the population between 1990 and 2000 was about 1.9 percent per year. However, it is important to note that there are two clearly distinct periods: the first from 1990 until 1995 when the population increased at a rate of 2.1 percent per year; and the second from 1996 until 2000 when the rate was 1.58 percent per year. This demonstrates the gradual reduction in demographic growth in the country. Of all residents in Mexico about 40 million (41 percent) live below the poverty line and, of these, almost 51 percent live in extreme poverty. In 1990, the ratio of men to women was 97:100, falling to 95:100 in the year 2000, largely owing to the predominately male migration to the USA. The national population density in the year 2000 was 50 inhabitants per square kilometre, although analysis by state gives another picture: in the federal district, the State of Mexico and Morelos, there were 5,643, 611 and 313 inhabitants per square kilometre, respectively; while Chihuahua, Sonora, Campeche and Durante have about 12 inhabitants per square kilometre and Baja California Sur has barely 6 inhabitants per square kilometre. According to the Population and Household Census for 2000 (INEGI, 2000), 78 percent of the families in Mexico have drainage, 89 percent have running water and 95 percent have electricity.
In 1999, for every 100,000 inhabitants there were 117 physicians, 188 nurses and 79 hospital beds. In the same year, the Secretariat of Health, the National Institute of Public Health, and the National Institute of Statistics, Geography and Information Systems led a National Nutrition Survey 1999 (INEGI, 1999), the first since 1988. The following comparative results emerged:
Comparative data on the nutritional status of children under 5 and women
1. Underweight in children under 5
2. Stunting in children under 5
3. Prevalence of wasting
4. Prevalence of anaemia in children under 5
5. Prevalence of anaemia in pregnant women
6. Prevalence of anaemia in non-pregnant women
7. Prevalence of overweight in children under 5
Source: National Nutrition Survey, 1999. Mexico
The same national nutrition survey indicated that approximately 28 percent of households in the country received some type of food aid through one of the following four assistance programmes:
Some data mention that as much as 70 percent to 80 percent of the efforts of some programmes (DICONSA 75 and TORTIBONOS 76) have focused on urban areas of the country and less in the rural areas, due largely to the dispersion of the population. Dispersion has also weakened basic education and health services, in terms both of coverage and of quality. PROGRESA would be the exception to that tendency: as a newer programme, it has focused on the population living in extreme poverty.
According to PROGRESA estimates, nearly 21 percent of the total population (almost 4.6 million families) currently lives in extreme poverty. In relation to education in 2000, among those aged 15 years and older, 9.5 percent were recorded as illiterate. During the same year, 92.3 percent of the population between 6 and 14 years of age attended school.
PROGRESA, the Education, Health and Nutrition Programme, run by the Federal Executive Office of Mexico, began in May 1997 within the framework of Human Development. It functions as part of an integrated social policy, promoting intersectorial activities for education, health and nutrition of families in extreme poverty. PROGRESA is one of several programmes for fighting extreme poverty and at the same time works to strengthen other activities included in the three areas previously mentioned.
The Federal Government is responsible for establishing the ground rules of the Programme and the Secretariat for Social Development (SEDESOL) is responsible for the general coordination of the programme through the National Coordination of PROGRESA (CONPROGRESA). To carry out its activities and in order to ensure an efficient, effective, fair and transparent operation, PROGRESA relies on the combined commitment of the executive powers at the federal and state levels within the framework and spirit of the Social Development Conventions. In order to ensure uniform operative criteria throughout the nation, PROGRESA’s policies and general rules of operation are established at the federal level for nationwide application.
PROGRESA’s target is the extremely poor, measured by a number of factors. That population is generally located in the rural areas, in communities which are very dispersed geographically. PROGRESA works primarily in the three areas of education, health and nutrition, aiming to be integrative, in contrast with other programmes implemented in Mexico.
To support families living in extreme poverty in order to strengthen their ability and opportunities to improve their living standards.
In order to carry out these objectives, the following three main components were devised:
It is clear that PROGRESA has had a centrally managed structure since the beginning, even at the operational level with programme beneficiaries in the localities. PROGRESA’s financial resources come from the Mexican Federal Government. By the end of 2001, the number of families covered was 3.2 million with a programme budget of about 14 billion Mexican pesos (US$ 1.4 million). Efforts are under way to incorporate 1.4 million additional families during 2002, including a significant percentage of re-certified families that had been covered by FIDELIST (tortillas programme), which ended at the end of 2001.
The PROGRESA payroll budgets for 380 regular employees, supplemented by additional employees during periods when new families join the programme and during census operations. Other non-permanent staff include municipal liaison people and technical and professional staff from the Secretariat of Health and Education via existing operative units in the programme areas.
Various studies have been conducted to monitor and learn about changes in the PROGRESA implementation process. The most recent study, in 2001, involved a much larger sample than in previous studies and more communities, with a study design that included PROGRESA localities (205) and non-PROGRESA control localities (142). The following findings are worth noting:
No data were available to assess the progress and impact of agricultural and livestock diversification projects. Some PROGESA beneficiaries and staff mentioned the need for the programme to emphasise these food security activities, in order to teach them to fish, do not just give them the fish”.
In the national context, PROGRESA is an innovative programme for combating extreme rural poverty, integrating support in three critical and complementary areas – education, health and nutrition – for the development of basic human resources. While recognizing the immediate impact the programme has achieved, the real challenge is to ensure that it has an effect in the longer term and that it achieves a fair level of sustainability in its various activities. In this way, it may succeed in breaking the intergenerational cycles of extreme poverty associated with high fertility rates, malnutrition, infant mortality and school dropout prevalence in the rural sector.
In interviews conducted with beneficiaries in Tabasco and Tlaxcala, we found no information to indicate that the programme leads to economic improvement and this has not in fact been the programme’s focus. The beneficiaries continually expressed gratitude to PROGRESA for the food supplements given to women and children and for the funds that allow children to go to school even if they have to go for monthly checkups at the health clinic. The most important thing is for the programme to continue. PROGRESA is seen by the government authorities as a programme with important strengths. This support means a green light to continue expanding its population and geographical coverage in the country. Work is under way to incorporate an additional 1.4 million families in 2002, which will also mean a substantial budget increase.
The programme has always been an initiative of the federal authorities of the Mexican Government, via the Secretariat of Social Development in coordination with the National Coordination Committee of PROGRESA and the Secretariats of Health and Education. PROGRESA initiated activities in 14 states in 12,483 municipalities, including approximately 150,000 families. The number of families joining increased yearly, until by the end of 2001 it covered 31 states including 68,282 localities in 2,166 municipalities, serving 3.2 million families.
In order for a locality and a family to have access to PROGRESA, the following selection process is used:
The next step is the identification of families within a locality that are eligible for PROGRESA, as follows:
The actions aim to encourage and support the enrolment, continuation and benefits of school attendance by the beneficiary families’ children who attend primary school (starting at the third grade), secondary school and high school (media superior), emphasizing gender equality. Support given takes the form of scholarships and basic school supplies.
Scholarships consist of economic support in cash each month, given directly to the beneficiaries, with the amount increasing with the grade level attended. The purpose of this is to compensate for the wages that children would contribute if they worked. In addition, starting at the secondary school level, scholarships for girls are slightly higher than those for boys so as to encourage greater school attendance by girls. The monthly amount of the scholarships is 90 pesos (about US$ 9) for the third year of primary school, rising to 290 pesos (about US$ 30) for boys and 335 pesos (US$ 35) for girls in the third year of secondary school. Requirements for retaining the scholarship are that the students attend class at least 85 percent of the time and that the teachers report on the attendance and progress of the students through established mechanisms.
School supplies are provided twice a year to students in the third to the sixth grade in primary school, in cash or in kind. To those students in the first to third year in secondary school and in high school, a cash amount is given annually for the procurement of school supplies.
The aim is to help expand the coverage and quality of health care, as well as to increase the number of families in the social security system so that in addition to health care, they enjoy other benefits that improve their well-being. Four key strategies are used:
The first strategy entails 13 health activities included in the basic package: basic sanitation, family planning, prenatal care, growth monitoring and immunizations, prevention and control of tuberculosis, hypertension and diabetes, prevention of accidents and cervical uterine cancer, treatment for diarrhoea, acute respiratory infections and parasites, promotion of health self-care.
The second strategy is achieved through growth monitoring and nutrition education; and through supplementary food for children between the ages of four months and two years, to those malnourished between the ages of two and four years, and to pregnant and lactating women. Supplements provide 100 percent of the daily requirement of micronutrients and an average of 20 percent of the basic calorie needs. They are distributed once a month when the mother and her children visit the health clinic, the visit being a pre-requisite for continued enrolment in the programme.
Evidence from some studies shows that the provision of fortified supplement to women and children is one of the programme’s most important activities: approximately 1,800 million pesos are assigned to that activity alone, compared to the total expenditure of 14 billion pesos in 2001. It is interesting to note that some health service personnel expressed concern that they were reaching the limit of their time and ability to take care of PROGRESA beneficiaries whose numbers increase by the day. This issue could pose a risk to the quality of health care if not addressed immediately.
The third strategy is implemented through the training process and educational sessions for the programme’s main beneficiaries. Twenty-five subjects are included in the basic health package and ten new topics will be added in 2002.
The fourth strategy is implemented through the strengthening of the health care infrastructure and is the responsibility of the Secretariat of Health.
The programme supports beneficiary families through direct cash remittances which offer a contribution towards the quantity, quality and diversity of their diet, in the hope that this will improve the situation of food, nutrition and health. Each female head of household receives 145 pesos per month which entails the following responsibilities:
Failure by the head of household and families to comply with these responsibilities leads to the suspension of support. The cash remittances and student scholarships are monthly supports, but are distributed every two months for operational reasons. Interviews conducted in Tabasco and Tlaxcala indicated that many women beneficiaries go to the health clinics only because it is a requirement for receiving financial support. There was no sense of appropriation by the women beneficiaries towards PROGRESA in the interviews.
Moreover, a recent study mentions that substantial programme resources had to be devoted to activities linked to getting the cash remittances to the households, so that only a fraction of the budget is actually available for poverty alleviation. These costs can be classified as follows:
The households incur expenses to receive the remittances and these expenses include the time and cost of transportation to the schools and to the health care centres (given the conditions established by the programme), as well as to pick up the remittances at the distribution points. The cost of time spent is recognized, but no attempt is made to assign it a value. While information on such private costs is a useful factor for analysing policies, for the purposes of the evaluation the only relevant costs are the incremental costs that derive from starting the programme.
In order for a household to qualify for food grants, all family members must make a series of visits to the health clinics for medical checkups, approximately two per month per member. The mother of the family must also attend educational talks on health. The average travel time of the trip to the health clinic is almost two hours per round trip and time spent at the clinic averages a little more than an hour. Thus, on average, the family invests approximately 6.3 hours per month to fulfil their obligations to attend the health clinic activities.
Within the programme there is a system for choosing PROGRESA promotoras (social development agents) who are at the same time programme beneficiaries. It is a volunteer job and they are elected in a meeting of the community, based on criteria of knowledge, credibility and trust within their own communities. The promotora’s main responsibilities are to:
The promotoras are subject to direct supervision through a municipal liaison and by PROGRESA technical staff. However, many of the interviewed promotoras emphasized more the municipal liaisons and the advantage of being able to rely on them for clearing up questions that arise during the process of implementing the programme, since they live in the same municipalities. The promotoras also check on the type of service the beneficiaries receive in the banks when they take out their money or in the city halls when it comes as cash, or from health care personnel and teachers. The promotoras have a form they can fill out easily for reporting which leads to being able to the identification of bottlenecks and relevant solutions.
One aspect worth mentioning is coordination at the state and municipal levels. According to the empirical evidence found during the visits to Tabasco and Tlaxaca, the relation of the PROGRESA delegate to the state is stronger with the municipal presidents and very lukewarm with the governors, probably owing in some cases to the governors’ numerous commitments.
As mentioned previously, PROGRESA is a programme of the Federal Government and since the very beginning central guidelines have defined the entire system that currently makes the programme work. Undoubtedly the system of monitoring and evaluation is one of the most carefully carried out since it is critical that no eligible family be left out, given the families’ reliance on these resources. While the economic support is calculated as monthly, disbursement takes place every two months and the delivery is usually punctual. One reason for making the distribution every two months is that the central offices must wait for consolidated reports from the health and education sectors in order to carry out the procedure thoroughly. This is the point at which reports might reveal whether mothers have attended checkups at the health clinics each month or whether students are attending school regularly. Each month packets of food supplements are distributed for each child according to age, and to the mother so that she may make use of them during the month. During interviews with beneficiaries, the majority mentioned that the children do not always like the food supplements. Sometimes there are packets left over and so beneficiaries might decide not to request more the following month in order to avoid wasting them.
PROGRESA has a rigorous monitoring system of the quantitative aspects of the implementation process in the areas of education, health and nutrition. Various organizations such as the Salvador Subirán Nutrition Institute, the International Food Policy Research Institute (IFPRI, USA), the National Institute for Public Health and PROGRESA itself are continually conducting studies aimed at understanding the programme’s impact. This has provided PROGRESA’s central level with technical information able to suggest programme modifications. In fact, at the time PROGRESA was reviewed for the present study, new 2001 Rules of operation were being promoted for implementation in 2002.
Community participation in choosing a local monitoring system is translated into mere completion of the tasks assigned to the promotora when she is elected by her community during an assembly. The promotora receives training and information as well as documentation that shows her the proper way to report to PROGRESA each month or semester to provide the information it requires.
Many of the promotoras have been volunteers since the programme began in their localities. Some of them have been volunteers for more than two years and know very well the tasks to be done, to the point of performing their activities as part of their routine. Examples include gathering beneficiaries together on the day that funds are given out; being present at the health clinics once a month to assist with the health talks; accompanying beneficiaries when funds are given out, because there are cases where many beneficiaries do not know how to count their money; and advising beneficiaries on how to use their funds. Some beneficiaries were grateful for the support promotoras give their communities, but others noted that politics is always part of these programmes and that many promotoras campaign for their political parties at these meetings. Others said that being a promotora means having the chance to include all the relatives as programme beneficiaries when she adds new members. Some promotoras, especially those visited in Tabasco and Tlaxcala, have had a more active role that has allowed them to strengthen the groups through their own initiatives, in some cases going so far as to produce handicrafts (sewing and weaving). However, the issue of marketing and distribution in order to sell their products continues to be a challenge for these projects.
Mexican social policy is situated within the framework of renewed federalism where the three levels of government converge to focus on social demands. In the past ten years and, especially since 1995, Mexico has intensified the process of administrative and financial decentralization in order to provide the municipalities (through the state governments) with additional legal and financial powers that strengthen their management, autonomy and ability to respond to demands. Currently the municipalities are directly responsible for the planning and implementation of actions aimed at the social and productive integration of the most economically and socially disadvantaged groups.
This process has contributed also to the population gradually participating in various stages of the implementation processes of projects designed to improve their living standards. The establishment of a Social Municipal Development Fund coordinated by the state governments has given important support to the decentralization process at the municipal level in Mexico. It can be said that in the last six years there have been a series of activities aimed at consolidating the decentralization process at the municipal level, incorporating aspects of local participation.
The President of Mexico mentioned in a December 2001 78 speech that “..today the policy of social and human development is a priority on the public agenda and it is currently government policy, because it is unacceptable that communities lack services as necessary as drinking water, drainage, and electricity; that they do not have a doctor and cannot have their own medicine; that the girls and boys do not attend school and that the earnings are not enough to cover the basic needs of the family. .... We will reach these objectives with an integrated focus, with actions coordinated between different agencies in the three levels of government and with the support of all of society. .... The most vulnerable groups in our society have found an answer to their educational needs through the expanded coverage of the new programme PROGRESA. This programme increased its coverage to an additional 763,000 families this year (2001), and was expanded to urban and semi-urban marginal areas.” As mentioned in the President’s speech, tackling the social problems of the most vulnerable communities requires an integrated focus, especially in the areas of health and education and supporting coordination between all institutions working at the local level.
Some PROGRESA officials mentioned that if the programme continues to be centrally managed, it will be very difficult to correct certain deficiencies such as the inclusion of families that do not really need the programme. In addition, they said that PROGRESA in several cases simply “appropriates” the figure of the governor and of the municipal presidents in order to make it look as if it is a coordinated programme. This has, on occasion, upset local authorities when they see their names linked to directions already given by PROGRESA and with no opportunity to propose localities or families. Until now the localities have not had the possibility of proposing themselves as candidates for inclusion in the programme, much less families, given that the selection procedure is quite rigid and conducted at the central level.
Apparently PROGRESA has placed almost all responsibility for its implementation with the human resources of the central government through SEDESOL/CONPROGRESA, with the strong and unconditional support of the Health and Education Secretariats through the infrastructure installed in all localities where it currently operates.
Specific aspects of local participation have been permitted and enabled, as in the role of the “promotora”. According to evidence from interviews with beneficiaries and promotoras, the promotora is viewed in a variety of ways, from someone who is truly a facilitator and purveyor of information and emotional support to the beneficiaries, to a “political” human resource who must be treated with respect. Information derived from previous studies confirms the statements of some beneficiaries who said that what PROGRESA does is to foment splits in the localities since some families are uncertain whether they will be able to join the programme. On the other hand many beneficiaries and promotoras say that PROGRESA includes some families that really do not need the programme given that in their localities they enjoy decent living conditions including gas stoves, good housing, a vehicle, and some even lend money on commission to some beneficiaries who use their PROGRESA support to pay it back with interest.
Some promotoras have taken initiatives locally to strengthen their groups and in the near future these could generate some income to contribute to the family economy. Groups of women beneficiaries who have devoted themselves to weaving, or sewing, might have some more time available to dedicate to activities that supplement their income. This could be seen by the PROGRESA decision-makers to mean that there is also a need to enter a new dimension in local development through more sustainable income-generating programmes.
Because PROGRESA is a government programme, it obviously enjoys political support and will continue to operate. The government position expressed in the President’s speech is one clear indication that its future is secure; another indication is the plan to extend the project for the first time into the peripheral urban areas, where it had not entered previously. Additional evidence of political support for the programme is the fact that in 2001 about 763,000 families have joined PROGRESA and there are plans to add another 1.4 million families in 2002. The political conditions for the programme’s future are well-established, keeping the integrated approach to education, health and nutrition that has characterized it. The programme will certainly continue to rely on the same institutions that have provided it with technical assistance. In the area of nutrition, it will continue to receive the support of the Department of Food and Nutrition of the Health Secretariat, the National Institute of Public Health and of the Salvador Subirán Nutrition Institute as authorized entities in the field of nutrition in Mexico.
On the other hand, consideration should be given to the fact that the programme is still in its first stage (three years of actual operation), and that many of the impacts reflected in the studies can still be called important even if only related to specific aspects. Only by continuing to evaluate over the longer term the lives of low-income families who benefit from the programme will it be possible to determine if the vicious circle of poverty and its transmission from one generation to the next has been interrupted.
Of course attention must be paid to all the possible bottlenecks that might occur in the stage of rapid growth that PROGRESA proposes, because the increase in population coverage demands that the institutional capacity be sufficient to meet the new demands. This fact has been detected by operational personnel at the local level as well.
PROGRESA will have to analyse in what other ways organized community participation can be accommodated. The programme is probably planning first to lay the groundwork for satisfying basic services in the localities so that it can then move to operating in a more open fashion with greater community participation. According to evidence from interviews with beneficiaries, promotoras and some PROGRESA personnel, at this time there is not much sense of ownership of the programme on the part of the beneficiaries. The impression is that it is still viewed as government assistance and that this is good enough. When beneficiaries are asked, “What would happen if PROGRESA leaves?”, answers such as “Oh well, others will come” and “Let’s hope it does not go away because it helps me”, could reflect a certain passive approach by the beneficiaries.
Some study results indicate there has not been any particular reduction in the adults’ rate of participation in the labour market, in spite of what some economic behaviour models might have predicted. Local levels of organization easily detect cases of families where the father physically abuses the mother and demands that she turn over the money the programme gives her. Fortunately, these are isolated cases that the promotoras come to know about and that are mitigated using local means.
Overall, the impression is that PROGRESA’s current sustainability is entirely dependent on the financial resources that the central government continues to provide. No clear mechanisms are envisioned for how the states and municipalities and much less the localities could play a much more active role in the current efforts.
Republic of Mexico. 2001. Speech by the President of Mexico. On occasion of the presentation of the National Social Development Programme 2001-2006, 6 December 2001 (available at www.presidencia.gob.mex).
INEGI. 1999. National Nutrition Survey 1999. Secretariat of Health and National Institute of Public Health. Mexico.
INEGI. 2000. XII General Population and Household Census. Mexico.
Behrman, Jere R., and John Hoddinott. 2001. An Evaluation of the Impact of PROGRESA on Pre-School Child Height. March. FCND DP No. 104. International Food Policy Research Institute, Washington, D.C.
68 Programa de Educación, Salud y Alimentación.
69 A branch of the Mexican Social Security Institute which provides health services to the uninsured rural population.
70 Secretaría de Desarrollo Social.
71 Coordinación Nacional de PROGRESA.
72 Leche Industrializada Conasupo S.A.
73 Desarrollo Integral de la Familia.
74 Fideicomiso Liquidador de Subsidio a la Tortilla.
75 Distribuidora e Impulsora Comercial Conasupo S.A.
76 Editor’s note: A food stamp programme (1985 to 1989) created by Conasupo to subsidize the price of tortillas for low-income families in urban areas.
77 Área geoestadística básica.
78 See references (discurso del 6 de diciembre de 2001 – presentación del Programa Nacional de Desarrollo Social 2001-2006).