A Brief History of Evidence-Informed Decision Making for Nutrition in Mexico.

The Progresa Conditional Cash Transfer program in Mexico began in 1997, with a strong evidence-based design. The program's ultimate objective was to foster the development of human capital through 3 components-education, health, and food. Rigorous impact evaluation generated evidence of impact on several outcomes, including child growth, but also aspects of program design and implementation challenges that may have limited impact. The objective of this supplement is to present research that led to the redesign of the health component, its implementation and evaluation at pilot scale, and its scale-up to national level, representing >15 y of collaboration among evaluators, program implementers, and funders. The studies used various methodologies, including process evaluation, cohort studies, ethnographic assessments, and a cluster-randomized trial, among others. The articles report previously unpublished results and citations of published literature. Article 1 uses an impact pathway to highlight gaps and bottlenecks that limited potential for greater impact, the original recognition of which was the impetus for this long collaboration. Article 2 explores the social and cultural factors that influence decisions to participate in programs and to adopt the actions proposed by them. Article 3 presents a cluster-randomized trial implemented to inform the choice of nutritional supplements for pregnant and lactating women and children 6-59 mo of age and how this and other evidence from the studies were used to redesign the health component of the program. Articles 4 and 5 present results of the development and pilot testing of the modified health component, the Integrated Strategy for Attention to Nutrition (abbreviated to EsIAN from its name in Spanish) (article 4), and the process and challenges of training and supervision in taking the EsIAN to scale (article 5). The final article provides reflections on the relevance of this body of work for implementation research in nutrition.

Supply-side interventions to improve health: Findings from the Salud Mesoamérica Initiative.

BACKGROUND: Results-based aid (RBA) is increasingly used to incentivize action in health. In Mesoamerica, the region consisting of southern Mexico and Central America, the RBA project known as the Salud Mesoamérica Initiative (SMI) was designed to target disparities in maternal and child health, focusing on the poorest 20% of the population across the region. METHODS AND FINDINGS: Data were first collected in 365 intervention health facilities to establish a baseline of indicators. For the first follow-up measure, 18 to 24 months later, 368 facilities were evaluated in these same areas. At both stages, we measured a near-identical set of supply-side performance indicators in line with country-specific priorities in maternal and child health. All countries showed progress in performance indicators, although with different levels. El Salvador, Honduras, Nicaragua, and Panama reached their 18-month targets, while the State of Chiapas in Mexico, Guatemala, and Belize did not. A second follow-up measurement in Chiapas and Guatemala showed continued progress, as they achieved previously missed targets nine to 12 months later, after implementing a performance improvement plan. CONCLUSIONS: Our findings show an initial success in the supply-side indicators of SMI. Our data suggest that the RBA approach can be a motivator to improve availability of drugs and services in poor areas. Moreover, our innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings.

BACKGROUND: Health has improved markedly in Mesoamerica, the region consisting of southern Mexico and Central America, over the past decade. Despite this progress, there remain substantial inequalities in health outcomes, access, and quality of medical care between and within countries. Poor, indigenous, and rural populations have considerably worse health indicators than national or regional averages. In an effort to address these health inequalities, the Salud Mesoamérica 2015 Initiative (SM2015), a results-based financing initiative, was established. METHODS: For each of the eight participating countries, health targets were set to measure the progress of improvements in maternal and child health produced by the Initiative. To establish a baseline, we conducted censuses of 90,000 households, completed 20,225 household interviews, and surveyed 479 health facilities in the poorest areas of Mesoamerica. Pairing health facility and household surveys allows us to link barriers to care and health outcomes with health system infrastructure components and quality of health services. RESULTS: Indicators varied significantly within and between countries. Anemia was most prevalent in Panama and least prevalent in Honduras. Anemia varied by age, with the highest levels observed among children aged 0 to 11 months in all settings. Belize had the highest proportion of institutional deliveries (99%), while Guatemala had the lowest (24%). The proportion of women with four antenatal care visits with a skilled attendant was highest in El Salvador (90%) and the lowest in Guatemala (20%). Availability of contraceptives also varied. The availability of condoms ranged from 83% in Nicaragua to 97% in Honduras. Oral contraceptive pills and injectable contraceptives were available in just 75% of facilities in Panama. IUDs were observed in only 21.5% of facilities surveyed in El Salvador. CONCLUSIONS: These data provide a baseline of much-needed information for evidence-based action on health throughout Mesoamerica. Our baseline estimates reflect large disparities in health indicators within and between countries and will facilitate the evaluation of interventions and investments deployed in the region over the next three to five years. SM2015's innovative monitoring and evaluation framework will allow health officials with limited resources to identify and target areas of greatest need.

Unintended effects of poverty programmes on childbearing in less developed countries: experimental evidence from Latin America.

Because conditional cash transfer (CCT) programmes (which make payments to poor households, conditional on their behaviour) potentially affect both household resource levels and parental preferences for quality vs. quantity of children, they may have unintended consequences for fertility. We use panel data from experimental CCT programmes in three Latin American countries to assess the unintended impact of these programmes on childbearing. Our findings, based on difference-in-difference models, show that the programme in Honduras, which inadvertently created large incentives for childbearing, may have raised fertility by between 2 and 4 percentage points. The CCT programmes in the two other countries, Mexico and Nicaragua, did not have the same unintended incentives for childbearing, and in these countries we found no net impact on fertility. Subsequent analysis examined several potential mechanisms by which fertility in Honduras may have been raised but was not able to identify a primary mechanism with the available data.