Oportunidades: Co-responsibility and the Politics of Health Care in Mexico

Public health mural, 2009.  Photo by Veronica Miranda.

On September 3, 2012, outgoing president Felipe Calderon made his sixth and last televised State of the Nation address. He reiterated that every low-income woman in Mexico would have access to free prenatal care and delivery. This monumental change in the national public health system came in response to Mexico’s pledge to achieve the United Nations’ Millennium Goal Five that aims to significantly improve maternal health by the year 2015. The goal encompasses two primary objectives: 1) reduce maternal deaths by 75 percent; and 2) provide universal access to reproductive health including prenatal care (MacArthur Foundation 2008). Implementation of the policy has taken place through the adoption of the poverty alleviation program Oportunidades; founded in 2002 and based off its predecessor, the social program known as Progresa. 

It is critically imperative to assess and analyze Oportunidades, especially since it is currently supported by powerful financial institutions such as the World Bank and the Inter-American Development Bank.  Both of these influential institutions promote the progam as a model for global social and economic development. Oportunidades is based on the assumption that maternal health disparities can be overcome by providing biomedical services to marginal populations through the distribution of performance-based cash incentives (Levy 2006). According to Calderon, it has become the most important federal program to fight poverty and social inequality. By the end of his presidential term, more than 6 million families, one in four Mexicans, have benefited from the program. The universal health program Seguro Popular works in conjunction with Oportunidades to provide poor women with state health insurance that grants them free hospital births.

Oportunidades provides small financial stipends along with education and access to health care for Mexico’s most vulnerable populations: children under five and pregnant and nursing mothers. It is a program that attempts to solve poverty through a complementary approach that focuses on nutrition, education, and health. An important component of the program is the belief that individuals have a responsibility for their own livelihood and economic future. Unlike poverty alleviation programs in past decades, this program breaks away from a practice of providing food subsidies or actual food staples, such as tortillas and milk. Instead, participants are given cash transfers so that they can freely participant in the market economy, therefore providing them with more decision-making freedom. As Santiago Levy (the program’s co-creator) boldly states, Oportunidades “seeks to break the vicious cycle of poverty in all extremely poor households, rural and urban, in Mexico” (2006:21). The rhetoric behind this program pushes for three primary principles: participation, empowerment, and co-responsibility (here is a short video about the program from PBS).

Since 2002, I have completed my undergraduate training, master thesis research, and initiated doctoral fieldwork in two sister pueblos (Saban and Huay Max) located in southwestern Quintana Roo, Mexico. The research community is rural and located away from major highways, which inevitably means that vital economic, political, and social resources are limited. The community sits in the heart of the Caste War region where 150 years ago Yucatec Maya revolted against the Mexican government and local ruling elite. This history is remembered not only through visual markers on the landscape but also by the political and economic repercussions of the war that left the region underdeveloped, disconnected, and impoverished. This is an indigenous community where Spanish and Yucatec Maya are spoken. Saban is the larger pueblo (pop. approx. 2,000) and has 500 women of reproductive age (INEGI 2005). All major state and community resources are located in Saban (state clinic, police station, higher educational institutions, and la casa ejidal—meeting place for communal land owners). Huay Max has just over a 1,000 inhabitants, 250 of which are women of reproductive age (INEGI 2005). The pueblos are connected through marriage, shared farmlands, state resources, and a socio-political organization that is dominated by Saban. Main sources of economic subsistence are agriculture and male migration to tourist zones along the coast (such as Cancun and Playa del Carmen). Few economic opportunities exist for women; yet, some raise money by selling livestock, weaving hammocks, and embroidering clothing.

Women in the community spend most of their time in their domestic sphere, the solar (housing complex). The government clinic is one of the few places that women gather outside of the home. It is also the main place were women interact with members of the government and participate in what Joseph and Nugent (1994) referred to as “everyday forms of state formation”. The clinic is located in Saban and has been there for more than thirty years. It is a first tier health facility that provides primary care and is the only health center in the immediate region. The closest second tier facility is located an hour’s drive away and the closest tertiary care is in the capital city of Chetumal, 3½ hours away. Depending on the state health administration’s budget and availability, the clinic is sometimes appointed a full-time resident doctor and a senior physician. The clinic also employs 2-3 full time bilingual (Spanish/Yucatec Maya) nurses.

The federal program Oportunidades is managed and distributed through the clinic. It has two primary goals: 1) to reduce maternal and infant mortality through preventative care and education and 2) to support continuous education among school age children. My research focuses exclusively on the first category. The majority of pregnant women in the research site participate in Oportunidades. Participants are awarded 400 pesos (approximately $34 US) every two months on the condition that they meet certain demands such as attending monthly education meetings and prenatal appointments at the clinic. As a result of limited economic opportunities, most women depend on this cash stipend as their primary source of income. Women also participate in the federal health insurance program Seguro Popular, yet their involvement is minimal. Women only use Seguro Popular when/if they seek care at the regional hospital.

Although the majority of women use the resources provided by the clinic, most seek additional care from local midwives and prefer midwifery during childbirth. Three midwives work in the research site: two in Huay Max and one in Saban. All three are from the community and speak Spanish and Maya. They are empirically trained but have also attended various health education and capacitating programs provided by the Mexican government. Unlike the clinic physicians, midwives live and work in the community and they practice out of their homes unless they are attending a birth. Women in the community view midwifery and state biomedical care as two separate health systems that offer specific resources that at times can be combined to create approaches to pregnancy and childbirth that are specifically tailored to each woman.

One of the main tenets of Oportunidades is an agreement to accept “co-responsibility” for the health and education of the participant’s children, both born and unborn. Co-responsibility begins with the state’s fulfillment of its part of the agreement by educating and providing health care to all participating mothers, as well as giving them a financial incentive for their cooperation. The other half of the agreement states that women are responsible for adequately feeding and clothing their children, making sure that they continue to attend school, and that they receive suitable nutrition and healthcare. Pregnant women are told that their responsibility as mothers and care providers for their children begins with the baby in utero, which is why they are required to attend monthly prenatal checkups. Failure to comply with any of the co-responsibility stipulation, results in immediate elimination from the program and therefore no cash stipend. The local government clinic physician and school administrators are in charge of evaluating if participants are fulfilling all program requirements.

The majority of the women I interviewed said that although they were grateful for the financial stipend they receive every two months, they found the program requirements to be inflexible and sometimes unrealistic. Many women said that occasionally they had a difficult time attending all of their educational talks and/or prenatal checkups as a result of familial obligations or unexpected circumstances. These situations varied; from a child being sick, to a commitment to help another family member or friend, or the fact that the person was just not feeling well. Many women commented that, in the end the cash transfer did not really equal the amount of time they spent fulfilling their agreed responsibilities. In some case, women’s workload was significantly extended as a result of their need to fulfill all of their Oportunidades requirements. The unintended burden that conditional cash transfer program implementations have on female participants has also been documented by researchers working in Nicaragua (Bradshaw and Quiros Viquez 2009). Regardless of their many complaints and critiques of the program, all the women I spoke with in Saban and Huay Max adamantly stated that they valued and in many cases depended on the resources that they received from Oportunidades and did not want the program to go away. Instead, what they wanted was more involvement in program development and implementation.

An additional critical analysis of Oportunidades demonstrates the Mexican state’s attempt to place the responsibility for the care of its young citizens onto their mothers. Through Oportunidades, women are given everything that they need to support the education, health, and nutrition of their children. Therefore, the program absolves the state of any responsibility for the welfare of poor Mexican children. Oportunidades is similar to other state poverty alleviation campaigns that have historically taken place throughout the world which focus on the responsibilities of motherhood and “good citizenship” (Davin 1997). England instituted a similar national program during the early twentieth century that stated, “the infant cannot indeed be saved by the state. It can only be saved by the mother. But the mother can be helped and can be taught by the state” (Davin 1997:125). This case is a clear example of how classical ideology about the designated responsibilities of the state and its citizens continues to affect current social programs.

Oportunidades is revered both nationally and internationally as a success and a model poverty alleviation program. These evaluators support the Mexican government’s emphasis on including the extremely poor in programs that ultimately lead to their transition out of poverty. In Oportunidades, the poor are required to participate in specifically designated practices that are intended to increase their “human capital”; these include the attainment of continuous education, the regular attendance of health checkups, and the eating of nutritional foods. Mexico is framing Oportunidades, a conditional cash transfer program, as an agreement of “co-responsibility”. This co-responsibility is two sided. The Mexican state will help its extremely poor citizens by giving them financial cash stipends as well as providing them with the education and good health that they need to succeed. According to the state, by removing these social and economic barriers poor individuals no longer have damaging obstacles set in front of them that would limit their potential.

Yet, it is important to remember that Oportunidades is a conditional program. Participants are required to follow all requirements or face immediate removal of the program. In the end, the discourse of co-responsibility absolves the state of its obligation to its citizens by placing all social and economic welfare on individuals. As Molyneux (2006) explains, Oportunidades’ practices of monitoring, coercion, and surveillance benefit the larger political and economic goals of the state government and not the participants. The program negates to address critical infrastructural and social barriers that directly contribute to the overall health and reduction of poverty for women and children. These include better roads, clean water, enhanced literacy for women, and much needed medical resources for rural clinics and hospitals. The last two are crucial points, especially since the program attempts to move participants away from traditional forms of health into a formal biomedical health care system. Yet, the clinic in Saban, along with the two nearest public hospitals, currently lack the medical technology and staff to meet the needs of all the women and children in the area.

Ultimately, supporters of programs like Oportunidades argue that poor and unhealthy people are to blame for their own circumstances, since the government has provided all the resources needed to ensure a good quality of life (e.g. education, health care, and financial assistance). This discourse about personal responsibility is nothing new, and has been discussed extensively in much of the anthropological and development literature.

But an interesting and important phenomenon that I am seeing in my current research is how rural indigenous women are using Oportunidades’ discourse of co-responsibility to make claims on the state. According to the women in the community, if they comply with all of the requirements of the program then the state must be responsible to fulfill its obligations as well. This was evident in the women's resistance to a community clinic physician who they felt refused to respect their cultural traditions and approaches to birth. When these women complained to government officials about the local physician, they specifically focused on the fact that this physician had mismanaged her position as a regulator and assessor of Oportunidades.

The tenuous relationship between the physician and many of the women in the community climaxed when the physician penalized all the of the 300 plus women from Saban who were participating in Oportunidades by officially stating that the they did not comply with the program requirements for that payment cycle and therefore they should not receive their cash stipend. According to the women this was not true--they argued that they had met all of their obligations and it was the physician, not them, who failed to follow the contractual rules of the program. In response, the women organized together and protested their grievances to state health policy officials and demanded that the government replace the physician with someone who would was more willing to work with the community while also fairly managing his/her responsibilities within the program of Oportunidades. The key part of this issue is that the women in the community are not making arguments against biomedicine or even the Mexican state; instead, they are demanding better oversight from the government, and accountability from local physicians. Ultimately, these women are also standing up to doctors and the government in an attempt to make them understand that their continued use of midwifery is a response to the practical, economic, and political limitations of state health care systems in rural Quintana Roo. In many respects, midwifery is a safety net that many women rely on when the Mexican government is unable or unwilling to hold up its end of the health care bargain.

Veronica Miranda
PhD Candidate
Department of Anthropology
University of Kentucky

References

Bradshaw, Sarah and Ana Quiros Viquez. 2009. Even if conditionalities work, do women pay the price. Poverty Insights 80: 6.

Davin, Anna. 1997. Imperialism and Motherhood. In Tensions of Empire: Colonial Cultures in a Bourgeois World, Fredrick Cooper and Ann Laura Stoler, eds. Berkeley: University of California Press. (87-151).

Joseph, Gilbert M. and Daniel Nugent, eds. 1994. Everyday Forms of State Formation: Revolution and The Negotiation of Rule in Modern Mexico. Durham: Duke University Press.

Levy, Santiago. 2006. Progress against Poverty: Sustaining Mexico’s PROGRESA-Oportunidades Program. Washington DC: Brookings.

MacArthur Foundation. 2008. Mexico Offers Free Prenatal Care to Poor Women. Published May 27, 2008. http://www.macfound.org/site/apps/nlnet/content2.aspx?c=lkLXJ8MQKrH&b=1479547&ct=2051861. Accessed November 28, 2010.

Molyneux, Maxine. 2006. Mothers at the Service of the New Poverty Agenda: Progresa/Oportunidades, Mexico’s Conditional Transfer Programme. Social Policy and Administration 40(4): 425-449.

Motherhood and Internal Migration in Quintana Roo, Mexico

During my thesis research in the communities of Saban and Huay Max, located in the state of Quintana Roo, Mexico, I watched how children from three different familial units living on the same housing lot were constantly reorganized and re-circulated as adult family members came and went. For many rural communities in Quintana Roo, Mexico, child circulation is taking on a new meaning as many young women are joining men and now choosing to migrate out of the community in search of work in tourist and urban centers. The research for this essay grew out of my focus on how young migrant women negotiate the culturally prescribed role of motherhood versus the complex demands they face as economic providers. This essay explores how the dual pressures of economics and relocation are affecting Yucatec Maya mothers, fathers, and children.

Quintana Roo is a critical part of the tourism development boom that has taken place throughout Mexico since the early 1970s (see Clancy 2001; Castellanos 2010). While tourism development throughout the region generates both revenue and employment, there are also many serious negative social and environmental repercussions to this pervasive form of development (Sanchez-Gil et al 2004:588; Clancy 2001; Hiernaux 1999; Castellanos 2010). Tourism development in Quintana Roo has led to a dramatic increase of internal migration to the coastal regions, which has resulted in tremendous population concentrations that surround well-known destinations such as Cancun. In many of the households that I have encountered over the last several years, a vast majority had at least one member of the family who migrated out to tourists zones in search of work.

The social effects and impacts of tourism development are often deeply gendered (Casellas and Holcomb 2001). Although tourism may produce positive and/or negative consequences for women, Casellas and Holcomb point out that the employment women gain from tourism, among other benefits, can improve women’s economic and social positions within their respective communities (2001:162).

In Saban and Huay Max, most men and some women leave the community on a regular basis in search of wages and work—either weekly, monthly, or for longer periods of time—while their children stay behind. Ramon*, a middle aged father from Huay Max, explained what was driving the need for many men and women to leave the community:

There is no work here. We have to leave and find work in places like Playa [del Carmen] and Cancun in order to bring back money to pay for our children’s clothes and food.

Many other parents echoed Ramon’s sentiments that temporary out-migration was motivated by the need to fulfill parental and familial obligations.  This lack of economic opportunities is not an isolated issue; it is a problem faced by many families in the region.

Specifically, in rural Quintana Roo, children are being circulated because of the challenging situations that many women and their families face. In the past few decades it has traditionally been males who have been pushed to find work outside of the local community; but this trend has been drastically modified, as women are now starting to migrate out of their natal communities in search of a way to further supplement their family incomes. The main factor driving this out-migration is economic; however ecological changes to the environment have further affected rural communities’ economic needs. In response to these pressures, there are two primary factors that enable rural to urban migration for women in Quintana Roo: access to higher education and a thriving tourist economy.

Emily Walmsley argues that when rural regions become subsumed within wider global markets, “earlier practices of fostering and kinship are continually being shaped by new economic and social pressures” (2008:174). As Walmsley (2008) and Jessaca Leinaweaver (2007) demonstrate in their research, the practice of fostering or child circulation also serves as a survival strategy during times of economic crisis and reinforces kinship ties. In response, families are utilizing a highly dynamic and flexible family structure to facilitate child rearing. In rural Quintana Roo, children whose parents migrate out for work are moved around and primarily sent to live with close extended kin like older sisters, aunts, or grandparents. Although mothers and their husbands are the primary decision makers in determining the fate of the child, children also have a say as to where they choose to live. Sometimes it is the child’s desire to stay behind with family that influences the way in which they are circulated. Such occurrences are illustrative of not only the dynamic nature of the family unit, but also of the fluidity and flexibility of individual agency.

The majority of the residents of Saban and Huay Max are subsistence agriculturalists that rely on getting their main food staples from their milpa (agricultural plot). The families in the region have to constantly fight with environmental elements such as drought, floods, and hurricanes. In 2005, Hurricane Wilma (the strongest tropical cyclone on record in the Atlantic basin) had devastating effects throughout the peninsula in particular along the coast of Quintana Roo. Those effects were also felt close to home in both Saban and Huay Max with the complete loss of harvest due to floods and the salting of the fields caused by rainwater mixed with ocean water. During the summer of 2008 the communities once again completely lost their harvests due to drought. I was in these communities in early September when the rains came just two weeks too late. Nothing could be done; the crops dried out and the years’ work was lost.

After losing the harvest for the sixth year in a row and experiencing increasing food costs, the economic realities and hardships are undeniable and often seemingly insurmountable for many community members. As a result, many people are temporarily diversifying their modes of subsistence and choosing to migrate out in larger numbers than in past years to help supplement the costs of food, shelter, and clothing for their families. Many new migrants are now women. The majority of these women are in their late teens to late twenties. Those who are married usually have children; these children are often left behind with extended kin while the mothers migrate out in search of work. Because the majority of women who leave the community in search of work are of reproductive age, the well-being and social reproduction of children whose mothers migrate out is an issue of great importance.

As women negotiate their absence within their families they incorporate various strategies to help protect their children’s emotional and physical wellbeing. As much as mothers stated that they would like to be with their children, many expressed their feeling that the safety and well-being of their children is more important than their own personal desires, sense of identity, and fulfillment of traditional gender roles.

Maribel, a 30-year-old mother who has steadily migrated out for work over the last five years, told me during an interview how difficult it was for her to be away from her children. She explained that she had wanted them to stay and live with her (and her husband) in the city, but knew that they wanted to be back in the pueblo. She understood that her children were happier in the pueblo with all of their friends and family and knew that forcefully making them relocate would have devastating effects on them. However, in choosing to leave her children behind, Maribel felt a sense of loss. Due to her extended migration out of the community, Maribel’s youngest child would sometimes accidentally call her mother “aunt”, which Maribel said hurt her sense of motherhood and the value that she had in the lives of her children. In Maribel’s case, motherhood meant economically providing for her children rather than participating in their daily care.  

Liliana is the main economic provider in her household; she is one of the few women fortunate to have been able to make a living working in the community. Liliana has helped raise all three of her bother Jose’s children as well as the oldest son of her brother Mario. Liliana states that the main reason that the children don’t migrate out with their parents is because they are freer back in the pueblo than when they are in the city. She went on to say,

here in the pueblo they can run around and play with other children in the streets. They can stay out all day if they want to. Here they are not confined to a room or a small yard. In the cities it is not safe for children to walk or play around in the streets and that’s why they have to stay inside all day. The children don’t like it and that’s why they choose to stay in the pueblo.

The two youngest children that Liliana looks after are four and six, and they have openly expressed their desire to remain in the pueblo. To them the pueblo is their home, where they feel comfortable and safe surrounded by everything they know including their family and friends. They both had the opportunity to live in Chetumal, the capital city of Quintana Roo, with their parents but chose to return to the freedom of pueblo life were they were are able to play and wander around all day. Moving to urban cities, while sometimes exciting for children, can also be a lonely and shocking experience. For that reason, children often decide to stay in their natal community, where the comfort of routine, friends, familiar places, and family is readily available. 

Community ties are clearly important for children, just as they are for adults. Santiago, Liliana’s teenage nephew said that unlike his younger brother and two older sisters, he chose to stay behind because he didn’t want to leave all of his friends. Access to greater educational opportunities and resources were not significant factors influencing Santiago’s ultimate decision to stay in the community; for him the freedom he had in the pueblo, as well as his established relationships with friends and family, proved to be more important. I watched Santiago frequently move in and out of the house. He spent most of his time outside hanging out around the plaza, visiting the internet café, picking up a game of futbol, or visiting with various friends.

Stepping back and looking at how a rural community attempts to cope with increasing economic pressures through the migration of men, and now women, to tourist and urban centers demonstrates the powerful ways in which economic pressures can move bodies. It also highlights the creative and flexible ways in which families adapt to these pressures. In the case of rural Quintana Roo, the out-migration of women has further affected the lives of children, and reshaped socially acceptable norms about how children are positioned within larger family units. For families facing economic difficulties in Saban and Huay Max, the practice of child circulation enables women who migrate out for work to rely on kin relatives like their mothers, sisters, sister-in-laws, or older daughters to help raise their children and provide them with a better quality of life. This results in the establishment of closer kinship ties through the sharing of mothering. 

Here child circulation functions as a survival and betterment strategy as children are moved and transferred between households. Yet, as Maribel’s experiences demonstrate, female out-migration and the subsequent circulation of children can have difficult social costs for families in places like rural Yucatan.  This reality underscores the need to understand the implications of globalization beyond macro-economic perspectives. By analyzing how economic pressures affect the intimate relationships of family and motherhood, we gain a much deeper—and more complex—understanding of the local social meanings and impacts of wider political and economic processes.

Veronica Miranda

PhD Candidate

University of Kentucky

*All names used in this essay are pseudonyms.

References

Casellas, Antònia and Briavel Holcomb. 2001. Gender, Tourism, and Development in Latin America. In Women as Producers and Consumers of Tourism in Developing Regions. Apostolopoulos, Y., Sönmez, S. F., & Timothy, D. J., ed. Westport, Conn: Praeger.

Castellanos, M. Bianet. (2010). A Return to Servitude: Maya Migration and the Tourist Trade in Cancun. Minneapolis: University of Minnesota Press.

Clancy, Michael. 2001. Exporting Paradise. New York: Pergamon.

Hiernaux, Daniel Nicolas. (1999). Cancún Bliss. In The Tourist City. Dennis R. Judd and Susan S. Fainstein, eds. Pp. 124-142. New Haven: Yale University Press.

Leinaweaver, Jessaca B. (2007). On Moving Children: The Social Implications of Andean Child Circulation. In American Ethnologist, Vol. 34, No. 1. pp 163-180.

Sanchez-Gil, Patricia et al. (2004). Some socio-economic indicators in the Mexican states
of the Gulf of Mexico. In Ocean & Coastal Management, Vol. 47, pp. 581-596.

Walmsley, Emily. (2008). Raised by Another Mother: Informal Fostering and Kinship

Ambiguities in Northwestern Ecuador. In Journal of Latina American and Caribbean Anthropology, Vol. 13, No.1, pp. 168-195.

Visual Anthropology: Yucatecan Archaeological Sights

My first critical encounter with the Yucatan was during the summer of 2002. Before that, I visited the peninsula twice during the early 1990s, but those experiences were heavily filtered and constrained by tourism. My family and I spent our entire vacation in Cancun and only ventured out for a few day trips to popular archaeological and tourist sites. There were so many aspects of life that we completely passed by. It was not until the summer of 2002 that I was introduced to the complex and dynamic history of the peninsula--this was also the first time I was exposed to what life was like for the majority of its residents.

In 2002, I was an undergrad at Humboldt State University and had decided to spend my summer working as a field technician for an American archaeological project located in the interior of the state of Quintana Roo. Since the archaeological site was rather remote, a base camp was set up in the nearest pueblo. Although the pueblo was one of the largest in the area with a population of 3,000 it still lacked many of the conveniences of urban life including running water and a sanitation system. Every week we had to drive two hours to the closest city to get supplies. By the end of the summer I had a new understanding and relationship with the Yucatan, which came primarily from experiencing life in a rural Yucatec Maya pueblo. These experiences greatly contrasted from the encounters I had in my youth, which were heavily influenced by the images and narratives promulgated by tourist media, international hotels, and popular discourses.

It has been nine years since I first started working in the Yucatan and every year I continue to delve deeper into the history, politics and culture of the region. And although I chose to change my focus--from archaeology to cultural anthropology--I will never forget that it was archaeology that started me on my research path.

These sets of photos were taken during several different field trips from 2008-2010.

Veronica Miranda
University of Kentucky

Coba, Quintana Roo, Mexico

Ek Balam, Yucatan, Mexico

Chichen Itza, Yucatan, Mexico

  

 

Valladolid, Mexico