Non - Contributory Pensions,Functional Limitations,and Unpaid Family Care for Older Adults in Mexico

Abstract

Objectives: We explore the effects of non-contributory pensions on functional limitations and receipt of unpaid family care by gender and frequency of pension payment. Methods: We employ a difference-in-differences estimator to identify the causal effects of non-contributory pension programs disbursed monthly or every two months for adults 70 years and older in the state of Yucatan, Mexico. Results:The monthly payment program led to lower difficulties in functional limitations and less receipt of help from family or relatives for older men and women as compared to the bimonthly program. We found a larger decline on receipt of family care for older women than for men. Discussion:Our results suggest that more frequent pension payments may have greater health benefits for recipients. They also highlight the need for greater understanding of policies that prevent or delay functional limitations and that could indirectly alleviate unpaid caregiver burden.

Keywords

caregiving Mexico poverty policy non-contributory pensions

Introduction

In 2020, Mexico had a population of 126 million. Population 60 years or older represented 12% of the total population in 2020 (INEGI, 2021) and are expected to represent 21% by the year 2050 (González, 2016), showing a rapid aging process. Mexican life expectancy at birth was 75 years in 2020, while that at age 60 was 22.9 years for women and 20.9 years for men (INEGI, 2021). Mexico is at an advanced stage in the epidemiologic transition, with most disease and injury burden coming from non-communicable chronic diseases. Diabetes mellitus, ischemic heart disease, chronic kidney disease, and visual and hearing impairment are the main influences on disability-adjusted life-years among Mexican older adults (Parra-Rodríguez et al., 2020), resulting in high prevalence rates of disability, especially among the oldest old where 35% of adults 80 years and older are disabled (Gerst-Emerson, et al., 2015).

Non-communicable chronic diseases generally have a long duration and steadily progress. They are an important source of functional limitations, disability, and frailty among older adults (Bello-Chavolla, et al., 2020; Jacob et al., 2020). Dependency associated with chronic diseases has created substantial health and financial burdens for older adults, their family caregivers, and the overall health care system (Mendoza-Núñez, et al., 2009). Several studies have characterized disability prevalence, progression and recovery among Mexican older adults, as well as their determinants (Díaz-Venegas, et al., 2016; Díaz-Venegas & Wong, 2020). There has been limited research, however, on the overall effect of public policies and programs on functional limitations, and receipt of unpaid family care.

Though the Mexican population is aging, and many of the disabling conditions of aging are becoming more prevalent, a large part of this population group lacks access to health care services, social security benefits, and publicly funded long-term care systems and policies are still lacking (Angel, et al., 2016; Gutiérrez Robledo, et al., 2015; López-Ortega & Aranco, 2019). As a result, unpaid family health care provided within the household is constantly increasing its role in satisfying the health and personal care needs of the total population and of older adults (López-Ortega & Aranco, 2019). Mexico’s National Health Accounts indicate that Mexican expenditures in the health sector represent 5.7% of total Gross Domestic Product (GDP), with 4.1% representing total production of goods and services of the health sector and 1.6% representing unpaid health care within the household for those who are ill or disabled (INEGI, 2019). Put another way, unpaid health care represents 29.1% of the total health sector GDP. This means that unpaid health care represents a larger proportion of health services than does all hospital services (20.3%) and ambulatory or primary care services (17.0%) (INEGI, 2019).

In Mexico, in contrast to high income countries that obtained economic and social development before ageing, a highly compressed aging process is taking place amid weak economies, high poverty rates and inequality and rapidly changing intergenerational relations (Guzman, 2002; Palloni, et al., 2002). A study by the National Council for the Evaluation of Social Policy in Mexico showed that on average 41.9% of adults 65 years and older were in poverty in 2018 with a range from 23% in Mexico City to 43.0%, 71.9%, and 72.6% in the states of Yucatan, Chiapas, and Oaxaca, respectively (CONEVAL, 2020). In many low- and middle-income countries, governments have introduced safety net programs that provide cash and other benefits such as a basic food basket, free meals, and subsidies to help pay for utilities, health insurance, or health care (Macias Sanchez, 2016). Conditional cash transfer programs mainly targeting households with children have been introduced in more than 60 countries (Baird, et al., 2014; Fiszbein et al., 2009; Parker & Todd, 2017). On the other hand, unconditional cash transfer programs, also called social pensions or non-contributory pensions, were developed to enable economic security, raise living standards and reduce poverty of older adults in low- and middle-income countries, who did not have access to social security, old age pensions or income during retirement (Bando, et al., 2017; Gertler, et al., 2012). Generally, these programs provide a flat-rate amount to recipients and age-eligibility is the only requirement. Non-contributory old age pension programs have been introduced in more than 30 countries around the world (HelpAge International, 2018).

Given the low access to social security old age pensions, that is, those received from contributory pension schemes, Mexico City started a social or non-contributory pension program in 2001. Several states, including Yucatan in 2007, followed by offering income support programs and in 2007 the federal government launched the Older Adult Program (PAM) to provide an income support pension to older adults. In this study, we focus on the effects of two non-contributory pension programs in the state of Yucatán, Mexico, a state-level (disbursed monthly) non-contributory pension program, and the federal PAM (disbursed bimonthly or every two-months) non-contributory pension program. The Yucatán state-level non-contributory pension for individuals 70 or older was introduced in 2007 in three phases. The first stage of the state program included localities with fewer than 6500 and more than 2500 inhabitants, the second included localities with fewer than 20,000 inhabitants, and the third phase included localities with 20,000 or more inhabitants. The federal PAM program started in 2007 for adults 70 years and older not receiving any other social security benefits or state-level non-contributory pensions and that lived in rural areas of less than 2500 inhabitants. In 2008, PAM was expanded to localities with fewer than 20,000 inhabitants, in 2009 to localities with fewer than 30,000 inhabitants, and the program was expanded to the whole country in 2012. In 2013, the PAM lowered the age of eligibility to 65 years, expanded to urban areas and from 2019 changed its focus to be a universal pension irrespective of entitlement to other social security pensions (Villareal & Macías, 2020).

With the expansion of PAM at the national level, by 2018, seven out of ten Mexicans 65 or older received contributory or non-contributory pension income (CONEVAL, 2020). Among these, the majority receive a non-contributory pension which are significantly smaller than social security pensions (Aguila, et al., 2011), and for many, these represent the main means for providing income security in old age (Newson & Bourne, 2011; Willmore, 2007).

Study Aims and Contributions of the Study

Because non-contributory pensions are the sole means of income and support for a large proportion of Mexican older adults, the aim of this study was to explore the effects on functional limitations and on unpaid family care of two non-contributory pension programs, one of them disbursed monthly and the other one disbursed every two months for adults 70 years and older.

To our knowledge, this is the first study that investigates the impact of non-contributory pensions on functional limitations and receiving unpaid family care. Our study contributes to understand the effects of non-contributory pension programs on physical health and how this impact on physical health could indirectly change unpaid family care provision. Moreover, previous studies have acknowledged the difficulty establishing causality between income and health because of reverse causality (e.g., Smith, 1999). A more general contribution of our study is that using experimental data allows us to examine the effects of an exogenous household income shock disbursed monthly or every two-months has on functional limitations and unpaid family care provision of older adults.

Previous Studies of Non-contributory Pension Programs

Previous research on the effect of non-contributory pensions in Mexico have shown mixed results on physical health and more consistent results of improvements on mental health of recipients. In Brazil, a monthly non-contributory pension program for older adults found improvements on subjective wellbeing (Lloyd-Sherlock, et al., 2012). In China, a monthly non-contributory pension program had positive effects on cognitive function and physical health (incidence of hypertension, IADL performance, and measure height), positive but modest effects on mental health, and no effects on self-reported health (Cheng, et al., 2018). In Paraguay, a monthly non-contributory pension program improved mental health and self-reported health but no changes on difficulties with ADL (Bando, et al., 2021). In Peru, a bimonthly program improved mental health but no effects on health or health care utilization (Bando, et al., 2020).

In South Africa, a monthly non-contributory pension program found improvements on self-reported health, happiness, life satisfaction, and increased hypertension awareness (Case, 2004; Lloyd-Sherlock & Agrawal, 2014; Schatz, et al., 2012), but in another study, Lloyd-Sherlock and Agrawal (2014) found no association with self-reported health or quality of life. For Mexico, a bimonthly, (disbursed every two-months) non-contributory pension program has shown to have improved mental health, memory, and reduced the proportion with anemia but no other effects on physical health (Aguila & Smith, 2020; Bando et al., 2017; Galiani, et al., 2016; Salinas-Rodríguez, et al., 2014). Other studies show that a monthly non-contributory pension program improved beneficiaries’ memory, lung functioning, and mental health, frailty, and reduced the proportion of recipients with anemia (Aguila, et al., 2018; Aguila, Kapteyn, et al., 2015; Aguila & Smith, 2020; Armenta, et al., 2021; Bando et al., 2017; Galiani et al., 2016; Salinas-Rodríguez et al., 2014). However, there is scarce evidence for Mexico or elsewhere on the effects of non-contributory pension programs specifically on functional limitations and unpaid family care.

Angst et al., (2018) using the same data for the State of Yucatán before the introduction of the non-contributory pension programs found that 77.7% of caregivers were women, specifically daughters of the older adults with lower educational attainment that had a higher likelihood of living in the same household as the older adult. Also, Aguila et al., (2019) using the same data for the State of Yucatán, found that older adults had a primary caregiver and that after the introduction of the non-contributory pension program, most caregiving responsibilities continued to fall on the main caregiver, that is, income support does not substitute unpaid care for paid care as 98% of caregivers remained unpaid after the introduction of the state non-contributory pension program.

Hypotheses

Our first hypothesis is that the non-contributory pensions may help reduce functional limitations when the income support helps improve food intake, health care use, and access to medicines for the older recipients, and that this effects are differentiated by gender (Mendez-Luck, et al., 2009). Functional disability is generally not a linear process of deterioration, but more often a pathway or trajectory, not a static state but a dynamic process where individuals move in and out of it with time (Gerst-Emerson et al., 2015; Lawrence & Jette, 1996; Verbrugge & Jette, 1994). Moreover, previous studies have found that not only health but demographic and socioeconomic characteristics such as income, gender, and place of residence determine disability (Gerst-Emerson et al., 2015).

Second, we hypothesize that a reduction on functional limitations, would reduce unpaid family care provision and that there will be differences on receiving care by gender (Mendez-Luck et al., 2009; Robles et al., 2000).

Third, we hypothesize that the monthly state program will have larger reduction on functional limitations and as a consequence on unpaid family care provision than the bimonthly program. In a previous study, Aguila et al., (2017) found that recipients of the monthly state program were able to smooth better consumption than in the bimonthly program. Also, the monthly program led to larger effects on food availability and health care utilization in contrast to the bimonthly program that had a lower impact on food availability, no effect on health care utilization, and an increase in the consumption of durable goods.

Methods

Research Design

Our research focuses on the effects of two non-contributory pension programs in the state of Yucatán, Mexico, a state-level (disbursed monthly) program in the town of Valladolid, and the federal-level PAM (disbursed bimonthly or every 2-months) program in the town of Motul. We collected baseline survey data (Wave 1) between August and November 2008 before the introduction of the non-contributory pension programs. The state-level program started in December 2008 and the federal PAM program started in July 2009. We collected survey data (Wave 2) after the introduction of both non-contributory programs between June and July 2010.

We employed a cluster randomized control trial design among 11 eligible towns in the State of Yucatan, matched in pairs with similar demographic and economic characteristics according to the available 2005 Census data (see Appendix Table A1). We randomly chose a pair of towns—Vallodolid (45,868 inhabitants) and Motul (21,508 inhabitants), both in the northeastern corner of the state and randomly chose one town, Valladolid, to receive the state-level program.

Valladolid began receiving the state-level non-contributory pension in December 2008 of MXN$550 per month (US$78.30 at 2014 purchasing power parity, or PPP) that represented about one-third of the monthly minimum wage in Yucatan (MXN$1,865.95 in January 2014 or US$265.80 at 2014 PPP) before any other income support program was in place. Approximately six months after the introduction of the monthly state-level program in Valladolid, the town of Motul began receiving the PAM which provided MXN$1000 paid every two months, or MXN$500 per month (US$52.80 at 2014 PPP). In 2009, Motul (21,508 inhabitants) qualified to receive the federal PAM pension program as it was extended to localities with fewer than 30,000 inhabitants but Valladolid (45,868 inhabitants) did not qualify to receive PAM until 2012. This meant that in Valladolid, older adults were eligible for a state government non-contributory pension paid every month beginning in December 2008 and throughout the 18-month period of our study (June–July 2010), while those in Motul were eligible for the federal PAM non-contributory pension paid every two months beginning July 28, 2009.

Both programs offered cash payments only and they were not conditional to any other requirements but age eligibility. They did not offer payments or any type of support for family caregivers or any other benefits. The state and federal programs had the same requirements in terms of documentation to enroll and claim their cash payment (Aguila, et al., 2014; Secreataría de Gobernación, 2009). In a previous study, Aguila et al. (2017), tracked non-contributory pension disbursement dates in the state and federal programs, and found that disbursement dates in the state and federal programs were the last week of the month or every 2-months, respectively. There were a few exceptions: a) for the federal non-contributory pension program was disbursed few days later, the first days of the following month for the payment in January 2009 and b) for the state program, the non-contributory pension program was disbursed in December 15 or 16 of 2008, 2009, and 2010 and not in the last week of the month to avoid any delays in the payment during the month of December. In sum, older adults in both localities received similar average monthly amounts and programs were similar, but those in Valladolid began receiving their pensions six months earlier than those in Motul and received them in monthly rather than bi-monthly payments.

Data Collection

We identified participants of the study by screening all households with adults 70 years or older in partnership with the National Institute of Statistics in Mexico (INEGI). National Institute of Statistics in Mexico trained the data collection team, provided quality assurance during the listing process, and provided maps of the communities. With INEGI’s support, we updated the maps as necessary (with a cartographer accompanying our data-collection team). In screening the selected communities, interviewers listed each household to identify age-eligible respondents and, using a brief form, collected first and last names, age, date of birth, gender, and preferred interview language (Spanish or Mayan). A detailed description of the study design has been previously published in (Aguila et al., 2014).

Between August and November 2008, prior to introduction of either program, the field team conducted baseline surveys with all households with adults 70 years and older in these two localities. This Wave 1 (W1) had a response rate of 93.3%, calculated using the American Association for Public Opinion Research guidelines (The American Association for Public Opinion Research (AAPOR), 2016). Wave 2 (W2) survey in June and July 2010 had a response rate of 79.5% (for further details, see Aguila et al., 2014). The field team and staff consisted of 48 members including a general coordinator, an operating director, a fieldwork coordinator, an administrator and administrative assistant, two programmers, a logistics manager, five field supervisors, and 35 interviewers. The field-interviewer position required Mayan-Spanish bilingual abilities. Over the course of the study, data-collection staff received over 250 hrs of training including sample identification and listing, cartography and census methodology, application of the survey instruments, human-subject protection, working with elderly populations, data safeguarding, data transfer, validation and quality control, reading and writing the Mayan language, and professionalism and teamwork (Aguila et al., 2014).

The survey involved an in-person interview to collect information on socioeconomic, demographic, and household characteristics; health care utilization; self-reported health indicators; anthropometrics; and biomarkers of blood pressure, lung capacity, and grip strength. The survey instrument was drawn from the Health and Retirement Study, whose measures were translated, validated, and tested in the Mexican Health and Aging Survey (MHAS) for the Mexican context. The baseline and follow-up surveys were developed in English; we subsequently translated them to Spanish (using existing translations from the MHAS when possible) and Mayan. Bilingual reviewers (English-Spanish and Spanish-Mayan) checked the translated versions of the instruments and the surveys were tested extensively in the field (Aguila et al., 2014). The Internal Review Board at the RAND Corporation revised and approved the protocol (approval number 2008-0513-CR07) for the surveys. The study complied with U.S. and Mexican requirements and standards for conducting ethical research. An informed-consent form that followed the Helsinki Declaration II was provided to each participant (Aguila, Cervera, et al., 2015).

Sample

The original sample consisted of 1186 men and 1265 women in both communities. Of those, 1136 men and 1215 women responded to the W1 survey, with the remaining 4.1% of the sample not interviewed because of refusal or changed address since the initial listing. Of those responding to the W1 survey, 793 men and 854 women responded to the W2, with the remaining 29.9% lost because of death (10.1%), refusal (6.5%), changed address (1.9%), or other reason (11.4%). After dropping 2 cases with missing information in our covariates, we had a final working sample of 791 men and 854 women.

Outcome Variables

Functional disability was measured following the Katz Index of Activities of Daily Living (Katz, 1983) and the Lawton Instrumental Activities of Daily Living Scale (IADL) (Lawton & Brody, 1969).We include three dichotomous outcome variables indicating whether respondents reported difficulty performing at least one activity of daily living (ADL) (1=yes, 0=no), with at least one instrumental activity of daily living (IADL) (1=yes, 0=no), and difficulty with at least one ADL and one IADL (1=yes, 0=no). ADL included eating, bathing, getting in and out of bed, using the toilet, and dressing. Instrumental activity of daily living included preparing hot meals, shopping for groceries, taking medications, and managing money. We also analyzed three dichotomous variables indicating whether older adults reported receiving help (yes=1, no=0) with performing ADL, IADL, or both ADL and IADL for those indicating difficulties performing ADLs or IADLs at W1, given the different type and intensity of care each implies. As noted, ADLs concentrate on personal care, requiring focused and highly intensive tasks performed for the older adult only, whereas IADLs involve support tasks that are non-exclusive and can be done while performing other activities such as cooking and shopping. Lastly, to identify those with more limitations who could in turn be those who receive most help, we identified those who report difficulties with both ADLs and IADLs.

Covariates

We included variables for age, age squared, years of education, marital status (1 = married or in consensual union, 0 = otherwise), living alone (yes=1, no=0), number of additional household residents living with the older adult, a wave indicator (W2=1, W1=0), and a dummy for indicating receiving the state or federal non-contributory pension program (state=1, federal=0) .

Statistical Analysis

We first calculated descriptive statistics on the percent of older adults reporting difficulties with performing ADL, IADL, and both ADL and IADL. We also calculated the percent who received help performing ADL, IADL, or both. We calculated these percentages separately by gender and for those that received the state (Valladolid) or federal (Motul) program. We calculated descriptive statistics and analyzed the trajectories of our outcome variables by gender and program received (state or federal).

We used Stata version 17 (StataCorp, 2021) and we analyzed the effects of the income supplemental programs following the program evaluation methods used in Aguila et al., (2017) and Aguila et al., (2018) . We compared the differences between the towns receiving state and federal programs using differences-in-mean outcomes between W1 and W2 (pre vs post estimator). We compared the change in outcomes for the two programs (difference-in-differences or DID estimator) to identify the causal effect of the state program relative to that of the federal program, assuming both towns follow common trends or similar natural tendency in the absence of treatment. The common-trends assumption allows the confounded time trend of the pre-versus-post estimators to drop out when conducting the DID analysis that identifies the causal effect. Differences in levels between towns are corrected by the DID estimator, but both towns must follow similar trends before the introduction of the non-contributory pension program (Cameron & Trivedi, 2005). We found that both towns satisfied the common-trends assumption (see Appendix Table A2 and previous analysis in Aguila et al., 2017). To test multiple hypotheses, we applied a Holm-Bonferroni correction (Holm, 1979).

To check the robustness of our results, we also estimated the intention-to-treat (ITT) differences-in-difference (DID) OLS regression with the covariates described above that were not affected by the non-contributory pension programs

Y_{i t} = α_{0} + α_{1} w_{t} + α_{2} N C P_{i} + α_{3} (N C P_{i} * w_{t}) + α_{4} X_{i t} + ε_{i t}

where

Y_{i t}

is the outcome variable of interest for individual

i

in wave

t

w_{t}

is a wave dummy (W2 = 1, W1 = 0),

N C P_{i}

is a non-contributory pension program dummy (state = 1, federal = 0), and

X_{i t}

includes sociodemographic characteristics.

α_{3}

measures the difference in the treatment effects between W1 and W2 for the state (monthly) and federal (bimonthly) programs. We estimate robust and clustered standard errors at the household level. Additionally, we employ non-parametric propensity score matching that compares recipients with similar characteristics in the state and federal programs, using the same covariates as in the OLS regression analysis. The propensity score is estimated using a probit model. We impose the region of common support and dropped less than ten observations in the estimations by gender and each outcome variable. We use Kernel matching with the Epanechnikov kernel function. We compute standard errors using the bootstrap method with 1000 replications. We used covariates in the parametric methods using OLS regression and in the non-parametric method to improve the precision of our estimates. In this analysis, we identified the effects of the state program 18 months after its introduction relative to the effects of the federal program 12 months after its introduction.

To assess potential sample selection issues, we conducted two robustness analyses. First, to assess the effects of mortality bias, we compared W1 characteristics of individuals who died prior to W2 with those who remained alive. Second, to assess sample attrition bias, we compared W1 characteristics of individuals who did not complete W2 with those who did complete it. We found no indication of sample selection issues in these analyses (see Appendix Tables A3 and A4).

Results

Our baseline sample comprised 1645 older adults 70 years or older: 791 men and 854 women. Table 1 shows the descriptive characteristics at W1 for men and women. Mean age for each of the four groups—state (Valladolid) program men, state program women, federal program (Motul) men, and federal program women—was about 77 years. Mean years of education was less than 2.5 for all four groups, though higher for men in both towns than for women. The mean number of additional household residents for all four groups was between 2.3 and 2.6, and 12–14 percent lived alone.

Table 1.

Descriptive Characteristics

	State Program (Valladolid) % or Mean (SD)	Federal Program (Motul) % or Mean (SD)	Diff.	T test, P value	State Program (Valladolid) % or Mean (SD)	Federal Program (Motul) % or Mean (SD)	Diff.	T test, P value	Difference Women -Men
	Women				Men					p
Covariates
Age	77.06 (0.27)	76.89 (0.38)	0.17	0.71	77.50 (0.30)	76.85 (0.31)	0.65	0.13	0.03	0.601
Years of education	1.82 (0.10)	1.97 (0.12)	−0.15	0.35	2.38 (0.13)	2.27 (0.10)	0.10	0.54	−0.31	0.567
Couple (yes=1, no=0)	0.35	0.44	−0.09	0.01	0.74	0.62	0.12	0.00	−0.18	0.325
Living alone (yes=1, no=0)	13.41	13.55	−0.14	0.95	11.98	12.61	−0.62	0.79	0.01	0.501
No. of additional household residents	2.31 (0.09)	2.54 (0.11)	−0.23	0.12	2.47 (0.11)	2.59 (0.11)	−0.12	0.46	−0.05	0.807
No. Observations	522	332			434	357
Outcomes difficulty
Difficulty with ADL (yes=1, no=0)	62.84	62.65	0.18	0.96	54.61	51.26	3.35	0.35	0.11	0.399
Difficulty with IADL (yes=1, no=0)	47.89	45.18	2.71	0.44	37.10	31.93	5.16	0.13	0.13	0.058
Difficulty with ADL & IADL (yes=1, no=0)	39.66	38.25	1.40	0.68	30.18	26.33	3.85	0.23	0.12	0.146
No. Observations	522	332			434	357
Outcomes receive help
Receive help with ADL (yes=1, no=0)	41.46	37.50	3.96	0.36	32.91	28.96	3.95	0.39	0.09	0.100
No. Observations	328	208			237	183
Receive help with IADL (yes=1, no=0)	33.60	23.33	10.27	0.03	27.95	18.42	9.53	0.06	0.05	0.085
No. Observations	250	150			161	114
Receive help with ADL & IADL (yes=1, no=0)	32.37	25.20	7.17	0.16	25.19	18.09	7.11	0.20	0.07	0.155
No. Observations	207	127			131	94

The proportion reporting difficulties with ADL, IADL, or both were similar comparing the proportions across towns by gender but higher overall for women than men. We also find a larger proportion of women than men that report receiving help with ADL, IADL, or both but we do not find statistically significant different among women and men when compared across towns.

Figure 1 shows trajectories, by town, between wave 1 and wave 2 of the percent of older adults who had ADL difficulties, IADL difficulties, and both ADL and IADL difficulties for women and Figure 2 for men. Figure 1 also includes the percent of older women who received help to perform these activities and Figure 2 is for men. In Figure 1, we found that women who received the state program experienced fewer ADL and IADL difficulties in wave 2 than in wave 1, but women who received the federal program saw their ADL and IADL difficulties increase. Consequently, we found a decline in the proportion of women in the state program who received help with these activities, but an increase in the proportion of women in the federal program who did.

Figure 1.

Women Trajectories of Functional limitations and help received with ADL, IADL, or both.

Figure 2.

Men Trajectories of Functional limitations and help received with ADL, IADL, or both.

In Figure 2, among men who received the state program, the proportion reporting ADL or IADL difficulties decreased, while the proportion who reported receiving help for these issues also decreased. Among men who received the federal program, the proportion reporting ADL or IADL difficulties increased substantially, as did the proportion who reported receiving help.

Table 2 shows that the differences-in-mean outcomes between W1 and W2 for the state program show a decline in women and men reporting ADL, IADL, or both and these are statistically significant. In contrast, the differences-in-mean outcomes between W1 and W2 for the federal program show no change in women reporting ADL, IADL, or both; and a statistically significant increase in men reporting ADL, IADL, or both. The change in outcomes for the two programs or DID estimator, shows that the proportion of state program recipients reporting ADL, IADL, or both ADL and IADL difficulties decreased relative to the proportion of federal program recipients with such difficulties. The effects were statistically significantly larger for men than for women reporting difficulties with IADL and were statistically significant for all after correcting for multiple hypothesis testing separately for men and women.

Table 2.

Effects of the noncontributory pension programs on receive help and difficulty with ADL, IADL, and ADL/IADL (W1, W2).

	State Program (Valladolid) W1	Federal Program (Motul) W1	State Program (Valladolid) W2-W1		Federal Program (Motul) W2-W1		DID of Means				Difference Women -Men
	Mean (SE)	Mean (SE)	Diff. (SE)	p	Diff. (SE)	p	Diff. (SE)	95% CI	p	HB		p
Women
Difficulty with ADL	0.63 (0.02)	0.63 (0.03)	−0.05 (0.02]	0.005	0.04 (0.02)	0.086	−0.08 (0.03)	[−0.14, −0.03]	0.002	**	0.04	0.399
Difficulty with IADL	0.48 (0.02)	0.45 (0.03)	−0.09 (0.02]	0.000	0.01 (0.02)	0.705	−0.10 (0.03)	[−0.16, −0.04]	0.002	**	0.11	0.058
Difficulty with ADL & IADL	0.40 (0.02)	0.38 (0.03)	−0.07 (0.02]	0.000	0.01 (0.02)	0.796	−0.08 (0.03)	[−0.14, −0.02]	0.010	**	0.08	0.146
No. Observations	522	332
Receive help with ADL	0.41 (0.03)	0.38 (0.03)	−0.07 (0.02]	0.001	0.04 (0.03)	0.164	−0.11 (0.03)	[−0.17, −0.04]	0.002	**	−0.04	0.553
No. Observations	328	208
Receive help with IADL	0.34 (0.03)	0.23 (0.03)	−0.10 (0.02]	0.000	0.15 (0.03)	0.000	−0.25 (0.04)	[−0.33, −0.16]	0.000	**	−0.10	0.234
No. Observations	250	150
Receive help with ADL & IADL	0.32 (0.03)	0.25 (0.04)	−0.06 (0.03]	0.022	0.10 (0.04)	0.006	−0.17 (0.05)	[−0.26, −0.08]	0.000	**	−0.04	0.387
No. Observations	207	127
Men
Difficulty with ADL	0.55 (0.02)	0.51 (0.03)	−0.05 (0.02]	0.033	0.08 (0.02)	0.000	−0.13 (0.03)	[−0.19, −0.07]	0.000	**
Difficulty with IADL	0.37 (0.02)	0.32 (0.02)	−0.10 (0.02]	0.000	0.10 (0.02)	0.000	−0.21 (0.03)	[−0.26, −0.15]	0.000	**
Difficulty with ADL & IADL	0.30 (0.02)	0.26 (0.02)	−0.09 (0.02]	0.000	0.07 (0.02)	0.001	−0.16 (0.03)	[−0.21, −0.10]	0.000	**
No. Observations	434	357
Receive help with ADL	0.33 (0.03)	0.29 (0.03)	−0.06 (0.02]	0.009	0.01 (0.03)	0.701	−0.07 (0.04)	[−0.14, 0.00]	0.054
No. Observations	237	183
Receive help with IADL	0.28 (0.04)	0.18 (0.04)	−0.04 (0.03]	0.211	0.11 (0.03)	0.000	−0.15 (0.04)	[−0.23, −0.07]	0.000	**
No. Observations	161	114
Receive help with ADL & IADL	0.25 (0.04)	0.18 (0.04)	−0.01 (0.03]	0.821	0.12 (0.04)	0.002	−0.12 (0.05)	[−0.22, −0.03]	0.013	**
No. Observations	131	94

Note.Diff = Difference; SE = Standard errors.

**p < .05 after HB correction.

Similarly, for women, we found the proportion of state program recipients receiving help with ADLs and IADLs decreased relative to federal program recipients receiving such help. For men, we found a reduction in the proportion of state program recipients receiving help for with ADLs and IADLs relative to federal program recipients receiving such help but only statistically significant for those receiving help with IADLs and both ADL & IADL. The differences-in-mean outcomes between W1 and W2 for women recipients of the state program show a statistically significant decline on help received with ADLs, IADLs, or both. For men who received the state program, we observe a similar statistically significant decrease for help received with ADLs, IADLs, or both. In contrast, the differences-in-mean outcomes between W1 and W2 for the federal program show a similar increase in the proportion of women and men recipients reporting receive help with ADLs, IADLs, or both.

Table 3 shows the results of the DID of the means, OLS regression, and propensity score matching. We find a statistically significant decline in the proportion of women and men reporting difficulties with ADLs, IADLs, or both using propensity score matching after correcting for multiple hypothesis testing. When we employ OLS regression, we only find a statistically significant decline in the proportion of men but not women reporting difficulties with ADLs, IADLs, or both. The p-value when using OLS regression, indicates a decline for women reporting difficulties with ADLs and IADLs is statistically significant (p-value < .05) but when correcting for multiple hypothesis testing, these estimates are no longer statistically significant. We find a statistically significant decline for women receiving help with ADLs, IADLs, or both but these estimates are not statistically significant for men after correcting for multiple hypothesis testing using propensity score matching. We find similar results using OLS regression.

Table 3.

Difference−in−Differences (DID) of the Means, OLS Regressions, and Propensity Score Matching.

	State-Federal (W2/W1)
	DID of the means				DID OLS regressions				DID propensity score matching
	Diff.(SE)	95% CI	p	HB	Coef. (SE)	95% CI	p	HB	Coef.(SE)	95% CI	p	HB
Women
Difficulty with ADL	−0.08 (0.03)	[−0.14, −0.03]	0.002	**	−0.08 (0.04)	[−0.16, −0.01]	0.032		−0.10 (0.04)	[−0.11, −0.10]	0.006	**
Difficulty with IADL	−0.10 (0.03)	[−0.16, −0.04]	0.002	**	−0.10 (0.04)	[−0.18, −0.01]	0.031		−0.12 (0.04)	[−0.12, −0.11]	0.003	**
Difficulty with ADL & IADL	−0.08 (0.03)	[−0.14, −0.02]	0.010	**	−0.08 (0.04)	[−0.16, 0.01]	0.078		−0.10 (0.04)	[−0.10, −0.09]	0.015	**
Receive help with ADL	−0.11 (0.03)	[−0.17, −0.04]	0.002	**	−0.10 (0.05)	[−0.20, −0.01]	0.034	**	−0.11 (0.05)	[−0.12, −0.11]	0.019	**
Receive help with IADL	−0.25 (0.04)	[−0.33, −0.16]	0.000	**	−0.25 (0.06)	[−0.37, −0.13]	0.000	**	−0.26 (0.06)	[−0.27, −0.26]	0.000	**
Receive help with ADL & IADL	−0.17 (0.05)	[−0.26, −0.08]	0.000	**	−0.16 (0.07)	[−0.29, −0.03]	0.015	**	−0.18 (0.07)	[−0.19, −0.17]	0.004	**
Men
Difficulty with ADL	−0.13 (0.03)	[−0.19, −0.07]	0.000	**	−0.13 (0.04)	[−0.21, −0.04]	0.003	**	−0.12 (0.04)	[−0.13, −0.12]	0.003	**
Difficulty with IADL	−0.21 (0.03)	[−0.26, −0.15]	0.000	**	−0.20 (0.04)	[−0.29, −0.12]	0.000	**	−0.19 (0.05)	[−0.20, −0.19]	0.000	**
Difficulty with ADL & IADL	−0.16 (0.03)	[−0.21, −0.10]	0.000	**	−0.16 (0.04)	[−0.23, −0.08]	0.000	**	−0.14 (0.04)	[−0.14, −0.14]	0.000	**
Receive help with ADL	−0.07 (0.04)	[−0.14, 0.00]	0.054		−0.07 (0.05)	[−0.17, 0.03]	0.180		−0.07 (0.05)	[−0.07, −0.06]	0.103
Receive help with IADL	−0.15 (0.04)	[−0.23, −0.07]	0.000	**	−0.15 (0.06)	[−0.27, −0.04]	0.011	**	−0.13 (0.06)	[−0.14, −0.12]	0.018
Receive help with ADL & IADL	−0.12 (0.05)	[−0.22, −0.03]	0.013	**	−0.13 (0.07)	[−0.27, 0.01]	0.075		−0.09 (0.08)	[−0.10, −0.08]	0.124

Note. Diff = Difference; Coef = Coefficient; SE = Standard errors.

**p < .05 after HB correction.

Discussion and Implications

The objective of this research was to estimate the effect of two non-contributory pension programs with different disbursement frequency (monthly vs bimonthly) on functional limitations and receiving unpaid family care in a sample of Mexican older adults. As such, this research helped document further the impact of non-contributory pensions among older adults in Mexico, beyond their economic impact. Our results can help policymakers identify target populations for future interventions to prevent or slow the onset of ADL and IADL difficulties for older adults, and ideally having a subsequent impact on the increasing help needed to perform these activities.

The populations analyzed—community-dwelling adults 70 years or older in two towns of Yucatán, Mexico—have confronted several adverse conditions, including high poverty levels, low educational attainment, and reduced access to advanced health care services and social security benefits (Aguila et al., 2014). They likely have been exposed to health and social inequalities throughout their lives, leading to higher levels of disability and care needs.

Non-contributory pensions may change these contexts for older adults in the near future, but the way such additional income is used, and its impact needs continued investigation. We found that for women, the non-contributory pension program disbursed monthly reduced difficulties with ADLs, IADLs, and associated care receipt relative to the program disbursed every two months. We found a reduction in functional limitations for women recipients of the state program but no changes for women recipient of the federal program. For men, we found that the non-contributory pension program disbursed monthly reduced difficulties with ADL, IADL, or both and did not change care receipt relative to the program disbursed every two months.

Our findings are consistent with our first, second, and third hypotheses. Previous studies have documented that functional disability is not a static state but a dynamic process where individuals move in and out of it (Gerst-Emerson et al., 2015; Lawrence & Jette, 1996; Verbrugge & Jette, 1994) and that socioeconomic characteristics also determine disability (Gerst-Emerson et al., 2015). In Mexico, previous research in older adults show large differences in functional limitations by gender (Díaz-Venegas et al., 2016) but have found similar short-term effects of income-support programs on health for men and women (Aguila & Smith, 2020; Armenta et al., 2021).

On the other hand, previous studies on unpaid family care for older adults showed that women receive almost twice the support in daily activities compared to men (Robles et al., 2000) and that women are more likely to receive social support; with being married or in a union increasing the likelihood of counting on a more extensive support network that can provide the care needed (Garay Villegas, et al., 2014).

Results of our study show a differentiated impact of the state- and federal-level pensions on men and women, likely signaling longstanding gender differences among these populations groups. We found that the monthly non-contributory pension program reduces functional limitations but not the program disbursed every-two months. Interestingly, we find a larger and statistically significant decline in unpaid family care provision for women than for men recipients of the monthly program when there is a larger decline for men than for women in difficulties with ADL, IADL, or both. These findings may indicate that there are different social norms by gender in terms of giving and receiving unpaid family care (Mendez-Luck et al., 2009) and how functional limitations are perceived and dealt with, supporting our first and second hypotheses.

Our findings also indicate that frequency of program payment can help reduce difficulties with ADLs and IADLs even more than the program itself. We do not find evidence that non-contributory pension programs reduce functional limitations per se but that more frequent payment may in fact help reduce recipients’ financial barriers to access food and health care, with these in turn having longer-term effects on nutrition, health, and wellbeing, ultimately reducing the level of functional limitations for recipients. This would support our third hypothesis where we expected the monthly program to have larger or more positive effect in reducing functional limitations and, in consequence, receipt of unpaid family care.

As mentioned, localities where the non-contributory pension programs were introduced had similar geographic location, demographic, and socioeconomic characteristics (Aguila et al., 2014) and therefore, we expected both programs to have similar effects, so that any differences would be attributed to the frequency of payment: monthly vs every two months. In a previous study, Aguila et al., (2017) found the monthly program led to larger effects on food availability and health care in contrast to the bimonthly program that had a lower impact on food availability, no effect on health care utilization, and an increase in the consumption of durable goods. Aguila and Smith, (2020) found larger improvements in several objective health measures (highest expiratory flow to measure lung disease, low hemoglobin levels, and verbal immediate and delayed recall) for recipients of the monthly program than of the bimonthly program. Aguila, Kapteyn, et al., (2015) found that six months after the introduction of the monthly program there was an increase in household food availability, health care utilization, and access to medicines for older adults as well as an increase in the proportion of out-of-pocket health expenditures paid by older adults rather than by relatives. These findings may indicate that more frequent and lower amount of pension benefits may lead to improvements in food availability, health care use, and health outcomes that may persist in the longer-term. More frequent payments may lessen difficulties or vulnerable situations that low-income older adults are exposed to for saving or family pressures to share larger amounts of their income (e.g., Banerjee & Duflo, 2007; Dupas & Robinson, 2013).

Limitations

There are some limitations to our research. Our study covers only a short period of time. Disability among the elderly is not a linear process, but one that can occur over a long period of time, with individuals even transitioning into and out of disability (Jette, 1999; Lawrence & Jette, 1996; Peek & Coward, 1999; Peek, et al., 2003; Verbrugge & Jette, 1994). Longer periods of observation would help in better understanding disability trajectories and their impact on health, wellbeing, and care needs.

Specifically, we analyze the effects of the non-contributory pension programs one and a half years after Valladolid started receiving the monthly state-level pension and approximately one year after Motul started receiving the bimonthly federal PAM pension. Both programs were very similar as discussed in the Research Design section. The main differences were that the state program disbursed the non-contributory pension in cash monthly and the federal PAM was disbursed in cash every two months (Aguila et al., 2017; Aguila & Smith, 2020) and that the state program provided $7.10 USD at 2014 PPP more per month than the federal program. We expect these differences not to affect our conclusions. As mentioned previously, the monthly program showed strong effects on health care utilization, food availability, and objective measure of health six months after the introduction of the state program (Aguila, Kapteyn, et al., 2015). In contrast, the program disbursed every two months had no effects on health care utilization, smaller effects on food availability, and some effects on health 12 months its introduction (Aguila & Smith, 2020).

Implications

The current universal monthly non-contributory pension scheme provides MXN$1900 (US$266.10 at 2014 PPP) disbursed every two months for all adults 68 or older as well as indigenous adults 65 or older (Secretaría de Gobernación, 2021). To improve health and well-being of older adults—indeed, to assure that these pension payments are spent in ways that are most likely to benefit older adults—policymakers may wish to issue payments from this program monthly rather than bimonthly. The indirect effects of the non-contributory pension on functional limitations that we observed in this study may be the result of better food intake, increased health care use, and access to medicines for pension recipients. The similar effects in reducing care needs are also relevant in a context of increased aging and decreased availability of unpaid family caregivers with other economic and care responsibilities (Andrade & López-Ortega, 2021).

Governments should also consider strategies to support unpaid family caregivers. Currently, some social security institutions train family caregivers on how to provide better care (López-Ortega & Aranco, 2019). Although such programs are welcomed and well-received, they do not reduce the burden of caregiving nor eliminate the opportunity costs borne by unpaid family caregivers. Programs that provide caregiving to the most vulnerable older adults should be implemented.

Future research should also collect detailed information on the characteristics of unpaid family caregivers and the type and level of care they provide, and how it impacts their development and overall wellbeing. This is especially true for those providing care to older adults who are frail and those living with dementia and who have particularly complex and demanding care needs (Mejia-Arango et al., 2020).

Supplemental Material

Supplemental Material—Non-Contributory Pensions, Functional Limitations, and Unpaid Family Care for Older Adults in Mexico

Supplemental Material for Non-Contributory Pensions, Functional Limitations, and Unpaid Family Care for Older Adults in Mexico by Mariana López-Ortega, and Emma Aguila in Journal of Aging and Health

Footnotes

Acknowledgements

We thank the staff in Yucatan—supervisors, directors, coordinators, interviewers, programmers, and administrators—who made the project possible. We also thank Clifford Grammich and Jorge Peniche for his excellent research assistance.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the State of Yucatan; the National Institute on Aging (NIA) (grants numbers R01AG035008, P01AG022481, and R21AG033312); and the RAND Center for the Study of Aging (grant number P30AG012815 from NIA).

ORCID iD

Emma Aguila

Supplemental Material

Supplemental material for this article is available online.

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