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How effective and efficient are social programs on food and nutritional security?

How effective and efficient are social programs on food and nutritional security? Engineering in Food Industries, Faculty The analysis of the impact assessment of social programs allows to identify whether of Chemical Engineering and Metallurgy, Universidad Nacional San they fulfil the established objectives and evidencing the weaknesses to be strength- Cristóbal de Huamanga, Ayacucho, Perú ened in future actions, and modify or propose new intervention strategies. In Peru, Faculty of Agronomy, Universidad the substantial economic progress since the 90s decade promoted dramatical invest- Nacional Agraria La Molina, Lima, Perú ments in the social sector, especially on children well-being, as around 30% of the Correspondence total Peru population are children under the age of 15, being the age group most af- Susan Pillaca-Medina, Condominio los fected by poverty in the country. This review was aimed to present an overview of Álamos Dpto. H-204, Parques del Agustino, El Agustino, Lima, Perú. the current situation of social programs in Peru in terms of food (and nutritional) Email: ssusan_14@yahoo.es security (FS), emphasizing on the institutional framework and the impact of the so- cial programs implemented by the Government, as well as some social programs implemented by nongovernmental organizations. To this end, information available on the world wide web, including peer-reviewed papers on databases (mainly SciELO and LiLACs for their relevance for the Latin American region) regarding FS in Peru from 1989 onwards, and information published by the Peruvian official organisms directly involved in FS, was used. Studies addressing at least four of the seven points of the food and nutritional security in Peru analyzed in this paper (access, availabil- ity, consumption, biological use, stability, current situation, and institutionality) were considered. It was concluded that investment and resources should be used to improve social programs strategies designed according to the reality of each focused area, as in Peru, the achievements show an enormous potential for replicability of the interventions. Children must be prioritized through child-sensitive programs, instead of considering them just as indicators and investments for the future—especially in rural areas whipped by the past internal conflicts—in order to contribute to the sus- tainable development of the country and assuring FS. KEYWORDS chronic malnutrition, food security, impact assessment, Peru (Source: DeCS BIREME), social programs Both authors contributed equally to the manuscript. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2017 The Authors. Food and Energy Security published by John Wiley & Sons Ltd. and the Association of Applied Biologists. Food Energy Secur. 2017;6:e120. wileyonlinelibrary.com/journal/fes3 | 1 of 22 https://doi.org/10.1002/fes3.120 2 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO Amaru (CNDDHH 1997; CVR 2003). During the 1990s de- 1 INTRODUCTION cade, the internal conflict was virtually over (CVR 2003), Although global food availability per capita has improved and the country went through a period of economic adjust- markedly over the past half century simultaneously to a de- ment and structural reforms including trade liberalization and crease in real food prices, hunger, malnutrition, and food increased flexibility in the labor market, which still remain insecurity remain widespread (Barret, 2002). Around one bil- as a considerable concern (Streuli, 2012). Since then, Peru is lion people suffer undernourishment today, while probably at making a substantial economic progress (Paxson & Schady, least one- third of the world’s population bears nutritional risk 2002). After 1990, growth has been generally strong, infla- (Barret, 2002). Despite food assistance and private charitable tion low, and poverty reduction sustained (World Bank 1996, programs from governments and/or other institutions (non- 1999). Considering full 2016, the Peruvian economy ex- governmental organizations, federal programs, etc.), food in- panded 3.9 percent, the highest growth rate in the last 3 years security is a persistent worldwide problem, affecting not only (Trading Economics 2017). Consequently, investments from to developing countries, but also to highly industrialized and the Peruvian government in the social sectors have increased developed countries, as US (Bickel, Nord, Price, Hamilton, & dramatically, attempting to target these social investments to Cook, 2000), where it has been reported to affect to 11% of the poor. Indeed, between 2001 and 2006, a number of social all households (Nord, Andrews, & Carlson, 2004) and 16% of programs were implemented by the Peruvian Government to households with children (Nord, 2003). help the most vulnerable sections of the population to bear According to FAO (2015), (World Summit on Food, the transition (Cueto, Escobal, Penny, & Ames, 2011), and 1996), food security (FS) occurs when all people have phys- important measures were taken to tackle poverty in gen- ical and economic access to sufficient, safe and nutritious eral, emphasizing the improvement of the situation of chil- foods that meet their daily energy needs and food preferences dren (Streuli, 2012). However, the effectivity and efficiency for living a healthy and active life. Thus, FS encompasses of Peruvian social programs remains not completely clear different dimensions such as access and availability, con- (World Bank, 1999). sumption, biological utilization and stability in food supply, For these reasons, the aim of this work has been to de- where the institutional aspect contributes to the reduction in termine whether the social programs developed in Peru do Food Insecurity (FI) (Salcedo, 2005), which refers to limited achieve their original goals (settled before the onset of the or uncertain availability of or inability to acquire nutrition- project/action), discussing the impact of social assistance ally adequate, safe, and acceptable foods due to financial programs implemented in Peru during the last years, mainly resource constraint (Bickel et al., 2000). More specifically, of those which have been qualified as successful accord- food insufficiency refers to an inadequate amount of food in- ing to different entities. The methodology of investigation take due to resource constraints (Sahyoun & Basiotis, 2000). followed was reviewing literature documenting the impact Thus, finding appropriate distribution mechanisms to solve assessment of social programs developed in Peru, using as the problem is considered a strong political imperative, that, data sources the published information available on the world however, does not guarantee success. Food security remains wide web, including peer-reviewed papers on different data- a prominent concern for economists, as most nations have bases (mainly SciELO and LiLACs due to their relevance for implemented food assistance programs of some sort, but the Latin American region) regarding food (and nutritional) many of these have proved to be expensive and/or ineffective security (FS) of Peru from 1989 onwards. Information pub- (Barret, 2002). lished by the official organisms directly involved in FS in The worst economic and political crises in the history Peru was also used. Studies were assessed for relevance based of Peru occurred from 1980s to 1990s: inflation peaked at on information quality, and only those addressing at least four over 7,000 per cent; unemployment rose considerably and of the seven topics of the food and nutrition security in Peru the proportion of poor households increased (Escobal et al., analyzed in this paper (access, availability, consumption, 2003). During that period, the Peruvian population, in par- biological use, stability, current situation, and institutional- ticular those living in rural areas, experienced an internal ity) were considered. Studies containing less than 4 of the 7 conflict between the Government and Sendero Luminoso were excluded. Likewise, whenever possible, the information (Shining Path), a terrorist communist organization inspired about the methodology followed by the different authors to by Mao’s Cultural Revolution in China, that imposed a ruth- assess the impact of every social program has been detailed at less rule on the rural areas it seized, killing elected officials, the beginning of the correspondent paragraph (items 2.2.1 to trade union organizers, peasants, and villagers suspected of 2.2.10). Thus, only three (Haku Wiñay, Proyecto Educativo siding with the Government. Approximately 69,280 people Nutricional (…) Pachacútec, Con todas las manos) out of the were killed or disappeared at the hands of Sendero Luminoso, ten projects under analysis have not clear and/or detailed in- Government forces, self- defense committees, and other guer- formation about the methodology followed for their impact rilla groups such as the Movimiento Revolucionario Túpac assessment. PILLACA- MEDINA AND CHAVEZ- DULANTO 3 of 22 Yamada and Pérez (2014) pointed out that impact as- 5–11 years old are already involved in economic activities— sessments provide valuable information as a policy tool against only 4% in urban areas (UNICEF 2004). for establishing whether projects, programs or public poli- cies are effectively meeting their development objectives. 1.1.1 Access Quantitative results of impact assessments enable the iden- tification of which programs achieve the stated objectives INEI evaluates poverty at national and local level peri- and which programs have the greatest impact, turning them odically, considering to be in poverty when people have a into an indispensable guide for an adequate distribution of budget- income below the cost of the “basic basket” com- scarce resources from public sources and from the interna- posed of food and nonfood (housing, clothing, education, tional cooperation for development (Yamada & Pérez, 2014). health, transportation, etc.) items, and as in extreme pov- Therefore, section 1 describes the current situation of the erty when their per capita budget- income is below the cost Peruvian population with emphasis in food and nutrition se- of the basic food basket (Instituto nacional de estadística e curity, section 2 describes and discusses the impact of cur- informática- INEI, 2016b). rently ongoing and some past social programs developed in Despite the political stability and economic growth since the last years, and finally, section 3 presents the main conclu- early 2000s, almost half of the population in Peru still lives sions, emphasizing food security aspects, highlighting their in poverty (Streuli, 2012), with one in six facing extreme weaknesses and suggesting actions for improvement and poverty (Escobal, Ames, Cueto, Penny, & Flores, 2008). strengthening. Poverty rates started to fall slightly, from 49% to 45% be- tween 2004 and 2006 (INEI, 2002; INEI, 2006; World Bank 2005). The analysis of poverty by natural regions carried 1.1 Characteristics of the peruvian population out by INEI in 2006, suggests that the number of “poor” regarding food and nutrition security people in rural areas is not only greater than urban areas, By 2015, according to the National Institute of Statistics and but that people are also two times more “poor” than their Informatics of Peru (INEI), there were 31 151 643 inhabit- counterparts in urban areas (excluding Lima city), calcu- ants in the whole country, 57.8% of them living in the coastal lated in 28% against 14% (INEI, 2006). Nowadays, signifi- area, 27.3% in the mountain range and only 14.9% in the rain- cant differences still exist within the population. forest area (Instituto nacional de estadística e informática- Total and extreme poverty has declined from 33.50% and INEI, 2015a). Most of the population lives in the urban area 9.50%, respectively, in 2009, to 21.77% and 4.07%, respec- (76.2%) and is relatively young: 29.9% are under 15 years tively, in 2015, with a higher percentage in the rural area old, 62.0% between 15 and 64 years old, whereas only 8.2% (Figure 1). For 2015, the monthly average real income per are 65 years old and over (INEI, 2015b). capita (estimated in Nuevos Soles (S/.) = PEN) was S/. 886, As described above, around 30%of the total Peruvian pop- showing an increase in S/. 773 respect to 2009, being S/. 1027 ulation are children under the age of 15 (INEI, 2007), being in the urban area and S/. 432 in the rural area. Likewise, the this the age group most affected by poverty in Peru (UNICEF average real monthly expenditure (rme) per capita for 2015 2008). In 2004, while 45% of Peru’s total population was at the national level was S/. 673, being in the urban area S/. living in poverty, around 60% of children aged 3–16 years 765 and in the rural area S/. 375, showing an increase with old were poor (INEI 2006). In other words, the poverty rate respect to 2009, since the average rme per capita for that for children was approximately 15 percentage points higher year at the national level was S/. 591, being in the urban than the poverty rate for the overall population. The situation area S/. 704 and in the rural area S/. 284 (INEI, 2016b). The was even worse in rural areas, where an estimated 80% of 3- inequality in the distribution of the income measured by to 16- year- old experienced poverty (Streuli, 2012). To face the Gini coefficient for 2015 reached 0.44 at national level, their family’s poverty situation, some children are involved in showing a reduction from that of 2009 (0.49) (INEI, 2016b). economic activities, either through paid work or undertaking Total and extreme poverty according to area of residence in a range of different work activities at their parent′s work or the years 2009 and 2015 are shown in Figure 1. at home (Streuli, 2012). Indeed, in 2004, UNICEF estimated Regarding the per capita distribution of expenditure in that one out of every four children under 18 years old in Peru 2015, it is observed that 41.3% addressed food (S/. 278), is involved in economic activities. Almost 21% of Peruvian showing a slight increase compared to 2009, which was S/. children combine work and schooling, whereas around 5% of 255 (INEI, 2016b). children only work. Child work seems to be associated with poverty: around 40% of children coming from households 1.1.2 Food availability classified as “extremely poor” work, whereas only 20% of those classified as “nonpoor” do. The highest incidences of According to the Peruvian Multisector Commission on child work are found in rural areas, where more than 30% of Food and Nutrition Security (2013), the Food Balance 4 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO 66.72 % 45.18 % 29.81 % 21.3 % 14.54 % 20 13.93 % 2.07 % 1.02 % FIGURE 1 Total and extreme Total Total Total Total Extreme Extreme Extreme Extreme rural rural urban urban rural rural urban urban poverty according to area of residence in poverty poverty poverty poverty poverty poverty poverty poverty the years 2009 and 2015 (Source: INEI, 2009 2015 2009 2015 2009 2015 2009 2015 2016b) Sheet (HOBALI) of the Ministry of Agriculture (MINAG) Only 75.5% of Peruvian children between 6 and of (2007) considers that the net per capita food availabil- 35 months of age has minimum food diversity, regarding ity in Peru is: cereals and derivatives (115 kg), tubers (114 caloric and protein adequacy. It reflects the food insecu- Kg), fruit (91 kg), live animal products (80 kg), vegetables rity and low educational level of mothers or caregivers of (47 kg), sugar crops (38 kg), oils and fats (22 kg). The main children, whom would be limiting their food consumption. component (cereals and derivatives) depends on 88.7% of Food diversity has shown to be higher in the urban area, wheat imports (Eguren, 2012), which in 2016 was the most where it is observed that children consume grains, roots imported food item—as durum wheat— together with soy- and tubers regardless of age, followed by fruits and vegeta- bean oil (INEI, 2017). bles rich in vitamin A (Tarqui, Álvarez, Gómez, & Rosales, In the third quarter of 2016, during the same period, pro- 2016). According to Tarqui et al. (2016), 54% of the stu- duction was lower than 2015 for the following crops (with dents participating in the Global School Health Survey percentage of decrease): rice 20%, potato 14%, durum yellow 2010, stated to consume soda at least once a day, and 10.7% corn 10%, maize starch 22%, quinoa 42%. The reasons for the to consume fast- foods three or more days a week, with a decreased production have been highlighted as less harvest- low consumption of fruits and vegetables (31.7% reported ing area availability, low yields, adverse climatic conditions, to consume a banana, apple and/or orange once or twice scarce rainfall during different stages of crop development a day, whereas only 8.9% reported consuming vegetables that affected yields, among others. However, it is worthy such as lettuce, carrot, tomato, radish, at least three times pointing out that in the case of the citrus- fruit (tangerine), the a day). Furthermore, the survey revealed a high percentage production increased by 32%, as onion by 13.4%, avocado by of students engaged in sedentary activities, a situation that 12.4%, and in the case of chicken, production increased by predisposes to students to present an increased risk of non- 11% (Moreyra et al., 2016). transmissible diseases (MINSA, 2011). Exclusive breastfeeding, the practice of feeding the child with only breast milk, free of contaminants and germs, pre- 1.1.3 Consumption venting acute respiratory infections and strengthening the According to the food pyramid described by Díaz (2010), the immune system MINSA (2017a), is considered the only consumption of carbohydrate- rich foods in Peru is excessive, food capable of satisfying all the nutritional needs of the while paradoxically, fruit consumption is in deficit. Fruit con- child during the first 6 months of life, without requiring sumption should be about 15% of the daily intake, but records other foods or additives such as water or juices (MINSA, for all areas (coast, mountain, rainforest) did not reach even 2017a). In the first semester of 2016, 66.7% of the mothers half of the ideal proportions, whereas the consumption of said that they feed their children under 6 months of age with carbohydrate- rich foods reached almost 50%, when it should breast milk. This practice is greater in the rural area (83.8%) be around 40% (Díaz, 2010). Furthermore, according to the than in the urban area (59.5%) (MINSA, 2017a). Between Quarterly Report on Living Conditions by INEI (2016a), 2013 and the first half of 2016, the prevalence of breast- 32.5% of households in the country have at least one member feeding in the rural area increased from 80.8% to 83.8%. with a caloric deficit, affecting in 38.2% of the rural house- Regarding e xclusive breastfeeding practices, according to holds and 30.9% of the urban area (Lima City excluded). INEI (2015b), 65.2% of girls and boys under 6 months of age % of poverty PILLACA- MEDINA AND CHAVEZ- DULANTO 5 of 22 had exclusive breastfeeding and 6.3% from 6 to 9 months of Comisión Multisectorial De Seguridad Alimentaria y age continued to be fed with only breast milk. Velásquez Nutricional, 2013). et al. (2014), in a study carried out in 2012 in Peru’s extreme Climate phenomena do affect the stability and availability poverty zones (Cajamarca, Amazonas, Huánuco, Ayacucho, of food in Peru. Every year, the population of the Andean Huancavelica, Apurímac, Cusco, Puno, and Ucayali), did highlands and rainforest face the negative effects of the low find that 89.6% of children under 6 months received exclu- temperature season (frost and cold), known locally as friaje. sive breastfeeding. It affects their health, education, agricultural, livestock farm- ing, and infrastructure, especially in populations with high vulnerability, either because of their social condition (pov- 1.1.4 Biological use erty and extreme poverty), age (children, old- adults, etc.), or According to the demographic survey of family health in above all, their territorial location (Presidencia del Consejo 2015, at national level, 81.3% of households used potable de Ministros 2016). water from the public network, either inside or outside the It is estimated that a total of 1342 districts with dwelling or public tap. The highest percentage corresponds 1,866,327 inhabitants are exposed to frost danger, with lev- to the direct connection within the dwelling (74.9%). In the els of exposure between Very- high and High. The popula- urban area, 85.4% of households used water from the public tion with high rates of poverty and food insecurity, which water network, either inside or outside the dwelling or pub- subsist by the raising of sheep and camelids (llamas and lic tap, compared with 69.6% of rural households. However, alpacas) and subsistence agriculture, are the most vulnera- 16.0% of households in this area still use spring water, the ble to low temperatures. Bronchopulmonary diseases pre- river or irrigation ditches (INEI, 2015b), a figure lower than vail, especially among children under 5 years of age and that registered in 2009, which was 24.9% (INEI, 2009). adults over age of 60. Often, these diseases become fatal Arenas and Gonzales (2011) found a correlation between (INDECI, 2016). the percentage of access to potable water and drainage and On the other hand, climate change undoubtedly poses the percentage of medical consultations due to intestinal- a threat to food security in vulnerable areas. Indeed, in the infectious diseases from 2002 to 2009 in Peru. district of Pariahuanca (Junín, central highlands) the tropi- On the other hand, 91.8% of households accounted with calization of climate is occurring due to the increase in tem- hygienic services: 66.9% with the toilet connected to the out- perature, which has accelerated the life cycle of insects. The flow public network and 24.9% with latrine, including a cess- key pest of potato, the Andean weevil, is present in all its pool/septic tank. The proportion of households with hygienic life- cycle stages during the whole crop season. Similarly, the services in the urban area (96.8%) was higher than in the rural increase in pathogenic diseases outbreaks is causing wreak- area (77.0%). However, the percentage of households with- ing havoc on crops (Zárate & Miranda, 2016). out sanitary services in the rural area has declined from 2009 Likewise, from December 2016 to April 2017, a cascade (33.3%) to 2015 (21.8%) (INEI, 2009, 2015b). of climatological phenomena (strong rainfalls, floods, land- Another important factor affecting biological use is hand slides, thunderstorms, snowfalls, and hailstorms) affected washing. Pillaca and Villanueva (2015) did find in the dis- Peru, endangering life and health of people, damaging dwell- trict Los Morocuchos (Ayacucho, mountain area, south- ings, public places, cropping areas, and roads in a number ern Peru) that only 74.2% of mothers washed their hands of districts. A total of 1,104,247 people were severely af- before preparing food, 48.4% before eating, 41.4% before fected, 188 073 people were in damage, 133 people died, 21 feeding their children and 37.5% after going to the toilet. 294 households collapsed, 21 333 households disabled, 247 The percentage of families who always washed their hands 127 households affected, 326 bridges destroyed, 3563 km with water and soap was 7.8%, which is an important fac- of roads and 2114 km of rural roads were destroyed, 25671 tor to consider in future preventive strategies for intestinal- hectares of crops lost, 61403 hectares of crops affected, and infectious diseases. 6593 irrigation channels destroyed (INDECI, 2017). These events are considered a serious threat to food and nutritional security of the Peruvian population. 1.1.5 Stability Another aspect to consider influencing food security in The main risks faced by the country in relation to the stability Peru, are social conflicts. They cause food insecurity by of food supply depend fundamentally on the vulnerability in shortages of agricultural products (roadblocks, cessation of the production of food at the national level due to climatic production of products, etc.), which also causes instability in changes and, secondly, on the fluctuation of international citizen’s security (Multisectoral Comisión Multisectorial De prices of import food such as oil, soybean, hard yellow corn, Seguridad Alimentaria y Nutricional, 2013). According to wheat and derivatives, since these products are part of the the Defending People’s Office (2017) in February 2017 there basic consumption basket of Peruvian families (Multisectoral were a record of 212 social conflicts, 155 still active and 57 6 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO in latent situation. The largest number of social conflicts oc- the urban area (40.2%) during the first half of 2016. Between curring in a single region was registered in the departments 2015 and the first half of 2016, the prevalence of anemia in of Apurímac (26 cases), Ancash (26 cases), Cusco and Puno girls and boys under 3-y ear old shows a constant of 43.5% (18 each one). The socio- environmental conflicts occupied (MINSA, 2017b). 67.9% of the total conflicts registered in the month. They are Chronic malnutrition and anemia at national level, ac- followed by conflicts on local government issues with 9.4%, cording to the area of residence, are shown in Table 1. and conflicts on national government issues with 6.1%. A high percentage of intestinal parasitosis (enteropar- asitosis) has been reported by several authors in different districts of Peru. For instance, Alarcón, Iannacone, and 1.1.6 Nutrition and health situation in Espinoza (2010) conducted a study in the population of Peru Parque Industrial de Huaycán, district of Ate Vitarte (Lima), Peru has experienced significant changes in the epidemiolog- concluding that prevalence of enteroparasitosis was 74.24%. ical, feeding and nutritional patterns during the last 20 years, The risk factors that favored the persistence of intestinal par- due to changes in the economic, social and demographic as- asitosis, according to the study, were as follows: poor basic pects. For example, the massive migration to the cities from sanitation (houses with dirt floor, lack of potable water and rural areas, has generated important changes in living condi- drainage, throwing of debris to the clearing, etc.), and poor tions and welfare of the migration groups (Peña & Bacallao, hygiene habits such as playing with dirt or do not washing 2000). hands before eating or after going to the toilet. In addition, Since 2000, the mortality rate for children under 5 years having domestic animals at home, specially dogs. Similarly, old has gone down by 30%, although the child mortality rate Cabrera, Verástegui, and Cabrera (2005) found 77.88% of in rural areas is still almost double that in urban areas. In con- parasitosis due to one or more entero- parasites in the prov- trast, stunting rates among children under 5 years old have ince of Victor Fajardo, Department of Ayacucho, southern remained almost unchanged since 1996 (in a period of mostly Peru. GDP growth)—representing 30% of children. Stunting is Obesity, defined as an excess of body fat generated when much worse in rural areas (46%) than in urban areas (14%), the energy input (food) is greater than the energy expendi- and affects boys more than girls (33% and 26%, respec- ture (determined mainly by physical activity) over a suffi- tively). Geographically, all regions with stunting above 40% ciently long period, has increased in the Latin American are clustered in the Andes (INEI, 2007). Even though there (LA) region during the last years (Peña & Bacallao, 2001). is a number of food programs provided by the Government, Peru is not the exception. Although in recent years genetic but the evidence so far suggests that some of them do not factors have been identified to explain the greater suscepti- have a nutritional impact on children (Alcázar, Lopez-Calix, bility of some individuals, the abrupt increase in obesity that & Wachtenheim, 2003; Cortez, 2001). In terms of children’s has occurred in the last decades and its great extension is due access to basic services, the scenario is not very positive ei- mainly to significant changes in the diet of the population ther. Only seven out of ten children have access to safe water, whereas only five have access to improved sanitation services TABLE 1 Nutrition and health situation in children under (UNICEF 2004), both of which are essential in supporting 5 years of age (Source: Chronic malnutrition measured according to international patterns of WHO (INEI, 2009, 2014)) child growth and development (Streuli, 2012). Peru counts with a national vaccination program led by Nutrition and health situation in MINSA. Vaccines are medical substances that are capable of children under 5 years 2014% 2009% inducing an immune response in a living being, this response Chronic malnutrition—nationwide 14.6 23.8 conferred by the antibodies is capable of producing protec- Chronic malnutrition—urban area 8.3 14.2 tion from diseases known as immuno-pr eventable (MINSA, Chronic malnutrition—rural area 28.8 40.3 2017b). In Peru, the complete basic vaccines for children Anemia—nationwide 35,6 37.2 under 36 months include one dose of BCG, three doses of Anemia—urban area 31.7 33.2 DPT, three doses against polio and one dose against measles. In the first half of 2016, 70.3% of children under 36 months Anemia—rural area 44.4 44.1 received complete basic vaccines for their age, being this Acute respiratory infections—nationwide 15.1 6.4 value similar in the urban area (70.6%) but lower in the rural Acute respiratory infections—rural area 16.5 7.7 area (69.3%). Acute respiratory infections—urban area 14.6 5.7 In Peru, iron deficiency anemia is estimated from the level Acute diarrheal disease—nationwide 12.1 14 of hemoglobin in the blood. It is a national deficiency that Acute diarrheal disease—urban area 11.7 14 affects four out of ten children under 3 years of age (43.0%). Acute diarrheal disease—rural area 12.9 13.9 Anemia was more frequent in the rural area (52.3%) than in PILLACA- MEDINA AND CHAVEZ- DULANTO 7 of 22 (Popkin, 1998), the pattern of physical activity (Peña & abilities. Since then, MIDIS coordinates and articulates with Bacallao, 2000) and other factors of sociocultural nature. the public and private sectors and civil society, encouraging Even childhood obesity has increased in the last years. For that social programs achieve their goals through constant 2010, it was estimated at national level in 8.2% of exceeded- evaluation, empowerment, training and coordinated work weight in children under 5 years (6.4% overweight and 1.8% among their managers (MIDIS, 2017). obesity). According to the area of residence, the exceeded- weight in the rural area was 3.8% and 7.7% in the urban area. The prevalence of overweight and obesity among members 2 SOCIAL PROGRAMS of Peruvian households is a public health problem also for the group of children aged from 5 to 9 years, with exceeded- Social programs are an organized grouping of actions and weight 24.4%, being overweight 15.5% and obesity 8.9% resources, systematically designed and implemented in a par- (Alvaréz- Dongo, Sánchez- Abanto, Gómez- Guizado, & ticular social reality, to solve a problem that affects to its pop- Tarqui- Mamani, 2012). ulation and improve its quality of life in some aspects (Vara, 2007). Social programs aim to achieve certain objectives and benefit clearly identified groups. Before being implemented, 1.1.7 Institutionality these programs may seem potentially beneficial, but often do This aspect refers to policy interventions that guarantee a not produce the expected impacts and benefits (Ramoni & good organization of the programs and projects that are for- Orlandoni, 2014). mulated and implemented (Salcedo, 2005), delivered from Therefore, the impact assessment of social programs governmental institutions to face and succeed against poverty constitutes a policy tool that provides valuable information and social exclusion. As stated above, the social component about whether they are effectively achieving their develop- in the fight against poverty in Peru was shifted up since the ment objectives and goals. It is carried out by comparing a 90s decade with the creation of several governmental institu- “baseline”, which evaluates the initial situation of the target tions to achieve this challenge (Streuli, 2012). population, with a “comparison line”, showing the condition The Social Development Cooperation Fund (Foncodes) of that population after a certain time of operation of the was created in 1991 with the stated objective of helping to project, eliminating or minimizing the incidence of external alleviate poverty through generating employment and im- factors (Cohen & Franco, 2005). The quantitative results of proving access to social services, through community- based the impact assessment of social programs (IASP) constitute projects, which included initiatives in health, education, ag- an indispensable guide for an adequate distribution of pub- riculture, community centers, rural electrification, water and lic’s and international cooperation for development resources sanitation, as well as executing a series of centrally designed (Yamada & Pérez, 2014). Therefore, IASP is especially im- special projects in education, which included a school break- portant in developing countries where resources are scarce fast program and the distribution of uniforms for school- and every spent dollar should maximize its impact on poverty children (Paxson & Schady, 2002). Similarly, the current reduction. However, in Peru, despite the billions of dollars Ministry of Women and Vulnerable Populations (MIMP) was spent on social investment each year, little is known about the created in 1996 (firstly as Ministry of Women Promotion and real effect of such projects (Vara, 2007). Human Development - PROMUDEH), which in turn became Social programs in Peru are developed mainly by govern- the Ministry of Women and Social Development (MIMDES) mental institutions (Foncodes, MIDIS, MIMP, etc.), and non- in 2002, to finally be established as Ministry of Women and governmental organizations (NGOs), which can be national Vulnerable Population (MIMP) in 2012, with the objective of or foreign institutions. There are 55 private international being the governing body of national and sectoral policies on cooperation organizations for development working in Peru, the rights of women, as well as the prevention, protection and grouped in the Coordinadora de Entidades Extranjeras de attention on violence against women, as well as promotion Cooperación Internacional COEECI (Coordinator of Foreign and strengthening of gender mainstreaming, policies, plans, Entities of International Cooperation), which work in coor- programs and projects, and the promotion and protection of dination with the Peruvian State, as well as private and pub- vulnerable populations, such as children and adolescents, lic institutions to contribute to national development efforts the elderly, people with disabilities, displaced persons and (COEECI, 2017). internal migrants (MIMP, 2017). In 2011, the Ministry of Between 2001 and 2006, the Peruvian Government im- Development and Social Inclusion (MIDIS) was created as plemented important measures to tackle poverty in general, a body of the Executive Branch with the main objective of with emphasis in improving the situation of children: (i) a improving the quality of life of the population in situations Plan Nacional de Acción por la Infancia y la Adolescencia of vulnerability and poverty, promoting the exercise of their 2002–2010 (National Plan of Action for Childhood and rights, access to opportunities and development of their own Adolescence) which was based on the United Nations 8 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO Convention on the Rights of the Child (UNCRC 1989) and globally demonstrated that children are the age group most settled out the strategic priorities of the Peruvian Government likely to experience the effects of poverty (Gordon, Nandy, with regard to its actions for children (PNAIA, 2002); (ii) a Pantazis, Pemberton, & Townsend, 2003; Streuli, 2012; new Ley General de Educación (General Law for Education) UNICEF 2005), and it is estimated that over a billion chil- (MINEDU, 2003) that includes preschool education as part dren experience “severe deprivation of basic human needs” of the basic education, thus making it free and compulsory; such as food, safe drinking water, health, education, and ad- (iii) a Plan Nacional de Educación Para Todos (National equate shelter (Gordon et al., 2003). These CCTs programs Plan of Education for All) (2004), which follows the interna- are social protection measures that have rapidly become a tional agreements at Jomtien and Dakar; and (iv) a Proyecto critical component of poverty reduction strategies (Streuli, Nacional de Educación 2006–2021 (National Education 2012), addressingshort- term income needs as well as pro- Project) CNE (2006), which identifies issues of equity and moting “longer term accumulation of human capital” by pro- quality as major challenges to Peru’s education system, among viding money to families in poverty contingent upon certain other things. In relation to poverty alleviation measures, there verifiable actions and behaviors, such as school attendance are two major initiatives: the Acuerdo Nacional (National or basic preventative healthcare (De la Brière & Rawlings, Agreement) and the Mesa de Concertación de Lucha Contra 2006). In addition, increasing family income puts people in la Pobreza (MCLCP, the Round Table for the Fight against a better position to accrue longer term resources (e.g.,, make Poverty), signed in 2002 as a long-ter m plan for the economic investments, avoid debt). Therefore, by linking cash transfers and social development of Peru agreed by political parties to certain desirable behavior, CCTs highlight the corespon- and civil society organizations. It has 31 long- term state sibility of beneficiaries for their own well-being. This is as- policies planned until 2022, seven of which are specifically sumed to strengthen social citizenship, with rights and duties aimed at children (Government of Peru 2002). The MCLCP shared between authorities and citizens (Coady, Grosh, & is a multisectoral, government–civil-socie ty forum aimed at Hoddinott, 2004; Cohen & Franco, 2006). There is also some facilitating dialog and participation in public policies on pov- political motivation to demonstrate to nonrecipients that ben- erty reduction. In 2005, the Government of Alejandro Toledo eficiaries are deserving of the cash transfers. The benefits of implemented the Programa Nacional de Apoyo Directo a CCTs for children include improvements in nutrition, school los Más Pobres (National Programme of Direct Support to attendance, use of health services and birth registration, the Poorest), known as Juntos (“Together”), which was con- though there is debate about whether or not it is the cash or tinued and expanded by the successive Governments (Alan the conditionality (or indeed the associated development of García 2006–2011 and Ollanta Humala 2011–2016). More infrastructure) which makes the difference (Devereux, 2009). information is provided in the next section. Nowadays, CCTs programs are the most important targeted social programs, not only because of their achievements, but also because of their scale and budget. According to Trivelli 2.1 Types of social programs and Clausen (2016), the budget allocated to CCT programs According to Streuli (2012), social programs fall into two in Latin America was more than US$20 billion in 2011. They main groups: (1) those with universal coverage, such as are not the only programs, but they play a key role, along with social services (contributory pension plans), education and noncontributory pensions, in most countries in the region. health, and, (2) the targeted social policies programs, which Within the CCTs social programs developed at country- are aimed at a population group with certain characteristics wide level by the Peruvian Government with certain positive associated particularly with their degree of poverty, vulner- impacts, according to the Economy and Finance Ministry of ability and social exclusion—the conditional cash transfer Peru (MEF), are the following: (1) “Pension 65”, a solidarity (CCT) programs are the typical example of targeted social assistance program that increased the food expenditure of se- policy, although there are many others. This division between nior citizens in Peru, evaluated between the years 2012 and social policy types correlates with government administra- 2015 (MEF, 2016); (2) “Juntos”, a direct support program to the tion; many countries in the Latin America region have min- poor, evaluated from 2006 to 2009, which reduced the percent- istries that provide universal services and ministries of social age of extreme poverty in the target districts (Perova & Vakis, development—such as Peru’s Ministry of Development and 2011); and, (3) the Haku Wiñay project, currently carried out Social Inclusion (Ministerio de Desarrollo e Inclusión Social, by Foncodes, for beneficiaries of the “Juntos” program, which MIDIS) - , which oversees targeted services, although some reported an increase in the number of crops grown and their sectorial ministries may also have targeted programs. yield, especially in vegetables, tubers, and in the production of The conditional cash transfer (CCT) programs in Latin eggs, at household level (Escobal & Ponce, 2016). America constitute a new generation of programs specifi- On the other hand, universal coverage social programs cally targeting children from poor households, introduced in Peru are developed by both agents, the government and mainly during the 1990s (Streuli, 2012), as it has been the nongovernmental organizations (NGO). Within those PILLACA- MEDINA AND CHAVEZ- DULANTO 9 of 22 universal social programs developed by NGOs with encour- visited. It was found that the beneficiary seniors’ households aging results, can be mentioned, (1) the Food Security and increased their monthly average consumption per capita by Nutrition Program, developed by CARE, which has shown 40%, an equivalent to the total amount of the per capita trans- an important impact in the reduction in chronic malnutrition fer received by the home of the beneficiary, from which 66% in children under the age of 3 years and in the increase in was spent on food consumption. There were no effects on the household food expenditure in 125 districts in the regions of physical and cognitive health of the beneficiaries nor on their Ancash, Apurímac, Ayacucho, Cajamarca, Huancavelica, and own perception of health status. There were also no effects Puno, in Peru (Rojas, Flores, & Céspedes, 2007); and, (2) reported in the use of health services, despite the articulation “Con todas las manos” (With all the hands), a social program actions with the health sector carried out by the program for focused in hygienical practices, developed by PRISMA in the provision of prevention campaigns during the payment 2004 with the financial and technical support of the “Change dates (Ministerio de Economía y Finanzas (MEF), 2016). AID Project” in Peru, has shown a considerable increase in the appropriate hand washing practices, and therefore, in the 2.2.2 “juntos” reduction in diarrhea in children until the age of 5 years, in the district of Uchiza, San Martín department (mountain rain- JUNTOS (Together) is a currently ongoing national program forest area) (Bartolini, Cevallos, Pastor, & Segura, 2008). of direct support to the extreme poverty group, launched in 2005 by the Peruvian Government under the management of the current MIDIS, being the first program of conditioned 2.2 Relevant social programs developed in transfers or direct subsidy that was applied in the country Peru in the last years (CGR, 2008). The target population is the household, where There is a number of social programs developed in Peru, mothers are recipients of the monetary transfer. At the be- either by governmental or nongovernmental organiza- ginnings of this program, eligible households received a tions (NGOs). This section describes some of the most rel- fixed monthly cash transfer of 100 nuevos soles per month evant (ongoing and past) social programs developed by the which was conditional on their compliance with accessing Peruvian government and also by NGOs, with greater impor- basic healthcare and primary education services for their tance and coverage in Peru. Table 2 presents a summary of children, targeting specifically at “poor” households which the analyzed programs. had children under the age of 14, with the purpose of sup- porting them to invest more in their human capital—that is, through education, nutrition, and healthcare—and thereby 2.2.1 “pension 65” break the cycle of poverty in the long term. In 2010, Juntos “Pension 65” is a currently ongoing national solidarity as- started a new phase and some important changes has been sistance program created in October 2011 by the Peruvian amended: The household must be in poverty and/or extreme government, through MIDIS, aiming in providing economic poverty and counting with children up to 14 years old and/ subsidy to adults over 65 years old living in extreme pov- or pregnant women among their members (Alcázar, 2009). erty (PCM, 2011). The project strategy is the delivery of Its short- term objective is reducing poverty by transferring a economic subsidies equivalent to S/. 250 (approximately 76 bimonthly amount of 200 soles (approximately 60 USD) to USD), bimonthly. In addition, the population affiliated to households’ mothers, whose payment is conditional to fulfill- Pension 65 receive public health services at noncost through ing the commitments or coresponsibilities established by the the Seguro Integral de Salud (SIS) (Comprehensive Health program (Correa & Roopnaraine, 2014). In the long term, the Insurance). Additionally, the promotion of social protection objective is stopping the generational transmission of poverty through intersectoral and intergovernmental coordination ac- as inheritance through primary education assistance, reduc- tions aimed at facilitating the access of Pension 65 users to tion in child labor and increasing the use of health services public services provided by the Government (health, identifi- (Escobal & Benites, 2012). The conditionality of the program cation and Civil Status—RENIEC, etc.) are also focused by includes: a) for children under 5 years: health checks, com- Pension 65 (MEF, 2016). plete vaccination, iron and vitamin A supplements and para- site examinations; B) for children between 6 and 14 years Impact studies of Pension 65 old: school attendance at least 85% of the scholar year, and, INEI collected the baseline data between November and c) for pregnant or lactating women: prenatal and postnatal December 2012 and the follow- up data between July and check- ups (Escobal & Benites, 2012). October 2015. The baseline consisted in a sample of 4031 senior adults between the ages of 65 and 80 years old liv- Impact studies of “Juntos” ing in 3031 households, from which 64% were assigned as a The latest evaluation of the Juntos program was per- treatment group. In the follow- up, the same households were formed by Sánchez and Jaramillo (2012), who conducted 10 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO TABLE 2 Social programs developed in Peru assessed in the present study Type of Period of Social program Developed by program Beneficiaries Target group activity Aims Pensión 65 Government CCT Adults > 65 y- old Extreme poverty2011- today Improving access to food and health (MIDIS) (ongoing) Juntos Government CCT Households with children Poverty, Extreme poverty 2005–today Education, nutrition and healthcare of children (MIDIS) < 14 y- old, pregnant (ongoing) women Qali Warma Government Type 1 Children ≥3y- old, in School- children from public 2012—today Warranting food during the academic year to favor (MIDIS) initial & primary school, schools (ongoing) children’s attendance and permanence at school and secondary school (Amazonia) Haku Wiñay/Noa Government CCT Households Poverty, Extreme poverty2009- today Development of productive and entrepreneurial skills Jayatai (FONCODES) (ongoing) to increase household income enhancing food security Proyecto Articulado Government Type 1 Children ≤3y- old, their Attendants to health public 2008–2021 Education on nutrition and healthcare of children, Nacional - PAN (MINSA) parents and caregivers; services (ongoing) avoiding low weight at birth, fighting anemia, pregnant women and controlling children’s development and full lactating mothers vaccination Chispitas Government Type 1 Children from 6 to Attendants to health public 2009- today Education on nutrition and children healthcare, (MINSA) 35 months old services (ongoing) preventing/controlling nutritional deficiencies through micronutrients supplement for a period of 18 months Vaso de Leche Government Type 1 Children < 0 to 6 y- old, National level, no restrictions1985- today Complementing food intake delivering a food portion (Municipalities) their mothers, pregnant (ongoing) (milky product) of 207 Kcal (12–15% protein, women and lactating 20–25% fat, 60–68% carbohydrate), 7 days a week mothers. Elderly adults and patients with TBC Redes de Desarrollo NGO CARE Peru Type 1 Children ≤ 3y- old Andean highlands communities 2001–2006 Reducing chronic malnutrition Sostenible - REDESA Proyecto Educativo WFP, PRONAA, Type 1 Children < 5 y- old and Urban marginal district of 2004–2007 Improving nutritional level of children through Nutricional (…) NGO Alternativa pregnant women Ventanilla, Callao Region education, healthcare, food supplementation and Pachacútec strengthening of social organizations Con todas las manos NGO A.B. Prisma Type 1 Households with at least Uchiza district, Rainforest- 2004 Increasing hand washing practices with soap to one child <5y- old central highlands, San Martín decrease the prevalence of diarrhea PILLACA- MEDINA AND CHAVEZ- DULANTO 11 of 22 a nonexperimental study requested by the Banco Central de Similarly, using the official records of ENDES, ENAHO, Reserva del Peru (Central Reserve Bank of Peru) to evalu- INEI, SIS, MINSA, MINEDU, Hidalgo (2013) conducted a ate the nutritional impact of Juntos in children, in which the longitudinal nonexperimental study, and concluded that there database of the Encuesta Nacional Demográfica y de Salud is a significant influence of JUNTOS on the reduction in pov- (ENDES—National Demographic and Health Survey) for erty in its area of intervention, from 45% in 2005 to 31% in 2008, 2009 and 2010 was used. The results suggested that 2009. JUNTOS has had a positive impact on early nutritional status, However, one of the main and most complete impact reducing the incidence of extreme chronic malnutrition, thus fa- evaluation studies on the Juntos program was performed by voring those children in the lower percentiles of the nutritional the World Bank (Perova & Vakis, 2009), based on a nonex- status distribution, helping them to overcome extreme chronic perimental methodology and mixed data from the ENAHO malnutrition, but not necessarily moderate chronic malnutri- and the Registro Nacional de Municipalidades (RENAMU— tion. However, these results can be questioned, as evidence of National Registry of Municipalities). This study points out heterogeneous effects have been found, thus suggesting that that the program has significant and positive effects in the households with lower assets, possibly the poorest among the comparison between both beneficiaries and control groups poor, would be benefiting less (Sánchez & Jaramillo, 2012). as well as between beneficiaries that have been part of the Both the 2009 and the 2012 evaluations corroborate the posi- program for a longer period of time and those who are more tive effects of the Juntos program (Streuli, 2012). recent. The positive effects revealed by this study are sig- On the other hand, Escobal and Benites (2012), carried out nificant increases in consumption and income levels, with a a study by taking a subsample of the Young Lives study (longi- subsequent reduction in the incidence and intensity of mone- tudinal study investigating the determinants and consequences tary poverty. It also shows positive impacts on the enrolment of child poverty over a period of 15 years in four developing rates for the first 2 years of basic schooling, in the number countries—Ethiopia, India, Peru, and Vietnam), comparing of medical consultations and the fulfillment of the vaccina- beneficiary households of JUNTOS with others who are not tion calendar in the case of children under 5 years old and enrolled in the program, to identify its impacts on children. mothers in the perinatal period. The same study, however, The authors found that JUNTOS has changed some household does not point to significant effects on student school atten- spending patterns, increasing the likelihood of incorporating dance or on child nutrition (the noted nutritional impacts are products such as eggs, fruits, and vegetables into the benefi- for adults only), and it highlights that the Juntos program ciaries’ diets. However, they found no significant positive im- does not cause undesirable effects on the labor market or on pacts in the long-ter m nutritional effects or improvements in conspicuous consumption, a sharp increase in birth rates or cognitive performance of children. Therefore, they concluded other such variables (Lara Arruda, Nazareno, Salles, Alves, that cash transfers are generating positive impacts, but com- & Courau, 2016). plementary policies are required to maximize their impact. Similarly, Perova and Vakis (2011) conducted a non- 2.2.3 “qali warma” experimental study, using official data sources such as the National Household Survey (ENAHO—Encuesta Nacional Qali warma, which means “strong child” in Quechua lan- de Hogares) from 2006 to 2009. They found that almost all guage, constitutes a currently ongoing national food supply indicators of interest are significantly higher among benefi- program to public schools, created in 2012 and conducted by ciaries with longer treatment periods. However, in many cases MIDIS, aiming in providing quality- sustainable and healthful these improvements are too small to be captured in the overall food services adapted to local consumption habits, coman- effects analysis when beneficiaries are compared to nonben- aged with the community (CGR, 2013a). The target popula- eficiaries. Their conclusions suggest that while the program tion is compounded by girls and boys from 3 years old, from undoubtedly works, there is still an important improvement the initial level of education to primary education of public to be implemented. Overall consumption increased by 33%, educational institutions, and progressively, Qali warma as- which includes the positive change in food consumption as sists schoolchildren in the secondary education level of basic well as in nonfood products, although consumption of non- education in public educational institutions of native com- food products is nearly 65%, compared to a 15% increase in munities located in the Peruvian Amazonia (MIDIS, 2014, food consumption. Overall income also increased by 43%, MIDIS, 2012). Qali Warma assures food for these children, whereas the poverty rate decreased by 19%. It is important warranting the alimentary service during all days of the to pinpoint that the estimate was made based on the sam- scholar (academic) year according to the characteristics of the ple of JUNTOS districts, where poverty and extreme poverty zones where they live. This way, it is expected that attention rates are higher than national poverty rates (70% and 36% of of children in class will improve, favoring their attendance households in 2009, respectively, compared to 34% and 11% and permanence at school (MIDIS, 2012). Additionally, pro- country- wide) (Perova & Vakis, 2011). moting good eating habits in children is also aimed, as Qali 12 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO warma comprises the food component, being responsible for 2017). Gordillo (2014) also carried out a cross-sectional, de - planning the menu and providing the resources for quality scriptive, and observational study. The population consisted food service, accounting that breakfast and lunch contribute of children aged 3–8 years old from two educational institu- with 25% and 35% of daily energy requirements, respectively tions in the village of Quirihuac, Department of La Libertad, (Romero, Riva, & Benites, 2016). The educational compo- in the year 2013, finding a relationship between the preva- nent of the program also includes the promotion of good lence of dental caries and the sugars of Qali Warma program feeding habits in various actors involved in the implementa- and school refreshment, indicating that this could be since tion of the school feeding service, through training, technical the food supplied by the Qali Warma program and food con- assistance, and educational tools (Romero et al., 2016). sumption in school (snacks) are highly cariogenic. The lack of proper hygiene after eating such foods increases the risk of Impact of Qali warma suffering this disease. Maqui (2015) carried out a nonexperimental, descriptive and explanatory research in the district of Guadalupito, depart- 2.2.4 “haku wiñay/noa jayatai” ment of La Libertad, in the period 2012–2014, finding the following: a) 69.86% of parents indicated that Qali warma The Haku Wiñay/Noa Jayatai (“My enterprising farm” in both, has contributed to improving the learning of school- age chil- Quechua and Amazonic languages) program is a currently on- dren, indicating that children who did not consume their food going initiative of FONCODES, designed in 2009 as a pilot at home, consume it at school, thus completing the energies project to serve rural households in situations of poverty and for the study- journey; b) 26.03% of parents who considered extreme poverty (Trivelli, 2017). Since 2012, Haku Wiñay that Qali warma contributes only partially did not discredit was officially launched and operates with special emphasis the program and believe that there are exogenous variables on the areas where the Juntos program operates (Escobal & linked to food to improve learning, such as support from Ponce, 2016; Robino & Fabio Veras, 2015). The project seeks parents and improving teaching methods of teachers; c) 11% to strengthen strategies for generation and diversification of of people who reported that the program did not deliver the income of a set of agricultural households with subsistence service uninterruptedly during the scholar year, and stated economies (Escobal & Ponce, 2016), developing productive that at the beginning of the program, food delivery was not and entrepreneurial management capacities in rural house- carried out in some areas. However, it seems that it does not holds under poverty and extreme poverty. Thus, Haku Wiñay happen anymore at present. focuses on the development of productive and entrepreneurial Additionally, from a selective evaluation to more than skills to help households strengthen their income generation 1600 educational institutions throughout the country in capacities and diversify their livelihoods, as well as to en- 2016, several deficiencies in the Qali warma food service hance food security (Robino & Fabio Veras, 2015). were identified. The analysis of 158 rations of food distrib- The program strategy is structured in four components. uted in Metropolitan Lima reveals the need to improve the The first is to strengthen and consolidate the family produc- nutritional contribution of some foods. It was found that the tion system by a farmer- to- farmer evaluation. The second sugar content of some food products exceeded by 400% the component of the project seeks to improve living conditions maximum limit recommended by the Pan American Health in housing through the implementation of healthy practices Organization (PAHO) to prevent the occurrence of over- in three areas: (a) use of safe water for human consumption, weight, obesity, and chronic diseases, whereas the saturated (b) adequate management of solid waste, and (c) adequate fat content exceeded by more than 230% the maximum limit storage and preparation of food, including the installation recommended by this international organization. Also, the of improved kitchens. The third component has as main ob- combination “milk with cereal flour and biscuit” delivered jective the promotion of inclusive rural businesses from the by the program Qali warma provides less protein than the provision of technical assistance and is implemented via the minimum required. With regard to the consumption of dis- organization of competitions. Under this component, project tributed foods from a sample of 317 educational institutions users interested in implementing or expanding a business are at the national level, it was found that 34% of the children organized in existing associations for the competition. The do not consume foods of the ration modality (prepared and fourth component is the development of financial capacities, ready-t o-eat f oods that are distributed in individual pack- which focuses in training users to access to the financial sys- ages), 37% of children do not wash their hands with soap and tem (Escobal & Ponce, 2016). water before eating; and a sample of 1290 educational insti- The project foresees the participation of each user house- tutions at the national level, found that 27% of children do hold for a period of 3 years. In the first two, the training, not consume foods of the product modality (foods that are technical assistance and transfers of assets, comprised in the prepared and served at each school), 29% of children do not four components described above, are developed. One ex- wash their hands with soap and water before eating (CGR, pectation about the project is to accompany farmers in the PILLACA- MEDINA AND CHAVEZ- DULANTO 13 of 22 implementation of productive technologies and entrepreneur- 45- min training and counseling sessions that promote the ship, in order to ensure the consolidation of the learnt lessons adoption of three in- home childcare practices such as exclusive (Escobal & Ponce, 2016). breastfeeding, hand washing and feeding of children between 6 and 12 months old (Cruzado, 2012). In the case of basic vac- Impact of Haku Wiñay/Noa Jayatai cines, besides improving and enhancing the supply and dis- Early findings of Robino and Fabio Veras (2015) from the tribution of the permanent basic vaccination scheme (BCG, first (pilot) phase of Haku Wiñay, based on a comparison DPT, polio, and measles) to prevent prevalent diseases, two with the baseline, showed encouraging results, including a new vaccines against diarrhea (rotavirus) and acute respiratory significant increase in total family income that is attributed to infections (pneumococcus) have been added (Cruzado, 2012). the intervention. There were also significant improvements in perceptions of well- being, financial literacy, nutritional, Impact studies of PAN and some health outcomes when comparing the treated group Cruzado (2012) conducted a study using a database of chil- with a matched control group (Robino & Fabio Veras, 2015). dren to exploit the gradualness of the intervention throughout On the other hand, incorporating both direct impacts of birth cohorts, and calculated the average treatment effect for the Haku Wiñay project and potential complementarities the prevalence of malnutrition in the regions with the highest with the Juntos program, in the districts of Anta, Rosario degree of intervention. The analysis was performed for the and Andabamba (department of Huancavelica), district of period between the first quarter of 2006 and the first quarter Umari, Panao (department of Huánuco), and the districts of of 2011. The age of children included in the sample was from Chalamarca, Conchán, Pacha (department of Cajamarca), in 0 to 59 months and from 0 to 36 months. The baseline was the years 2012 to 2015, Escobal and Ponce (2016) found out the situation existing in 2007. Results showed that the PAN that 67% of treated households recognized that their incomes products were not new, as they were already offered in health have improved over the past 2 years, whereas 68% believe that centers. However, the great difference that was established incomes in their village have improved over the same period. with the PAN is that the design of these products was im- In addition, the treated households report an increase in the proved. In the case of CRED, educational and demonstrative number of crops grown in 2015, which is especially concen- counseling was added, and in the case of vaccines, addition- trated in the areas of vegetables and tubers, increasing crop ally to increase the provision, two new vaccines were added yields, and egg production as well (Escobal & Ponce, 2016). to the scheme that directly affected acute diarrheal diseases and acute respiratory diseases (Cruzado, 2012). Additionally, Cruzado (2012) obtained an estimator of the 2.2.5 “programa articulado nacional— average impact factor attributed to the PAN in the reduction pan” in malnutrition, which was 3.5 in Apurímac, while it was 1.5 The Articulated National Program (PAN, from its Spanish ac- and 2 points lower in the rate of malnutrition in Ayacucho and ronym) is a joint initiative of MIDIS, the Ministry of Health Huánuco, respectively. For an average child, having pneumo- of Peru (MINSA), the Ministries’ Council of Peru, the SIS coccal and rotavirus vaccines implies a reduction in the prob- and the regional and local governments. The program, con- ability of being malnourished by 4 percentage points, from ducted by MINSA, was implemented since 2008, prioritiz- 14% to 10%. However, the limitations of the used methods to ing intervention in favor of children (Cruzado, 2012), whose determine causality evidence could had resulted in possible objective is reducing the prevalence of chronic malnutrition unobservable inputs (Cruzado, 2012). in children under 5 years old (Cruzado, 2012). An extension of the PAN has been approved by the Peruvian Government, 2.2.6 “chispitas” until 2021. Originally, the program strategy consisted in the allocation of resources prioritizing the delivery of two prod- Between 2009 and 2011, the MINSA and the former ucts: (1) Child Growth and Development Controls (CRED), MIMDES, in collaborative work with UNICEF and the World and (2) a vaccination program. In its last phase from 2017 Food Program WFP (Programa Mundial de Alimentos PMA), to 2021, the PAN beneficiaries include pregnant women and developed a pilot experience of a supplemental food program lactating mothers, in order to avoid low weight of children at with multi- micronutrients called “Chispitas” (“Sparkles”), birth, and get strong mothers and children, as well as fight- incorporating iron (Fe), zinc (Zn), vitamin A, vitamin C and ing against anemia and low developmental performance folic acid in a powder presentation. This supplementation (MINSA, 2017b). was focused on children under 3 years of age (MINSA- PMA- In its original version, CRED was essentially conceived UNICEF, 2012), with the general objective of preventing and of periodic visits to health centers to monitor the growth and controlling nutritional problems due to micronutrient defi- health of children, where they are measured and weighed. ciencies in children from 6 to 35 months old, through supple- Nowadays, in its current version, additionally mothers receive mentation with multimicronutrients for a period of 18 months 14 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO (MINSA- PMA- UNICEF, 2012). Nowadays, and according adverse effects associated with the multimicronutrients were to the impacts obtained until 2011, the program was extended registered. and it is currently ongoing under the initiative of MINSA, and Similarly, Huamán et al. (2012) carried out a cross- called “Nutriwawa” (MINSA, 2015). sectional study to evaluate the impact of the “Chispitas” The specific objectives of this program have been: (1) en- program in the Apurímac region. The study population con- suring that children of 6 to 35 months old, who access the sisted of children from 6 to 35 months old and their mothers medical health service center, are supplemented with micro- or caregivers. Almost all (97.3%) of the population partici- nutrients; (2) strengthening intersectoral working groups at pated in a social program of the Peruvian government; 94.7% the national, regional and local levels in the areas covered by of the children participated in the “Papilla” program; 70.3% the proposal; (3) strengthening the capacities of MINSA and in the “Vaso de Leche” program, and 37.5% in the “Juntos” MIMDES staff, as well as community agents, parents and program. It was found that 49% of children consumed ade- caregivers; (4) strengthening the information management quately, whereas in 84% of cases of those who received the that, in turn, strengthens existing systems for monitoring sup- intervention and did not use it properly, it was because chil- plementation within the framework of comprehensive care; dren not finished the meal as they disliked the taste. Those and (5) generating scientific evidence that contributes to im- children who consumed the supplement adequately had proving future intervention strategies (Ministerio de Salud 17.4% lower prevalence of anemia than those who did not. (MINSA), Programa Mundial de Alimentos (PMA), Fondo One positive aspect that was found is the greater promotion de las Naciones Unidas para la Infancia (UNICEF), 2012). and extend of intervention in rural and poorer communities. The program strategy was the distribution of multimicro- Based on these results, Huamán et al. (2012) pointed out that nutrients to every child from 6 to 35 months attended in the it is not enough to deliver the multimicronutrients, but to en- health establishment of MINSA, as well as the Peruvian Social sure that the consumption process is adequate to achieve a Security, as part of a comprehensive health care, consisting reduction in the prevalence of anemia, an aspect that must be in the control of their growth and development (CRED) rates, improved within this intervention. reaching approximately 100 000 children in the whole three departments (Apurímac, Ayacucho and Huancavelica). The 2.2.7 “vaso de leche” incumbent health professionals were trained to teach and ad- vise on the correct consumption of the powder supplement. The Vaso de Leche (Glass of milk) is one of the largest cur- A supplementation scheme of 18 months was selected with rently ongoing food- assistance program of the country, cre- the basic formulation of multi- micronutrients for the preven- ated in 1985. The program is administered and executed by tion of nutritional anemia, called “Nutritional Chispitas”. all the provincial municipalities in the country. The target According to international recommendations, the supple- population of Vaso de Leche are the maternal and child popu- mentation scheme would consist of the monthly distribution lation between 0 and 6 years of age, as well as pregnant and of 15 envelopes to be consumed interdaily during two 6- lactating mothers, prioritizing in those who are malnourished month cycles, with a 6- month resting period between the two or affected by tuberculosis. Subsequently, the coverage in cycles (Ministerio de Salud (MINSA), Programa Mundial the province of Lima is extended to children between 6 and de Alimentos (PMA), Fondo de las Naciones Unidas para la 13 years of age as a second priority, and elderly adults and Infancia (UNICEF), 2012). patients with tuberculosis as a third priority (Suaréz, 2003). The objective of the program is complementing the food Impact studies of Chispitas intake of beneficiaries at national level, delivering a food por- A surveillance study conducted on 759 children who received tion (milk in any form or other product) of 44.6 g that must the supplementation strategy in Apurimac (Andahuaylas), meet the established nutritional contribution of 207 Kcal, Ayacucho and Huancavelica, during the first (pilot) phase with a balance of 12–15% protein, 20–25% fat, 60–68% car- of the program, found a remarkable decrease in anemia in bohydrate, and must cover the 7 days a week (CGR, 2013b). 51.8% (Ministerio de Salud (MINSA), Programa Mundial de Alimentos (PMA), Fondo de las Naciones Unidas para la Impact studies of Vaso de Leche Infancia (UNICEF), 2012). The adherence of children to the Even though the Vaso de Leche constitutes the largest (and program exceeded to 90%. From the children who presented oldest) food program provided by the Government in the moderate anemia prior to supplementation, 55.3% resolved country, the evidence so far suggests that it does not achieve their problem, whereas 28.6% changed to mild anemia and the expected nutritional impact on children (Alcázar et al., 16.1% remained in the same situation. At the same time, 2003; Streuli, 2012). Buob (2015) used official information 68.9% children with mild anemia at the baseline, solved their from 2007 to 2011 of the INEI, the Integrated Administration problem, whereas 22% remained with mild anemia and in and Financial System (SIAF) of the Ministry of Economy and 8.35% of them the problem evolved to moderate anemia. No Finance (MEF) and information available from the General PILLACA- MEDINA AND CHAVEZ- DULANTO 15 of 22 Comptroller of the Republic of Peru (CGR), concluding that participation of the organized community and local gov- there is no relation between the resources allocated to the ernment; (B) The improvement of hygiene, health care and program and its results, and there is no clear relationship be- infant feeding practices (through improved access to com- tween expenditure and effectiveness, despite the visible limi- munal surveillance systems); (C) direct the production of tations in the samples to carry out the impact assessments on the families to products with demand in the market and link the program. This study suggests that Vaso de Leche has a them to competitive production chains (through the creation rather limited effect on nutrition, so it would not be meeting of local markets for technical assistance, access to credit the objectives for which it was created from the outset, which and organization of production chains); D) diversification is improving nutritional levels of the vulnerable population. of the production for self- consumption through the instal- Similarly, from a selective evaluation of 800 provincial and lation of family gardens and small animal modules that district municipalities regarding the expenditure of servings would provide them with a greater availability of micronu- of the Vaso de Leche program during 2012, the CGR (2013b) trients, vitamin A and iron, essentially (implemented and found that 84.1% of delivered portions presented nutritional cofinanced with the participation of the organized commu- contributions lower than the minimum established by the nity and local government); (E) strengthening communal Ministry of Health (MINSA), and only 8.8% of the rations management capacity (through committees of community reported fulfilled the quantity of macronutrients, energy and development committees) and local governments, mainly nutritional distribution established. With regard to coverage, related to the development of communal and local devel- only 11% of the municipalities delivered a ration that meets opment plans; and the better use of municipal resources the minimum nutritional value for more than 271 days a year. (mainly participatory budgets) for actions that contribute to Buob (2015) concluded that, because the determinants of mal- reducing chronic malnutrition (Rojas et al., 2007). nutrition are found at different levels, Vaso de Leche seeks to tackle this problem by offering a food portion whose protein Impact study of REDESA level is not high enough, suggesting that Vaso de Leche could To determine the impact of the program, a comparison was be representing a sink of budget for Peruvians, since it is an made of the variables corresponding to the program objectives, expense that the Government has assumed year to year with- measured before (baseline) and after the intervention. Chronic out evaluating the impacts in a specific period (Buob, 2015). malnutrition was reduced from 34.2% to 24.3%, the acute diar- rheal diseases were reduced from 35.0% to 16.4%, and exclu- sive breastfeeding increased from 25.0% to 72.2%. The annual 2.2.8 Redes Sostenibles para la Seguridad family income increased by 61%, while money for food pur- Alimentaria - REDESA chases increased by 34.5% (Rojas et al., 2007). An important The program Redes Sostenibles para la Seguridad Alimentaria aspect highlighted by REDESA has been the participation of REDESA (Sustainable Networks for Food Security) was im- women in the improvement of the health and nutrition of their plemented by the NGO CARE Peru, from 2001 to 2006, in families, as it is the mother who is the one concerned in the 1854 communities of 125 districts belonging to the regions decision making. REDESA evidenced that in rural areas, social of Ancash, Apurímac, Ayacucho, Cajamarca, Huancavelica, and cultural aspects influence the effects that can be achieved, and Puno. In its last year of intervention, the beneficiary pop- such as the use of the Quechua language and the family envi- ulation accounted with 34 203 boys and girls (Rojas et al., ronment, where young women are restricted to make decisions 2007) in a total of 58 570 families (Flores & Rojas, 2007). about their children’s health and food alone, without the par- Its general objective was to reduce chronic malnutrition ticipation of the mother- in- law or grandmother of her husband, in children under 3 years old from Andean highlands of and even of any other “older” women recognized in the com- Peru. The specific objectives were (1) reducing diarrheal munity for their experience (Flores & Rojas, 2007). diseases (acute diarrheal disease), (2) improving infant feeding practices, and (3) increasing family income (Rojas 2.2.9 Proyecto Educativo Nutricional et al., 2007). To achieve them, REDESA implemented a en Prevención de la anemia y desnutrición comprehensive strategy to reduce chronic malnutrition, en Niños menores de cinco años y mujeres with actions addressing both its immediate causes and their gestantes en Pachacútec (Ventanilla, Lima, underlying causes, with the important distinction of not in- Peru) cluding food distribution among its lines of action, which marked a substantive difference with the food assistance The Program of Educational Intervention in Prevention approach that exists in the country. It was achieved by de- of Anaemia and Undernutrition in Pachacútec (Ventanilla veloping the following lines of action: (A) Safe water ac- District, Callao, Lima), was a nutritional educational pro- cess and basic sanitation, through the installation of water ject in anemia and malnutrition prevention in children under systems and latrines implemented and cofinanced with the 5 years of age and pregnant women, implemented between 16 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO 2004 and 2007 in the urban marginal district of Ventanilla, children facing chronic malnutrition and anemia. There is Callao Region, in order to improve the nutrition of children evidence that inadequate feeding practices in early childhood under the age of five. This program constituted a joint initia- are among the most important factors leading to malnutri- tive of the World Food Program of the United Nations (WFP), tion. After 3 years of initiation of the intervention, the impact the National Food Assistance Program of Peru (PRONAA), assessment study estimated a reduction of 4.5 percentage and the NGO Alternativa—Centre for Social Research and points (50%) in chronic malnutrition or growth retardation Popular Education (PMA et al. 2008). The project was devel- of the children who benefited from the project. For the in- oped by a group of families living in the area, that contributed dicators of global malnutrition and acute malnutrition, the actively to their own organization to extension of the resources initial prevalences were 8% and 2%, respectively, and could provided through training. The intervention model had four be reduced to 7% and 1%, respectively. At the beginning of components: education, health care, food supplementation, the intervention, the anemia affected to 60.2% of the children and strengthening of social organizations (Programa Mundial evaluated, and at the end, it affected to 18.4% of the children, de Alimentos, Pronaa y Alternativa, 2008). which indicates a reduction in 70% (Programa Mundial de The educational intervention was one of the most im- Alimentos, Pronaa y Alternativa, 2008). It was observed that portant components, through training and communication after 2 years of intervention, 98% of the beneficiary children during the first months of the experience, to identify the had adequate food for their age. The contribution and com- community problems. The food supplementation was car- mitment of the mothers themselves and their community, the ried out through the elaboration and distribution of a por- educational activities for the health care in the homes and the tion of porridge or Maize meal to children under 5 years strengthening of social organizations had positive effects on old, made by their own mothers previously trained. The their children nutritional status. It is estimated that the mes- daily basket per child consisted of 34 grams of cereals, 18 sage of the program was disseminated to approximately 5,800 of menestra (Leguminosae grains), 13 of sugar and 9 of people in 234 replicate sessions during the 4 years of project vegetable oil, provided by the project PER 6240, whereas execution. Therefore, according to the Programa Mundial de the mothers supplied 25 grams of vegetables or fruits and Alimentos, Pronaa y Alternativa (2008), the achievements 21.6 grams of vegetable products. of the project show a great potential for replicability of the The porridge was delivered from Monday to Friday, to an intervention model in the measure that suits different socio- average of 850 children. Between 2004 and 2005 the por- economic contexts in the country, and that it is possible to ridge was intended for pregnant women and children under achieve these quantifiable achievements through training and two, but for 2006 and 2007 it was extended to children up strengthening social organizations to improve the health and to 5 years. One reason for the expansion was the perceived nutrition of their children. demand for older siblings and cousins. The health care com- ponent consisted of two activities: deworming twice a year 2.2.10 “con todas las manos” and supplementation with iron sulfate intended for pregnant mothers and young children. “Con todas las manos” (With all hands) was a project de- Strengthening of social organizations was considered a veloped by the NGO A.B. PRISMA with the financial and basic component in the program model, taking into account technical support of the Change Aid Project in Peru, in 2004. that the sustainability of the experience was in the hands of Different approaches on communication and promotion of the community itself. For this, it was essential to have a team health and hygiene were combined to enhance the influ- of leaders or health promoters who handled basic concepts ence of knowledge factors on motivation toward a behavior in food, nutrition and hygiene, and would be responsible change regarding hand washing with soap in 402 families for disseminating the messages not only to the beneficia- with mothers with at least one child under 5 years old, from ries, but to the entire population of Pachacútec. Therefore, 32 communities and quarters of the Uchiza district, located in it was linked with the association of community promoters, the central highlands of the rainforest region of Peru, depart- community leaders and active social organizations (public ment of San Martín. As a secondary target group, it was es- food programs, Vaso de Leche, etc.) (Programa Mundial de tablished the participation of other members of the family, as Alimentos, Pronaa y Alternativa, 2008). well as the local municipality authorities, the education and health personnel working in the area, and whose unsatisfied Impact studies of proyecto educativo nutricional en basic needs were mainly related to the lack of public network prevención de la anemia y desnutrición en Niños services for the elimination of excrements, overcrowding and menores de cinco años y mujeres gestantes en inadequate housing (Bartolini et al., 2008). Pachacútec The objective of the program was to increase the practices Final evaluations of the results, compared with the base- of hand washing with soap and, therefore, the decrease in the line, have shown that the program had a protective role in prevalence of diarrhea in children under 5 years (Bartolini PILLACA- MEDINA AND CHAVEZ- DULANTO 17 of 22 et al., 2008). Con todas las manos used a ludic- educational area. On the other hand, the food delivered by Qali warma, methodology at the family and individual level, as well as at the greatest coverage in food distribution program, seems to the mass and political levels, making visible and affirming in contain sugar and fat in excess, and that a considerable per- everyday practices the importance of hand washing for the centage of children do not consume it. Regarding Pension healthcare of children. The intervention at the individual and 65, although it has increased the monetary income of elderly family level was carried out through personalized campaigns people, it is not reflected in the care of their health. Similarly, to motivate, reinforce and consolidate the practice of hand the PAN has been also featured as an iterative intervention, washing with soap in the form of home- based educational despite the reduction in infectious diseases in the target chil- and play visits. The intervention at the level of public ac- dren population. Therefore, these four programs (Chispitas, tors was effectuated through a public campaign to promote Qali Warma, Pension 65 and PAN) are considered having positive practices in healthcare. It was sought that municipal fulfilled partially their objectives. Contrastingly, the Vaso de authorities and representatives of mass media (radio, news- Leche program would not have met its aim, as the nutritional papers) developed activities that supported messages at the supply of a personal portion is not enough to complement the household level, thus placing a private hygiene rule in the daily nutritional uptake of the target population. Therefore, it public space (Bartolini et al., 2008). is evidenced that all social programs must carry out an articu- lated and complementary work in order to reduce FI, avoid- Impact study of “Con todas las manos” ing duplication of interventions, as well as doing a wise use After the intervention period of 5 months, comparing with the of financial resources to contribute to the sustainable devel- baseline, a statistically significant decrease in diarrhea was opment of the country. achieved in children under five, from 50% to 37% for the pre- In the case of the universal coverage (food, health, ed- vious 15 days between baseline and final evaluation. It was ucation) assistance programs (Type 1, Table 2), it can be evidenced a change of 18 percentage points in the behavior concluded that there are at least three main psycho- social of using soap in hand washing in the participant population of components that would affect negatively the achievement of the campaign of education, without any additional campaign the programs objectives. The first component is related to so- having taken place simultaneously. The percentage in hand cial relations, as a great part of the success of the program de- washing with soap increased from 15% to 34%. Therefore, it pends on the contact to the leaders of the community, which can be inferred that it is possible to make, in the short term, are usually organized as comedores populares (expenditures changes in the practices of hand washing with soap as a result where food, prepared by mothers of the community, is sold at of intensive interventions of home visits and public activities. the cheapest price), Vaso de Leche committees, etc. The sec- The reason why there is an increase in the practice of hand ond component is linked to gender issues, as in many cases it washing with soap would be given because the interest in was reported that men (couples, husbands, etc.) did not allow healthcare was activated in general, the enjoying- the- taste of women going to the training sessions or even to receive the learning from mothers and children based on games, and for food supply in the comedores populares. Women obeyed for the existence of recalling elements to remember the behavior. fear to reprisals (domestic violence, mainly). The reason for It is important to mention as crucial for mothers to adopt the this behavior was, in turn, linked to the perception of their change and benefit, the social recognition for having a clean own poverty and their image to the community, which was in and well- cared child (Bartolini et al., 2008). several cases shared by women, as accepting participate in the programs would mean that they are needy and their children are malnourished, anemic, and suffering deficiencies, there- 3 CONCLUSIONS fore facing with personal expectations and undermining their already deteriorated self- esteem, generating frustration. The According to the impact studies of the social programs under third component is the desertion of mothers to participate in analysis, most of them reported having met most of their ob- the program, due to their own poverty situation, as mothers jectives (Juntos, Haku Wiñay, REDESA, Proyecto Educativo preferred going to work (e.g., doing cloth hand washing and Nutricional Pachacútec, Con todas las manos). However, other domestic tasks in the rich sectors of Lima City) in order there are controversial evaluations of some programs. In the to earn some money that would allow buying food for all case of Chispitas (Nutriwawa), some studies state that it re- their children in the comedor popular, instead of going to the duced anemia significantly, but others indicate that the reduc- educational training sessions. However, some mothers have tion rate is rather small, as at the national level, the anemia limited access to work, as having more than one child means has been not reduced since 2009 (37.2%) to 2014 (35.6%), being not accepted in nowhere (as they have to take their chil- and according to MINSA, the prevalence of anemia in girls dren with them), and even so, they did not participate in the and boys under 3 years shows a constant of 43.5% between program due to the lack of proper clothes to protect their chil- 2015 and the first half of 2016, being more critical in the rural dren against the cold climate (winter) outside the household. 18 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO Therefore, it can be suggested that, firstly, programs must and Harrison (2014) carried out a study using data from the change the image of the participants, focusing the participants national monitoring of nutritional indicators for the years 2003, as winners, responsible parents, for “best boys and girls”, and 2004, 2006, 2008, 2009, and 2010, finding an association be- not focusing so much on the problem (anemia, malnutrition, tween the participation of food assistance programs (FAP) and illiteracy, etc.), but on the possibility of overcoming it, trans- overweight/obesity among nonpoor Peruvian women who re- mitting this positive message since the first contact with the ceive FAP benefits. Among women living in households with 0 community leaders. Secondly, it can be suggested to opt for poverty indicators, FAP participation was associated with 30% a house- to- house approach to the program during the seasons to 50% increase in overweight/obesity risk after controlling for where the climate represents an obstacle, as winter and sum- several possible confounding factors. Among women living in mer, for example, in order to create a multiplicative effect and households with at least one poverty indicator, FAP participa- achieve the maximum adherence of the target population. tion was not associated with overweight/obesity. Therefore, the On the other hand, it can be concluded that child- centered correct orientation of the FAP, particularly those who provide CCT programs need to be more child-sensitiv e, especially food baskets, can play an important role, as delivering extra in rural areas whipped by the past internal conflicts. Indeed, calories to people who do not need them could increase their CCT programs must consider children within the context risk of overweight and obesity, which have been pointed out as of their relationships with their families and wider society, public health problems in Peru by Alvaréz-Dongo e t al. (2012). in order to avoid systematic and institutionalized exclusion, Being nonpoor and living in urban areas seem to be social de- being crucial to understand the roles of different actors and terminants of overweight in the Peruvian population. institutions in the lives of the children (Ray & Carter, 2007; Despite the weaknesses of the social programs developed Streuli, 2012). CCTs also would show more knowledge and in Peru so far, the achievements show a great potential for awareness of child- specific risks vulnerabilities—which replicability of the interventions, if they are adapted to dif- may include the effects of environmental shocks; nutrition; ferent socioeconomic contexts in the country. Moreover, they violence within the household, school and community; so- show that it is possible to achieve quantifiable achievements cial exclusion; and the sense of powerlessness that children through the training and strengthening of social organiza- and their families experience—and incorporate different tions, including and developing tools according to the reality family models and structures, that is, recognizing that there of the target areas, which can be considered as a key to ob- are multiple family forms and structures of care, including tain the final results to redress FI, emphasizing on children, grandparents (grandparental care), the extended family (other as they constitute the largest population group in Peru, and relatives) and child-headed households, ins tead of basing therefore, must be prioritized by the social programs, spe- interventions upon the nuclear family norm. Furthermore, cially from those coming from the Government. child- centered CCT programs would also pay more attention As seen above, the evaluation of impact assessment of the to community history, backgrounds, and social cohesion and social programs in Peru has enabled to contrast their results dynamics to minimize tensions and maximize people’s use of with their original objectives, and therefore to identify their social networks. For example, CCTs like Juntos need to com- achievement level, as well as their weaknesses and possible bine their focus on individual households with community- secondary negative consequences. We conclude that the im- level actions to strengthen mutual collaboration and sense of pact assessment analysis enhances the necessity for rethink- reciprocity, which is vital to most rural communities in the ing the forms of intervention in social programs. country (Streuli, 2012). Indeed, to be more child- sensitive, CCTs should build better links between child protection C ONFLICT OF INTEREST and broader social protection measures, instead to be based None declared. on a rather narrow approach to childhood poverty and well- being, in which children are mainly seen as indicators, and investments for the future. Finally, a move away from the OR CID focus on beneficiaries’ “duties” toward a view that respects Susan Pillaca-Medina people’s dignity and rights, simultaneously to a move away http://orcid.org/0000-0003-4204-5939 from “monitoring, policing and surveillance” to an approach that emphasizes inclusion, as listening and working together Perla N. Chavez-Dulanto would enhance the achievements and therefore the impact on http://orcid.org/0000-0003-2057-4565 the target population. 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H., … Henry, C. A. (2014). Evaluación de las http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Food and Energy Security Wiley

How effective and efficient are social programs on food and nutritional security?

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Abstract

Engineering in Food Industries, Faculty The analysis of the impact assessment of social programs allows to identify whether of Chemical Engineering and Metallurgy, Universidad Nacional San they fulfil the established objectives and evidencing the weaknesses to be strength- Cristóbal de Huamanga, Ayacucho, Perú ened in future actions, and modify or propose new intervention strategies. In Peru, Faculty of Agronomy, Universidad the substantial economic progress since the 90s decade promoted dramatical invest- Nacional Agraria La Molina, Lima, Perú ments in the social sector, especially on children well-being, as around 30% of the Correspondence total Peru population are children under the age of 15, being the age group most af- Susan Pillaca-Medina, Condominio los fected by poverty in the country. This review was aimed to present an overview of Álamos Dpto. H-204, Parques del Agustino, El Agustino, Lima, Perú. the current situation of social programs in Peru in terms of food (and nutritional) Email: ssusan_14@yahoo.es security (FS), emphasizing on the institutional framework and the impact of the so- cial programs implemented by the Government, as well as some social programs implemented by nongovernmental organizations. To this end, information available on the world wide web, including peer-reviewed papers on databases (mainly SciELO and LiLACs for their relevance for the Latin American region) regarding FS in Peru from 1989 onwards, and information published by the Peruvian official organisms directly involved in FS, was used. Studies addressing at least four of the seven points of the food and nutritional security in Peru analyzed in this paper (access, availabil- ity, consumption, biological use, stability, current situation, and institutionality) were considered. It was concluded that investment and resources should be used to improve social programs strategies designed according to the reality of each focused area, as in Peru, the achievements show an enormous potential for replicability of the interventions. Children must be prioritized through child-sensitive programs, instead of considering them just as indicators and investments for the future—especially in rural areas whipped by the past internal conflicts—in order to contribute to the sus- tainable development of the country and assuring FS. KEYWORDS chronic malnutrition, food security, impact assessment, Peru (Source: DeCS BIREME), social programs Both authors contributed equally to the manuscript. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2017 The Authors. Food and Energy Security published by John Wiley & Sons Ltd. and the Association of Applied Biologists. Food Energy Secur. 2017;6:e120. wileyonlinelibrary.com/journal/fes3 | 1 of 22 https://doi.org/10.1002/fes3.120 2 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO Amaru (CNDDHH 1997; CVR 2003). During the 1990s de- 1 INTRODUCTION cade, the internal conflict was virtually over (CVR 2003), Although global food availability per capita has improved and the country went through a period of economic adjust- markedly over the past half century simultaneously to a de- ment and structural reforms including trade liberalization and crease in real food prices, hunger, malnutrition, and food increased flexibility in the labor market, which still remain insecurity remain widespread (Barret, 2002). Around one bil- as a considerable concern (Streuli, 2012). Since then, Peru is lion people suffer undernourishment today, while probably at making a substantial economic progress (Paxson & Schady, least one- third of the world’s population bears nutritional risk 2002). After 1990, growth has been generally strong, infla- (Barret, 2002). Despite food assistance and private charitable tion low, and poverty reduction sustained (World Bank 1996, programs from governments and/or other institutions (non- 1999). Considering full 2016, the Peruvian economy ex- governmental organizations, federal programs, etc.), food in- panded 3.9 percent, the highest growth rate in the last 3 years security is a persistent worldwide problem, affecting not only (Trading Economics 2017). Consequently, investments from to developing countries, but also to highly industrialized and the Peruvian government in the social sectors have increased developed countries, as US (Bickel, Nord, Price, Hamilton, & dramatically, attempting to target these social investments to Cook, 2000), where it has been reported to affect to 11% of the poor. Indeed, between 2001 and 2006, a number of social all households (Nord, Andrews, & Carlson, 2004) and 16% of programs were implemented by the Peruvian Government to households with children (Nord, 2003). help the most vulnerable sections of the population to bear According to FAO (2015), (World Summit on Food, the transition (Cueto, Escobal, Penny, & Ames, 2011), and 1996), food security (FS) occurs when all people have phys- important measures were taken to tackle poverty in gen- ical and economic access to sufficient, safe and nutritious eral, emphasizing the improvement of the situation of chil- foods that meet their daily energy needs and food preferences dren (Streuli, 2012). However, the effectivity and efficiency for living a healthy and active life. Thus, FS encompasses of Peruvian social programs remains not completely clear different dimensions such as access and availability, con- (World Bank, 1999). sumption, biological utilization and stability in food supply, For these reasons, the aim of this work has been to de- where the institutional aspect contributes to the reduction in termine whether the social programs developed in Peru do Food Insecurity (FI) (Salcedo, 2005), which refers to limited achieve their original goals (settled before the onset of the or uncertain availability of or inability to acquire nutrition- project/action), discussing the impact of social assistance ally adequate, safe, and acceptable foods due to financial programs implemented in Peru during the last years, mainly resource constraint (Bickel et al., 2000). More specifically, of those which have been qualified as successful accord- food insufficiency refers to an inadequate amount of food in- ing to different entities. The methodology of investigation take due to resource constraints (Sahyoun & Basiotis, 2000). followed was reviewing literature documenting the impact Thus, finding appropriate distribution mechanisms to solve assessment of social programs developed in Peru, using as the problem is considered a strong political imperative, that, data sources the published information available on the world however, does not guarantee success. Food security remains wide web, including peer-reviewed papers on different data- a prominent concern for economists, as most nations have bases (mainly SciELO and LiLACs due to their relevance for implemented food assistance programs of some sort, but the Latin American region) regarding food (and nutritional) many of these have proved to be expensive and/or ineffective security (FS) of Peru from 1989 onwards. Information pub- (Barret, 2002). lished by the official organisms directly involved in FS in The worst economic and political crises in the history Peru was also used. Studies were assessed for relevance based of Peru occurred from 1980s to 1990s: inflation peaked at on information quality, and only those addressing at least four over 7,000 per cent; unemployment rose considerably and of the seven topics of the food and nutrition security in Peru the proportion of poor households increased (Escobal et al., analyzed in this paper (access, availability, consumption, 2003). During that period, the Peruvian population, in par- biological use, stability, current situation, and institutional- ticular those living in rural areas, experienced an internal ity) were considered. Studies containing less than 4 of the 7 conflict between the Government and Sendero Luminoso were excluded. Likewise, whenever possible, the information (Shining Path), a terrorist communist organization inspired about the methodology followed by the different authors to by Mao’s Cultural Revolution in China, that imposed a ruth- assess the impact of every social program has been detailed at less rule on the rural areas it seized, killing elected officials, the beginning of the correspondent paragraph (items 2.2.1 to trade union organizers, peasants, and villagers suspected of 2.2.10). Thus, only three (Haku Wiñay, Proyecto Educativo siding with the Government. Approximately 69,280 people Nutricional (…) Pachacútec, Con todas las manos) out of the were killed or disappeared at the hands of Sendero Luminoso, ten projects under analysis have not clear and/or detailed in- Government forces, self- defense committees, and other guer- formation about the methodology followed for their impact rilla groups such as the Movimiento Revolucionario Túpac assessment. PILLACA- MEDINA AND CHAVEZ- DULANTO 3 of 22 Yamada and Pérez (2014) pointed out that impact as- 5–11 years old are already involved in economic activities— sessments provide valuable information as a policy tool against only 4% in urban areas (UNICEF 2004). for establishing whether projects, programs or public poli- cies are effectively meeting their development objectives. 1.1.1 Access Quantitative results of impact assessments enable the iden- tification of which programs achieve the stated objectives INEI evaluates poverty at national and local level peri- and which programs have the greatest impact, turning them odically, considering to be in poverty when people have a into an indispensable guide for an adequate distribution of budget- income below the cost of the “basic basket” com- scarce resources from public sources and from the interna- posed of food and nonfood (housing, clothing, education, tional cooperation for development (Yamada & Pérez, 2014). health, transportation, etc.) items, and as in extreme pov- Therefore, section 1 describes the current situation of the erty when their per capita budget- income is below the cost Peruvian population with emphasis in food and nutrition se- of the basic food basket (Instituto nacional de estadística e curity, section 2 describes and discusses the impact of cur- informática- INEI, 2016b). rently ongoing and some past social programs developed in Despite the political stability and economic growth since the last years, and finally, section 3 presents the main conclu- early 2000s, almost half of the population in Peru still lives sions, emphasizing food security aspects, highlighting their in poverty (Streuli, 2012), with one in six facing extreme weaknesses and suggesting actions for improvement and poverty (Escobal, Ames, Cueto, Penny, & Flores, 2008). strengthening. Poverty rates started to fall slightly, from 49% to 45% be- tween 2004 and 2006 (INEI, 2002; INEI, 2006; World Bank 2005). The analysis of poverty by natural regions carried 1.1 Characteristics of the peruvian population out by INEI in 2006, suggests that the number of “poor” regarding food and nutrition security people in rural areas is not only greater than urban areas, By 2015, according to the National Institute of Statistics and but that people are also two times more “poor” than their Informatics of Peru (INEI), there were 31 151 643 inhabit- counterparts in urban areas (excluding Lima city), calcu- ants in the whole country, 57.8% of them living in the coastal lated in 28% against 14% (INEI, 2006). Nowadays, signifi- area, 27.3% in the mountain range and only 14.9% in the rain- cant differences still exist within the population. forest area (Instituto nacional de estadística e informática- Total and extreme poverty has declined from 33.50% and INEI, 2015a). Most of the population lives in the urban area 9.50%, respectively, in 2009, to 21.77% and 4.07%, respec- (76.2%) and is relatively young: 29.9% are under 15 years tively, in 2015, with a higher percentage in the rural area old, 62.0% between 15 and 64 years old, whereas only 8.2% (Figure 1). For 2015, the monthly average real income per are 65 years old and over (INEI, 2015b). capita (estimated in Nuevos Soles (S/.) = PEN) was S/. 886, As described above, around 30%of the total Peruvian pop- showing an increase in S/. 773 respect to 2009, being S/. 1027 ulation are children under the age of 15 (INEI, 2007), being in the urban area and S/. 432 in the rural area. Likewise, the this the age group most affected by poverty in Peru (UNICEF average real monthly expenditure (rme) per capita for 2015 2008). In 2004, while 45% of Peru’s total population was at the national level was S/. 673, being in the urban area S/. living in poverty, around 60% of children aged 3–16 years 765 and in the rural area S/. 375, showing an increase with old were poor (INEI 2006). In other words, the poverty rate respect to 2009, since the average rme per capita for that for children was approximately 15 percentage points higher year at the national level was S/. 591, being in the urban than the poverty rate for the overall population. The situation area S/. 704 and in the rural area S/. 284 (INEI, 2016b). The was even worse in rural areas, where an estimated 80% of 3- inequality in the distribution of the income measured by to 16- year- old experienced poverty (Streuli, 2012). To face the Gini coefficient for 2015 reached 0.44 at national level, their family’s poverty situation, some children are involved in showing a reduction from that of 2009 (0.49) (INEI, 2016b). economic activities, either through paid work or undertaking Total and extreme poverty according to area of residence in a range of different work activities at their parent′s work or the years 2009 and 2015 are shown in Figure 1. at home (Streuli, 2012). Indeed, in 2004, UNICEF estimated Regarding the per capita distribution of expenditure in that one out of every four children under 18 years old in Peru 2015, it is observed that 41.3% addressed food (S/. 278), is involved in economic activities. Almost 21% of Peruvian showing a slight increase compared to 2009, which was S/. children combine work and schooling, whereas around 5% of 255 (INEI, 2016b). children only work. Child work seems to be associated with poverty: around 40% of children coming from households 1.1.2 Food availability classified as “extremely poor” work, whereas only 20% of those classified as “nonpoor” do. The highest incidences of According to the Peruvian Multisector Commission on child work are found in rural areas, where more than 30% of Food and Nutrition Security (2013), the Food Balance 4 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO 66.72 % 45.18 % 29.81 % 21.3 % 14.54 % 20 13.93 % 2.07 % 1.02 % FIGURE 1 Total and extreme Total Total Total Total Extreme Extreme Extreme Extreme rural rural urban urban rural rural urban urban poverty according to area of residence in poverty poverty poverty poverty poverty poverty poverty poverty the years 2009 and 2015 (Source: INEI, 2009 2015 2009 2015 2009 2015 2009 2015 2016b) Sheet (HOBALI) of the Ministry of Agriculture (MINAG) Only 75.5% of Peruvian children between 6 and of (2007) considers that the net per capita food availabil- 35 months of age has minimum food diversity, regarding ity in Peru is: cereals and derivatives (115 kg), tubers (114 caloric and protein adequacy. It reflects the food insecu- Kg), fruit (91 kg), live animal products (80 kg), vegetables rity and low educational level of mothers or caregivers of (47 kg), sugar crops (38 kg), oils and fats (22 kg). The main children, whom would be limiting their food consumption. component (cereals and derivatives) depends on 88.7% of Food diversity has shown to be higher in the urban area, wheat imports (Eguren, 2012), which in 2016 was the most where it is observed that children consume grains, roots imported food item—as durum wheat— together with soy- and tubers regardless of age, followed by fruits and vegeta- bean oil (INEI, 2017). bles rich in vitamin A (Tarqui, Álvarez, Gómez, & Rosales, In the third quarter of 2016, during the same period, pro- 2016). According to Tarqui et al. (2016), 54% of the stu- duction was lower than 2015 for the following crops (with dents participating in the Global School Health Survey percentage of decrease): rice 20%, potato 14%, durum yellow 2010, stated to consume soda at least once a day, and 10.7% corn 10%, maize starch 22%, quinoa 42%. The reasons for the to consume fast- foods three or more days a week, with a decreased production have been highlighted as less harvest- low consumption of fruits and vegetables (31.7% reported ing area availability, low yields, adverse climatic conditions, to consume a banana, apple and/or orange once or twice scarce rainfall during different stages of crop development a day, whereas only 8.9% reported consuming vegetables that affected yields, among others. However, it is worthy such as lettuce, carrot, tomato, radish, at least three times pointing out that in the case of the citrus- fruit (tangerine), the a day). Furthermore, the survey revealed a high percentage production increased by 32%, as onion by 13.4%, avocado by of students engaged in sedentary activities, a situation that 12.4%, and in the case of chicken, production increased by predisposes to students to present an increased risk of non- 11% (Moreyra et al., 2016). transmissible diseases (MINSA, 2011). Exclusive breastfeeding, the practice of feeding the child with only breast milk, free of contaminants and germs, pre- 1.1.3 Consumption venting acute respiratory infections and strengthening the According to the food pyramid described by Díaz (2010), the immune system MINSA (2017a), is considered the only consumption of carbohydrate- rich foods in Peru is excessive, food capable of satisfying all the nutritional needs of the while paradoxically, fruit consumption is in deficit. Fruit con- child during the first 6 months of life, without requiring sumption should be about 15% of the daily intake, but records other foods or additives such as water or juices (MINSA, for all areas (coast, mountain, rainforest) did not reach even 2017a). In the first semester of 2016, 66.7% of the mothers half of the ideal proportions, whereas the consumption of said that they feed their children under 6 months of age with carbohydrate- rich foods reached almost 50%, when it should breast milk. This practice is greater in the rural area (83.8%) be around 40% (Díaz, 2010). Furthermore, according to the than in the urban area (59.5%) (MINSA, 2017a). Between Quarterly Report on Living Conditions by INEI (2016a), 2013 and the first half of 2016, the prevalence of breast- 32.5% of households in the country have at least one member feeding in the rural area increased from 80.8% to 83.8%. with a caloric deficit, affecting in 38.2% of the rural house- Regarding e xclusive breastfeeding practices, according to holds and 30.9% of the urban area (Lima City excluded). INEI (2015b), 65.2% of girls and boys under 6 months of age % of poverty PILLACA- MEDINA AND CHAVEZ- DULANTO 5 of 22 had exclusive breastfeeding and 6.3% from 6 to 9 months of Comisión Multisectorial De Seguridad Alimentaria y age continued to be fed with only breast milk. Velásquez Nutricional, 2013). et al. (2014), in a study carried out in 2012 in Peru’s extreme Climate phenomena do affect the stability and availability poverty zones (Cajamarca, Amazonas, Huánuco, Ayacucho, of food in Peru. Every year, the population of the Andean Huancavelica, Apurímac, Cusco, Puno, and Ucayali), did highlands and rainforest face the negative effects of the low find that 89.6% of children under 6 months received exclu- temperature season (frost and cold), known locally as friaje. sive breastfeeding. It affects their health, education, agricultural, livestock farm- ing, and infrastructure, especially in populations with high vulnerability, either because of their social condition (pov- 1.1.4 Biological use erty and extreme poverty), age (children, old- adults, etc.), or According to the demographic survey of family health in above all, their territorial location (Presidencia del Consejo 2015, at national level, 81.3% of households used potable de Ministros 2016). water from the public network, either inside or outside the It is estimated that a total of 1342 districts with dwelling or public tap. The highest percentage corresponds 1,866,327 inhabitants are exposed to frost danger, with lev- to the direct connection within the dwelling (74.9%). In the els of exposure between Very- high and High. The popula- urban area, 85.4% of households used water from the public tion with high rates of poverty and food insecurity, which water network, either inside or outside the dwelling or pub- subsist by the raising of sheep and camelids (llamas and lic tap, compared with 69.6% of rural households. However, alpacas) and subsistence agriculture, are the most vulnera- 16.0% of households in this area still use spring water, the ble to low temperatures. Bronchopulmonary diseases pre- river or irrigation ditches (INEI, 2015b), a figure lower than vail, especially among children under 5 years of age and that registered in 2009, which was 24.9% (INEI, 2009). adults over age of 60. Often, these diseases become fatal Arenas and Gonzales (2011) found a correlation between (INDECI, 2016). the percentage of access to potable water and drainage and On the other hand, climate change undoubtedly poses the percentage of medical consultations due to intestinal- a threat to food security in vulnerable areas. Indeed, in the infectious diseases from 2002 to 2009 in Peru. district of Pariahuanca (Junín, central highlands) the tropi- On the other hand, 91.8% of households accounted with calization of climate is occurring due to the increase in tem- hygienic services: 66.9% with the toilet connected to the out- perature, which has accelerated the life cycle of insects. The flow public network and 24.9% with latrine, including a cess- key pest of potato, the Andean weevil, is present in all its pool/septic tank. The proportion of households with hygienic life- cycle stages during the whole crop season. Similarly, the services in the urban area (96.8%) was higher than in the rural increase in pathogenic diseases outbreaks is causing wreak- area (77.0%). However, the percentage of households with- ing havoc on crops (Zárate & Miranda, 2016). out sanitary services in the rural area has declined from 2009 Likewise, from December 2016 to April 2017, a cascade (33.3%) to 2015 (21.8%) (INEI, 2009, 2015b). of climatological phenomena (strong rainfalls, floods, land- Another important factor affecting biological use is hand slides, thunderstorms, snowfalls, and hailstorms) affected washing. Pillaca and Villanueva (2015) did find in the dis- Peru, endangering life and health of people, damaging dwell- trict Los Morocuchos (Ayacucho, mountain area, south- ings, public places, cropping areas, and roads in a number ern Peru) that only 74.2% of mothers washed their hands of districts. A total of 1,104,247 people were severely af- before preparing food, 48.4% before eating, 41.4% before fected, 188 073 people were in damage, 133 people died, 21 feeding their children and 37.5% after going to the toilet. 294 households collapsed, 21 333 households disabled, 247 The percentage of families who always washed their hands 127 households affected, 326 bridges destroyed, 3563 km with water and soap was 7.8%, which is an important fac- of roads and 2114 km of rural roads were destroyed, 25671 tor to consider in future preventive strategies for intestinal- hectares of crops lost, 61403 hectares of crops affected, and infectious diseases. 6593 irrigation channels destroyed (INDECI, 2017). These events are considered a serious threat to food and nutritional security of the Peruvian population. 1.1.5 Stability Another aspect to consider influencing food security in The main risks faced by the country in relation to the stability Peru, are social conflicts. They cause food insecurity by of food supply depend fundamentally on the vulnerability in shortages of agricultural products (roadblocks, cessation of the production of food at the national level due to climatic production of products, etc.), which also causes instability in changes and, secondly, on the fluctuation of international citizen’s security (Multisectoral Comisión Multisectorial De prices of import food such as oil, soybean, hard yellow corn, Seguridad Alimentaria y Nutricional, 2013). According to wheat and derivatives, since these products are part of the the Defending People’s Office (2017) in February 2017 there basic consumption basket of Peruvian families (Multisectoral were a record of 212 social conflicts, 155 still active and 57 6 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO in latent situation. The largest number of social conflicts oc- the urban area (40.2%) during the first half of 2016. Between curring in a single region was registered in the departments 2015 and the first half of 2016, the prevalence of anemia in of Apurímac (26 cases), Ancash (26 cases), Cusco and Puno girls and boys under 3-y ear old shows a constant of 43.5% (18 each one). The socio- environmental conflicts occupied (MINSA, 2017b). 67.9% of the total conflicts registered in the month. They are Chronic malnutrition and anemia at national level, ac- followed by conflicts on local government issues with 9.4%, cording to the area of residence, are shown in Table 1. and conflicts on national government issues with 6.1%. A high percentage of intestinal parasitosis (enteropar- asitosis) has been reported by several authors in different districts of Peru. For instance, Alarcón, Iannacone, and 1.1.6 Nutrition and health situation in Espinoza (2010) conducted a study in the population of Peru Parque Industrial de Huaycán, district of Ate Vitarte (Lima), Peru has experienced significant changes in the epidemiolog- concluding that prevalence of enteroparasitosis was 74.24%. ical, feeding and nutritional patterns during the last 20 years, The risk factors that favored the persistence of intestinal par- due to changes in the economic, social and demographic as- asitosis, according to the study, were as follows: poor basic pects. For example, the massive migration to the cities from sanitation (houses with dirt floor, lack of potable water and rural areas, has generated important changes in living condi- drainage, throwing of debris to the clearing, etc.), and poor tions and welfare of the migration groups (Peña & Bacallao, hygiene habits such as playing with dirt or do not washing 2000). hands before eating or after going to the toilet. In addition, Since 2000, the mortality rate for children under 5 years having domestic animals at home, specially dogs. Similarly, old has gone down by 30%, although the child mortality rate Cabrera, Verástegui, and Cabrera (2005) found 77.88% of in rural areas is still almost double that in urban areas. In con- parasitosis due to one or more entero- parasites in the prov- trast, stunting rates among children under 5 years old have ince of Victor Fajardo, Department of Ayacucho, southern remained almost unchanged since 1996 (in a period of mostly Peru. GDP growth)—representing 30% of children. Stunting is Obesity, defined as an excess of body fat generated when much worse in rural areas (46%) than in urban areas (14%), the energy input (food) is greater than the energy expendi- and affects boys more than girls (33% and 26%, respec- ture (determined mainly by physical activity) over a suffi- tively). Geographically, all regions with stunting above 40% ciently long period, has increased in the Latin American are clustered in the Andes (INEI, 2007). Even though there (LA) region during the last years (Peña & Bacallao, 2001). is a number of food programs provided by the Government, Peru is not the exception. Although in recent years genetic but the evidence so far suggests that some of them do not factors have been identified to explain the greater suscepti- have a nutritional impact on children (Alcázar, Lopez-Calix, bility of some individuals, the abrupt increase in obesity that & Wachtenheim, 2003; Cortez, 2001). In terms of children’s has occurred in the last decades and its great extension is due access to basic services, the scenario is not very positive ei- mainly to significant changes in the diet of the population ther. Only seven out of ten children have access to safe water, whereas only five have access to improved sanitation services TABLE 1 Nutrition and health situation in children under (UNICEF 2004), both of which are essential in supporting 5 years of age (Source: Chronic malnutrition measured according to international patterns of WHO (INEI, 2009, 2014)) child growth and development (Streuli, 2012). Peru counts with a national vaccination program led by Nutrition and health situation in MINSA. Vaccines are medical substances that are capable of children under 5 years 2014% 2009% inducing an immune response in a living being, this response Chronic malnutrition—nationwide 14.6 23.8 conferred by the antibodies is capable of producing protec- Chronic malnutrition—urban area 8.3 14.2 tion from diseases known as immuno-pr eventable (MINSA, Chronic malnutrition—rural area 28.8 40.3 2017b). In Peru, the complete basic vaccines for children Anemia—nationwide 35,6 37.2 under 36 months include one dose of BCG, three doses of Anemia—urban area 31.7 33.2 DPT, three doses against polio and one dose against measles. In the first half of 2016, 70.3% of children under 36 months Anemia—rural area 44.4 44.1 received complete basic vaccines for their age, being this Acute respiratory infections—nationwide 15.1 6.4 value similar in the urban area (70.6%) but lower in the rural Acute respiratory infections—rural area 16.5 7.7 area (69.3%). Acute respiratory infections—urban area 14.6 5.7 In Peru, iron deficiency anemia is estimated from the level Acute diarrheal disease—nationwide 12.1 14 of hemoglobin in the blood. It is a national deficiency that Acute diarrheal disease—urban area 11.7 14 affects four out of ten children under 3 years of age (43.0%). Acute diarrheal disease—rural area 12.9 13.9 Anemia was more frequent in the rural area (52.3%) than in PILLACA- MEDINA AND CHAVEZ- DULANTO 7 of 22 (Popkin, 1998), the pattern of physical activity (Peña & abilities. Since then, MIDIS coordinates and articulates with Bacallao, 2000) and other factors of sociocultural nature. the public and private sectors and civil society, encouraging Even childhood obesity has increased in the last years. For that social programs achieve their goals through constant 2010, it was estimated at national level in 8.2% of exceeded- evaluation, empowerment, training and coordinated work weight in children under 5 years (6.4% overweight and 1.8% among their managers (MIDIS, 2017). obesity). According to the area of residence, the exceeded- weight in the rural area was 3.8% and 7.7% in the urban area. The prevalence of overweight and obesity among members 2 SOCIAL PROGRAMS of Peruvian households is a public health problem also for the group of children aged from 5 to 9 years, with exceeded- Social programs are an organized grouping of actions and weight 24.4%, being overweight 15.5% and obesity 8.9% resources, systematically designed and implemented in a par- (Alvaréz- Dongo, Sánchez- Abanto, Gómez- Guizado, & ticular social reality, to solve a problem that affects to its pop- Tarqui- Mamani, 2012). ulation and improve its quality of life in some aspects (Vara, 2007). Social programs aim to achieve certain objectives and benefit clearly identified groups. Before being implemented, 1.1.7 Institutionality these programs may seem potentially beneficial, but often do This aspect refers to policy interventions that guarantee a not produce the expected impacts and benefits (Ramoni & good organization of the programs and projects that are for- Orlandoni, 2014). mulated and implemented (Salcedo, 2005), delivered from Therefore, the impact assessment of social programs governmental institutions to face and succeed against poverty constitutes a policy tool that provides valuable information and social exclusion. As stated above, the social component about whether they are effectively achieving their develop- in the fight against poverty in Peru was shifted up since the ment objectives and goals. It is carried out by comparing a 90s decade with the creation of several governmental institu- “baseline”, which evaluates the initial situation of the target tions to achieve this challenge (Streuli, 2012). population, with a “comparison line”, showing the condition The Social Development Cooperation Fund (Foncodes) of that population after a certain time of operation of the was created in 1991 with the stated objective of helping to project, eliminating or minimizing the incidence of external alleviate poverty through generating employment and im- factors (Cohen & Franco, 2005). The quantitative results of proving access to social services, through community- based the impact assessment of social programs (IASP) constitute projects, which included initiatives in health, education, ag- an indispensable guide for an adequate distribution of pub- riculture, community centers, rural electrification, water and lic’s and international cooperation for development resources sanitation, as well as executing a series of centrally designed (Yamada & Pérez, 2014). Therefore, IASP is especially im- special projects in education, which included a school break- portant in developing countries where resources are scarce fast program and the distribution of uniforms for school- and every spent dollar should maximize its impact on poverty children (Paxson & Schady, 2002). Similarly, the current reduction. However, in Peru, despite the billions of dollars Ministry of Women and Vulnerable Populations (MIMP) was spent on social investment each year, little is known about the created in 1996 (firstly as Ministry of Women Promotion and real effect of such projects (Vara, 2007). Human Development - PROMUDEH), which in turn became Social programs in Peru are developed mainly by govern- the Ministry of Women and Social Development (MIMDES) mental institutions (Foncodes, MIDIS, MIMP, etc.), and non- in 2002, to finally be established as Ministry of Women and governmental organizations (NGOs), which can be national Vulnerable Population (MIMP) in 2012, with the objective of or foreign institutions. There are 55 private international being the governing body of national and sectoral policies on cooperation organizations for development working in Peru, the rights of women, as well as the prevention, protection and grouped in the Coordinadora de Entidades Extranjeras de attention on violence against women, as well as promotion Cooperación Internacional COEECI (Coordinator of Foreign and strengthening of gender mainstreaming, policies, plans, Entities of International Cooperation), which work in coor- programs and projects, and the promotion and protection of dination with the Peruvian State, as well as private and pub- vulnerable populations, such as children and adolescents, lic institutions to contribute to national development efforts the elderly, people with disabilities, displaced persons and (COEECI, 2017). internal migrants (MIMP, 2017). In 2011, the Ministry of Between 2001 and 2006, the Peruvian Government im- Development and Social Inclusion (MIDIS) was created as plemented important measures to tackle poverty in general, a body of the Executive Branch with the main objective of with emphasis in improving the situation of children: (i) a improving the quality of life of the population in situations Plan Nacional de Acción por la Infancia y la Adolescencia of vulnerability and poverty, promoting the exercise of their 2002–2010 (National Plan of Action for Childhood and rights, access to opportunities and development of their own Adolescence) which was based on the United Nations 8 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO Convention on the Rights of the Child (UNCRC 1989) and globally demonstrated that children are the age group most settled out the strategic priorities of the Peruvian Government likely to experience the effects of poverty (Gordon, Nandy, with regard to its actions for children (PNAIA, 2002); (ii) a Pantazis, Pemberton, & Townsend, 2003; Streuli, 2012; new Ley General de Educación (General Law for Education) UNICEF 2005), and it is estimated that over a billion chil- (MINEDU, 2003) that includes preschool education as part dren experience “severe deprivation of basic human needs” of the basic education, thus making it free and compulsory; such as food, safe drinking water, health, education, and ad- (iii) a Plan Nacional de Educación Para Todos (National equate shelter (Gordon et al., 2003). These CCTs programs Plan of Education for All) (2004), which follows the interna- are social protection measures that have rapidly become a tional agreements at Jomtien and Dakar; and (iv) a Proyecto critical component of poverty reduction strategies (Streuli, Nacional de Educación 2006–2021 (National Education 2012), addressingshort- term income needs as well as pro- Project) CNE (2006), which identifies issues of equity and moting “longer term accumulation of human capital” by pro- quality as major challenges to Peru’s education system, among viding money to families in poverty contingent upon certain other things. In relation to poverty alleviation measures, there verifiable actions and behaviors, such as school attendance are two major initiatives: the Acuerdo Nacional (National or basic preventative healthcare (De la Brière & Rawlings, Agreement) and the Mesa de Concertación de Lucha Contra 2006). In addition, increasing family income puts people in la Pobreza (MCLCP, the Round Table for the Fight against a better position to accrue longer term resources (e.g.,, make Poverty), signed in 2002 as a long-ter m plan for the economic investments, avoid debt). Therefore, by linking cash transfers and social development of Peru agreed by political parties to certain desirable behavior, CCTs highlight the corespon- and civil society organizations. It has 31 long- term state sibility of beneficiaries for their own well-being. This is as- policies planned until 2022, seven of which are specifically sumed to strengthen social citizenship, with rights and duties aimed at children (Government of Peru 2002). The MCLCP shared between authorities and citizens (Coady, Grosh, & is a multisectoral, government–civil-socie ty forum aimed at Hoddinott, 2004; Cohen & Franco, 2006). There is also some facilitating dialog and participation in public policies on pov- political motivation to demonstrate to nonrecipients that ben- erty reduction. In 2005, the Government of Alejandro Toledo eficiaries are deserving of the cash transfers. The benefits of implemented the Programa Nacional de Apoyo Directo a CCTs for children include improvements in nutrition, school los Más Pobres (National Programme of Direct Support to attendance, use of health services and birth registration, the Poorest), known as Juntos (“Together”), which was con- though there is debate about whether or not it is the cash or tinued and expanded by the successive Governments (Alan the conditionality (or indeed the associated development of García 2006–2011 and Ollanta Humala 2011–2016). More infrastructure) which makes the difference (Devereux, 2009). information is provided in the next section. Nowadays, CCTs programs are the most important targeted social programs, not only because of their achievements, but also because of their scale and budget. According to Trivelli 2.1 Types of social programs and Clausen (2016), the budget allocated to CCT programs According to Streuli (2012), social programs fall into two in Latin America was more than US$20 billion in 2011. They main groups: (1) those with universal coverage, such as are not the only programs, but they play a key role, along with social services (contributory pension plans), education and noncontributory pensions, in most countries in the region. health, and, (2) the targeted social policies programs, which Within the CCTs social programs developed at country- are aimed at a population group with certain characteristics wide level by the Peruvian Government with certain positive associated particularly with their degree of poverty, vulner- impacts, according to the Economy and Finance Ministry of ability and social exclusion—the conditional cash transfer Peru (MEF), are the following: (1) “Pension 65”, a solidarity (CCT) programs are the typical example of targeted social assistance program that increased the food expenditure of se- policy, although there are many others. This division between nior citizens in Peru, evaluated between the years 2012 and social policy types correlates with government administra- 2015 (MEF, 2016); (2) “Juntos”, a direct support program to the tion; many countries in the Latin America region have min- poor, evaluated from 2006 to 2009, which reduced the percent- istries that provide universal services and ministries of social age of extreme poverty in the target districts (Perova & Vakis, development—such as Peru’s Ministry of Development and 2011); and, (3) the Haku Wiñay project, currently carried out Social Inclusion (Ministerio de Desarrollo e Inclusión Social, by Foncodes, for beneficiaries of the “Juntos” program, which MIDIS) - , which oversees targeted services, although some reported an increase in the number of crops grown and their sectorial ministries may also have targeted programs. yield, especially in vegetables, tubers, and in the production of The conditional cash transfer (CCT) programs in Latin eggs, at household level (Escobal & Ponce, 2016). America constitute a new generation of programs specifi- On the other hand, universal coverage social programs cally targeting children from poor households, introduced in Peru are developed by both agents, the government and mainly during the 1990s (Streuli, 2012), as it has been the nongovernmental organizations (NGO). Within those PILLACA- MEDINA AND CHAVEZ- DULANTO 9 of 22 universal social programs developed by NGOs with encour- visited. It was found that the beneficiary seniors’ households aging results, can be mentioned, (1) the Food Security and increased their monthly average consumption per capita by Nutrition Program, developed by CARE, which has shown 40%, an equivalent to the total amount of the per capita trans- an important impact in the reduction in chronic malnutrition fer received by the home of the beneficiary, from which 66% in children under the age of 3 years and in the increase in was spent on food consumption. There were no effects on the household food expenditure in 125 districts in the regions of physical and cognitive health of the beneficiaries nor on their Ancash, Apurímac, Ayacucho, Cajamarca, Huancavelica, and own perception of health status. There were also no effects Puno, in Peru (Rojas, Flores, & Céspedes, 2007); and, (2) reported in the use of health services, despite the articulation “Con todas las manos” (With all the hands), a social program actions with the health sector carried out by the program for focused in hygienical practices, developed by PRISMA in the provision of prevention campaigns during the payment 2004 with the financial and technical support of the “Change dates (Ministerio de Economía y Finanzas (MEF), 2016). AID Project” in Peru, has shown a considerable increase in the appropriate hand washing practices, and therefore, in the 2.2.2 “juntos” reduction in diarrhea in children until the age of 5 years, in the district of Uchiza, San Martín department (mountain rain- JUNTOS (Together) is a currently ongoing national program forest area) (Bartolini, Cevallos, Pastor, & Segura, 2008). of direct support to the extreme poverty group, launched in 2005 by the Peruvian Government under the management of the current MIDIS, being the first program of conditioned 2.2 Relevant social programs developed in transfers or direct subsidy that was applied in the country Peru in the last years (CGR, 2008). The target population is the household, where There is a number of social programs developed in Peru, mothers are recipients of the monetary transfer. At the be- either by governmental or nongovernmental organiza- ginnings of this program, eligible households received a tions (NGOs). This section describes some of the most rel- fixed monthly cash transfer of 100 nuevos soles per month evant (ongoing and past) social programs developed by the which was conditional on their compliance with accessing Peruvian government and also by NGOs, with greater impor- basic healthcare and primary education services for their tance and coverage in Peru. Table 2 presents a summary of children, targeting specifically at “poor” households which the analyzed programs. had children under the age of 14, with the purpose of sup- porting them to invest more in their human capital—that is, through education, nutrition, and healthcare—and thereby 2.2.1 “pension 65” break the cycle of poverty in the long term. In 2010, Juntos “Pension 65” is a currently ongoing national solidarity as- started a new phase and some important changes has been sistance program created in October 2011 by the Peruvian amended: The household must be in poverty and/or extreme government, through MIDIS, aiming in providing economic poverty and counting with children up to 14 years old and/ subsidy to adults over 65 years old living in extreme pov- or pregnant women among their members (Alcázar, 2009). erty (PCM, 2011). The project strategy is the delivery of Its short- term objective is reducing poverty by transferring a economic subsidies equivalent to S/. 250 (approximately 76 bimonthly amount of 200 soles (approximately 60 USD) to USD), bimonthly. In addition, the population affiliated to households’ mothers, whose payment is conditional to fulfill- Pension 65 receive public health services at noncost through ing the commitments or coresponsibilities established by the the Seguro Integral de Salud (SIS) (Comprehensive Health program (Correa & Roopnaraine, 2014). In the long term, the Insurance). Additionally, the promotion of social protection objective is stopping the generational transmission of poverty through intersectoral and intergovernmental coordination ac- as inheritance through primary education assistance, reduc- tions aimed at facilitating the access of Pension 65 users to tion in child labor and increasing the use of health services public services provided by the Government (health, identifi- (Escobal & Benites, 2012). The conditionality of the program cation and Civil Status—RENIEC, etc.) are also focused by includes: a) for children under 5 years: health checks, com- Pension 65 (MEF, 2016). plete vaccination, iron and vitamin A supplements and para- site examinations; B) for children between 6 and 14 years Impact studies of Pension 65 old: school attendance at least 85% of the scholar year, and, INEI collected the baseline data between November and c) for pregnant or lactating women: prenatal and postnatal December 2012 and the follow- up data between July and check- ups (Escobal & Benites, 2012). October 2015. The baseline consisted in a sample of 4031 senior adults between the ages of 65 and 80 years old liv- Impact studies of “Juntos” ing in 3031 households, from which 64% were assigned as a The latest evaluation of the Juntos program was per- treatment group. In the follow- up, the same households were formed by Sánchez and Jaramillo (2012), who conducted 10 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO TABLE 2 Social programs developed in Peru assessed in the present study Type of Period of Social program Developed by program Beneficiaries Target group activity Aims Pensión 65 Government CCT Adults > 65 y- old Extreme poverty2011- today Improving access to food and health (MIDIS) (ongoing) Juntos Government CCT Households with children Poverty, Extreme poverty 2005–today Education, nutrition and healthcare of children (MIDIS) < 14 y- old, pregnant (ongoing) women Qali Warma Government Type 1 Children ≥3y- old, in School- children from public 2012—today Warranting food during the academic year to favor (MIDIS) initial & primary school, schools (ongoing) children’s attendance and permanence at school and secondary school (Amazonia) Haku Wiñay/Noa Government CCT Households Poverty, Extreme poverty2009- today Development of productive and entrepreneurial skills Jayatai (FONCODES) (ongoing) to increase household income enhancing food security Proyecto Articulado Government Type 1 Children ≤3y- old, their Attendants to health public 2008–2021 Education on nutrition and healthcare of children, Nacional - PAN (MINSA) parents and caregivers; services (ongoing) avoiding low weight at birth, fighting anemia, pregnant women and controlling children’s development and full lactating mothers vaccination Chispitas Government Type 1 Children from 6 to Attendants to health public 2009- today Education on nutrition and children healthcare, (MINSA) 35 months old services (ongoing) preventing/controlling nutritional deficiencies through micronutrients supplement for a period of 18 months Vaso de Leche Government Type 1 Children < 0 to 6 y- old, National level, no restrictions1985- today Complementing food intake delivering a food portion (Municipalities) their mothers, pregnant (ongoing) (milky product) of 207 Kcal (12–15% protein, women and lactating 20–25% fat, 60–68% carbohydrate), 7 days a week mothers. Elderly adults and patients with TBC Redes de Desarrollo NGO CARE Peru Type 1 Children ≤ 3y- old Andean highlands communities 2001–2006 Reducing chronic malnutrition Sostenible - REDESA Proyecto Educativo WFP, PRONAA, Type 1 Children < 5 y- old and Urban marginal district of 2004–2007 Improving nutritional level of children through Nutricional (…) NGO Alternativa pregnant women Ventanilla, Callao Region education, healthcare, food supplementation and Pachacútec strengthening of social organizations Con todas las manos NGO A.B. Prisma Type 1 Households with at least Uchiza district, Rainforest- 2004 Increasing hand washing practices with soap to one child <5y- old central highlands, San Martín decrease the prevalence of diarrhea PILLACA- MEDINA AND CHAVEZ- DULANTO 11 of 22 a nonexperimental study requested by the Banco Central de Similarly, using the official records of ENDES, ENAHO, Reserva del Peru (Central Reserve Bank of Peru) to evalu- INEI, SIS, MINSA, MINEDU, Hidalgo (2013) conducted a ate the nutritional impact of Juntos in children, in which the longitudinal nonexperimental study, and concluded that there database of the Encuesta Nacional Demográfica y de Salud is a significant influence of JUNTOS on the reduction in pov- (ENDES—National Demographic and Health Survey) for erty in its area of intervention, from 45% in 2005 to 31% in 2008, 2009 and 2010 was used. The results suggested that 2009. JUNTOS has had a positive impact on early nutritional status, However, one of the main and most complete impact reducing the incidence of extreme chronic malnutrition, thus fa- evaluation studies on the Juntos program was performed by voring those children in the lower percentiles of the nutritional the World Bank (Perova & Vakis, 2009), based on a nonex- status distribution, helping them to overcome extreme chronic perimental methodology and mixed data from the ENAHO malnutrition, but not necessarily moderate chronic malnutri- and the Registro Nacional de Municipalidades (RENAMU— tion. However, these results can be questioned, as evidence of National Registry of Municipalities). This study points out heterogeneous effects have been found, thus suggesting that that the program has significant and positive effects in the households with lower assets, possibly the poorest among the comparison between both beneficiaries and control groups poor, would be benefiting less (Sánchez & Jaramillo, 2012). as well as between beneficiaries that have been part of the Both the 2009 and the 2012 evaluations corroborate the posi- program for a longer period of time and those who are more tive effects of the Juntos program (Streuli, 2012). recent. The positive effects revealed by this study are sig- On the other hand, Escobal and Benites (2012), carried out nificant increases in consumption and income levels, with a a study by taking a subsample of the Young Lives study (longi- subsequent reduction in the incidence and intensity of mone- tudinal study investigating the determinants and consequences tary poverty. It also shows positive impacts on the enrolment of child poverty over a period of 15 years in four developing rates for the first 2 years of basic schooling, in the number countries—Ethiopia, India, Peru, and Vietnam), comparing of medical consultations and the fulfillment of the vaccina- beneficiary households of JUNTOS with others who are not tion calendar in the case of children under 5 years old and enrolled in the program, to identify its impacts on children. mothers in the perinatal period. The same study, however, The authors found that JUNTOS has changed some household does not point to significant effects on student school atten- spending patterns, increasing the likelihood of incorporating dance or on child nutrition (the noted nutritional impacts are products such as eggs, fruits, and vegetables into the benefi- for adults only), and it highlights that the Juntos program ciaries’ diets. However, they found no significant positive im- does not cause undesirable effects on the labor market or on pacts in the long-ter m nutritional effects or improvements in conspicuous consumption, a sharp increase in birth rates or cognitive performance of children. Therefore, they concluded other such variables (Lara Arruda, Nazareno, Salles, Alves, that cash transfers are generating positive impacts, but com- & Courau, 2016). plementary policies are required to maximize their impact. Similarly, Perova and Vakis (2011) conducted a non- 2.2.3 “qali warma” experimental study, using official data sources such as the National Household Survey (ENAHO—Encuesta Nacional Qali warma, which means “strong child” in Quechua lan- de Hogares) from 2006 to 2009. They found that almost all guage, constitutes a currently ongoing national food supply indicators of interest are significantly higher among benefi- program to public schools, created in 2012 and conducted by ciaries with longer treatment periods. However, in many cases MIDIS, aiming in providing quality- sustainable and healthful these improvements are too small to be captured in the overall food services adapted to local consumption habits, coman- effects analysis when beneficiaries are compared to nonben- aged with the community (CGR, 2013a). The target popula- eficiaries. Their conclusions suggest that while the program tion is compounded by girls and boys from 3 years old, from undoubtedly works, there is still an important improvement the initial level of education to primary education of public to be implemented. Overall consumption increased by 33%, educational institutions, and progressively, Qali warma as- which includes the positive change in food consumption as sists schoolchildren in the secondary education level of basic well as in nonfood products, although consumption of non- education in public educational institutions of native com- food products is nearly 65%, compared to a 15% increase in munities located in the Peruvian Amazonia (MIDIS, 2014, food consumption. Overall income also increased by 43%, MIDIS, 2012). Qali Warma assures food for these children, whereas the poverty rate decreased by 19%. It is important warranting the alimentary service during all days of the to pinpoint that the estimate was made based on the sam- scholar (academic) year according to the characteristics of the ple of JUNTOS districts, where poverty and extreme poverty zones where they live. This way, it is expected that attention rates are higher than national poverty rates (70% and 36% of of children in class will improve, favoring their attendance households in 2009, respectively, compared to 34% and 11% and permanence at school (MIDIS, 2012). Additionally, pro- country- wide) (Perova & Vakis, 2011). moting good eating habits in children is also aimed, as Qali 12 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO warma comprises the food component, being responsible for 2017). Gordillo (2014) also carried out a cross-sectional, de - planning the menu and providing the resources for quality scriptive, and observational study. The population consisted food service, accounting that breakfast and lunch contribute of children aged 3–8 years old from two educational institu- with 25% and 35% of daily energy requirements, respectively tions in the village of Quirihuac, Department of La Libertad, (Romero, Riva, & Benites, 2016). The educational compo- in the year 2013, finding a relationship between the preva- nent of the program also includes the promotion of good lence of dental caries and the sugars of Qali Warma program feeding habits in various actors involved in the implementa- and school refreshment, indicating that this could be since tion of the school feeding service, through training, technical the food supplied by the Qali Warma program and food con- assistance, and educational tools (Romero et al., 2016). sumption in school (snacks) are highly cariogenic. The lack of proper hygiene after eating such foods increases the risk of Impact of Qali warma suffering this disease. Maqui (2015) carried out a nonexperimental, descriptive and explanatory research in the district of Guadalupito, depart- 2.2.4 “haku wiñay/noa jayatai” ment of La Libertad, in the period 2012–2014, finding the following: a) 69.86% of parents indicated that Qali warma The Haku Wiñay/Noa Jayatai (“My enterprising farm” in both, has contributed to improving the learning of school- age chil- Quechua and Amazonic languages) program is a currently on- dren, indicating that children who did not consume their food going initiative of FONCODES, designed in 2009 as a pilot at home, consume it at school, thus completing the energies project to serve rural households in situations of poverty and for the study- journey; b) 26.03% of parents who considered extreme poverty (Trivelli, 2017). Since 2012, Haku Wiñay that Qali warma contributes only partially did not discredit was officially launched and operates with special emphasis the program and believe that there are exogenous variables on the areas where the Juntos program operates (Escobal & linked to food to improve learning, such as support from Ponce, 2016; Robino & Fabio Veras, 2015). The project seeks parents and improving teaching methods of teachers; c) 11% to strengthen strategies for generation and diversification of of people who reported that the program did not deliver the income of a set of agricultural households with subsistence service uninterruptedly during the scholar year, and stated economies (Escobal & Ponce, 2016), developing productive that at the beginning of the program, food delivery was not and entrepreneurial management capacities in rural house- carried out in some areas. However, it seems that it does not holds under poverty and extreme poverty. Thus, Haku Wiñay happen anymore at present. focuses on the development of productive and entrepreneurial Additionally, from a selective evaluation to more than skills to help households strengthen their income generation 1600 educational institutions throughout the country in capacities and diversify their livelihoods, as well as to en- 2016, several deficiencies in the Qali warma food service hance food security (Robino & Fabio Veras, 2015). were identified. The analysis of 158 rations of food distrib- The program strategy is structured in four components. uted in Metropolitan Lima reveals the need to improve the The first is to strengthen and consolidate the family produc- nutritional contribution of some foods. It was found that the tion system by a farmer- to- farmer evaluation. The second sugar content of some food products exceeded by 400% the component of the project seeks to improve living conditions maximum limit recommended by the Pan American Health in housing through the implementation of healthy practices Organization (PAHO) to prevent the occurrence of over- in three areas: (a) use of safe water for human consumption, weight, obesity, and chronic diseases, whereas the saturated (b) adequate management of solid waste, and (c) adequate fat content exceeded by more than 230% the maximum limit storage and preparation of food, including the installation recommended by this international organization. Also, the of improved kitchens. The third component has as main ob- combination “milk with cereal flour and biscuit” delivered jective the promotion of inclusive rural businesses from the by the program Qali warma provides less protein than the provision of technical assistance and is implemented via the minimum required. With regard to the consumption of dis- organization of competitions. Under this component, project tributed foods from a sample of 317 educational institutions users interested in implementing or expanding a business are at the national level, it was found that 34% of the children organized in existing associations for the competition. The do not consume foods of the ration modality (prepared and fourth component is the development of financial capacities, ready-t o-eat f oods that are distributed in individual pack- which focuses in training users to access to the financial sys- ages), 37% of children do not wash their hands with soap and tem (Escobal & Ponce, 2016). water before eating; and a sample of 1290 educational insti- The project foresees the participation of each user house- tutions at the national level, found that 27% of children do hold for a period of 3 years. In the first two, the training, not consume foods of the product modality (foods that are technical assistance and transfers of assets, comprised in the prepared and served at each school), 29% of children do not four components described above, are developed. One ex- wash their hands with soap and water before eating (CGR, pectation about the project is to accompany farmers in the PILLACA- MEDINA AND CHAVEZ- DULANTO 13 of 22 implementation of productive technologies and entrepreneur- 45- min training and counseling sessions that promote the ship, in order to ensure the consolidation of the learnt lessons adoption of three in- home childcare practices such as exclusive (Escobal & Ponce, 2016). breastfeeding, hand washing and feeding of children between 6 and 12 months old (Cruzado, 2012). In the case of basic vac- Impact of Haku Wiñay/Noa Jayatai cines, besides improving and enhancing the supply and dis- Early findings of Robino and Fabio Veras (2015) from the tribution of the permanent basic vaccination scheme (BCG, first (pilot) phase of Haku Wiñay, based on a comparison DPT, polio, and measles) to prevent prevalent diseases, two with the baseline, showed encouraging results, including a new vaccines against diarrhea (rotavirus) and acute respiratory significant increase in total family income that is attributed to infections (pneumococcus) have been added (Cruzado, 2012). the intervention. There were also significant improvements in perceptions of well- being, financial literacy, nutritional, Impact studies of PAN and some health outcomes when comparing the treated group Cruzado (2012) conducted a study using a database of chil- with a matched control group (Robino & Fabio Veras, 2015). dren to exploit the gradualness of the intervention throughout On the other hand, incorporating both direct impacts of birth cohorts, and calculated the average treatment effect for the Haku Wiñay project and potential complementarities the prevalence of malnutrition in the regions with the highest with the Juntos program, in the districts of Anta, Rosario degree of intervention. The analysis was performed for the and Andabamba (department of Huancavelica), district of period between the first quarter of 2006 and the first quarter Umari, Panao (department of Huánuco), and the districts of of 2011. The age of children included in the sample was from Chalamarca, Conchán, Pacha (department of Cajamarca), in 0 to 59 months and from 0 to 36 months. The baseline was the years 2012 to 2015, Escobal and Ponce (2016) found out the situation existing in 2007. Results showed that the PAN that 67% of treated households recognized that their incomes products were not new, as they were already offered in health have improved over the past 2 years, whereas 68% believe that centers. However, the great difference that was established incomes in their village have improved over the same period. with the PAN is that the design of these products was im- In addition, the treated households report an increase in the proved. In the case of CRED, educational and demonstrative number of crops grown in 2015, which is especially concen- counseling was added, and in the case of vaccines, addition- trated in the areas of vegetables and tubers, increasing crop ally to increase the provision, two new vaccines were added yields, and egg production as well (Escobal & Ponce, 2016). to the scheme that directly affected acute diarrheal diseases and acute respiratory diseases (Cruzado, 2012). Additionally, Cruzado (2012) obtained an estimator of the 2.2.5 “programa articulado nacional— average impact factor attributed to the PAN in the reduction pan” in malnutrition, which was 3.5 in Apurímac, while it was 1.5 The Articulated National Program (PAN, from its Spanish ac- and 2 points lower in the rate of malnutrition in Ayacucho and ronym) is a joint initiative of MIDIS, the Ministry of Health Huánuco, respectively. For an average child, having pneumo- of Peru (MINSA), the Ministries’ Council of Peru, the SIS coccal and rotavirus vaccines implies a reduction in the prob- and the regional and local governments. The program, con- ability of being malnourished by 4 percentage points, from ducted by MINSA, was implemented since 2008, prioritiz- 14% to 10%. However, the limitations of the used methods to ing intervention in favor of children (Cruzado, 2012), whose determine causality evidence could had resulted in possible objective is reducing the prevalence of chronic malnutrition unobservable inputs (Cruzado, 2012). in children under 5 years old (Cruzado, 2012). An extension of the PAN has been approved by the Peruvian Government, 2.2.6 “chispitas” until 2021. Originally, the program strategy consisted in the allocation of resources prioritizing the delivery of two prod- Between 2009 and 2011, the MINSA and the former ucts: (1) Child Growth and Development Controls (CRED), MIMDES, in collaborative work with UNICEF and the World and (2) a vaccination program. In its last phase from 2017 Food Program WFP (Programa Mundial de Alimentos PMA), to 2021, the PAN beneficiaries include pregnant women and developed a pilot experience of a supplemental food program lactating mothers, in order to avoid low weight of children at with multi- micronutrients called “Chispitas” (“Sparkles”), birth, and get strong mothers and children, as well as fight- incorporating iron (Fe), zinc (Zn), vitamin A, vitamin C and ing against anemia and low developmental performance folic acid in a powder presentation. This supplementation (MINSA, 2017b). was focused on children under 3 years of age (MINSA- PMA- In its original version, CRED was essentially conceived UNICEF, 2012), with the general objective of preventing and of periodic visits to health centers to monitor the growth and controlling nutritional problems due to micronutrient defi- health of children, where they are measured and weighed. ciencies in children from 6 to 35 months old, through supple- Nowadays, in its current version, additionally mothers receive mentation with multimicronutrients for a period of 18 months 14 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO (MINSA- PMA- UNICEF, 2012). Nowadays, and according adverse effects associated with the multimicronutrients were to the impacts obtained until 2011, the program was extended registered. and it is currently ongoing under the initiative of MINSA, and Similarly, Huamán et al. (2012) carried out a cross- called “Nutriwawa” (MINSA, 2015). sectional study to evaluate the impact of the “Chispitas” The specific objectives of this program have been: (1) en- program in the Apurímac region. The study population con- suring that children of 6 to 35 months old, who access the sisted of children from 6 to 35 months old and their mothers medical health service center, are supplemented with micro- or caregivers. Almost all (97.3%) of the population partici- nutrients; (2) strengthening intersectoral working groups at pated in a social program of the Peruvian government; 94.7% the national, regional and local levels in the areas covered by of the children participated in the “Papilla” program; 70.3% the proposal; (3) strengthening the capacities of MINSA and in the “Vaso de Leche” program, and 37.5% in the “Juntos” MIMDES staff, as well as community agents, parents and program. It was found that 49% of children consumed ade- caregivers; (4) strengthening the information management quately, whereas in 84% of cases of those who received the that, in turn, strengthens existing systems for monitoring sup- intervention and did not use it properly, it was because chil- plementation within the framework of comprehensive care; dren not finished the meal as they disliked the taste. Those and (5) generating scientific evidence that contributes to im- children who consumed the supplement adequately had proving future intervention strategies (Ministerio de Salud 17.4% lower prevalence of anemia than those who did not. (MINSA), Programa Mundial de Alimentos (PMA), Fondo One positive aspect that was found is the greater promotion de las Naciones Unidas para la Infancia (UNICEF), 2012). and extend of intervention in rural and poorer communities. The program strategy was the distribution of multimicro- Based on these results, Huamán et al. (2012) pointed out that nutrients to every child from 6 to 35 months attended in the it is not enough to deliver the multimicronutrients, but to en- health establishment of MINSA, as well as the Peruvian Social sure that the consumption process is adequate to achieve a Security, as part of a comprehensive health care, consisting reduction in the prevalence of anemia, an aspect that must be in the control of their growth and development (CRED) rates, improved within this intervention. reaching approximately 100 000 children in the whole three departments (Apurímac, Ayacucho and Huancavelica). The 2.2.7 “vaso de leche” incumbent health professionals were trained to teach and ad- vise on the correct consumption of the powder supplement. The Vaso de Leche (Glass of milk) is one of the largest cur- A supplementation scheme of 18 months was selected with rently ongoing food- assistance program of the country, cre- the basic formulation of multi- micronutrients for the preven- ated in 1985. The program is administered and executed by tion of nutritional anemia, called “Nutritional Chispitas”. all the provincial municipalities in the country. The target According to international recommendations, the supple- population of Vaso de Leche are the maternal and child popu- mentation scheme would consist of the monthly distribution lation between 0 and 6 years of age, as well as pregnant and of 15 envelopes to be consumed interdaily during two 6- lactating mothers, prioritizing in those who are malnourished month cycles, with a 6- month resting period between the two or affected by tuberculosis. Subsequently, the coverage in cycles (Ministerio de Salud (MINSA), Programa Mundial the province of Lima is extended to children between 6 and de Alimentos (PMA), Fondo de las Naciones Unidas para la 13 years of age as a second priority, and elderly adults and Infancia (UNICEF), 2012). patients with tuberculosis as a third priority (Suaréz, 2003). The objective of the program is complementing the food Impact studies of Chispitas intake of beneficiaries at national level, delivering a food por- A surveillance study conducted on 759 children who received tion (milk in any form or other product) of 44.6 g that must the supplementation strategy in Apurimac (Andahuaylas), meet the established nutritional contribution of 207 Kcal, Ayacucho and Huancavelica, during the first (pilot) phase with a balance of 12–15% protein, 20–25% fat, 60–68% car- of the program, found a remarkable decrease in anemia in bohydrate, and must cover the 7 days a week (CGR, 2013b). 51.8% (Ministerio de Salud (MINSA), Programa Mundial de Alimentos (PMA), Fondo de las Naciones Unidas para la Impact studies of Vaso de Leche Infancia (UNICEF), 2012). The adherence of children to the Even though the Vaso de Leche constitutes the largest (and program exceeded to 90%. From the children who presented oldest) food program provided by the Government in the moderate anemia prior to supplementation, 55.3% resolved country, the evidence so far suggests that it does not achieve their problem, whereas 28.6% changed to mild anemia and the expected nutritional impact on children (Alcázar et al., 16.1% remained in the same situation. At the same time, 2003; Streuli, 2012). Buob (2015) used official information 68.9% children with mild anemia at the baseline, solved their from 2007 to 2011 of the INEI, the Integrated Administration problem, whereas 22% remained with mild anemia and in and Financial System (SIAF) of the Ministry of Economy and 8.35% of them the problem evolved to moderate anemia. No Finance (MEF) and information available from the General PILLACA- MEDINA AND CHAVEZ- DULANTO 15 of 22 Comptroller of the Republic of Peru (CGR), concluding that participation of the organized community and local gov- there is no relation between the resources allocated to the ernment; (B) The improvement of hygiene, health care and program and its results, and there is no clear relationship be- infant feeding practices (through improved access to com- tween expenditure and effectiveness, despite the visible limi- munal surveillance systems); (C) direct the production of tations in the samples to carry out the impact assessments on the families to products with demand in the market and link the program. This study suggests that Vaso de Leche has a them to competitive production chains (through the creation rather limited effect on nutrition, so it would not be meeting of local markets for technical assistance, access to credit the objectives for which it was created from the outset, which and organization of production chains); D) diversification is improving nutritional levels of the vulnerable population. of the production for self- consumption through the instal- Similarly, from a selective evaluation of 800 provincial and lation of family gardens and small animal modules that district municipalities regarding the expenditure of servings would provide them with a greater availability of micronu- of the Vaso de Leche program during 2012, the CGR (2013b) trients, vitamin A and iron, essentially (implemented and found that 84.1% of delivered portions presented nutritional cofinanced with the participation of the organized commu- contributions lower than the minimum established by the nity and local government); (E) strengthening communal Ministry of Health (MINSA), and only 8.8% of the rations management capacity (through committees of community reported fulfilled the quantity of macronutrients, energy and development committees) and local governments, mainly nutritional distribution established. With regard to coverage, related to the development of communal and local devel- only 11% of the municipalities delivered a ration that meets opment plans; and the better use of municipal resources the minimum nutritional value for more than 271 days a year. (mainly participatory budgets) for actions that contribute to Buob (2015) concluded that, because the determinants of mal- reducing chronic malnutrition (Rojas et al., 2007). nutrition are found at different levels, Vaso de Leche seeks to tackle this problem by offering a food portion whose protein Impact study of REDESA level is not high enough, suggesting that Vaso de Leche could To determine the impact of the program, a comparison was be representing a sink of budget for Peruvians, since it is an made of the variables corresponding to the program objectives, expense that the Government has assumed year to year with- measured before (baseline) and after the intervention. Chronic out evaluating the impacts in a specific period (Buob, 2015). malnutrition was reduced from 34.2% to 24.3%, the acute diar- rheal diseases were reduced from 35.0% to 16.4%, and exclu- sive breastfeeding increased from 25.0% to 72.2%. The annual 2.2.8 Redes Sostenibles para la Seguridad family income increased by 61%, while money for food pur- Alimentaria - REDESA chases increased by 34.5% (Rojas et al., 2007). An important The program Redes Sostenibles para la Seguridad Alimentaria aspect highlighted by REDESA has been the participation of REDESA (Sustainable Networks for Food Security) was im- women in the improvement of the health and nutrition of their plemented by the NGO CARE Peru, from 2001 to 2006, in families, as it is the mother who is the one concerned in the 1854 communities of 125 districts belonging to the regions decision making. REDESA evidenced that in rural areas, social of Ancash, Apurímac, Ayacucho, Cajamarca, Huancavelica, and cultural aspects influence the effects that can be achieved, and Puno. In its last year of intervention, the beneficiary pop- such as the use of the Quechua language and the family envi- ulation accounted with 34 203 boys and girls (Rojas et al., ronment, where young women are restricted to make decisions 2007) in a total of 58 570 families (Flores & Rojas, 2007). about their children’s health and food alone, without the par- Its general objective was to reduce chronic malnutrition ticipation of the mother- in- law or grandmother of her husband, in children under 3 years old from Andean highlands of and even of any other “older” women recognized in the com- Peru. The specific objectives were (1) reducing diarrheal munity for their experience (Flores & Rojas, 2007). diseases (acute diarrheal disease), (2) improving infant feeding practices, and (3) increasing family income (Rojas 2.2.9 Proyecto Educativo Nutricional et al., 2007). To achieve them, REDESA implemented a en Prevención de la anemia y desnutrición comprehensive strategy to reduce chronic malnutrition, en Niños menores de cinco años y mujeres with actions addressing both its immediate causes and their gestantes en Pachacútec (Ventanilla, Lima, underlying causes, with the important distinction of not in- Peru) cluding food distribution among its lines of action, which marked a substantive difference with the food assistance The Program of Educational Intervention in Prevention approach that exists in the country. It was achieved by de- of Anaemia and Undernutrition in Pachacútec (Ventanilla veloping the following lines of action: (A) Safe water ac- District, Callao, Lima), was a nutritional educational pro- cess and basic sanitation, through the installation of water ject in anemia and malnutrition prevention in children under systems and latrines implemented and cofinanced with the 5 years of age and pregnant women, implemented between 16 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO 2004 and 2007 in the urban marginal district of Ventanilla, children facing chronic malnutrition and anemia. There is Callao Region, in order to improve the nutrition of children evidence that inadequate feeding practices in early childhood under the age of five. This program constituted a joint initia- are among the most important factors leading to malnutri- tive of the World Food Program of the United Nations (WFP), tion. After 3 years of initiation of the intervention, the impact the National Food Assistance Program of Peru (PRONAA), assessment study estimated a reduction of 4.5 percentage and the NGO Alternativa—Centre for Social Research and points (50%) in chronic malnutrition or growth retardation Popular Education (PMA et al. 2008). The project was devel- of the children who benefited from the project. For the in- oped by a group of families living in the area, that contributed dicators of global malnutrition and acute malnutrition, the actively to their own organization to extension of the resources initial prevalences were 8% and 2%, respectively, and could provided through training. The intervention model had four be reduced to 7% and 1%, respectively. At the beginning of components: education, health care, food supplementation, the intervention, the anemia affected to 60.2% of the children and strengthening of social organizations (Programa Mundial evaluated, and at the end, it affected to 18.4% of the children, de Alimentos, Pronaa y Alternativa, 2008). which indicates a reduction in 70% (Programa Mundial de The educational intervention was one of the most im- Alimentos, Pronaa y Alternativa, 2008). It was observed that portant components, through training and communication after 2 years of intervention, 98% of the beneficiary children during the first months of the experience, to identify the had adequate food for their age. The contribution and com- community problems. The food supplementation was car- mitment of the mothers themselves and their community, the ried out through the elaboration and distribution of a por- educational activities for the health care in the homes and the tion of porridge or Maize meal to children under 5 years strengthening of social organizations had positive effects on old, made by their own mothers previously trained. The their children nutritional status. It is estimated that the mes- daily basket per child consisted of 34 grams of cereals, 18 sage of the program was disseminated to approximately 5,800 of menestra (Leguminosae grains), 13 of sugar and 9 of people in 234 replicate sessions during the 4 years of project vegetable oil, provided by the project PER 6240, whereas execution. Therefore, according to the Programa Mundial de the mothers supplied 25 grams of vegetables or fruits and Alimentos, Pronaa y Alternativa (2008), the achievements 21.6 grams of vegetable products. of the project show a great potential for replicability of the The porridge was delivered from Monday to Friday, to an intervention model in the measure that suits different socio- average of 850 children. Between 2004 and 2005 the por- economic contexts in the country, and that it is possible to ridge was intended for pregnant women and children under achieve these quantifiable achievements through training and two, but for 2006 and 2007 it was extended to children up strengthening social organizations to improve the health and to 5 years. One reason for the expansion was the perceived nutrition of their children. demand for older siblings and cousins. The health care com- ponent consisted of two activities: deworming twice a year 2.2.10 “con todas las manos” and supplementation with iron sulfate intended for pregnant mothers and young children. “Con todas las manos” (With all hands) was a project de- Strengthening of social organizations was considered a veloped by the NGO A.B. PRISMA with the financial and basic component in the program model, taking into account technical support of the Change Aid Project in Peru, in 2004. that the sustainability of the experience was in the hands of Different approaches on communication and promotion of the community itself. For this, it was essential to have a team health and hygiene were combined to enhance the influ- of leaders or health promoters who handled basic concepts ence of knowledge factors on motivation toward a behavior in food, nutrition and hygiene, and would be responsible change regarding hand washing with soap in 402 families for disseminating the messages not only to the beneficia- with mothers with at least one child under 5 years old, from ries, but to the entire population of Pachacútec. Therefore, 32 communities and quarters of the Uchiza district, located in it was linked with the association of community promoters, the central highlands of the rainforest region of Peru, depart- community leaders and active social organizations (public ment of San Martín. As a secondary target group, it was es- food programs, Vaso de Leche, etc.) (Programa Mundial de tablished the participation of other members of the family, as Alimentos, Pronaa y Alternativa, 2008). well as the local municipality authorities, the education and health personnel working in the area, and whose unsatisfied Impact studies of proyecto educativo nutricional en basic needs were mainly related to the lack of public network prevención de la anemia y desnutrición en Niños services for the elimination of excrements, overcrowding and menores de cinco años y mujeres gestantes en inadequate housing (Bartolini et al., 2008). Pachacútec The objective of the program was to increase the practices Final evaluations of the results, compared with the base- of hand washing with soap and, therefore, the decrease in the line, have shown that the program had a protective role in prevalence of diarrhea in children under 5 years (Bartolini PILLACA- MEDINA AND CHAVEZ- DULANTO 17 of 22 et al., 2008). Con todas las manos used a ludic- educational area. On the other hand, the food delivered by Qali warma, methodology at the family and individual level, as well as at the greatest coverage in food distribution program, seems to the mass and political levels, making visible and affirming in contain sugar and fat in excess, and that a considerable per- everyday practices the importance of hand washing for the centage of children do not consume it. Regarding Pension healthcare of children. The intervention at the individual and 65, although it has increased the monetary income of elderly family level was carried out through personalized campaigns people, it is not reflected in the care of their health. Similarly, to motivate, reinforce and consolidate the practice of hand the PAN has been also featured as an iterative intervention, washing with soap in the form of home- based educational despite the reduction in infectious diseases in the target chil- and play visits. The intervention at the level of public ac- dren population. Therefore, these four programs (Chispitas, tors was effectuated through a public campaign to promote Qali Warma, Pension 65 and PAN) are considered having positive practices in healthcare. It was sought that municipal fulfilled partially their objectives. Contrastingly, the Vaso de authorities and representatives of mass media (radio, news- Leche program would not have met its aim, as the nutritional papers) developed activities that supported messages at the supply of a personal portion is not enough to complement the household level, thus placing a private hygiene rule in the daily nutritional uptake of the target population. Therefore, it public space (Bartolini et al., 2008). is evidenced that all social programs must carry out an articu- lated and complementary work in order to reduce FI, avoid- Impact study of “Con todas las manos” ing duplication of interventions, as well as doing a wise use After the intervention period of 5 months, comparing with the of financial resources to contribute to the sustainable devel- baseline, a statistically significant decrease in diarrhea was opment of the country. achieved in children under five, from 50% to 37% for the pre- In the case of the universal coverage (food, health, ed- vious 15 days between baseline and final evaluation. It was ucation) assistance programs (Type 1, Table 2), it can be evidenced a change of 18 percentage points in the behavior concluded that there are at least three main psycho- social of using soap in hand washing in the participant population of components that would affect negatively the achievement of the campaign of education, without any additional campaign the programs objectives. The first component is related to so- having taken place simultaneously. The percentage in hand cial relations, as a great part of the success of the program de- washing with soap increased from 15% to 34%. Therefore, it pends on the contact to the leaders of the community, which can be inferred that it is possible to make, in the short term, are usually organized as comedores populares (expenditures changes in the practices of hand washing with soap as a result where food, prepared by mothers of the community, is sold at of intensive interventions of home visits and public activities. the cheapest price), Vaso de Leche committees, etc. The sec- The reason why there is an increase in the practice of hand ond component is linked to gender issues, as in many cases it washing with soap would be given because the interest in was reported that men (couples, husbands, etc.) did not allow healthcare was activated in general, the enjoying- the- taste of women going to the training sessions or even to receive the learning from mothers and children based on games, and for food supply in the comedores populares. Women obeyed for the existence of recalling elements to remember the behavior. fear to reprisals (domestic violence, mainly). The reason for It is important to mention as crucial for mothers to adopt the this behavior was, in turn, linked to the perception of their change and benefit, the social recognition for having a clean own poverty and their image to the community, which was in and well- cared child (Bartolini et al., 2008). several cases shared by women, as accepting participate in the programs would mean that they are needy and their children are malnourished, anemic, and suffering deficiencies, there- 3 CONCLUSIONS fore facing with personal expectations and undermining their already deteriorated self- esteem, generating frustration. The According to the impact studies of the social programs under third component is the desertion of mothers to participate in analysis, most of them reported having met most of their ob- the program, due to their own poverty situation, as mothers jectives (Juntos, Haku Wiñay, REDESA, Proyecto Educativo preferred going to work (e.g., doing cloth hand washing and Nutricional Pachacútec, Con todas las manos). However, other domestic tasks in the rich sectors of Lima City) in order there are controversial evaluations of some programs. In the to earn some money that would allow buying food for all case of Chispitas (Nutriwawa), some studies state that it re- their children in the comedor popular, instead of going to the duced anemia significantly, but others indicate that the reduc- educational training sessions. However, some mothers have tion rate is rather small, as at the national level, the anemia limited access to work, as having more than one child means has been not reduced since 2009 (37.2%) to 2014 (35.6%), being not accepted in nowhere (as they have to take their chil- and according to MINSA, the prevalence of anemia in girls dren with them), and even so, they did not participate in the and boys under 3 years shows a constant of 43.5% between program due to the lack of proper clothes to protect their chil- 2015 and the first half of 2016, being more critical in the rural dren against the cold climate (winter) outside the household. 18 of 22 PILLACA- MEDINA AND CHAVEZ- DULANTO Therefore, it can be suggested that, firstly, programs must and Harrison (2014) carried out a study using data from the change the image of the participants, focusing the participants national monitoring of nutritional indicators for the years 2003, as winners, responsible parents, for “best boys and girls”, and 2004, 2006, 2008, 2009, and 2010, finding an association be- not focusing so much on the problem (anemia, malnutrition, tween the participation of food assistance programs (FAP) and illiteracy, etc.), but on the possibility of overcoming it, trans- overweight/obesity among nonpoor Peruvian women who re- mitting this positive message since the first contact with the ceive FAP benefits. Among women living in households with 0 community leaders. Secondly, it can be suggested to opt for poverty indicators, FAP participation was associated with 30% a house- to- house approach to the program during the seasons to 50% increase in overweight/obesity risk after controlling for where the climate represents an obstacle, as winter and sum- several possible confounding factors. Among women living in mer, for example, in order to create a multiplicative effect and households with at least one poverty indicator, FAP participa- achieve the maximum adherence of the target population. tion was not associated with overweight/obesity. Therefore, the On the other hand, it can be concluded that child- centered correct orientation of the FAP, particularly those who provide CCT programs need to be more child-sensitiv e, especially food baskets, can play an important role, as delivering extra in rural areas whipped by the past internal conflicts. Indeed, calories to people who do not need them could increase their CCT programs must consider children within the context risk of overweight and obesity, which have been pointed out as of their relationships with their families and wider society, public health problems in Peru by Alvaréz-Dongo e t al. (2012). in order to avoid systematic and institutionalized exclusion, Being nonpoor and living in urban areas seem to be social de- being crucial to understand the roles of different actors and terminants of overweight in the Peruvian population. institutions in the lives of the children (Ray & Carter, 2007; Despite the weaknesses of the social programs developed Streuli, 2012). CCTs also would show more knowledge and in Peru so far, the achievements show a great potential for awareness of child- specific risks vulnerabilities—which replicability of the interventions, if they are adapted to dif- may include the effects of environmental shocks; nutrition; ferent socioeconomic contexts in the country. Moreover, they violence within the household, school and community; so- show that it is possible to achieve quantifiable achievements cial exclusion; and the sense of powerlessness that children through the training and strengthening of social organiza- and their families experience—and incorporate different tions, including and developing tools according to the reality family models and structures, that is, recognizing that there of the target areas, which can be considered as a key to ob- are multiple family forms and structures of care, including tain the final results to redress FI, emphasizing on children, grandparents (grandparental care), the extended family (other as they constitute the largest population group in Peru, and relatives) and child-headed households, ins tead of basing therefore, must be prioritized by the social programs, spe- interventions upon the nuclear family norm. Furthermore, cially from those coming from the Government. child- centered CCT programs would also pay more attention As seen above, the evaluation of impact assessment of the to community history, backgrounds, and social cohesion and social programs in Peru has enabled to contrast their results dynamics to minimize tensions and maximize people’s use of with their original objectives, and therefore to identify their social networks. For example, CCTs like Juntos need to com- achievement level, as well as their weaknesses and possible bine their focus on individual households with community- secondary negative consequences. We conclude that the im- level actions to strengthen mutual collaboration and sense of pact assessment analysis enhances the necessity for rethink- reciprocity, which is vital to most rural communities in the ing the forms of intervention in social programs. country (Streuli, 2012). Indeed, to be more child- sensitive, CCTs should build better links between child protection C ONFLICT OF INTEREST and broader social protection measures, instead to be based None declared. on a rather narrow approach to childhood poverty and well- being, in which children are mainly seen as indicators, and investments for the future. Finally, a move away from the OR CID focus on beneficiaries’ “duties” toward a view that respects Susan Pillaca-Medina people’s dignity and rights, simultaneously to a move away http://orcid.org/0000-0003-4204-5939 from “monitoring, policing and surveillance” to an approach that emphasizes inclusion, as listening and working together Perla N. Chavez-Dulanto would enhance the achievements and therefore the impact on http://orcid.org/0000-0003-2057-4565 the target population. 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H., … Henry, C. A. (2014). Evaluación de las

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