2 CONTENTS RIGHTS AND PERMISSIONS 4 FOREWORD BY PRESIDENT OF PERU 5 FOREWORD BY WORLD BANK PRESIDENT 6 ACKNOWLEDGEMENTS 8 ABBREVIATIONS, ACRONYMS, REPORTS AND ORGANIZATIONS 9 LIST OF CHARTS AND TEXT BOXES 10 SETTING THE SCENE: STANDING TALL - PERU’S SUCCESS IN OVERCOMING ITS 1.  11 STUNTING CRISIS 2. PERU’S ONCE PERSISTENTLY HIGH STUNTING RATES 15 PERU’S SOLUTION: MAKING STUNTING A NATIONAL PRIORITY 3.  21 PERU’S SOLUTION: A MULTI-PRONGED STRATEGY GEARED TOWARDS 4.  23 RESULTS 5. PERU’S SOLUTION: ALIGNING RESOURCES WITH RESULTS 29 PERU’S SOLUTION: CEMENTING BEHAVIORAL CHANGE BY 6.  37 EMPOWERING PARENTS PERU’S SOLUTION: INSTITUTIONALIZING SUCCESSFUL POLICIES 7.  40 8. A RENEWED COMMITMENT CRITICAL TO ADDRESS FUTURE CHALLENGES 42 9. SPOTLIGHT: BIG CHANGES IN SMALL COMMUNITIES 45 10. CONCLUSION: LESSONS LEARNT 47 ANNEX: NO SILVER BULLET BEHIND PERU’S REDUCTION IN STUNTING 49 PERU TIMELINE 54 REFERENCES 55 3 RIGHTS AND PERMISSIONS © 2017 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. 4 FOREWORD I Between 2005 and 2016, the rate of chronic malnutrition Chronic Malnutrition. Many sectors are committed to in children declined from 28 percent to 13 percent, an this challenge, including the Ministry of Health, regional achievement of which the Government of Peru is very proud. and local governments, institutions, community-based organizations and citizens. If we want a developed We recognize that this is the result of efforts of successive country, our children must be well-nourished. It is the governments that maintained an effective public policy. It only way to definitively break the cycle of poverty. We are relies on a joint strategy closely coordinated among the implementing a broad water and sanitation program, a key different levels of government, with the collaboration requisite for public health. of several national and international institutions and organizations. We would like to extend special thanks At the end of our government administration, we want to to the World Bank for its support and commitment. The be able to say that no child in Peru suffers from anemia or organization helped us identify and apply the evidence chronic malnutrition. from other countries, which demonstrated feasible, cost- effective interventions for combating chronic malnutrition. This book details the comprehensive strategy Peru implemented to achieve significant progress in reducing Our country still faces major challenges, however, and we chronic malnutrition. We believe that other countries are committed to continuing this work. Our government around the world facing similar challenges can replicate has proposed reducing chronic malnutrition in children this experience, adapting it to their regional and cultural from around 13 percent to 6.4 percent and anemia from characteristics. 43.6 percent to 19 percent between 2016 and 2021.  In other words, our goal is to eliminate anemia as a public Pedro Pablo Kuczynski Godard health problem. To this end, we have implemented President of the Republic of Peru the National Plan to Reduce and Control Anemia and 5 FOREWORD II Stunting is a silent killer. It deprives children of their right opportunity is the core of our mission at the World Bank to grow, to thrive, and to prosper. Today, stunting snatches Group. But we can’t begin to think about about equality away the opportunity for 156 million children around the of opportunity if children begin their lives unable to world to reach their full potential, locking them into lives participate or to compete in the economy of the future. of poverty and exclusion before their 5th birthday. It not only diminishes the development of children, it damages Now is the time for action. The international community communities and entire countries. has already included nutrition and early childhood development among the Sustainable Development Goals. The global epidemic of childhood stunting is one of the One of the targets of the SDGs aims to reduce stunting by most serious threats to humankind, and it has escaped the 40 percent by 2025. world’s attention for far too long. Children who are stunted have up to 40 percent less brain volume by the time they Globally, we have evidence of interventions that work – get past their first 1,000 days. This is an absolute stain on that are feasible and cost-effective in driving down chronic our collective conscience. malnutrition. Peru understood that its biggest asset is its people. So the government worked with the World Bank How will countries compete in an increasingly complex Group to provide financing to women to incentivize them and digitized economy when one out of four of their to take advantage of available programs designed to cut children literally have fewer neuronal connections, which stunting. In just 8 years, Peru cut its stunting rate from 28 are the foundation of human capital? Creating equality of percent to just 13 percent last year. 6 A civil society movement put chronic malnutrition on the We need to work together and leverage every dollar of political agenda in Peru, and it took sustained political development assistance to help governments make commitment at the highest levels to bring the stunting investments in the early years a top priority. The World rate to the lowest level in decades. Peru has shown the Bank Group is committed to the twin goals of eliminating world that country-wide engagement can reduce stunting, extreme poverty and boosting shared prosperity. We creating a path towards a brighter future for all children. cannot get there unless we tackle stunting with the speed and the scale that this crisis requires. This report details how Peru’s strong political commitment and good policies, coupled with economic growth, broke We have in front of us the opportunity to unlock the the cycle of poverty perpetuated by stunting. The country’s human potential of millions of children. Let’s seize that experience demonstrates that investing in nutrition in the opportunity together. first 1,000 days of a child’s life is critical to ending the world’s stunting crisis. Jim Yong Kim President But Peru is not completely there yet. There are still World Bank Group important challenges in need of more effective solutions. Stunting levels remain high in rural, remote areas. There are increasing rates of individuals who are overweight and high rates of anemia. 7 ACKNOWLEDGMENTS Appreciation and thanks go to: Core team who contributed to the publication through substantial inputs and the groups and field trip to Huánuco. And, Hedy Huarcaya, Deputy Director of coordination of the interviews and of the field work in Huánuco: Hugo Brousset, Public Budget in MEF, for leading her team with enthusiasm. Nelson Gutierrez and Gabriela Moreno, for tirelessly supporting the team. Former Minister of the Ministry of Development and Social Inclusion (MIDIS) Extended team, for their various contributions at different stages: Sara Burga, Carolina Trivelli and another former Minister of MIDIS Paola Bustamante, who Lucho Cordero, Ana Maria Oviedo, William Reuben, Javier Soriano Tabares, energetically implemented the most challenging reforms, strengthening those Silvana Vargas. programs that were recognized as most cost-effective in reducing chronic malnutrition and for providing exemplary leadership to their teams. Peer reviewers for their directions and precious advice and for patiently reviewing many versions of the document: Omar Arias, Leslie Elder and Carlos Maria Ines Sanchez Griñan, advisor to the Minister of Health, a long-term Felipe Jaramillo. External reviewer: Ellen Piwoz, from The Bill & Melinda Gates champion of nutrition who mobilized chefs and developed tools that could Foundation, for her valuable comments which helped sharpen the story. facilitate mothers’ understanding of nutrition. Former Vice Minister of MIDIS Ariela Luna, a champion for nutrition in her different reincarnations from the For comments throughout the process and various drafts: Sandra Arzubiaga, Ministry of Health to MEF to MIDIS -- a force of nature. Health expert Lucho Alan Berg, Marcelo Bortman, Daniel Cotlear, Patricia da Camara, Ramatoulaye Cordero, the mind behind the data, for tirelessly analyzing data to identify George-Alleyene, Julie McLaughlin, Marina Petrovic, Meera Shekar, Christel the factors that influence the growth of children. GRADE researcher Lorena Vermeersch, and Michele Zini (also thanks for the title!). For the analysis of Alcázar for sharing her rigorous work and one of the most complete analyses stunting and consumption: Emanuela Galasso and Adam Wagstaff. For the of determinants of malnutrition in the country. analysis of the budget data: Carlos Ricse. For allowing us to use the powerful brain images of the effects of stunting on white matter: Professor Charles Milo Stanojevich, of CARE Peru, for carefully recounting those initial moments Nelson of Harvard University. of the start of the Initiative against Chronic Infant Malnutrition and how its persistence ensured sustainability of nutrition as a priority in the political agenda. For administrative support: Gabriela Moreno, Sara Burga, Maria Colchao and Marize de Fatima Santos. Bibiana Melzi, who helped make the "invisible problem" visible through her powerful images in the video "Mi Futuro en Mis Primeros Centimetros," not For graphic design and layout: Carin Vlotman at Inkfish. only in Peru but throughout Latin America. For the cover: Carlos Reyes. Local government authorities, as well as local health staff, social program coordinators, community agents, officials from NGOs in Santa María del Valle, For technical guidance: Daniel Dulitzky and Margaret Grosh, our practice Huánuco and regional managers of health and social programs and of the managers for health and social protection, respectively, as well as the program Regional Government in Huánuco. leader for the Andean Countries Livia Benavides. World Bank: John Newman, former country manager for Peru for pulling the For providing the idea and impetus for the publication: Alberto Rodriguez, World Bank into this exciting adventure back in 2006. Carlos Felipe Jaramillo, Country Director for the Andean Countries. former country director for Peru for having prioritized nutrition as a worthwhile investment. Daniel Cotlear, former sector leader for Peru who had the idea For providing useful comments and support: Tim Evans, Senior Director for of producing a video to make the invisible problem visible. Omar Arias, the Health, Nutrition and Population Practice, and Steen Jorgensen, Director former sector leader for Peru and Livia Benavides, current program leader for for the Social Protection and Labor Practice. Peru, for their passion and dedication and for providing technical guidance and leadership to the World Bank technical teams on the ground over For Photography: Cecilia Larrabure. many years. Gideon Long and Silvana Vargas for tactfully carrying out the focus groups in And we express admiration for those whose story the book tries to tell: Huánuco and with key contributors in Lima. For all the health workers and local authorities who patiently showed Special thanks go to all the key contributors who shared their stories and passion commitment and shared their dedication to the youngest generations of Peru. with us, and drove Peru's efforts to reduce stunting. This is who they are: For the parents of the children who diligently visited health centers under the Former Prime Minister Jorge del Castillo, for his availability and time to narrate most difficult conditions, for the patience through which they followed the the history of building political commitment around nutrition. advice of the health workers, and for the love and care they dedicated to their children to secure them a better start in life. Former head of Crecer and of the Juntos program, engineer Iván Hidalgo, for his careful review of the driving forces, manifesting again his belief in the Thanks to the members of the Initiative against Chronic Malnutrition which importance of scientific evidence. tirelessly contributed to the achievement of results on the ground. These include: ADRA, CARE, Caritas, FAO, United Nation Population Fund, Action Rodolfo Acuña, Director of Public Budget at MEF, and Nelly Huamaní, Project against Hunger, Instituto de Investigacion Nutricional, Mesa de Concertacion Coordinator of the Public Budget Directorate at the Ministry of Economy and de Lucha contro la Pobreza, Micronutrient Initiative, MSH, Pan-American Health Finance, whose never-ending passion and dedication centered the nutrition Organization, Plan International, PRISMA, UNICEF, USAID, Welthungerhilfe, agenda in a powerful convening ministry that is rarely the leader on the issue. World Food Program, World Vision. Yolanda Zuniga and Diana Flores from the Public Budget Directorate team The World Bank and the Japan Trust Fund for their financial contributions that who coordinated the data collection process and the organization of the focus made this work possible. 8 ABBREVIATIONS, ACRONYMS, REPORTS AND ORGANIZATIONS Annual Balance of Actions to - Score card on government performance against targets Reduce Chronic Child Malnutrition Apega - Peruvian Gastronomical Association (Asociacion Peruana de Gastronomia) Budget Support Agreements - (Convenios de Apoyo Presupuestario) CARE Peru - Peru branch of international humanitarian aid organization CARE International CENAN - National Food and Nutrition Center (Centro Nacional de Alimentacion y Nutricion) CCT - Conditional Cash Transfer Cordon Bleu - The world's largest network of culinary and hospitality schools Crecer (To Grow) - National Strategy for Combating Poverty and Chronic Child Malnutrition in Peru CRED - Control of Growth & Development for infants and children in Peru (Control de Crecimiento y Desarrollo) Cuna Mas (More than a Crib) - Early childhood development program in Peru CUI - National Identity Code (Código Unico de Identidad) DBM - Double Burden Malnutrition GDP - Gross Domestic Product GRADE - Group for the Analysis of Development (Grupo de Analysis para el Desarollo) DIRESA - Regional Health Directorates (Direcciones Regionales de Salud) ENDES - Demographic and Family Health Survey (Encuesta Demografica y de Salud Familiar) EU - European Union FED - Performance Incentive Fund (Fondo Estimulo al Desempeno) FSC - Food Safety Commission (Consejo de Seguridad Alimentaria) INEI - Peru’s National Institute of Statistics (Insituto Nacional de Estadistica e Informatica) The Initiative - The Initiative against Chronic Infant Malnutrition Juntos (Together) - CCT program FSC - Food Security Strategy (Estrategia de Seguridad Alimentaria) MCLCP - Poverty Reduction Roundtable (Mesa de Concertacion para la Lucha Contra la Pobreza) MEF - Ministry of Economy and Finance (Ministerio de Economia y Finanza) MIDIS - Ministry of Development and Social Inclusion (Ministerio de Desarrollo e Inclusion Social) MINSA - Ministry of Health (Ministerio de Salud) NGO - Non-Governmental Organization Padron Nominado - National registry of children under six (Nominal Registry) PAN - Articulated Nutrition Budget Program (Programa Articulado Nutricional) PCM - Presidential Council of Ministers (Presidencia Consejo de Ministros) PRONAA - Food distribution program in Peru (Programa Nacional de Asistencia Alimentaria) Progresa/Oportunidades/Prospera - Mexico’s CCT program Qali Warma - School feeding program in Peru 9 SDG - Sustainable Development Goal SIAF - Integrated Financial Management System (Sistema Integrado de Administración Financiera) SIGA - Integrated Administrative Management System (Sistema Integrado de Gestión Administrativa) SIS - Peru’s Integral Health Insurance Program (Seguro Integral de Salud) RBB - Results-Based Budgeting (Presupuesto por Resultados) RPP - Peruvian radio station (Radio Programas del Peru) RENIEC - National Registry for Identification and Civil Status (Registro Nacional de Identificacion y Estado Civil) UNICEF - United Nations International Children’s Emergency Fund WBG - The World Bank Group WHA - The World Health Assembly WHO - World Health Organization LIST OF CHARTS AND TEXT BOXES TEXT BOXES Page 11 - BOX 1: An "Invisible Epidemic" Page 14 - BOX 2: Anthropometric Definitions of Malnutrition Page 19 - BOX 3: When economic growth is not enough Page 27 - BOX 4: What happens during the growth monitoring and promotion program CRED? CHARTS Page 17 - Chart 1: Remarkable results: Stunting in children under five-years of age (2005-2016) Page 18 - Chart 2: Brain of a child with stunted brain development vs a healthy child Page 31 - Chart 3: Aligning budget to areas in most need Page 33 - Chart 4: Proportion of children younger than 36 months with complete CRED for their age Page 49 - Chart A1: Stunting fell by 15 percentage points between 2008 and 2016 from 28 percent to 13 percent Page 51 - Chart A2: Stunting rate and per capita consumption in Peru (1995-2015) Page 52 - Chart A3: The relationship between poverty and stunting in Peru by area 10 1. SETTING THE SCENE This is the story of how Peru more than halved stunting rates in less than a decade BOX 1: An "Invisible Epidemic" Chronic malnutrition, or stunting, means children grow development of a country. For decades, stunting was an too slowly, reducing their physical abilities, cognitive “invisible problem" in Peru. Parents, especially in poor, and emotional development. It damages a child’s health, indigenous communities, often thought that their kids affects the growth of the brain and intelligence. It were growing normally, when they were not. Parents reduces the time they spend in school and increases the would compare the stature of their children with other likelihood that poor children will remain poor as adults. In stunted children and assume their height was normal. addition, as adults they face an increased risk of chronic The country’s lack of progress was even more striking diseases, such as diabetes, heart problems and obesity. given its rapid economic growth over much of the decade. It perpetuated the cycle of poverty down the generations, Stunting not only holds back a child’s growth and holding back the development of children and the country. development, but it holds back the growth and Standing Tall: Peru’s success in overcoming its 2006-2016 of the tragic consequences of stunting and stunting crisis how vital it was to take significant steps to reduce its impact on the development of children, communities and This publication tells the story of how Peru, in less than a the country. decade, more than halved its rate of chronic malnutrition, or stunting, among children under five from around 28 Peru’s politicians committed to reducing stunting and percent in 2008 to around 13 percent in 2016. set clear goals after a coalition of international and local organizations -- The Initiative against Chronic In 2005 Peru had one of the highest rates of chronic Infant Malnutrition (or the “Initiative”) and the Mesa de malnutrition in Latin America. The rate had hardly changed Concertacion de Lucha contra la Pobreza (MCLCP – despite the country enjoying some of the fastest rates of Poverty Reduction Roundtable) -- helped to put the issue economic growth in the region and significant investments on the national agenda in the 2006 election. It has been on in food and nutrition programs. the agenda ever since. Since then, Peru has found a recipe for successfully MCLCP, set up by Peru’s government, provided a vital reducing chronic malnutrition to give its children and the platform for national, regional and municipal government country a better future. representatives and grass-roots organizations to promote children’s rights, including lowering rates of chronic What was Peru’s recipe and what were the crucial ingredients? malnutrition. By 2006 they were promoting a list of priorities for investment in early child development. A year later Establishing political commitment, cooperation and 1.  these were enshrined in the government’s budget planning coordination and paved the way for prudent and effective spending to significantly reduce chronic malnutrition in children. The Persistent lobbying by civil society convinced presidential Ministry of Economy and Finance (MEF) played a crucial candidates during successive election campaigns from role by creating incentives for a coordinated response 11 across government to address malnutrition through health, growth monitoring and promotion check-ups at the Result-Based Budgeting (RBB). health centers and for ensuring their older children attended school. As the money started to reach poor households, The ambitious, yet clear and feasible, goal of reducing demand for health and social services in poor and rural stunting in children under five years of age by five communities increased. Juntos’ payment of 200 Peruvian percentage points in five years (The 5-by-5-in-5 Goal) was Soles – the equivalent of about $61 at today’s exchange set in 2006 and turned into specific regional targets. rate – every two months became a catalyst for the country’s major reduction in chronic malnutrition in children. Stunting became a sustained political priority and was treated as a serious human development issue. It was Central to improving child health and nutrition in Peru, recognized as a social, economic and health challenge. was the Control of Growth & Development for Infants and Successive governments showed their commitment Children in Peru (CRED) program. The program, delivered in to tackling the problem by setting a series of new and health centers, supports parents in tracking a child's growth ambitious targets. (both in terms of weight and height), health and nutrition, and provides counseling to foster behavioral changes. What is remarkable about Peru is the fact that four successive governments under Presidents Alejandro At the same time, regional Governments were given Toledo, Alan Garcia, Ollanta Humala and now Pedro Pablo monetary incentives, through the regional health Kuczynski have ensured continuity and commitment in directorates, encouraging them to provide more and the push to reduce child stunting. better nutrition services. Also in 2005, the Integral Health Insurance Program (SIS) for the poor, which had Peru made conquering chronic malnutrition everyone’s been created in 2002, was expanded, ensuring access business with national, regional and local governments, to preventive health and nutrition services for the most the private sector, Non-Governmental Organizations vulnerable, creating a virtuous circle. (NGOs), parents, prime ministers and presidents working in unison to give children the best start in life. Growth monitoring and promotion attendance for children under three years of age increased from 24 percent in Smarter policies: focus on evidence, incentives and 2.  2008 to 58 percent in 2016. The rise in rates in rural areas results was even more pronounced, climbing from 21 percent to 66 percent over the same period. Early stimulation After spending millions of dollars on ineffective feeding activities (such as teaching parents to sing songs to their programs, Peru was careful to only spend money on children and read to them from birth) were included as tried-and-tested methods, so-called “evidence-based part of growth monitoring and promotion. interventions,” that had already improved nutrition and children’s health. In 2007, Peru created a strategic road map for reducing stunting rates. The national nutrition strategy Crecer The government looked at the global evidence of what (To Grow) helped to focus spending on the poorest caused stunting and sought out proven ways to reduce communities to improve the health and nutrition of stunting rates. It prioritized investments in areas of higher children in the first two years of life. stunting, with a focus on results. In 2008, Peru established a RBB system for ensuring Cash incentives, through a Conditional Cash Transfer money was well-spent and produced the results that (CCT) program known as Juntos (Together), were a crucial politicians had pledged to achieve. The incentive system part of the mix. set up by the MEF contributed to improvements in the quality of health and nutrition services. The successful Juntos, launched in 2005, provided cash to mothers while steps taken then are evident today. requiring them to take their young children regularly to 12 Cash incentives to parents alone were not the answer. It was and national, regional and municipal governments coming the combination of the CCT program and improvements together to achieve a common goal (5-by-5-in-5). in the availability and use of health services, increased health insurance coverage by SIS, the rigor of RBB and the Malnutrition was no longer seen as a hunger problem but strategic focus of Crecer which forged a convergence in a public health matter, requiring smarter and coordinated the government's approach to reducing stunting. responses. Evidence showed that a multi-sectoral approach involving 3. Changing behavior health, social assistance and education, among others, was the only way to prevent malnutrition. Peru's multi-pronged For political commitment and smarter policies to approach to reducing rates of stunting took that into account. make a lasting impact, parents had to be educated and empowered. In addition, they needed the government to The importance of real-time, individualized data, regular provide health and social services to ensure their children surveys and comprehensive monitoring systems was grew at a healthy rate. recognized early on and action taken. Accountability mechanisms were established at the local level to monitor A superb communications strategy led by NGOs, the the steps taken to reduce child malnutrition. government and international partners created widespread understanding and awareness about the devastating Peru spent money where it made the biggest difference. impact of chronic malnutrition. As more mothers met It also cancelled, consolidated and revamped feeding more regularly with doctors, nurses and nutritionists in programs to ensure more targeted spending on pregnant clinics, their habits started to change and with it the health women and children in the first two years of life, when of millions of Peruvian children. nutrition, hygiene and health is most decisive. What was earlier an “invisible problem" to most parents The focus emphatically shifted from providing food and policy makers became visible (Box 1). The irreversible assistance to poor households to a multi-sectoral consequences of child stunting became evident to approach to nutrition that included incentives and improved everyone: parents, health officials and political leaders provision of services, and involved government ministries were finally ready to deal decisively with stunting. 13 Peru's lessons to the world context in 2005, including an explanation of what chronic malnutrition (stunting) is and its consequences (Box 2). Although Peru has not yet fully eliminated child stunting, its progress  has been extraordinary. And it provides Specific attention is given to Peru's phenomenal economic lessons for other countries ready to end this social and growth. This contributed to the reduction in stunting, but economic scourge. it was not enough to drive the rapid decline of chronic malnutrition rates. Peru is by no means alone in making significant progress in this area. Other countries which have accelerated the Throughout the publication, boxes and spotlights point rate at which they have reduced stunting include Vietnam, to specific issues and activities that cross the different Bangladesh, Senegal and Ethiopia. periods or do not lend themselves to a strict chronology. A timeline of the major relevant events is added as a But Peru stands out on the world stage for its rapid and reference at the end. pronounced progress in more than halving stunting rates in less than a decade. Peru recognized that its children are This publication is based on extensive interviews with its future, made fighting chronic malnutrition everyone’s former policy makers and political leaders, program business, took vital political decisions and prioritized long- and project task managers and development partners. lasting good governance. It is also based on a careful review of existing studies of Peru’s experience in reducing stunting and documents This publication is the story of how Peru did that. on the topic. Focus group discussions were held with beneficiaries, health workers and local government officials It recounts Peru's success in chronological order. It starts in Santa María del Valle, Huánuco, one of the regions with with a brief overview of Peru's geography, population and the highest stunting rates and the fastest rates of decline. BOX 2: Anthropometric Definitions of Malnutrition Stunting (Chronic Malnutrition): Stunted growth debilitating disease causes muscle and fat tissue to refers to low height for age, when a child is short for “waste” away. This is also known as “acute malnutrition” his/her age but not necessarily thin. It is caused by because the process of wasting occurs rapidly in inadequate nutrient intake and frequent infections over contrast to stunting. It is a strong predictor of mortality a long period of time. It is a leading indicator of chronic in children. malnutrition and carries long-term developmental risks. Underweight or weight for age reflects body mass relative Wasting (Acute Malnutrition): Wasting refers to low to chronological age. It is the combination of height for weight for height, when severe food shortage and/or age or stunting and weight for height or wasting. 14 PERU’S ONCE PERSISTENTLY 2.  HIGH STUNTING RATES Despite Peru's economic success during 2000-2006, chronic malnutrition rates stagnated Chapter Snapshot • In 2005, 28 percent of preschool children suffered from chronic malnutrition. This rate had hardly changed for over a decade. • Poverty, lack of awareness and lack of access to quality social and health services led to particularly high rates of stunting in remote, rural areas. Inefficient feeding programs failed to dent this. • Economic growth, urbanization, women’s education and improved access to water helped reduce poverty and contributed to reducing stunting rates but these developments alone were not enough. • The percentage of Peruvians living below the poverty line more than halved from 58.7 percent in 2004 to 22.7 percent in 2014. • Prosperity played a part in Peru’s success in reducing stunting but it was targeted policies that played a pivotal role in changing mindsets and meals. Peru's diverse geography and population lives there. The eastern slopes of the Andes and nearby rainforest are sparsely populated. Peru's geography is incredibly diverse. It is made up of a western coastal plain, the Costa, the mountainous The country's latitude, mountain ranges, sharp variations and rugged Andes in the center, the Sierra, and the in topography and the ocean create widely varied climatic eastern lowland jungle of the Amazon Basin, the Selva. zones. Peru is vulnerable to natural disasters, including Approximately one-third of its 31 million population lives flooding and landslides. Its diverse geography also makes along the desert coastal belt in the west, with a strong it hard to reach remote areas, raising the cost of providing concentration in the capital city of Lima. The Andean public services. The Sierra and the Selva regions, with their highlands, or Sierra, are the heartland of the country's remote communities, are difficult to travel across. indigenous population. Roughly half of Peru's population 15 Today, more than 75 percent of the population lives in attracting more foreign investment. It is now classified as urban areas, the result of significant urbanization in the an “upper-middle income country." last 60 years. The improvement in living conditions among the poor The home of the Inca Empire, Peru was cradle to one of and the bottom 40 percent of the population has been the oldest civilizations in the world and the oldest in the remarkable. Americas. Peru has three official languages, following the main ethnicities of its population groups: around 84 Persistently high rates of economic growth for more than percent speak Spanish, about 13 percent speak Quechan a decade were key to reducing monetary poverty and and less than 2 percent speak Aymara. extreme poverty. Between 2002 and 2013, the Peruvian economy expanded at an annual rate of 6 percent, much For over a decade Peru has been higher than the Latin American average. Peru doubled its enjoying the fruits of success from per capita income, an impressive performance by global these endeavors. standards. In that period, the country’s Gross Domestic Product (GDP) tripled from almost $67 billion to more than $201 billion (World Bank, 2015). Peru has a relatively young population, with a median age of 27, but is clearly in demographic transition with Moreover, the economic gains have been widely shared. about one fourth of its population under 16, the bulk Lower income households -- the bottom 40 percent -- have being between 25 and 40 years of age (40 percent) and a gained more from growth than the national average. Their growing 65+ population (7 percent in 2016). per capita income rose by about 6.8 percent per year over the last decade, against a 4.4 percent gain for the whole Peru today is labelled a "growth star" population. The percentage of Peruvians living below the poverty line more than halved from 58.7 percent in 2004 Although politically stable for several decades, for much to 22.7 percent in 2014, World Bank data shows. The Gini of the 20th century Peru suffered from coups and a index -- a measure of inequality -- fell from 51 in 2004 to guerrilla war resulting in high unemployment, poverty and 44 in 2014 (World Bank, 2015). economic setbacks. Today, Peru is dubbed a “growth star.” It has enjoyed an “economic miracle”, successfully cutting The country’s record on combating chronic malnutrition poverty by half during a decade-long boom in prices of can now also be added to its list of achievements in the gold, copper and other metals. Peru is rich in these and early part of the 21st century. other natural resources. The country has also reformed, 16 Chart 1: Remarkable results: Stunting in children under five-years of age (2005-2016) 50 47.1 45.7 National Urban 45 44.3 stunting rates (percentage) 40.3 40 38.8 Rural 37.0 35 31.9 32.3 30 28.0 28.5 28.8 27.5 27.7 26.5 25 23.8 23.2 20 19.5 18.1 17.5 15.6 16.2 15 13.5 14.2 14.6 14.4 14.1 13.1 10.1 10.5 10.3 10 8.3 9.2 7.9 5 0 2005 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Note: The ENDES survey began in 1986 and collected demographic and health data, including anthropometrics, every five years until 2000. In 2004, ENDES moved to a continuous survey scheme, collecting data every year. However, the sample was not initially designed to estimate the prevalence of malnutrition. In 2007, with the launch of Results-Based Budgeting, the sample size of the continuous survey was increased to be sufficient to estimate the prevalence of malnutrition by department starting in 2008. Given the sample design, estimates of malnutrition were available for 2005 and 2007, and on a yearly basis after 2008. Source: ENDES In 2005, 28 percent of children under five suffered from consequence (Chart 2). Malnutrition is not only responsible chronic malnutrition (Chart 1). This rate had not changed for nearly half of all deaths of children under five, it is much for over a decade. Particularly rural areas, remote estimated to reduce the world’s GDP by $1.4-$2.1 trillion, areas and indigenous regions suffered very high levels of equivalent to the entire economy of Sub-Saharan Africa stunting. In rural areas stunting reached 47 percent, more (Shekar et al, 2016). than three times the rate in urban areas (14 percent). Stunting affected 54 percent of children younger than five in “Did the average Peruvian know about malnutrition or the poorest quintile, against only 4 percent in the richest one. care about malnutrition? For many Peruvians, this was part of Peru. This was the way it was for a very long time,” Chronic malnutrition in children has a life-long detrimental said Felipe Jaramillo, who was the World Bank’s Country impact: a stunted brain being the most devastating Director for Peru in 2007-2011. 17 Chart 2: Brain of a child with stunted brain development vs a healthy child Whole brain tractography Stunted growth representative infant Never stunted growth representative infant Note: This figure illustrates the effects of stunting on white matter tracts. Specifically, diffusion weighted imaging was used to examine a variety of white matter fibers in a single stunted infant (top frame) and a single non-stunted infant (bottom frame), at 2-3 months of age. As is apparent, the density and richness of this network of fibers is far more elaborate in the non-stunted infant than in the stunted infant. It is important to keep in mind that this is but a single (albeit representative) infant. Thus, until these findings are replicated at the group level, such findings should be considered preliminary. This data was collected as part of an ambitious program of research taking place in Dhaka, Bangladesh (Charles A. Nelson, Ph.D., Principle Investigator), supported by The Bill & Melinda Gates Foundation. The goal of this work is to examine the effects of biological and psychosocial adversity on early brain development. Nadine Gaab, Ph.D. and her colleagues are overseeing the MRI portion of this project. Source: Nelson, 2016; Nelson, 2017. Economic growth certainly helped free up resources for vital development, you will lower poverty by one point. This is social spending in Peru, including rural roads and access what was called ‘trickle down,’” said del Castillo. to water. But Peru’s success in reducing stunting rates was in stark contrast to other countries around the world which One can expect the demographic transition, with reduction enjoyed similar rates of growth in the early 21st century but in fertility rates and the rapid rise in urbanization, to have saw stunting rates remain unchanged (Box 3). contributed to the secular trend (a non-cyclical trend over a longer period) of improvements in the nutrition status of “You have a growing economy, with employment generation, the Peruvian population. Disentangling these effects is not right? All this automatically translates into a way out of easy as there are many factors that contribute to reducing poverty but social redistribution is required, which is not stunting. Urbanization may have played a role. However, it only to pump money into social programs but to generate happened gradually over six decades and does not explain jobs, improve education and health,” said Jorge del Castillo, the acceleration in stunting reduction. In addition, the largest former Prime Minister of Peru. urbanization shift happened years before improvements in stunting levels became visible. “You have to have a pillar that is of economic development and another one is that of social development. The first Between 2007 and 2016 the number of children who were cannot grow alone. It must grow in parallel with the other. stunted fell by 49 percent in urban areas (from 310,000 to If there is only economic development without social 157,000) and by 50 percent in rural areas (from 452,000 to 18 228,000). That is, between 2007 and 2016, 153,000 children reduction in rural areas contributed 59 percent to the overall under five in urban areas avoided stunting, while 224,000 reduction nationally in the same period1. in rural areas avoided the same fate. In other words, the BOX 3: When economic growth is not enough Was the country’s strong economic growth part of reduction in stunting in Peru. The accelerated reduction the story of its success in combating stunting? Most in stunting rates is likely to be due to the systemic certainly, but it was not the whole story. policy changes (Annex). The historical responsiveness of stunting to economic growth observed in Peru before A simple look at the relationship between poverty rates and 2006 (with a 10 percent increase in economic growth chronic malnutrition within the country today indicates that translating into a 6-percentage point reduction in income is only part of the story, especially in rural areas. stunting) is in line with cross-country estimates (Ruel, Data from Peru’s National Institute of Statistics (INEI) and Alderman 2013). Peru’s Demographic and Family Health Survey (ENDES) shows that more than growth is needed to reduce chronic Research by Mejia Acosta (2011) and by the Group malnutrition. The correlation between poverty and chronic for the Analysis for Development (GRADE) (2015) malnutrition in urban districts is only 0.4 and only half as backs this up, stressing that Peru’s success in tackling high in rural districts (Annex). stunting has been driven more by good policies than by good growth2. In a different study, data from seven national health surveys from 2009 to 2015 shows how the use of Mejia Acosta highlighted that government success in Peru's Articulated Nutrition Budget Program (PAN) of reducing malnutrition was less related to structural nutrition and health services -- such as vaccinations factors, such as economic growth or the commodities and growth monitoring and promotion programs boom, than to nutrition policy improvements. which were prioritized through the RBB by the MEF- Those improvements are believed to be associated - are associated with lower stunting rates in children with: greater government efforts to create national born after 2009, independently of income quintiles or coordination structures and mechanisms; increased mother's education (Cordero, forthcoming). targeted public (and private) spending on nutrition programs and alignment of social programs with the Recent work by Galasso and Wagstaff suggests that national nutrition strategy Crecer which focused on the growth alone can explain up to 50 percent of the highest risk groups. 1 It is also worth noting that the absolute number of children age 0-5 remains constant over time in urban areas at around 2 million. Total number of Urban children Rural children Number of stunted Number of stunted Number of Stunted children (0-5) (0-5) (0-5) kids (urban areas) kids (rural areas) kids (total) 2007 2,976,799 1,988,574 988,574 310,163 451,779 761,942 2,845,845 1,988,207 857,638 157,068 227,274 384,343 2016 153,095 224,504 377,599 absolute change 49% 50% % change Contribution to total 51% 59% reduction 2 The GRADE-model suggests that while mothers’ education and height turned out to be important explanatory variables, some effects were also associated with vaccination and pre-natal controls. Little effect was associated with CRED (possibly because of the quality of the counseling). Access to water was also found to be significant and important while the strongest effect was related to household income and the community or the enabling environment. Mothers’ height and education, as well as birth order were associated with a stronger effect among age sub-groups, similarly, vaccinations (during the first year) and CRED (during the first months of life) (GRADE, 2015). 19 Lack of vision, political will and a series of scattered and Chronic malnutrition was rooted in poverty and lack uncoordinated nutrition programs resulted in persistently of access to health, sanitation, water and other social high rates of stunting, which stagnated for most of a services. An understanding of the multiple and reinforcing decade and then started to drop in 2008. Economic causes of stunting was growing in Peru in 2006. It has success was not trickling down to reduce stunting, become scientific consensus today. jeopardizing the country's long-term growth prospects. The remainder of this publication is about how Peru more The government had been pumping an estimated $250 than halved stunting in less than a decade by changing million a year into food and nutrition programs by 2002 policies and mindsets. (Rogers et. al, 2002). Much of that expenditure, however, went to children older than two years of age, resulting in little movement in Peru’s stunting rates. It was clear that other policies were needed. 20 PERU'S SOLUTION: MAKING 3.  STUNTING A NATIONAL PRIORITY Peru showed unprecedented political commitment to the health of its children Chapter Snapshot • The Initiative against Chronic Infant Malnutrition put stunting on the political agenda in the 2006 election with all presidential candidates committing to reduce malnutrition in children under the age of five by five percentage points within five years. • The Initiative successfully argued that Peru’s most valuable resource was its people with a “window of opportunity” to tackle chronic malnutrition during the first 1,000 days of a child’s development. The 2006 election – campaign for change “One of the salient features of the Peruvian success is the fundamental role played by the international aid system A remarkable campaign to tackle chronic malnutrition and civil society organizations in the formation in early in children succeeded in putting nutrition firmly on the 2006 of the Initiative against Chronic Infant Malnutrition, political agenda in 2006, an election year. that recognized the multi-causal nature of the problem and effectively lobbied the government to prioritize the The Initiative against Chronic Infant Malnutrition, a civil allocation of resources and formation of policy around society group of 18 national and international NGOs and proven tactics against chronic child malnutrition,” the development partners spearheaded by UNICEF, CARE Peru paper concluded. and the Pan American Health Organization (PAHO), urged Peru to adopt goals and policies to harness its growing Peru’s recipe for accelerating the reduction of stunting economic prosperity to reduce stunting. rates undoubtedly had many ingredients, but changes in the political economy of Peru were pivotal in creating The Initiative would not only analyze and publish reports a recipe which made a sustained reduction in chronic on government efforts to fight malnutrition but would also malnutrition possible. The right mix of unique ingredients call for elected officials to be held accountable for their galvanized political commitment to the cause of reducing commitments to tackle the problem. The reports were chronic malnutrition.  critical in making regional and local efforts public and creating an official benchmark. This together with RBB Communication was instrumental in making an “invisible introduced by MEF created robust incentives for regional problem" visible, in setting simple and easy to understand governments to act on nutrition. targets and in illustrating how to reach them. Videos and TV spots mobilized champions at the highest levels A 2011 paper by Mejia Acosta highlighted the critical role of government and helped parents understand what played by civil society and international aid organizations stunting was. Everyone at every level of Peruvian society in putting stunting on the national agenda. was quickly convinced of the urgent need to deal with the problem, as well as the returns on investment. 21 There is a strong body of evidence that shows high “We went candidate by candidate and started talking to economic returns from investing in nutrition: stunting them. We got one candidate to sign a one-page pledge. reduction returns 11 dollars for each dollar invested Once we got one to sign others signed too!” (Shekar et al, 2016). Finally, international donors and lenders were ready to mobilize significant resources The campaign issued 10 recommendations for how linked to achieving nutrition results and provided technical the government could reduce child malnutrition in the support for Peru to invest in nutrition. first 100 days in office. It called for a concerted plan to start up investments and implement multi-sectoral nutritional The 5-by-5-in-5 Goal programs under the authority of the Presidential Council of Ministers (PCM) and fully involve local governments4. The Initiative campaign helped to put malnutrition firmly on the political agenda in the 2006 election by initially The Initiative was more than a catalyst for change. It getting 10 presidential candidates to sign a commitment offered vital support to the government – nationally and to reduce malnutrition in children under the age of five regionally – to live up to its pledges, offering technical by five percentage points within five years. Critically, the support alongside the World Bank and other international 5-by-5-in-5 Goal was rooted in successful experiments to organizations to ensure the effective and efficient reduce chronic malnutrition in Peru by organizations like implementation of the national strategy. UNICEF, CARE Peru and other NGOs, which had joined forces in the Initiative. The following year, the drive to reduce chronic malnutrition gained momentum, with Peru determined to show results. Simple and accessible targets and messages were critical in driving “If you ask me who is the Peruvian champion in the fight the campaign to reduce chronic against nutrition problems, I would not be able to give you malnutrition in children. Not only a name,” said Carolina Trivelli, Minister of Development was there a clear focus on what was and Social Inclusion from 2011-2013. “There is no one needed but on how to do it. national hero.” In addition to setting the 5-by-5-in-5 Goal, the Initiative Internationally renowned nutrition and development expert convinced presidential candidates that they had a Alan Berg famously identified the problem with nutrition strategic blue-print for tackling chronic malnutrition that globally. All too often it was perceived as “everybody’s could work and offered them support in implementing a business but nobody’s main responsibility" (Berg, 1973). nationwide program . 3 Peru understood that, if it was to tackle stunting, it had to create incentives for everyone – from mothers, doctors, “We decided that if the government could reduce chronic nurses and public officials to politicians and international malnutrition in children by five percentage points for organizations – to share in the success of lowering rates children under five in five years that would be a tremendous of chronic malnutrition. advance because up until now it had been stagnating,” said Milo Stanojevich, National Director of CARE Peru, an NGO working to reduce poverty. 3 The elected president Garcia then stepped up the challenge by increasing the goal to nine percentage points in five years. 4 The 10 recommendations included: the presidential ratification of the 5-by-5-in-5 goal; giving responsibility for the food security strategy to the PCM; reactivating the Food Security Commission; the Presidential commitment to present nutrition results annually; drawing up a clear and concerted plan to implement nutritional programs; the implementation of a national program to strengthen capacity of municipal governments; local and regional governments providing at least 30 percent of their budget to activities related to improvement in the nutritional status of children; MEF providing technical assistance to regional and local governments in the development of public investment projects; municipal governments establishing accountability mechanisms for actions undertaken to improve nutritional status; and the implementation of an incentive program for municipal governments to reward performance in activities to reduce chronic malnutrition. 22 PERU'S SOLUTION: A 4.  MULTI-PRONGED STRATEGY GEARED TOWARDS RESULTS The launch of conditional cash transfer program Juntos and national nutrition strategy Crecer marked critical steps in Peru's fight against stunting between 2005 and 2007 Chapter Snapshot • The launch in 2005 of the CCT program Juntos provided financial incentives to mothers to visit clinics with their children in rural areas for health checks. • The program raised demand for preventive health and nutrition services, encouraging mothers to change health, nutrition and hygiene practices. • The launch of Crecer5 in 2007, the national strategy for combating poverty and chronic malnutrition in children, focused on more cost-effective social spending by consolidating health and nutrition programs with an emphasis on maternal-child health, birth registration and access to social services. • Spending focused on “key interventions:” vaccinations to reduce childhood infections, monitoring and promoting the growth of infants and young children, as well as feeding and hygiene practices in the family home. • The government targeted the poorest areas with the highest rates of stunting, set clear targets and doubled spending to implement the strategy. 5 Crecer means “to grow” in Spanish. 23 The launch of Juntos changed mindsets The Juntos program had some initial start-up challenges related to coverage and linking to nutrition services, but with The Juntos program was established in 2005. It chronic malnutrition moving up the political agenda, early encouraged pregnant women and mothers with children shortcomings would be addressed as Peru made stunting of up to two years of age to visit clinics in rural areas for a national priority. The program placed a special emphasis health checks by providing cash transfers of 200 Peruvian on improving the registration of young children and the Soles every two months in return for attending health verification of their participation in health and nutrition and nutrition services. This allowed parents, doctors and services, given the importance of reaching children as early nurses to monitor the growth and development of Peru’s as possible, within the 1,000 days' window8. poorest children. In addition, mothers were encouraged to enrol and keep their children aged six to 19 in school. By 2007 Juntos was reaching around 373,000 households. Juntos was inspired by a similar successful CCT program By 2016, this had more than doubled to 772,000. in Mexico called Progresa/Oportunidades. households in the poorest rural areas of Peru, or about one quarter of poor households in Peru. Thanks to an effective targeting system, the poorest received the vital support they needed. Juntos’ targeting Health insurance coverage widened to ensure health and has been built on three stages: (i) Geographic targeting, nutrition services for most vulnerable children which identified priority districts in the poorest parts of Peru, based on selection criteria that combined Juntos put a strong value on preventive health services basic needs and estimates of the poverty gap, extreme and capitalized on the successful health insurance poverty and malnutrition indices. It also considered the program for poor households, SIS, established in 2002. percentage of towns affected by political violence; (ii) Household targeting, which relied on a proxy means test6 SIS was the first comprehensive public insurance scheme administered by INEI; and (iii) Community validation of the targeting the poor in Peru and increased coverage for list of selected households. the most vulnerable. SIS aimed to reduce economic barriers through the elimination of user fees for a While it is not possible to attribute Peru's reduction package of services. The program financed part of the in stunting to any single program, Peru’s CCT was an health provision by reimbursing the variable costs (i.e. important catalyst for rallying improvements in the supply not including salaries) incurred by service providers of health and nutrition services across the country, both to national hospitals and regional governments. SIS in terms of coverage and the quality of services7. Juntos represented, in practice, the first effort to plan budgets in fuelled demand for preventive health and nutrition services, line with demand for services. creating the opportunity for health workers to encourage mothers to change health, nutrition and hygiene practices. Between 2005 and 2014, the percentage of the population This proved critical in reducing stunting nationwide. covered by any health insurance increased from 38 6 The term "proxy means test" is used to describe a situation where information on household or individual characteristics correlated with welfare levels is used in a formal algorithm to proxy household income, welfare or need (Grosh and Baker, 1995).  7 The evidence about the impact of the Juntos program on child stunting is mixed. Escobal and Benites (2012) cannot find conclusive evidence about the association between the decline in stunting and participation in the Juntos program. Sánchez and Jaramillo (2012) concluded that Juntos is associated with reductions in severe stunting among beneficiary children younger than five, and that the reduction of both moderate and severe stunting was most prevalent among children of more educated mothers. Similar conclusions were presented in a more recent paper by Sanchez, Melendez, and Behrman (2016) that found no effects on stunting overall, but large effects on severe stunting for siblings of children who were exposed to Juntos as children younger than three years old. 8 1,000 days’ window refers to the period between conception and a child’s second birthday. This is approximately 1,000 days and is considered as a crucially important period for brain development and within which stunting is reversible. The 1,000 days are the most critical time for positive impact on a child's cognitive and physical development. 24 percent to 70 percent. The increase was disproportionally as well as across government ministries, regions and higher among the poor and vulnerable, whose coverage municipalities. increased from 32 percent to 75 percent in that period, thanks to SIS. “When malnutrition is so high in your country and you were not informed about it, your soul rebels and you ask Meanwhile, the intersectoral collaboration between the yourself: ‘What can I do about it?’" said former Prime health sector and the National Registry for Identification Minister Jorge del Castillo. “I could not accept that more and Civil Status Agency (RENIEC) resulted in increased than a quarter of Peruvian children were in that situation.” registration and affiliation. The focus of Juntos on encouraging parents' demand for services, especially birth The PCM became a powerful hub for coordinating all of registration and participation in preventive health services Peru’s initiatives to combat poverty and malnutrition at the was a marked success and the fruits of a combination of very heart of government. efforts by various sectors simultaneously. Crecer had its own secretariat, underpinning the National nutrition strategy Crecer focused on poorest importance of the initiative. areas and neediest children Crecer did not just focus on the symptoms of malnutrition The launch of Crecer in 2007 rallied national, regional but its direct and underlying causes, drawing inspiration and municipal governments to reduce poverty and from UNICEF’s Conceptual Framework for Malnutrition. boost development in cooperation with the private sector, international development agencies and grass- Initially, Crecer targeted one million children under five roots organizations. That required the government to tie with a focus on the first 1,000 days of life. The program together loose strands from a host of disparate initiatives targeted the poorest parts of Peru first. to reduce inefficiency in social spending. Some 82 public programs were consolidated into 26 initiatives focused “The essence of Crecer, which was the strategy to fight on poverty and child health after a rigorous review of against poverty and malnutrition, was to go to the poorest international evidence and their performance. Among the districts, to the 880 poorest districts (out of a total of most important were initiatives to provide maternal-child 1,838 districts in Peru), because that is where we needed health services, birth registration and increase access to to start,” said Ivan Hidalgo, a former coordinator of Crecer other social services. and Vice Minister of Social Development. The significance of Crecer was reflected in the political “The easiest thing is to work in urban areas but what about clout behind it. the rest of the country? Who are the ones who need it first? These districts had more than 50 percent poverty, The PCM took charge of the strategy, ensuring more than 30 percent illiteracy and more than 30 percent cooperation between public and private organizations, malnutrition, well above the national average. It was 25 based on these criteria that these districts were targeted,” resources) for tackling the problem to regional and Hidalgo said. municipal governments while holding them accountable. The strategy had three central elements. Peru recognized that chronic malnutrition was about more than just insufficient food. Firstly, it stressed that nutrition was a much wider issue than just food distribution. Water, sanitation, access “The [old] idea of combating malnutrition was narrow to health services, education and the empowerment of because it was focusing only on food,” said Nelly Huamani, women in poor, remote and rural communities were critical Project Coordinator of the Public Budget National to reducing stunting. It was impossible to effectively Directorate at the MEF. “The [new] idea was not to leave it combat chronic malnutrition without regular child growth aside because there was already a strong investment by monitoring and promotion as well as fighting infectious the country in food. However, there was another part that diseases, improving sanitation and access to water. was not considered in combating chronic malnutrition: reduction of childhood infections,” she said. “So, for Secondly, Crecer stressed the importance of coordination, that we had to allocate the resources to do nutritional horizontally across ministries and public bodies and counseling and distribute the new vaccines to combat vertically, between national, regional and municipal pneumonia and diarrhea.” authorities. Focus on growth monitoring and promotion Thirdly, and most crucial to actual implementation of the strategy, was the decision to give the power (and Crecer focused spending on “key interventions.” 26 BOX 4: What happens during the growth monitoring and promotion program CRED? While CRED protocols have been in place for a while, the monitored for her growth and seen by trained health reforms introduced between 2008 and 2010 by Results- workers almost 20 times. The health workers in her Based Budgeting guaranteed that the minimum inputs community were trained and were provided with needed for the provision of CRED services in the health educational materials that helped address any problem center were available across the country and especially that Maria might have encountered. They would have in areas with the highest malnutrition rates. helped to find tailored solutions. During her pregnancy, Maria Gonzales9, a 24-year- During every health check-up visit, in addition to a old from Santa Maria, paid more attention to healthy regular well-baby check-up, specific attention was weight gain than previously. She was also given at paid to record the child’s weight but more importantly least three months of iron/folic acid supplementation the child's height and age to allow close monitoring and advised on how and when to take the pills, which of adequate growth. Measuring height on a regular can have temporarily annoying, but avoidable, side (monthly) basis and the attention on the increase in effects. Iron folic acid supplementation was crucial height was novel. Previously, and in most other Latin for Maria to ensure her iron levels were adequate to American and Caribbean countries, most growth prevent anemia which increases the risk of bleeding monitoring and promotion programs still focused on (and even possible risk of death) during delivery. During weight gain. Depending on the progress, counseling is the last weeks of her pregnancy, Maria transferred iron adapted to the particular issue. In the case of growth to Isabella (her unborn child) to build up a sufficient faltering, the child is checked for underlying disease reserve for the first six months after birth. This makes and given treatment. Parents are also given nutrition up for the low levels of iron in breastmilk during the advice. During the same visits to the health center six-month exclusive breastfeeding period. Maria and Isabella was vaccinated according to the standard other mothers received precious information during norms and given Vitamin A. Her parents were given their regular ante-natal care visits at the health centers advice on other micronutrients such as the use of about the benefits of exclusive breastfeeding as iodized salt and the multiple micronutrient sprinkles well as continued counseling and advice in the case (or chispitas in Spanish)11 which can be added directly of problems during the subsequent regular baby to her food. check-ups10 until the child’s second birthday. Maria received critical information about personal hygiene The main purpose of the regular growth monitoring and handwashing, and she was urged to register her and promotion sessions, or CRED in Peru, is to prevent new infant and enrol in the health insurance scheme children from growth faltering and becoming stunted. SIS. The all-important complementary feeding period It is a collaborative effort between the parents and the after six months, when the infant is introduced to solid health workers, both at the community level and the foods, was also the subject of intensive counseling health center, supported by the entire community. until Isabella was 24 months. By then she had been 9 Names are fictional. 10 N  ewborn check-up at seven and 15 days; infant one to 11 months of age check-up every month; toddler between 12-23 months check up every two months; children between 24-29 months of age have four check-ups every year. 11  prinkles are multiple micronutrient powders in single-dose packets of vitamins and minerals in powder form that can be sprinkled onto any ready to eat S semi-solid food consumed at home, school or any other point of use. The powders are used to increase the micronutrient content of a child's diet without changing their usual dietary habits (http://www.who.int/elena/titles/micronutrientpowder_infants/en/). 27 One priority was growth monitoring and promotion for infants Commitment, cooperation and coordination across and young children in health centers and smaller health government posts, in addition to nutritional, care and hygiene advice given by health staff to pregnant women and mothers. Given the complexity and scale of regional politics in Peru, the Initiative against Chronic Infant Malnutrition During those sessions children were being vaccinated worked hard to persuade national, regional and municipal against rotavirus, which can cause gastroenteritis, and authorities that they needed to work closely together to against pneumococcus, the most common cause of achieve success in reducing malnutrition. bloodstream infections, pneumonia, meningitis, and middle ear infections in young children (Box 4). In 2007, the PCM, with support from the World Bank organized a conference with regional governors to persuade Moreover, women were encouraged to exclusively them to support the drive to combat chronic malnutrition. breastfeed for the first six months as part of nutritional counseling. Mothers were also invited to attend food “We made the case that this was going to be a success: preparation classes. They were advised on complementary would you like to be part of it?” said John Newman, a feeding for children aged 6-24 months, particularly the former World Bank Country Manager for Peru. importance of protein and iron-rich foods in their diets. The government encouraged regions, districts and But achieving targets set by the government in Lima municipalities to take on responsibility for meeting required commitment, cooperation and coordination right nutrition targets. Initially, results were mixed. A few across the country. regions, including Ayacucho, were highly successful, reducing chronic malnutrition by six percentage points “A key fact that has favored progress in the reduction of and poverty by more than 15 percentage points between chronic malnutrition has been to have objectives with 2005 and 2009. All results were made public, increasing clear goals and with very precise indicators. From these the motivation to achieve the targets that were set. components, it is possible to generate commitments,” one government official in Huánuco said in a series of focus “Taking quick actions that allowed for a reduction was group interviews in January 2017. important because when you have a lot to do and you make a good decision, the impact can be strong. And there was a strong impact,” said Paola Bustamante, Minister of Development and Social Inclusion from 2014-2016. 28 PERU'S SOLUTION: 5.  ALIGNING RESOURCES WITH RESULTS Result-Based Budgeting allowed for focus on results, value for money and ring- fenced budgets from 2008 Chapter Snapshot • Moving to Result-Based Budgeting (RBB) in 2008 was a watershed for investing in nutrition as it created a rigorous approach to allocating spending to achieve results in children’s health, growth and development. • Only the most cost-effective and globally proven ways of reducing stunting were allocated money. • Real time individualized data, as well as regular household and demographic surveys and birth registration, played a critical role in evaluating priorities and progress. • Regional health authorities were rewarded with an increase in their budgets if they achieved development targets, including on chronic malnutrition, sanitation and water. • Stunting became a shared national responsibility and priority across government with public officials trained to understand how to tackle the problem. MEF decided to start using RBB throughout the Peruvian This meant, in practice, that systems were required to government in 2008. RBB is the practice of developing identify the number of children who needed to be reached, budgets based on the relationship between program funding the amount of money needed to pay for key services, a levels and expected results. The government’s Articulated system for tracking that spending and its impact relative Nutrition Budget Program (PAN) was one of the first to national and regional targets. initiatives to benefit from this rigorous approach to achieving results. RBB worked as a tool for identifying and meeting the “The change to results-based management led not only needs of the most vulnerable citizens and increasing their to a better allocation of financial resources but also to access to services. a change in organizational culture not only within MEF but also in the entities that needed to understand that PAN used a multi-cause logical framework that targeted the goal of the resources we were assigning had a final several factors believed to be drivers of stunting based on purpose: that was to achieve changes in the lives of the medical and social policy literature and on baseline data people,” said Rodolfo Acuña, Director of Public Budget that identified gaps and constraints in Peru. at MEF. MEF took the lead in ensuring the country’s money was well The PAN program received financial and technical spent in the drive to curb chronic malnutrition and in tackling support from the European Union (EU) and the other social issues, taking an unusually prominent role in World Bank. National commitment to reducing defining and implementing PAN. The new approach outlined stunting was supported in parallel by international the results the government wanted to achieve and allocated technical cooperation. and protected the funds accordingly. 29 RBB boosts supply of critical health and nutrition right number of vaccines. RBB aligned planning, allocation services and accountability in a single cycle. The RBB approach led to a tremendous change in the RBB promoted the use of a budget planning tool planning and delivery of health and nutrition services. (Integrated Administrative Management System - Sistema By establishing “budgetary chains” for PAN "results," Integrado de Gestion Administrativa (SIGA) by regional resources were ring-fenced for the different inputs needed health authorities (DIRESAs) in their nutrition programs, to provide vital services. The budget was based on goals for analyzing the supply chain between budget executing and what was needed to achieve those goals and not just units and health networks. In 2010, a SIGA analysis on inertial expenditure in previous years. justified budget increments to PAN, which increased the per capita (child) budget for CRED and vaccination by For example, before the consolidation of RBB, inputs 331 percent and 150 percent, respectively, to fund CRED needed to vaccinate children in a village were planned and services in remote locations (Sierra and Selva regions), budgeted for every year based on historical trends. Say and improve awareness campaigns and vaccinations health personnel had received 1,000 Soles one year to buy against respiratory and diarrheic diseases. syringes, they would request 1,200 Soles the following year (a small increase). In addition, if at some point, they In 2010, PAN’s additional budget for regional governments were missing 300 Soles for buying utensils for a cookery (12 percent of total PAN budget) was assigned based on class (a completely different activity), they could take that malnutrition indicators, with bigger increases for regions money from the 1,200 Soles allocated for syringes. with higher rates of chronic malnutrition (Chart 3, Panel B). As shown in Chart 3, Panel A, the previous allocation With the introduction of RBB, a formal result was introduced of the nutrition budget did not correspond well with the and called “children with full package of immunizations.” geographic distribution of chronic malnutrition. This result was linked to different budgetary chains for each key input needed to deliver the service. To request the From 2010 budgetary programming for nutrition improved budget, health staff had to report the number of children and resources were channelled to the regions where they planned to vaccinate. In addition, they had to include malnutrition rates were the highest (Chart 3, Panel B). This all the inputs required to deliver the service for every child. was the result of improved awareness and agreements Also, funds could not be arbitrarily used for any other among decision makers, especially MEF, intentioned to purpose. RBB ensured the right “blend” of inputs needed to reallocate the budget for nutrition related interventions provide services. The system was designed to ensure that (PAN) to those regions with the highest burden of health workers had the right number of syringes for the malnutrition (World Bank, 2012). 30 Chart 3: Aligning budget to areas in most need Panel A: Comparison between stunting rates in 2007 (left) & 2008 budget allocation to PAN (right), by Regions. TACNA TACNA TACNA Total PAN Budget MOQUEGUA MOQUEGUA LIMA MOQUEGUA 2009: 1,052 Millions TUMBESLIMA LIMA 2010: 1,535 Millions TUMBES AREQUIPA TUMBES 50% Increases AREQUIPA AREQUIPA ICA ICA ICA MADRE DE DIOS MADRE DE DIOS MADRE DE DIOS LAMBAYEQUE LAMBAYEQUE LAMBAYEQUE SAN MARTIN SAN MARTIN SAN MARTIN Targeted increase in budget: PIURA PIURA PIURA Huancavelica received UCAYALI UCAYALI UCAYALI 2,100 soles per child LA LIBERTAD LA LIBERTAD LA LIBERTAD JUNIN JUNIN JUNIN LORETOLORETO LORETO PUNO PUNO PUNO CUSCO CUSCO CUSCO AMAZONAB AMAZONAB AMAZONAB ANCASH ANCASH ANCASH PASCO PASCO PASCO APURIMAC APURIMAC APURIMAC AYACUCHO AYACUCHO AYACUCHO CAJAMARCA CAJAMARCA CAJAMARCA HUANUCO HUANUCO HUANUCO HUANCAVELICA HUANCAVELICA HUANCAVELICA Prevalence of Stunting in children under 5 (%) Total amount assigned in January 2008 Prevalence of Stunting in children under 5 (%) inin 2007 2007 Total amount assigned 200936 in than 2010 & months) (soles per child younger (soles percchild younger than 36 months) Panel B: Comparison between stunting rates in 2007 (left) & 2009-10 budget allocation to PAN (right), by Regions. TACNA TACNA TACNA Total PAN Budget MOQUEGUA MOQUEGUA MOQUEGUA LIMALIMA LIMA 2009: 1,052 Millions TUMBES TUMBES TUMBES 2010: 1,535 Millions AREQUIPA AREQUIPA AREQUIPA 50% Increases ICA ICA ICA MADRE DE DIOS MADRE DE DIOS MADRE DE DIOS LAMBAYEQUE LAMBAYEQUE LAMBAYEQUE MARTIN SAN SAN MARTIN SAN MARTIN Targeted increase in budget: PIURA PIURA PIURA Huancavelica received UCAYALI UCAYALI UCAYALI 2,100 soles per child LA LIBERTAD LA LIBERTAD LA LIBERTAD JUNIN JUNIN JUNIN LORETO LORETO LORETO PUNO PUNO PUNO CUSCO CUSCO CUSCO AMAZONAB AMAZONAB AMAZONAB ANCASH ANCASH ANCASH PASCO PASCO PASCO APURIMAC APURIMAC APURIMAC AYACUCHO AYACUCHO AYACUCHO CAJAMARCA CAJAMARCA CAJAMARCA HUANUCO HUANUCO HUANUCO HUANCAVELICA HUANCAVELICA HUANCAVELICA Prevalence Prevalence of Stunting of Stunting in children in children under under 5in (%) 5 (%) in 2007 2007 Total amount assigned in January 2008 Total amount assigned in 2009 & 2010 (soles per child younger than 36 months) (soles percchild younger than 36 months) Source: MEF and ENDES 31 Selectivity was critical 1,980 million Soles in 2017. The budget was allocated to the sectors responsible for providing services through The PAN program gave the regions the green light to the Convenios de Apoyo Presupuestario. For example, increase their budgets for nutrition by 50 percent if they in the case of CRED or immunization, regional health met targets. MEF established Budget Support Agreements directorates were assigned additional resources based on (Convenios de Apoyo Presupuestario) 12 in those regions the agreements and expected results. with the highest stunting rates and the greatest gaps in coverage of prioritized services (immunization, CRED, iron Importantly, this went hand in hand with training in results- and folic acid supplementation). based budgeting for public officials in charge of social spending programs across Peru. It also was done in a The Convenios defined disbursements to the regional budget neutral manner, as the resources were essentially governments based on expected results. re-allocated within the budget. PAN focused on priority results in its drive to reduce “Yes, there was more money but a good part of the stunting. Only the most cost-effective and globally proven resources in the programs came from a reassignment interventions of reducing stunting were given money. of their own budgets,” said Nelly Huamani, Project Coordinator of the Public Budget Directorate at MEF. In First, it made vaccination of children against addition, money for the programs was ring-fenced and pneumococcus and rotavirus a priority. Rather than budgets could not be changed in priority areas unless choosing 20 vaccines, Peru chose to focus on just two. targets had been met. This was based on disease burden and international experience13, which showed that these two vaccines would Immunization and growth monitoring and promotion have the biggest impact on reducing chronic malnutrition. check-up rates surge Secondly, it spent money on quality preventive health and The focus of PAN on improving access to critical health nutrition services to ensure children grew properly. and nutrition services was reflected in a sharp rise in immunizations, growth checks and uptake of iron Thirdly, it invested in reducing iron deficiency by providing supplements, particularly in poor, remote and rural supplements to families, both for children (through communities. The percentage of children under 12 months sprinkles) and pregnant women, based on an equity-driven immunized against rotavirus and pneumococcus more preventive approach. than tripled from 25 percent in 2009 to around 79 percent in 2016, data from ENDES shows. The percentage of Crucially, it did so by shifting public spending to target children younger than 36 months attending regular growth regions where malnutrition rates were the highest, such monitoring and promotion sessions (CREDs) in the health as Huancavelica, located in the Andes (Chart 3). centers doubled from around 28 percent in 2009 to 58 percent in the same period, ENDES data reveals (Chart 4). Over time PAN spending also increased significantly, doubling from around 965 million Soles in 2008 to almost 12  he Convenios were supported by the EUROPAN project and established a fixed and a variable tranche. Fixed tranche disbursements were linked to fulfillment T of administrative/logistical processes needed to implement the PAN (including strengthening operational capacities of budget units). Variable tranches were disbursed against achievements of pre-established targets in coverage (percentage of children with immunizations; percentage of children with CRED; percentage of children affiliated to SIS, etc.). 13 International evidence helped convince stakeholders to prioritize to 2 out of 20 vaccines. 32 Chart 4: Proportion of children younger than 36 months with complete CRED for their age 66 65 62 59 58 58 55 56 55 52 51 51 50 49 47 47 47 44 43 40 38 28 29 28 27 25 24 24 24 22 22 21 20 National Rural Urban Source: ENDES This would not have been successful without the It was a shared priority and a shared responsibility. concurrent increase in health insurance coverage, facilitated by SIS, providing the supply of required services “They understood that PAN was not the monopoly of any at the facility level. Health facility staff were provided sector but was a state-wide program,” said Rodolfo Acuña, with additional training and were required to report on Director of Public Budget at MEF. the services provided to comply with the targets set for additional funds under the new RBB approach. Also, if The third pillar was specialized training in both targets were not reached, the information would have malnutrition and management of nutrition interventions become public and regional health directorates would for public servants, including in the local offices of MEF, have not received additional resources linked to achieving to ensure understanding and knowledge to tackle chronic results. malnutrition. Behind the success of PAN “For the first time in history, the MINSA (Ministerio de Salud – Health Ministry) Health Planning and Budget and The success of PAN rested on three pillars. Health Promotion teams came together with MEF. We formed teams and covered all the country from Tumbes to The first pillar was the use of result-based budgeting. Tacna and we realized that the workshops were crowded because people were very interested in this,” said Ariela The second pillar was a unified and coordinated approach. Luna, former Vice Minister of the Ministry of Development No one ministry or public body had “ownership” of nutrition. and Social Inclusion (MIDIS). 33 “In 2010, regional presidents and mayors were already of Health, SIS, the National Food and Nutrition Center talking about the brain, the logical framework, the use of (Centro Nacional de Alimentacion y Nutricion (CENAN), vaccines and nutrition counseling. These themes were Juntos, CRECER, RENIEC, INEI, MEF and the WB. Officials incorporated in their speech. It was no longer a health worked to strengthen standards, accountability and skills issue only,” she said. to ensure more effective and efficient delivery of social services to rural, remote and poor families. “Unlike other countries, where the methodological change (from inertial budget to RBB) was conducted under a The Grupo Apurimac drew up a plan to restructure, crisis scenario, we were caught in a time of abundance. relaunch, and consolidate Juntos, ensuring more efficient It became less painful but now that times of plenty are and effective spending on health and nutrition services over, we should prioritize. And the best way to prioritize is by the health sector. The experience validated a series through results-based management”, said Rodolfo Acuña. of changes needed at the local level in Apurimac to: (i) Guarantee the complete affiliation of Juntos’ beneficiaries The Apurimac experience to SIS; (ii) Adjust the allocation of Juntos' beneficiaries to the health centers; (iii) Establish a planning system In addition to cooperation between national, regional and for health visits of pregnant women and young children local government, within and between ministries, Peru and (iv) Enforce a strict verification of the health co- drew on international support to bolster its fight against responsibilities. In addition, Juntos also piloted the poverty and chronic malnutrition. transition from monthly to bi-monthly payment of transfers in Apurimac. The World Bank initially supported the government’s efforts to reduce chronic malnutrition, at first with Clearing bottlenecks technical assistance in 2008-2009. This led to the creation of a multi-sectoral team (also known as "Grupo The Grupo Apurimac identified critical bottlenecks in Apurimac") involved in an assessment and restructuring the link between the demand for services generated of Juntos to improve nutrition and healthcare for children. by Juntos and the supply of those services. Those The aim was to ensure that cash transfers created bottlenecks included, for example, inadequate verification demand among poor households for a basic health and that mothers were bringing all their children for height nutrition package from the “supply side" of social services. and weight check-ups in return for benefiting from the This helped to identify institutional, legal and operational CCT program. Another problem was a lack of clarity on changes in Juntos and in health and nutrition services. what health services pregnant women and children should This effort, initiated in 2008 with a pilot in the Apurimac attend in return for cash payments. A further issue was region in southern central Peru, involved the Ministry lack of effective coordination across different levels and 34 sectors of government, as well as gaps in evaluation and The Apurimac experience – figuring out what worked well monitoring. After identifying the bottlenecks, technical and what did not – became a role model for the rest of Peru. assistance set about introducing ways to clear them. When rolled out nationally, the government took a The World Bank then mobilized all its available instruments, centralized and coordinated approach to spending money such as development policy loans (budget support), in health facilities in the country’s districts. This was to analytical work and lending for results to strengthen ensure sufficient coverage and quality of health and standards and accountability around nutrition. It also nutrition services to meet increased demand for services provided financing and advice to the government while promoted by Juntos. At the same time Juntos improved it put in place some of the recommendations that were the way it registered young children, making payments identified through the Apurimac experience. conditional on families using health and nutrition services. And finally, the SIS increase in coverage of affiliated Money was spent on training local health center staff in children contributed significantly to the increase in child health and nutritional counseling and on improving participation and use of services. the quality of information available for running the Juntos program effectively. Management, monitoring and Recording births as a gateway to social services evaluation were introduced or tightened up. Birth registration has been critical in Peru to ensure every “What we must not forget is that these types of things do family gains access to the health and child care services they not happen spontaneously. Peru, like a lot of countries, need. Peru's Padron Nominado played a crucial role here. had problems with inter-institutional cooperation, from the Ministry of Health to municipalities,” said Livia Benavides, It is an individualized list of children under six years of the World Bank’s Human Development Program Leader age. The list is on an electronic platform and contains the for Bolivia, Chile, Ecuador, Peru and Venezuela. following data: names and surnames; identification numbers; names and surnames of the father and mother; address; Experts and decision makers in MEF, MINSA, Juntos, affiliation to social programs; type of health insurance; SIS, RENIEC and from the World Bank met regularly to among other information. It gets information from the find ways to ensure the strategy was working, to identify register of SIS, Juntos and from other sectors, including the problems and solutions. Ministry of Education. The data is used to measure coverage of health services and social programs at different levels by Fostering institutional cooperation and coordination department, province, district and communities. The main problems identified in the early days of Juntos and Having one platform to register children when they access Crecer included ensuring that more births were registered, social programs has allowed the state, through RENIEC, to that all eligible children were vaccinated and that they had fulfil the children’s right to identity. Also, for the first time their weight and height recorded. Rules and procedures in the history of Peru, it has allowed every health center were tightened to ensure mothers received conditional to know who its “final customers” were, contributing to a cash transfers on the basis that not just one but each one better service. It has allowed the early affiliation of children of their children were visiting health centers regularly. from poor families to health and nutrition services and to social programs. The Padron Nominado has served as a “They [the Grupo Apurimac] came together to think. That tool for effective institutional coordination and to ensure helped create rapport, a common purpose and a common services reach the most isolated citizens. approach: a united front,” said Omar Arias, the World Bank’s former sector leader for human development in The importance of parents registering the birth of their Peru from 2008-2011. children to gain access to vital health services is echoed by local government officials. 35 “Now, they get an ID from day one. Before, these children More resources were provided to Peru’s National Institute simply didn’t exist as far as the state was concerned,” said of Statistics (INEI), allowing Investment in more regular 40-year-old Julio Palacios Chumpitaz, a doctor working in surveys. The country’s Demographic and Family Health Huánuco. “We didn’t have an accurate list. The first benefit Survey (ENDES) provided vital data annually on the health the child receives is his or her packet of measures, like of mothers and children. Peru is one of very few countries vaccinations, and the sachets of dietary supplements." in transition that has annual demographic and health data at its disposal to inform decision making. Because of several policy measures, all Peruvian children born after 2006 automatically received a unique Critical to the long-term success of Peru’s drive to reduce identification number (National Identity Code or Codigo stunting has been a Social Monitoring tool: a process Unigo de Identidad, CUI in Spanish). Although there are developed to gather, evaluate and assess information on no education, health, or nutrition results directly linked the critical determinants of malnutrition at the grass-roots to the improvement of civil registration of children, there to ensure effective services and to develop a strong sense is evidence that increased identification contributed to of local involvement. improving targeting and the early detection of children at risk. The inclusion of the CUI in the birth certificate Under the leadership of local governments, local also became the first step towards the integration of the authorities, civil society organizations and community national civil registry by promoting information sharing leaders involved in combating stunting meet every six across social programs (World Bank, 2012). months. They monitor and share information about the coverage, quality and effectiveness of primary health and Monitoring and Measuring Success nutrition services as well as the impact they are having. In addition, they share their findings with local communities, Monitoring commitments was also critical. The Initiative creating downstream and upstream flows of information provided the government with a yearly report on its and accountability. Different information systems are used progress in reducing chronic child malnutrition, a so- to monitor the data: The Integrated Financial Management called Annual Balance of Actions to Reduce Chronic Child System (Sistema Integrado de Administracion Financiera- Malnutrition. The Mesa de Concertacion para la Lucha SIAF) for budget allocations; SIGA for inputs at the contra la Pobreza provided similar monitoring at national health facility level; and the Padron Nominado to monitor and regional level. every child with services provided, including data on the affiliation to Juntos and SIS. Guidelines were created to help municipal governments reduce chronic malnutrition by working hand in hand with “In 2006, we were allocating resources on an historical regional and national governments. Incentives were also basis and we did not see where the greatest gaps were. provided to municipalities through “Planes de Incentivos” In part, this was because we were not used to working (local initiative plans) aimed at increasing the coverage of with statistics. At that time, we decided to strengthen key services and to boost the registry of children in the the National Institute of Statistics so they could provide Padron Nominado. us with the information that we could use to improve the allocation of resources,” said Rodolfo Acuña. There was also a recognition that the government needed better data. INEI successfully used ENDES to monitor and track the success of government initiatives to improve the health and More detailed and frequent household and demographic nutrition of Peruvian children, including cross-referencing surveys were recognized as key because they could the data from the ENDES survey with the country’s Padron provide an invaluable snapshot of the lives and health of Nominado, the national registry of children developed by ordinary Peruvians. the Ministry of Health in coordination with RENIEC and MEF. 36 PERU'S SOLUTION: 6.  CEMENTING BEHAVIORAL CHANGE BY EMPOWERING PARENTS Communication about stunting empowered parents and deepened debate Chapter Snapshot • Peruvian parents often believed their children were growing normally when they were not or that their children’s short height was hereditary. • A video made public in 2007-2008 popularized simple-to-understand standards of what it means for a child to grow at a healthy rate. The video’s focus on the impact on stunting on a child’s brain shocked many across Peruvian society. • Awareness-raising encouraged mothers to bring their children to clinics to have them weighed and measured, to have them vaccinated and to change family meals to introduce more nutritious foods. For decades, many Peruvian parents in poor households The World Bank, in addition to lending financial and in remote communities were simply unaware that their technical support to Peru in its fight against stunting, children were chronically malnourished. Awareness produced and presented a seminal video in December 2007 raising had a crucial role to play in encouraging mothers that popularized simple-to-understand standards of what it to bring their children to health centers and smaller health means for a child to grow at a healthy rate: approximately posts to have them weighed and measured, to have them 24 centimeters in the first  year of life and 12 more in the vaccinated, to change family practices and meals to second year. The video was validated by the teams of MEF introduce more protein and iron-rich foods. and MINSA, the Initiative and other organizations. “The passive attitude of citizens changed over time to “My Future in my First Centimeters" ("Mi Futuro en Mis become an attitude of greater participation and involvement. Primeros Centimetros") presented success stories Now there are people who take the commitment to work for spearheaded by the UNICEF program Buen Inicio (Good their community. We saw this beforehand and it was very Start) in the fight against stunting in rural communities in unusual. Today it is becoming more frequent and they do Peru and inspired parents to take their children to clinics it with greater authority, with a greater level of knowledge to be weighed and measured and to receive counseling. and greater acceptance by their peers. This has led to TV and radio spots of this video still run today. (Video link: more progress on issues such as the use of safe water, https://www.youtube.com/watch?v=mJieb2Xgt9U) the recognition of the importance of preventive checks for children and pregnant women. These things have become daily practices for people,” said an official from the regional health office in Huánuco. 37 The story of two rural communities -- was so successful that the government distributed it to every health center targeted by Crecer to educate and The video told the story of two poor and remote farming inform public officials about the scale of the problem. It communities in the Apurimac region. Less than an hour was shown in community centers in the Andes, reaching apart, there were big differences in how well children were the most remote and impoverished areas. growing between Nueva Esperanza and Lliupapuquio. In Nueva Esperanza, the children were growing normally. In “The video showed so clearly what was happening Lliupapuquio, their growth was lagging. Eight out of every in the country’s hinterland and what it meant for the 10 children were suffering from chronic malnutrition. Less development of the children there. I think those of us who than a decade earlier, Nueva Esperanza had suffered a were in that session (video screening) thought a great similar problem. But it had successfully changed its fate, deal about what it would be like if our own children were with only two out of 10 children stunted at the time the in that situation. And we thought, well, why can’t we help video was filmed. them?” said Rodolfo Acuña, recalling the first time he and other government officials watched the video. A video that opened eyes The video pointed out that any child anywhere in the world under 80 cm tall on their second birthday was suffering The videos showed so clearly what “ from chronic malnutrition. Neither race nor ethnic origin has was happening in the country’s anything to do with a child’s growth potential at this age. hinterland and what it meant for the development of the children there.” “They [people from Nueva Esperanza] have reduced - Rodolfo Acuña, Director of Public malnutrition to a quarter of the previous level and they have Budget at MEF given lie to a myth which has doomed generations of Peru’s poor, rural children to suffer the lifelong consequences of chronic malnutrition,” the video told its viewers. The video not only stimulated national debate about the That reversal was thanks to pregnant women and scourge of stunting but became a major media story, mothers going for regular check-ups at health centers and particularly because of its hard-hitting images of the health posts, having their children weighed and measured irreversible impact of chronic malnutrition on a child’s monthly to make sure they were growing properly and brain development. to address the problem if they were not. Women were told about the benefits of exclusively breast feeding “What caught the attention of the Minister of Economy, their babies for the first six months and of making sure Luis Carranza, was to see, in an image that we showed him, children got the complementary foods they needed after the difference between how a neuron of a malnourished that. There was also a focus on hygiene and vaccinating child looks compared to that of a child that is not. When children against illnesses. he read the scientific papers, and heard other arguments, “It was an eye-opening video. Back then I had been a TV he said: ‘We must prioritize this,” said health expert reporter for 15 years. The way we saw malnutrition was Lucho Cordero. the typical picture of an emaciated child from Africa. We were absolutely clueless about what chronic malnutrition Newspapers, radio and television were awash with reports in children was,” said Bibiana Melzi, who produced “My about the country’s chronic malnutrition crisis for the Future in my First Centimeters”. first time. The video -- which was made available in Spanish, English The success of the video inspired other Latin American and Quechua (the indigenous language of the Inca empire) countries to emulate Peru’s example by producing similar 38 films on chronic malnutrition, including Guatemala, help develop guidebooks on healthy nutrition for pregnant Ecuador, Honduras, Mexico and Nicaragua. In Peru, the women and infants. Juntos mothers, who were winners of video was converted into radio spots played freely on a nutrition and gastronomy competition focusing on food Radio Programas Del Peru (RPP), a broadcaster which for children from six to 24 months of age, took part in the covers almost the entire country. national gastronomical fair in Lima. Cooking up recipes for success Peru has not only spent the last decade successfully striving to reduce stunting. It has become the culinary It was an eye-opening video.” “ capital of South America thanks to celebrity chefs such - TV producer Bibiana Melzi as Gastón Acurio, who, together with other chefs and the Peruvian Gastronomy Association (Asociacion Peruana de Gastronomia - Apega), has helped to make the country’s cuisine one of its proudest exports. Peru's National Food and Nutrition Centre (CENAN) initiated But lack of diversity in the diet of rural and remote a weekly campaign publishing nutritious recipes that used communities, particularly inadequate access to meat, inexpensive foods available in the local markets of the dairy and eggs was a persistent problem when the poorest districts of Peru. "The campaign provided affordable government set out to tackle chronic malnutrition. In 2009, and nutritious meal alternatives for poor families, ensuring the Ministry of Health, Juntos and the World Bank invited the right mix of foods and critical nutrients. In parallel, some of Peru’s top chefs to promote healthy eating with parents were given cookery lessons alongside counseling cookery lessons, cookery competitions and educational in health facilities. The cookery lessons promoted culinary sessions in communities and schools. hygiene as well as providing tips to families on how to combine different ingredients to ensure the right mix of Chefs and trained nutritionists worked with poor women nutrients in meals for different age groups", said Maria in remote areas to inspire them to find new ways to Ines Sanchez Grinan, advisor to the Minister of Health and prepare food for children from six to 24 months of age. former Director of CENAN. This activity was included in PAN Nutritionists, Apega and Cordon Bleu, the world’s largest with every health center in the country allocating sufficient network of culinary and hospitality schools, teamed up to money to implement it regularly. 39 PERU'S SOLUTION: 7.  INSTITUTIONALIZING SUCCESSFUL POLICIES The campaign to conquer chronic malnutrition did not lose momentum in 2011-2016: MIDIS and a new institutional home for coordinated policies to tackle stunting. Chapter Snapshot • Political continuity in the fight against malnutrition was vital in lowering stunting rates with the issue on the political agenda in three successive elections: 2006, 2011 and 2016. • From 2011, the Ministry of Development and Social Inclusion (MIDIS) took charge of coordinating the national campaign to curb chronic malnutrition. • The Ministry launched a new early child development program and closed an inefficient government agency responsible for food distribution. • A new Performance Incentive Fund was created to reward the delivery of a complete package of services to children. When Ollanta Humala was elected President of Peru in of MIDIS, including Juntos. While different sectors the 2011 election he pledged to further reduce chronic contributed to the drive to reduce chronic malnutrition, malnutrition and anemia. the initiatives were directed by the ministry. To ensure continuity the new ministry was staffed with officials His government set up MIDIS and put it in charge of who had earlier held senior positions in the finance and tackling chronic malnutrition. A National Plan for the health ministries. It also worked closely with MEF and the Reduction of Chronic Malnutrition and Child Anemia was Ministry of Health. adopted, setting the tone for national, regional and local government. At the end of 2013, MIDIS was made responsible for coordinating a multi-sectoral commission in charge of the The Ministry’s main job was to ensure Peru’s poor shared "Early Childhood" strategy and its action plan for 2014-2016. in the country’s economic growth. As part of that drive, a national “Inclusion for Growth Strategy” was unveiled to The strategy included Crecer, which then was renamed revamp the Crecer strategy. It set out to improve the lives of Incluir para Crecer15 (Inclusion for Growth). An ambitious Peru’s poor through national, regional and local government. target was set to reduce stunting further by 13 percentage The new ministry had responsibility for social development points in five years. Part of the ministry was responsible for and protection, inclusion, equality and nutrition. Five key targeting, coordination and evaluation to ensure coherent social programs were also moved under the responsibility and consistent nutrition policies across government. 15  ncluir para Crecer was designed to follow a life-cycle approach and targeted five outcomes including the reduction of malnutrition and improvement of early I childhood development to foster opportunities and provide early stimulation for those same children. 40 Incluir para Crecer was designed to follow a life-cycle Cuna Mas was created in 2012 to provide comprehensive approach and targeted five outcomes including the childcare to vulnerable children below three years of age, reduction of malnutrition and improvement of early in poor urban and rural districts. These regular childcare childhood development to foster opportunities and provide services included growth monitoring and home visits to early stimulation. families with children at risk of suffering malnutrition. In addition, the Ministry set up a school nutrition program “Personally, it’s a touching issue. We are a diverse and called Qali Warma and closed the government agency increasingly rich country. We cannot allow our kids not to take responsible for food distribution program known as advantage of that,” Carolina Trivelli, the first Minister of MIDIS PRONAA16. Peru’s ambitions to increase the quality of said. “You realize there is a change in the country, especially children’s nutrition and reduce stunting rates remained when parents talk to you with pride about how big their kids are firmly at the top of the political agenda, irrespective of today, how they are growing, how strong they are, how tall they which party was in power in Lima. are. That sense of pride shows they value the interventions, that there is a transformation in the lives of these families,” MIDIS and the MEF also created the FED (Fondo Estimulo she said. “This country has done amazingly well in translating al Desempeno), seeking to improve the delivery of priority a good economic situation into a better social situation for the services to reduce stunting and promote early childhood poorest people. It’s not just about economic growth but about development. In 2014, FED had a budget of 100 million Soles making the right choices,” she said. - about $30 million at today's exchange rate - to be allocated to regional governments based on their compliance with Setting goals for social transformation commitments to provide services to pregnant women or children up to five years of age. FED took an innovative The Ministry also launched the Cuna Mas early childhood approach by broadening the focus on early child development development program for children under 36 months living and by recognising the importance of delivering a complete in poverty, providing day care and home visiting services. package of services to "the same person". 16  RONAA was created in 1992 to provide food assistance to rural and isolated areas. PRONAA typically distributed a food package that included rice, soup, P cereals and vegetable oil (Alcazar, 2007). In 2012 PRONAA was closed due to significant deficiencies that pointed to problems of low coverage and high inclusion errors, sub-optimal planning, purchasing, delivery and storage processes causing delays and incomplete rations, and a big difference between the amount of food delivered and the amount effectively consumed by the beneficiaries (MIDIS, 2013). A new program, Qali Warma, was created immediately to replace feeding programs for school-aged children. It worked in collaboration with local communities and promoted local food diversity. These programs do not benefit children during the window of opportunity of the first 1,000 days to prevent stunting but they can be helpful in providing implicit transfers to poor families, encouraging school attendance and providing a vehicle for nutrition for school children. 41 A RENEWED COMMITMENT - 8.  CRITICAL TO ADDRESS FUTURE CHALLENGES Stunting has not been eradicated and other nutrition challenges have emerged Chapter Snapshot • More than one in 10 children under five years of age still suffered from stunting in Peru in 2016. • Disparities in rates of stunting still exist across Peru between rural and urban areas, between indigenous and non- indigenous communities. • New nutrition challenges have emerged, such as obesity. High levels of anemia in children and adults continue to persist. Despite Peru's remarkable progress in tackling chronic around 60 percent,” said Ariela Luna, former Vice Minister malnutrition, it still faces serious nutritional challenges at MIDIS. that must be addressed in the years ahead. Peru is also facing the growing problem of people who are Firstly, stunting has not been eradicated. More than one overweight and obese, as well as persistently high levels in 10 children (13 percent) suffered that fate in 2016. of iron-deficiency anemia among children under five. Disparities across the country and between rural and urban areas remain high. In 2016, stunting rates were still Peru also has a growing number of people suffering from 26.5 percent in rural areas compared to just 7.9 percent in so-called Double Burden Malnutrition (DBM), a combination urban areas. In the same year, stunting rates for children of under and overnutrition (stunting, micronutrient speaking Quechua or Amazonian languages were, deficiencies and obesity) within communities and families respectively, three and four times higher than the rates for with overweight mothers and underweight or stunted Spanish speaking children. children. DBM is a major problem because stunting in early life increases the risk of over-nutrition and chronic Although urban areas have lower stunting rates than rural diseases, such as diabetes and cardiovascular disease, areas, urban malnutrition has stagnated over the past in adulthood. According to the most recent estimates, the five years. This has highlighted the need for different prevalence of overweight children under five in Peru is 7.2 strategies to tackle malnutrition in such a diverse country. percent (> 2 S.D, GNR, 2016). One size does not fit all, with urban areas and rural areas with a significant indigenous population needing their own Peru is not alone in the fight against the problem of adults tailored approaches to reduce stunting. who are overweight and obese and the growing challenge of overweight and obese children. Worldwide, 41 million “In the Amazon, there are 400,000 indigenous people living children are overweight. Development, economic growth hours or days away from the capital of their own district. and increases in household income contribute to changes It’s another world. So, the big challenge now is to the get in diets that are not necessarily healthier. Over the past to Amazonian communities where child malnutrition is decade, Peru has experienced an increase in consumption 42 of processed foods, high in sugar and salt (Rigolini, 2017). disease. Both these successes should have had a positive As in other countries, this often goes hand in hand with a impact on anemia levels. Recent food-consumption data reduction in physical activity with children spending more analysis shows low levels of consumption of animal time in front of the television and using social media. source and other iron-rich food (Sanchez-Grinan 2015). (Shrimpton and Rokx, 2012). Food technology, food safety, food systems policy and agricultural producers need to be To reduce anemia, the problem needs to be understood included in the debate on preventing people becoming and recognized. But measuring anemia is harder than overweight or suffering from obesity. measuring stunting because blood samples and tests are needed. It also requires understanding of underlying The very rapid urbanization in Peru is likely to have diseases which may cause anemia, such as infectious contributed to the rise of this DBM problem, as it has gastro-intestinal disease. Regular supplements are needed in other countries in Latin America, the Caribbean and to correct and maintain blood iron levels if consumption beyond. It is not a new problem.In 2005, 43 percent of of iron rich foods is low, especially among young children women of reproductive age were overweight (body mass (Shekar et al., 2017). There have been shortages in iron index <25 kg/m2) or obese (body mass index <30 kg/m2) supplements in Peru in the past which partly explains (CENAN 2013). This increased to 58 percent of women the lack of success. The persistent high levels of anemia who were overweight or obese in 2014 (ENDES 2005, among children also indicates a likely high prevalence of 2010, 2014). Peru is conscious of this growing problem helminth and other parasitic infections and among young and is developing campaigns to curb the increasing use children tropical enteropathy17, which diminishes nutrient of processed foods which are high in calories and often absorption, contributing to anemia (Korpe and Petri 2012). low in quality. It is also promoting physical exercise and regular health check-ups for all ages. However, an assessment of what did not work is still ongoing. Attention to food fortification with iron is needed Tackling anemia given that the provision of iron-fortified food is among the most cost-effective interventions to address anemia For all Peru’s successes in reducing stunting, there is among children and their mothers and currently there is another mountain still to climb. no mandatory fortification in Peru. Anemia remains a major concern across Peru. Around Peru is the South American country that suffers most 59 percent of children between six and 11 months of age from anemia (matching only Guyana), Lorena Alcazar said suffer from anemia and 44 percent of children between in a report: “It affects more than 50 percent of preschool six and 36 months do. Despite the impressive reduction children, 42 percent of pregnant women and 40 percent in stunting, the prevalence of anemia has remained of non-pregnant women of reproductive age. These unchanged. There is no direct correlation between being prevalence levels put Peru in a similar situation to most stunted and being anemic and prevention of stunting does African countries." not have direct implications for tackling anemia. “The biggest problem we have with expectant mothers That said, it remains to be explained why efforts to reduce is anemia. Women here, when they’re pregnant, have anemia have not been as successful as the drive to lower difficulty getting enough iron in their diet. And there are stunting rates, even when preventing anemia was one of even lots of myths and misconceptions around, that we’re the goals of PAN. Dietary diversity has improved while trying to counter, about how pregnant women can’t absorb there has also been a significant reduction in infectious iron,” said nutritionist Brenda Infantes Yucra. 17  ropical enteropathy or environmental enteropathy is a condition or subclinical disorder believed to be due to frequent intestinal infections. There are T often minimal acute symptoms but there may be chronic problems with absorbing nutrients which may result in malnutrition in children. Environmental enteropathy results in changes in the intestines, including increased permeability and inflammatory cell build-up within the intestines. These changes result in poor absorption of food, vitamins and minerals. 43 “Many women don’t know anything about anemia. They Closing the indigenous gaps look at a child with anemia and they say: ‘He looks normal, so what’s the problem?’ So, we explain to them that if An increasing awareness of the nutrition gaps between they suffer from anemia during pregnancy, it will have indigenous and non-indigenous children has gradually an impact on how their child’s brain develops inside the also led the different institutions involved in providing womb. And that’s when they take the issue seriously: as services to develop specific strategies to achieve results soon as you mention the brain. They say: ‘I want my child in Quechua, Aymara and Amazonian communities. to be intelligent.’ So, they assume the responsibility…to Understanding the traditions and beliefs surrounding child get a good dose of iron while they’re pregnant but also to breastfeeding practices, and illnesses has been key. make sure their child takes their dietary supplements once they’re born,” she said. Speaking Quechua, Aymara, Awajun or Ashaninka during birth registering campaigns, or during early affiliation Reducing anemia is now a major priority for several drives and using indigenous languages in educational or government ministries, led by the Health Ministry and promotional radio spots and in soap operas has become with an important coordination role in the Presidency part of the way regional health networks, Juntos, SIS of the Council of Ministers. A new strategy to fight officials, and civil-registry officials work. childhood anemia has been approved with a major focus on a campaign to raise widespread awareness about the The Peruvian government has progressively understood magnitude of anemia and its consequences. Promotion the need to approve special legislation and protocols, and of dietary diversity and improved intake of iron-rich foods increase the budget to ensure the adequate provision of is part of this campaign. Ways to improve iron stores in basic services to distant communities. new-borns are being included in clinical guidelines . 18 The ministries encourage alignment of policies geared “There are health centers that can only reach a distant towards anemia reduction as well as improvements in village by river. Therefore, they need to have a canoe or a data-gathering (among the very young) and analysis to motor boat. The health network has to assign them extra better understand who and when to target and provide budget to buy gasoline, otherwise they would have to pay supplementation. An ambitious target of reducing anemia for transportation and that’s even more expensive”, said a by 20 percentage points by 2021 has been set. Regular health technician from Nuevo Seasme, in Condorcanqui, measurement mechanisms to monitor progress are being referring to the need to allocate extra budget to reach out established (Sanchez-Grinan, 2015). to distant communities. For MIDIS, reducing anemia is a priority. It is working with The stunting gap between Quecha and Spanish speaking MINSA and development partners on a strategy to increase households fell from 29.7 percent in 2009 to 21.6 percent the attention paid to anemia in its current programs. One in 2015. Yet, the gap between households speaking specific aim is to boost counseling in local communities Amazonian languages and Spanish is still very high at 35.7 with the help of staff working for programs administered percent, indicating the need to redouble efforts in the Selva. by MIDIS. A more general aim is to widen the availability of iron-supplements, such as so-called sprinkles (chispitas in Spanish). Fortification of foods with iron continues to be discussed at the national level. 18 Such as delayed umbilical cord clamping during the third stage of labor. 44 SPOTLIGHT - BIG CHANGES IN 9.  SMALL COMMUNITIES Huánuco, a region around 380 km north-west of Lima, is full of remote villages where health workers are helping families to raise stronger children Its villages and hamlets have seen big changes thanks la Cruz lives with her mother in a house with a small to Peru’s efforts to reduce stunting. Since 2007, the garden in front. They grow onions, beetroot, lettuce and percentage of children in the province with chronic parsley. She does not have a regular job but sometimes malnutrition has more than halved from almost 50 works picking fruit for a local farmer. Her only other percent to around 24 percent. income is the money she receives from Juntos. It is in isolated rural communities like San Isidro de Visag, a 90-minute drive from Huánuco's capital up a rutted, mountainous dirt road, that the success of It is in isolated rural communities programs like Juntos is visible. like San Isidro de Visag, a 90-minute drive from Huánuco up a rutted, Tomasa Sacramento Soto, a 35-year old mother of mountainous dirt road, that the three, lives with her husband and children. Thanks to success of programs like Juntos a Belgian NGO their village now has chlorinated water, is visible. reducing the threat of cholera and diarrhea to their children. She is also a recipient of Peru’s successful conditional cash transfer program Juntos. In addition, “The Juntos money is really important for me so I always the family breeds guinea pigs to sell and to eat them, make sure Yhersin is up to date with his vaccinations increasing the family’s protein intake. and his weight-check tests because if he misses the tests then I lose the money,” she said. “And I go to the “I get my payments every two months. I go to Huánuco meetings at the health center in Acomayo because if to receive them. It’s very welcome, although since I’ve you don’t go you don’t learn. I’ve learnt a lot from the started selling the guinea pigs it’s become a smaller staff there about diet, and what not to eat, and the part of my overall income,” she said. importance of hygiene, and lots about how to recognize illnesses like hepatitis or measles. Things have changed Throughout the locality, the lives of women, children a lot since I had my daughter 12 years ago. I didn’t give and families have been transformed. her supplements back then. They weren’t available.” Reaching out to remote communities In the district of Santa Maria del Valle, just outside the city of Huánuco, the government runs a health center In the small, rural community of Sogobamba, programs where women from rural and remote communities like Juntos have helped women like 29-year-old mother come to give birth. Ten other health posts serve smaller of two, Elizabeth de la Cruz. Her son Yhersin is 18 months and more inaccessible communities but women travel old. She also has a 12-year-old daughter. Elizabeth de to Santa Maria del Valle to give birth. 45 “The local government gave us more money so we said Dr Palacios Chumpitaz. “Because I can go out could employ more people at the other health centers as a doctor and say: ‘I want to reduce chronic child (the 10 in the rural areas). That’s allowed us to monitor malnutrition in your child.’ They might not understand. the growth of the children, make sure they’re being But if their neighbor says: ‘Look, I want your child to given their nutrients, check to see if they’re suffering grow as quickly as mine,’ they’re more likely to get it,” from anemia and give advice on things like diet and he said. “Some of the first babies I delivered are now what to do during pregnancy. That’s all been, absolutely, reaching adulthood.” key to reducing chronic child malnutrition,” said one of the health center’s doctors, 40-year-old Julio Understanding local communities is critical for health Palacios Chumpitaz. officials to deliver services to families. Support and services at the grass-roots “Knowledge of the local reality by health personnel is key. A clear example is vaccination. I was one of those who Collaboration between the Ministry of Health, programs went out to knock on doors. The first thing they did was like Juntos and NGOs has made a real difference to not open the door but let the dogs go. Now people are the lives of remote communities. Doctors, nurses and coming to ask for the vaccination and for their Control health workers receive both classroom and on-the-job of Growth and Development (CRED),” one official in training to ensure they have a better understanding of Huánuco told the World Bank in a series of focus group growth charts, weighing and measuring children and interviews in January 2017. This reflects an important correct counseling about nutrition, including in the change in attitude. The level of commitment of local Quechua language, a key aspect of communicating with field staff was extremely important in the process. many indigenous families. It is mothers like 25-year-old Edith Zambrano Reyes “To reduce child malnutrition, we promote regular home and her 17-month old son Yharif who have benefitted visits. Within the structure of the visit, care practices directly from Peru’s drive to give children the best start are strongly promoted. These include, for example, in life. hand-washing, good use of micronutrients and the reinforcement of messages so that mothers go in a “He’s up to date with all his checks-ups. He had a timely manner to their check-ups at the health posts,” few problems with being underweight in the first few one official said. months of life but not now. The nurses are very good at explaining how to look out for possible illnesses, like NGOs have also played a vital role in making mothers measles, or tuberculosis or flu,” she said. “During my aware of the threat of chronic malnutrition and anemia pregnancy, I got a lot of advice from the nutritionist to their children and in getting local women involved in about what to eat and what to avoid – like trying to eat communicating with families about steps they can take meat and vegetables and avoid fizzy drinks,” she said. to ensure their children grow up healthy. In addition to growth monitoring and promotion, “They’ve persuaded the communities to choose one nutritional advice to parents has been central to woman from within the community to be responsible for Peru’s success in reducing stunting rates. Part of the health issues. And that woman can help the nurses and nutritionist’s role working in remote communities is doctors when they go out to the communities, because to advise mothers on healthy eating and to challenge they speak the same language as their neighbors,” dietary traditions which reduce iron intake. 46 Brenda Infantes Yucra, a nutritionist at a healthcare center She has two other children, aged three years and for mothers and their children in the town of Acomayo, six months. gives monthly nutrition classes at the health center to mothers on what kind of food they should give their “When Helen was born, I used to give her pretty much children at different ages. This is welcomed by parents. the same food that we ate, but with the younger ones “A lot of people in this area breed and eat their own I’m more careful,” she said. “I always remember when animals, their chickens, their guinea pigs, but they drain one of the nutritionists said that what I ate when I was off all the blood, until you explain to them it’s a good pregnant could have an impact on the development of source of iron. Likewise, with the liver. They often discard my child’s brain, and that really made me think. And they the liver, but we tell them not to,” said the nutritionist. say that what a child eats during the first five years of their life is so important. So, with my second and third One mother, 28-year-old Liliana Pinzas Villar, attended child I’ve been more careful, always making sure I give a nutrition class with her six-year-old daughter Helen. them the right nutrients.” CONCLUSION – 10.  LESSONS LEARNT Where Peru has led, others can follow For a country to more than halve its stunting rate in less Director for Peru. “I have been frustrated by other cases than a decade is proof, if proof were needed, that chronic where the level of malnutrition is the same or worse than in child malnutrition can be conquered. Peru. You must have commitment. Ultimately, it’s in a nation’s hands, that of the government and its people,” he said. Today Peru stands out globally for its success in tackling stunting. The country receives regular delegations from Given the unacceptably high toll chronic malnutrition foreign governments to learn about how Peru did it. takes on individuals, families, communities and countries, "Peru’s experience in this area is also a unique asset for eradicating stunting is central to the World Bank’s goal of the World Bank, and allows it to better serve our clients ending extreme poverty and increasing shared prosperity. through sharing its example. Peru is hosting and has hosted high-level officials and their technical teams from “The question is not whether a country can afford to end Cameroon, Ecuador, Guatemala, Indonesia, Madagascar, chronic malnutrition in children. The question is whether a Mozambique and Tanzania and is welcoming others country can afford not to end it,” said World Bank President to come and see for themselves how Peru managed to Dr Jim Yong Kim. reduce stunting rates," says Alberto Rodriguez, the current World Bank Country Director for Peru. Peru offers us an exceptional example of how a nation can turn political commitment, good policies and good “It’s definitely something that can be replicated elsewhere,” governance into better health and social services for the said Felipe Jaramillo, the World Bank’s former Country poorest communities. 47 Peru’s recipe for success had many ingredients, which health personnel had all the necessary means and training were adapted and revised over time. But some key to delivery high quality services. ingredients stand out. Establishing political commitment, getting the right policies in place and changing behavior Cash, in the form of CCTs, incentivized parents to bring sowed the seeds for Peru’s success. their children to clinics for growth monitoring and promotion check-ups on a phenomenal scale. But cash Establishing political commitment, coordination and incentives to parents alone were not the answer. It was cooperation the combination of the CCT program and improvements in the availability and use of health services, increased What is remarkable about Peru is the fact that four health insurance coverage for the poor, the rigor of RBB successive governments under Presidents Alejandro and the strategic focus of the nutrition strategy Crecer on Toledo, Alan Garcia, Ollanta Humala and now Pedro Pablo selected interventions and on the neediest areas which Kuczynski have ensured continuity and commitment in forged a convergence in the government's approach to the push to reduce stunting. reducing stunting. “Continuity is really critical between governments,” said Credible systems, data, targets, incentives, monitoring Milo Stanojevich of CARE Peru. “International engagement and evaluation ensured a results-based approach to public is critical because that helps you put pressure on the spending to reduce stunting. government,” he said. Peru’s winning formula for reducing chronic malnutrition Pedro Pablo Kuczynski, elected President in 2016, has had three key elements, said Ivan Hidalgo, a former expressed the ambition for Peru to eradicate chronic President of Juntos. “First, political decisions at the child malnutrition. The government’s current targets are highest level. Without these, it is better not to get involved. to reduce Peru’s chronic malnutrition rate in children Second, have a budget assured. Third, have a technical to around six percent by 2021 and anemia rates to 19 team that can implement what has been agreed.” he said. percent. Changing Behavior “It got a lot of political and social attention. It was a social goal for all of us. We all need to be there at the same Communication was critical in persuading parents, public time and in the same place,” said Carolina Trivelli, who is officials and policy makers to unite in turning the tide now an economist working on rural finance and financial against stunting. Effective communication changed how inclusion in Peru. The secret of Peru’s success, in her view, people thought and behaved in response to a pervasive boiled down to political will and coherent policies with economic and social problem which manifested itself in clear goals and incentives. the poor health of children. Smarter policies: focusing on evidence, incentives and Peru stands out not just for its success but the nature in results achieving that success: the coherence with which it turned a multi-faceted problem into a single strategy with a single Consolidation was a critical component as Peru embraced goal: to make stunting a thing of the past. Peru is not there tried-and-tested methods and efficiency in its health, yet. But it is close, much closer than many other countries. nutrition and social programs and made sure that its Peru can stand tall. 48 ANNEX: NO SILVER BULLET BEHIND PERU’S REDUCTION IN STUNTING Stunting rate dropped precipitously in less than a decade Chart A1: Stunting rates fell by 15 percentage points between 2008 and 2016 from 28 percent to 13 percent Note: The ENDES survey began in 1986 and collected demographic and health data, including anthropometrics, every five years until 2000. In 2004, ENDES moved to a continuous survey scheme, collecting data every year. However, the sample was not initially designed to estimate the prevalence of malnutrition. In 2007, with the launch of Results-Based Budgeting, the sample size of the continuous survey was increased to be sufficient to estimate the prevalence of malnutrition by department starting in 2008. Given the sample design, estimates of malnutrition were available for 2005 and 2007 and on a yearly basis after 2008. Source: ENDES 49 Between 1991 and 2005 the decline in rates of stunting Was the fall in stunting part of a secular trend? in Peru was eight percentage points in 14 years. Between 2008 and 2015 the decline was two percentage points A secular trend seems to be only part of the story. Escobal per year. It is this acceleration in the reduction of stunting and Benites (2012) analyzed data from the Young Lives rates that we are trying to understand. project19 and found that stunting rates fell at a rapid pace in all areas of Peru even for the control group of non- Several studies and publications have tried to explain Juntos beneficiaries. However, Sanchez, Melendez and Peru’s success in reducing chronic malnutrition so rapidly. Behrman (2016), using the same data but a different There is sufficient evidence that the reduction in stunting methodology, found some indication of the impact of was not purely part of a secular change and that there was interventions, including the conditional cash transfer no single bullet solution. program Juntos, on the reduction of stunting. These estimates are based on propensity score matches to build Secular trends, steady economic growth, increased credible counterfactuals. It therefore seems that a secular spending, focus on results, and pro-poor, well-targeted trend only explains the reduction in part and that policies social programs and increased access to health services directed at reducing malnutrition played a role. Recent all appear to have contributed to the accelerated reduction work by Galasso and Wagstaff suggests that economic in stunting levels in Peru. The fact that they all happened in growth alone can explain up to 50 percent of the reduction the same decade certainly increased the combined effect. in stunting in Peru. The acceleration observed is likely to Disentangling the relative effects of all possible factors in be due to the systemic policy changes. The yellow line the reduction of stunting is an almost impossible task. plots the evolution of stunting prevalence (yellow line, left y-axis), and of average consumption expenditure per capita It was not only that all these actions took place during (green line, right x-axis) over time. The dashed orange line the same decade but, in fact, at the same time and in the represents the predicted reduction of stunting in response same territory. At the end of the day, Peru's success story to economic growth, assuming the same elasticity of in reducing stunting is a story about the convergence stunting to economic growth observed before 2006. The of government actions. Disentangling the effects is not historical responsiveness of stunting to economic growth the issue, promoting convergence is. Malnutrition is an observed in Peru before 2006 (with a 10 percent increase excellent example of a multi-causal problem that does not in economic growth translating into a six-percentage respond to a silver bullet solution. But there is no question point reduction in stunting) is in line with cross-country that a nutrition-focused program played a consequential estimates (Ruel, Alderman 2013). The graph shows how role in the dramatic improvements in Peru. income growth after-2006 could account for up to half of the observed stunting decline (Chart A2). This annex complements the story told in this publication by reviewing the evidence from the most recent analytical studies of the determinants of the reduction of stunting in Peru. 50 Chart A2: Stunting rate and per capita consumption in Peru (1995-2015) Date sources: World Development Indicators. stunting prevalence from the Global Database on Child Growth and Malnutrition (World Health Organization), and the Household final expenditure per capita from the World Bank national accounts data, and OECD National Accounts data files. Economic growth played a role, but not enough rates and chronic malnutrition indicates that income is only part of the story, especially in rural areas. Data from A country’s development and economic growth certainly Peru’s National Institute of Statistics (INEI) shows that contribute to reductions in stunting, however, it is not the correlation between poverty and chronic malnutrition enough to explain the accelerated trend seen in Peru. in urban districts is only about 0.4, where other studies GDP grew steadily for several decades with an annual claimed the effects of growth to be larger. The correlation percentage increase of about six percent in 2011,2012 between poverty and stunting is only half as high among and 2013 and 2.4 percent and 3.3 percent in 2014 and rural districts, showing that economic growth accounts 2015. A close look at the relationship between poverty for only a small part of the accelerated reduction. 19  oung Lives is an international study of childhood poverty following the lives of 12,000 children in Ethiopia, India (in the states of Andhra Pradesh and Y Telangana), Peru and Vietnam over 15 years. More information can be found at: http://www.younglives.org.uk/ 51 Chart A3: The relationship between poverty and stunting in Peru by area Poverty and Chronic Malnutrition, Rural Poverty and Chronic Malnutrition, Urban Source: INEI A combination of improvements in the underlying to study the role of Crecer. The authors analyzed the determinants was critical adequacy of three critical variables from the UNICEF model (access to care, health or environment and food The long recognized causal model of the determinants security) and show that only the combination of at least of malnutrition (UNICEF 1990) identified political will, two adequacy variables such as access to health services broad participation, public spending levels, pro-poor and a healthy environment are significantly associated programs and financing as key underlying factors behind with better nutritional status (increased height). The the reduction in stunting rates. Based on qualitative analysis does not allow for clear conclusions, but clearly and quantitative approaches, the Lancet 2015 Country points out that the reduction in stunting is highest in those Case Study (Lancet 2016) identified the trends in these districts prioritized by Crecer: 21.4 points reduction from determinants as critical contributors to the reductions in 54.7 percent to 33.3 percent, whereas in other rural areas child mortality and chronic malnutrition in Peru over the stunting fell 13.8 points from 45.7 percent to 31.9 percent. past decade. Another recent study conducted by GRADE for the Peru Analysis shows the remarkable reduction in stunting was Ministry of Health analyzed the impact of changes in multifactorial, encompassing improvements in social budget allocation and household income on stunting determinants, poverty reduction programs as well as rates. The GRADE-model explains 35-40 percent of the major investments in programs within and outside the total variation in stunting and is not able to draw any health sector (Lancet 2016). clear conclusion. While mothers’ education and height turned out to be important explanatory variables, some The health insurance program SIS contributed to effects were also associated with vaccination and pre- increased access to health services for the poor. Thanks natal controls. Very little effect was associated with to these investments, increased access to health CRED (possibly because of the quality of the counseling). services, improved caring and feeding habits (exclusive Access to water is a significant and important variable breastfeeding and appropriate complementary feeding while the strongest effect is seen in household income practices), stunting fell at unprecedented rates. and community or enabling environment. Mothers’ height and education, as well as birth order were associated Changes in social determinants were important with a stronger effect among age sub-groups, similarly, vaccinations (during the first year) and CRED (during the Genoni et al analyzed changes in social determinants first months of life). using the synergy model (Genoni et al, forthcoming) 52 The contribution of the conditional cash transfer Investments in cost-effective programs prioritized program Juntos under PAN were directed to those regions where child malnutrition was most severe. The Juntos CCT program was created at the same time as the acceleration in stunting reduction began. The program PAN offered the opportunity to break the institutional was designed as a safety net program to tackle chronic budgetary inertia: resources were assigned to achieve poverty and contribute to the accumulation of human nutrition goals rather than on an historical basis. capital. Over time, it included the reduction of chronic Additionally, various government agencies, including malnutrition as an explicit objective. While Peru’s CCT was regional health directorates and the Juntos CCT program, certainly an important catalytic force for improvements in were held accountable by MEF for improving specific the supply of health/nutrition services across the country, outcomes. Extra budgetary allocation was granted, for like for other interventions, there seems to be no rigorous instance, based on an increase in the number of poor evidence to attribute the impact of the reduction of children enrolled in the Juntos CCT, or the number of stunting solely to Juntos. child-growth check-ups and nutrition counseling sessions to poor families in targeted communities Using data from the Young Lives project and propensity score matching to compare the height of beneficiaries with To understand the role of PAN in the reduction of stunting, constructed control groups, Escobal and Benites (2012) Cordero compiled data from seven national health and cannot find conclusive evidence about the association demographic surveys, ENDES 2009-2015 and built a between the decline in stunting and participation in the representative sample of households with children Juntos program. The work by Sánchez Jaramillo (2012) under five, allowing comparisons at the regional and concluded that while on average it is not possible to departmental level, as well as between income quintiles. attribute an impact to the Juntos program, a positive Cordero constructed different cohorts of children and association is found for those beneficiaries suffering from looked at the association between stunting rates and severe stunting and for beneficiary children with relatively participation in PAN interventions (Cordero, forthcoming). more educated mothers. Similar conclusions were presented in a more recent paper by Sanchez, Melendez, After documenting the increase in the use of the PAN- and Behrman (2016) that used Young Lives data, pooling related interventions (pneumococcus and rotavirus Ordinary Least Squares (OLS) with child fixed effects. That immunizations and CRED), Cordero compares children found no effects on stunting overall, but large effects on born in 2009, who were exposed to PAN interventions, with severe stunting for siblings of children who were exposed children born in 2006, 2007, 2008, who were not exposed to Juntos as children younger than three years old. In to the same interventions. He shows lower stunting rates previous work, Perova and Vakis (2009) found that the among participating children independent of income program was associated with an increase in the use of quintile or mothers’ education. health and nutrition services for mothers and young children but did not find a correlation with final nutrition Increased awareness and attention to stunting locally outcomes. played a part The Result-Based Budgeting program PAN undoubtedly As part of this publication, focus group discussions were played a role held in early 2017 with local government representatives, program managers and health providers. Participants The strategic nutrition program PAN was introduced highlighted the increase in trust in government services, in 2008 as one of the Results-Based Budgeting (RBB) as well as a renewed awareness about the importance pilots of MEF. The purpose of RBB was to increase the of preventing chronic malnutrition. The participation efficiency and effectiveness of public spending, including of parents in health and nutrition services encouraged social programs. It led to much improved targeting and re- important changes in behavior. Social service providers allocation of funds where the need was highest. responded with more attention and motivation. Awareness 53 and outreach campaigns by local governments promoted with the CUI? It is just an expense.’ The work done by registration of new-born babies and increases in prenatal Participatory Budgeting and the awareness campaigns check-ups. helped mothers understand the benefits. Today they understand that logic and know that to continue accessing As reported by local government authorities in Santa the benefits, it is very important that they attend regular María del Valle, Huánuco: “Everything is related. Now the check-ups in the health center.” population knows that the National Identity Document (or CUI in Spanish) is critical for their children. Mothers know “Cookery lessons and counseling on hand-washing led that within 10 days of birth, a child should have his CUI. to behavioral changes in the population. Mothers have She knows that it will make her life easier. In 2013 there become aware about the consequences of malnutrition were mothers with three-year-old children who were not in their children. That work has not only been done in the identified and mothers were wondering: ‘What do I earn health center but on the spot." PERU TIMELINE 2000-2010 2006 • Peru’s public budget nearly doubles. • Formation of the Initiative against Chronic Infant Malnutrition, an alliance promoting a better start for 2002-2010 children across Peru. • Peru is one of the fastest growing economies in Latin • The Initiative succeeds in getting 10 Presidential America with its growth rate averaging 6.4 percent. candidates to sign a commitment to reduce chronic Growth is fueled by a mining and resource boom. child malnutrition in children under five by five percentage points in five years in the so-called 5-by- 2002 5-in5 pledge. • Peru is spending $250 million a year on food and • Alan Garcia Perez elected President for a second- nutrition programs but stunting rates remain high. term. Nutrition was selected as one of the 31 strategic • Garcia government creates the Integrated Nutrition policies prioritized by a national forum convened by Program (PIN) to consolidate six different food President Toledo, known as the National Agreement, distribution programs. signed by high level representatives from the government, the political parties and civil society. 2007 • Introduction of an article in the Ley de Presupuesto 2005 Publico that protected the resources to be allocated • Chronic malnutrition rates in children under five for 11 priorities for childhood, paving the way for stands at 28 percent. result-based budgeting. • Conditional cash transfer (CCT) program Juntos is set • The Garcia government launches a national poverty up to reduce poverty and improve nutrition and health reduction strategy called “Crecer”. His government in the last year of Toledo’s government, following the introduces reforms to focus efforts on combating examples of Brazil and Mexico. poverty and child malnutrition. There are 26 • Juntos pilot program runs in 110 districts of Peru and the initiatives, including maternal-child health, nutrition, National Health Insurance Program (SIS) is introduced early learning, birth registration and access to to provide support to the poorest households. basic services. 54 • The World Bank launches the video “My Future in 2009 my First Centimeters,” highlighting scale of chronic • The Ministry of Economy and Finance (MEF) starts malnutrition in children in Peru. to allocate money to hardest hit regions to tackle chronic child malnutrition. 2007-2011 • The World Bank supports Peru’s efforts in promoting 2011 standards for nutrition through budget-support • Ollanta Humala elected President. The Ministry of financing for reforms (DPL Series REACT) and through Development and Social Inclusion (MIDIS) is created. analytical and work on communication (RECURSO series). 2012 • MIDIS put in charge of Juntos. The inefficient food 2008 distribution program PRONAA is closed. • The Summit of the heads of State of Latin America, the Caribbean and the European Union (EU) make a 2014 declaration that the fight against child malnutrition is • Introduction of Incentive Fund for the Performance central to the fight against poverty and inequality. and Achievement of Social Results - Fondo de Est • The Ministry of Finance introduces performance mulo al Desempo y Logro de Resultados Sociales based budgeting and creates the Articulated Nutrition (FED). Budget Program (PAN) as one of the first pilots of result-based budgeting. 2016 • Pedro Pablo Kuczynski elected President. 2008-2009 • The World Bank supports Peru through a Non-Lending 2017 Technical Assistance program, aimed at enhancing • The government announces targets to reduce Peru’s the efficiency and effectiveness of Juntos in reducing chronic malnutrition rate in children to around six chronic malnutrition. percent by 2021 and anemia rates to 19 percent. REFERENCES Alcazar, L. (2007), Porque no funcionan los programas Escobal J. and S. Benites (2012), Algunos impactos del alimentarios en el Peru? Riesgos y Oportunidades para su programa JUNTOS en el bienestar de los niños: Evidencia reforma, GRADE, Lima, Peru. basada en el estudio Niños del Milenio,  Boletín 7 de Políticas Públicas del Estudio Niños del Milenio. Berg, A. (1973), The Nutrition Factor, Its Role in National Development, Brookings Institute, Washington D.C.. Escobal J. and S. Benites (2012), Transferencias y Condiciones: Efectos no previstos del Programa JUNTOS, Brousset, H. (forthcoming) Logros y Desafios de la Politica Boletín 5 de Políticas Públicas del Estudio Niños del Milenio. de Nutricion en el Peru, World Bank. Genoni, M, V. Silva, E. Skoufias, K. Vinha, S. Garriga, A. Cordero, L. (forthcoming) Evolucion de la Desnutricion Marini (forthcoming) Desnutricion Cronica Infantil en el Cronica en el Pery y de la cobertura de servicios de salud. Peru, World Bank. 55 Grosh, M. and J. Baker (1995), Proxy means tests for targeting Perova, E. and R. Vakis (2009), Welfare impacts of social programs: Simulations and speculation, World Bank. the “Juntos” Program in Peru: Evidence from a non- experimental evaluation. Mimeo. Washington D.C: The GRADE (2015), Estudio sobre los Factores Asociados a la World Bank. Disminucion de la Desnutritcion Cronica Infantil en el Peru, Instituto National de Salud/Ministerio de Salud MINSA. Rigolini, J. (2016), A case study: geography and healthy diets. How city planning can promote healthy diets and IFPRI (2016), the Global Nutrition Report, Washington D.C.. help solving the nutrition challenge, working paper, World Bank, Lima. Jaramillo, M. and A. Sanchez (2012), Impacto del Programa Juntos sobre la Nutricion Temprana, GRADE Rogers, B., S. Rajabiun, J. Levinson, and K. Tucker (2002), Research Paper n.61. Reducing Chronic Malnutrition in Peru: A Proposed National Strategy, Tufts University. Korpe, PS; Petri WA, Jr (June 2012). "Environmental enteropathy: critical implications of a poorly understood Ruel, M. T., and H. Alderman (2013), "Nutrition-sensitive condition.". Trends in molecular medicine. 18 (6): 328–36. interventions and programmes: how can they help to accelerate progress in improving maternal and child Lancet (2016), Child Health and Nutrition in Peru within an nutrition?" Lancet 382(9891): 536-551. antipoverty political, Lancet Global Health 2016; 4:e414-26. Sanchez, A., G. Melendez and J. Behrman (2016), The Levinson, J. and A. Marini, Peru: Nutrition Targets, Impact of the JUNTOS conditional cash transfer program Budgeting and Incentives, supported by civil society in Peru on nutritional and cognitive outcomes; does the advocacy, Case study in Levinson, J., Balarajan, Y. and A. age of exposure matter? Marini (2013), Addressing Malnutrition Multisectorally: What have we Learned from Recent International Sanchez-Grinan, M. (2015), Tendencias en el Consumo Experience? MDG Achievement Fund, UN, New York. Aparente de Alimentos entre 2004 y 2014 asociadas a la anemia, el sobrepeso y la obesidad en el Peru – working draft. Mejia Acosta, P. (2011), Analysing Success in the Fight against Malnutrition in Peru, IDS Working Paper 367. Shekar, M., Kakietek, j., Eberwein, J and D. Walters (2017), An Investment Framework for Nutrition: Reaching the MIDIS (2013), Evaluación de la Calidad y Restricciones Global Targets for Stunting, Anemia, Breastfeeding, and en la Cadena de Provisión de la Ración de Alimentos del Wasting. Directions in Development. Washington, DC: Subprograma Infantil PIN - PRONAAA. Lima, Perú. World Bank. doi:10.1596/978-1-4648-1010-7, available at https://tinyurl.com/InvestmentFrameworkNutrition. MINSA Technical norms CRED, R.M. No 990/2010, Peru. Ozler, B. (2016), Did Peru’s CCT program halve its stunting Shrimpton R. and C. Rokx (2012) The Double Burden rate? World Bank Blogs, October 10, 2017. Malnutrition; a Review of Global Evidence, HNP Series, Washington DC: World Bank. Nelson, C. (2016) Brain Imaging as a Measure of Future Cognitive Outcomes: A study of children in Bangladesh World Bank (2012), Operationalizing accountability: the exposed to multiple levels of adversity, Presentation at the RECURSO/REACT Program, Washington D.C.. Grand Challenges meeting, London, October 2016. World Bank (2015), Peru Building on Success, Boosting Nelson, C. (2017), Brain Imaging as a Measure of Future Productivity for Faster Growth. World Bank Poverty Report, Cognitive Outcomes, Presentation at the WHO meeting on Washington D.C. Early Child Development Measurement Framework, 17-18 January 2017. 56