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