Child health and nutrition in Peru within an antipovertyudpolitical agenda: a Countdown to 2015 country case study

摘要

Background Peru is an upper-middle-income country with wide social and regional disparities. In recent years,udsustained multisectoral antipoverty programmes involving governments, political parties, and civil society haveudincluded explicit health and nutrition goals and spending increased sharply. We did a country case study with the aimudof documenting Peru’s progress in reproductive, maternal, neonatal, and child health from 2000–13, and explored theudpotential determinants.udMethods We examined the outcomes of health interventions coverage, under-5 mortality, neonatal mortality, andudprevalence of under-5 stunting. We obtained data from interviews with key informants, a literature review of publishedudand unpublished data, national censuses, and governmental reports. We obtained information on social determinantsudof health, including economic growth, poverty, unmet basic needs, urbanisation, women’s education, water supply,udfertility rates, and child nutrition from the annual national households surveys and the Peruvian Demographic andudHealth Surveys. We obtained national mortality data from the Interagency Group for Child Mortality Estimation, andudcalculated subnational rates from 11 surveys. Analyses were stratifi ed by region, wealth quintiles, and urban or ruraludresidence. We calculated coverage indicators for the years 2000–13, and we used the Lives Saved Tool (LiST) toudestimate the eff ect of changes in intervention coverage and in nutritional status on mortality.udFindings From 2000 to 2013, under-5 mortality fell by 58% from 39·8 deaths per 1000 livebirths to 16·7. LiST, whichudwas used to predict the decline in mortality arising from changes in fertility rates, water and sanitation,udundernutrition, and coverage of indicators of reproductive, maternal, neonatal, and child health predicted that theudunder-5 mortality rate would fall from 39·8 to 28·4 per 1000 livebirths, accounting for 49·2% of the reportedudreduction. Neonatal mortality fell by 51% from 16·2 deaths per 1000 livebirths to 8·0. Stunting prevalence remainedudstable at around 30% until 2007, decreasing to 17·5% by 2013, and the composite coverage index for essentialudhealth interventions increased from 75·1% to 82·6%, with faster increases among the poor, in rural areas, and inudthe Andean region. Socioeconomic, urban–rural, and regional inequalities in coverage, mortality, and stuntingudwere substantially reduced. The proportion of the population living below the poverty line reduced fromud47·8% to 23·9%, women with fewer than 4 years of schooling reduced from 11·5% to 6·9%, urbanisation increasedudfrom 68·1% to 75·6%, and the total fertility rate decreased from 3·0 children per woman to 2·4. We interviewedud175 key informants and they raised the following issues: economic growth, improvement of social determinants,udcivil society empowerment and advocacy, out-of-health and within-health-sector changes, and sustainedudimplementation of evidence-based, pro-poor reproductive, maternal, neonatal, and child health interventions.udInterpretation Peru has made substantial progress in reducing neonatal and under-5 mortality, and child stunting. Thisudcountry is a good example of how a combination of political will, economic growth, broad societal participation, strategiesudfocused on poor people, and increased spending in health and related sectors can achieve signifi cant progress inudreproductive, maternal, neonatal, and child health. The remaining challenges include continuing to address inequalitiesudin wealth distribution, poverty, and access to basic services, especially in the Amazon and Andean rural areas.