El Estado peruano con base en la evidencia define dónde y qué intervenciones desarrollará para reducir la desnutrición crónica infantil

Por Anibal Velásquez

Con la Directiva 004-2012-MIDIS publicada el día 25 de julio de 2012 en el diario El Peruano,  se aprueban los Lineamientos para la Gestión Articulada Intersectorial e Intergubernamental orientada a Reducir la Desnutrición Crónica Infantil, en el marco de las Políticas  de Desarrollo e Inclusión Social. De esta manera, se espera acelerar los esfuerzos en la reducción de la desnutrición infantil en el país.

La Directiva 004, es una herramienta muy útil para los decisores en el nivel local y regional ya que allí se establecen los distritos priorizados para las intervenciones en nutrición infantil, bajo criterios de mayor desnutrición, vulnerabilidad a la inseguridad alimentaria, porcentaje de población en proceso de inclusión, entre otros. Asimismo, se plantean 12 intervenciones efectivas basadas en evidencia nacional e internacional,  que han mostrado muy buenos resultados.  De esta manera, se espera ampliar las coberturas de las intervenciones  efectivas en zonas críticas facilitando la programación y asignación presupuestal por resultados, y la formulación de proyectos de inversión pública de los gobiernos locales, regionales y programas sociales.

El importante crecimiento económico por el que atraviesa el Perú, sobre todo en los últimos años, ha venido reflejándose en la reducción sostenida de la pobreza, sin embargo la tasa de desnutrición crónica infantil, si bien se ha reducido de 31% en el año 2000 a 19,5% en el 2011 (ENDES 2011) en el promedio nacional, aún  mantiene valores altos en la zona rural y más pobre. La desnutrición infantil es un indicador que va más allá de la salud, ya que afecta a la primera infancia, está asociada a  múltiples causas y  requiere la participación activa de múltiples sectores y niveles de gobierno  en los diferentes niveles de gobierno. Esta Directiva permite articular los esfuerzos e inversión pública en áreas prioritarias  y en intervenciones que funcionan.

La contribución del MIDIS como órgano rector de la política social, ha contado además con la experiencia y participación de instituciones públicas tales como el Ministerio de Salud, Ministerio de Economía y Finanzas así como privadas tales como la Iniciativa Contra la Desnutrición Infantil, que agrupa a organismos de Naciones Unidas y no gubernamentales.  La suma de este esfuerzo facilitará  la implementación de las acciones y estrategias para acelerar la reducción de la desnutrición infantil en el país.

Para implementar esta Norma se necesitará el concurso de los sectores de salud, educación, agricultura, producción, desarrollo e inclusión social y vivienda. La asignación de recursos y la generación de proyectos de inversión deberán ser articuladas en los distritos seleccionados con el fin de expandir las coberturas de las intervenciones efectivas identificadas.

Incrementar las coberturas de las intervenciones efectivas para reducir la desnutrición infantil, en especial en las áreas de mayor pobreza, significa una mayor asignación de recursos (1,2,3) y asegurar una gestión eficaz y eficiente de los programas en los gobiernos regionales y locales.

Las evaluaciones han demostrado que estas intervenciones efectivas no llegan a todos aquellos que las necesitan, en particular a los más pobres (4, 5, 6),  y los programas destinados a ofrecer estas intervenciones han sido muy a menudo irregulares, de baja calidad, inequitativos y de corta duración (7). Esta situación se explica en parte por las limitaciones y deficiencias en los servicios, la inequidad de acceso a los servicios básicos y porque se necesita mayor esfuerzo en la implementación intersectorial e intergubernamental de estas intervenciones. Adicionalmente, los recursos financieros y técnicos han sido insuficientes, y la oferta de servicios es casi inexistente en las áreas más pobres (8).

Con esta norma se espera superar estas limitaciones concentrando la acción del Estado con intervenciones que si funcionan y en los ámbitos geográficos que más necesitan.

REFERENCIAS

(1) Hanson K, Ranson K, Oliveira-Cruz V, Mills A. Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up. J Int Dev 2003; 15: 1–14.

(2) Gericke CA, Kurowski C, Ranson MK, Mills A. Intervention complexity – a conceptual framework to inform priority-setting in health. Bulletin of the World Health Organization 2005; 83: 285–93.

(3) Simmons R, Fajans P, Ghiron L (eds). 2007. Scaling Up Health Service Delivery: From Pilot Innovations to Policies and Programmes. Geneva: World Health Organization. In: Mangham L, Hanson K. Scaling up in international health: what are the key issues?  Health Policy and Planning 2010;1–12

(4) Bryce J, el Arifeen S, Pariyo G, et al, and the Multi-Country Evaluation of IMCI Study Group. Reducing child mortality: can public health deliver? Lancet 2003; 362: 159–64.

(5) Claeson M, Gillespie D, Mshinda H, et al, The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362: 323–27.

(6) Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003; 362: 233–41.

(7) Victora C, Hanson K, Bryce J, Vaughan P. Achieving universal coverage with health interventions. The Lancet 2004; 364:1541-1548

(8) Travis P, Bennet S, Haines A, et al. Overcoming health systems constraints to achieve the Millennium Development Goals. Lancet 2004; 364: 900–06

Knowledge into action and scaling-up key child survival interventions

By Anibal Velasquez

Children and mothers represent the well-being of a society and its potential for the future. We can save and improve the quality of the lives of thousands of children by putting our knowledge into action and scaling-up key child survival interventions to ensure that no women or child will be kept from living a healthy life and achieving their human potential. Translation of current knowledge into effective action will require leadership, strong health systems, and targeted human and financial resources. By scaling-up actions now and solving early risks we can have an impact on the next generation’s years of health and quality of life-style.           

In Latin America and the Caribbean, the United Nations reported in 2007 a total of 10.7 million births and approximately 350,000 deaths in children under five years, of which 220,420 of these deaths were in children less than 1 year old (IMR). In 2009, the IMR in Latin America and the Caribbean was a reported 20.6 per 1000 live births. However, the regional averages of infant mortality hide major disparities between and within countries illustrating the wide range of health needs of different population groups in the most vulnerable areas, including key pockets of poverty, border areas or geographically remote places, and indigenous population groups. In four countries the IMR rate was 30 or more (Haiti, Bolivia, Nicaragua, and Dominican Republic) which reflects insufficient progress of achieving other MDGs (Fig. 1). These rates show the importance of gaining a better understanding of and addressing the social determinants of health and the inequalities of access to and utilization of basic health services which still persist in the Region.

These inequalities of access are partly explained by the existence of people who live on less than US$ 1.25 per day (Fig. 2) and by the low health sector budgetary allocation in several countries (Fig. 3). Public expenditure on health is usually a major factor in respect of the capacity of the health systems. Poor health results, lack of personnel and low investment in health and logistical infrastructure are common in those countries with low rates of per capita expenditure. In 2004, the average expenditure on public health in low and medium income Latin American countries as a whole was scarcely 2.6% of GDP, a marked contrast with the expenditure of high income countries which amounts to almost 7% of GDP (1).

Fig. 1. Rate of Progress of the under 5 mortality rate in Latin America. Percentage of reduction since 1990 to 2008

Source: UNICEF (2010). The State of the World’s Children (2)

Fig. 2. Percentage of population below international poverty line of US$1.25 per day in Latin America, 1992-2007

Source: UNICEF (2010). The State of the World’s Children (2)

Fig. 3. Percentage of central government expenditure allocated to Health in Latin America, 1998-2007

Source: UNICEF (2010). The State of the World’s Children (2)

In circa 2006, neonatal deaths less than 1 month of age corresponded to 39% of under five mortality, 26% for other diseases, and 19% for communicable diseases (Source: CEPAL Report, 2010). Most of the other deaths are attributable to diarrhea, malaria, neonatal infection, malnutrition and pneumonia - the majority of these deaths are preventable. In countries with high mortality, preventive interventions (The Lancet Child Survival Series, 2003) could reduce the number of deaths by more than 50%, but levels of coverage are still unacceptably low in most low-income and middle-income countries.

Chronic malnutrition is the most common growth disorder in Latin America and the Caribbean (Fig. 4) with nearly 9 million children under the age of 5 who suffer from this disease (PAHO Strategy and Plan of Action for Chronic Malnutrition, PAHO, 2010). These are ethically unacceptable figures for the Region (Fig. 4). In addition, obesity stands as the most visible and serious risk factors for developing non-communicable diseases.  Between 7% to 12 % of children under five years of age are obese (Health in the Americas, 2007, Volume 1).

Fig. 4. Prevalence of stunting (WHO) moderate and severe in Latin America, 2003-2008

Source: UNICEF (2010). The State of the World’s Children (2)

Other deaths are related to accidents, child abuse and violence against women by an intimate partner shown to be associated with mortality in children under 5 years. In addition, nearly one-third of the under-five child deaths are associated with environmental-related causes and conditions (3).

Other deaths are related to accidents, child abuse and violence against women by an intimate partner shown to be associated with mortality in children under 5 years. In addition, nearly one-third of the under-five child deaths are associated with environmental-related causes and conditions (3).

The strategies and interventions for maternal, neonatal and child survival are being developed in Latin America and the Caribbean, but there is a problem with their implementation in countries with high levels of child mortality. This poor coverage is clearly a result of the weakness in the provision of services and a consequence of inadequately functioning health systems (4). The extension of coverage of priority interventions not only requires additional financial resources but also a health system capable of delivering interventions on a large scale (5).

The capacity of the Latin American countries with high mortality rates to utilize efficiently the additional help may be limited in the short term by a shortage of human resources (6), the ability of the health workers, the political and institutional framework, or by barriers preventing people from gaining access to health services (7,8). Despite the widespread consensus on the need to increase aid, worries have been expressed regarding the capacity of the countries to absorb it (9,10). 

At present, strategies for the provision of effective interventions in the Region of the Americas are a combination of vertical and horizontal organization or of integrated and selective vertical organization (11). In countries with scarce resources and limitations in the health system, no scaling-up of the IMCI strategy may be done without vertical management because full-time coordinators, operational plans and a specific budget are required (12,13). The countries with major limitations in the health system for implementing effective interventions are Bolivia, Guatemala, Honduras, Nicaragua and Paraguay, according to the country typology criteria used by Ranson et al (2003) (14).

Children in the Region of the Americas also die as a result of a number of largely preventable environment-related causes, including climatic change and increased urbanization (15). The poorest and most marginalized children in developing countries suffer most. Although many commitments and international agreements have been made in relation to protecting children’s health from environmental threats, progress towards stemming these risks has been slow. Evidence is increasing that environmental degradation, harmful chemicals, radiation and global climate change pose major threats to the health, development and survival of the world’s children.

Environmental conditions affect food availability and quality of nutrition as well as levels of physical activity. In more developed countries, childhood obesity is most common in low-income households, because it is driven in part by low-cost foods of poor nutritional value (15).

In air pollution from solid fuel use is a neglected problem that requires urgent action. In developing countries, the traditional use of biomass fuels can pose a serious threat to children’s health (15).

Once children reach the age of five years, unintentional injuries are the most significant threat to their survival. Among those children who live in poverty, the burden of injury is highest, as these children are less likely to benefit from the protective measures others may receive. The unintentional injuries include road traffic injuries, burns, drowning, poisoning and falls; and intentional injuries that are the consequences of acts of violence, either inter-personal (such as homicide or collective violence such as war) or self-directed (suicide, self-harm) (15).

REFERENCES

(1) UNICEF (2009). The State of the World’s Children Special Edition: Celebrating 20 Years of the Convention on the Rights of the Child. New York: United Nations Children’s Fund 

(2) WHO. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action. Geneva: World Health Organization, 2007

(3)WHO (2009). WHO Global Heath Risks. Available at: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf  (accessed Jan 22, 2011)

(4) Bryce J, el Arifeen S, Pariyo G, et al, and the Multi-Country Evaluation of IMCI Study Group. Reducing child mortality: can public health deliver? Lancet 2003; 362: 159–64.

(5) Kurowski C, Wyss K, Abdulla S, Yémadji N, Mills A. Human resources for health: Requirements and availability in the context of scaling-up priority interventions in low-income countries, Case studies from Tanzania and Chad, Report to the Department for International Development. London: London School of Hygiene and Tropical Medicine, IRC & Swiss Tropical Institute, 2004

(6) Lu C, Michaud CM, Khan K, Murray CJ. Absorptive capacity and disbursements by the Global Fund to fight AIDS, Tuberculosis and Malaria: analysis of grant implementation. The Lancet 2006; 368:483–8.

(7) Garrett L. The challenge of global health. Foreign Affairs 2007; 86: 1–17.

(8) De Renzio P. Aid effectiveness and absorptive capacity: which way aid reform and accountability? ODI Opinions. London: Overseas Development Institute.2007

(9) International Monetary Fund. Fiscal Policy Response to Scaled-up Aid. Washington, DC: International Monetary Fund., 2007

(10) Msuya J. Horizontal and vertical delivery of health services: what are the trade offs? . Washington DC: World Bank, 2004

(11) Victora CG, Adam T, Bryce J, Evans D. Integrated management of the sick child. In: Jamison DT, Alleyne G, Breman J, et al, eds. Disease control priorities in developing countries. Second edition. P: 1177-1191

(12) World Health Organization. Analytic review of the IMCI strategy. Geneva: Department of Child and Adolescent Health and Development (CAH) World Health Organization, 2003

(13) The Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet. 2003; 362:65–71

(14) Ranson MK, Hanson K, Oliveira-Cruz V, Mills A. Constraints to expanding access to health interventions: an empirical analysis and country typology. J Int Dev 2003; 15: 15–39.

(15) 3^rd International Conference on Children’s Health and Environment. Busan Pledge for Action on Children’s Health and Environment. Busan: 3^rd WHO International Conference on Children’s Environmental Health, 2009