Food Policy 44 (2014) 2635

Contents lists available at ScienceDirect

Food Policy
journal homepage: www.elsevier.com/locate/foodpol

The politics of success in the ght against malnutrition in Peru

Andrs Meja Acosta a,, Lawrence Haddad b
a
Kings College London, Strand, London WC2R 2LS, United Kingdom
b
Institute of Development Studies, Falmer, BN1 9RE, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: The dramatic reduction in childrens chronic malnutrition in Peru observed in recent years has deed the
Received 28 May 2012 patterns of stunting reduction worldwide. After nearly a decade of stalled progress, the government
Received in revised form 15 September reported a reduction in stunting rates of nearly 10 points, from 29.8% in 2005 to 18.1% in 2011. The spe-
2013
cialized literature has acknowledged the critical role that immediate (e.g. increasing breastfeeding pro-
Accepted 29 October 2013
motion) and underlying (e.g. investments to improve household food security) interventions have
played in reducing stunting (Black et al., 2013), as well as the contributing role of enabling factors related
to economic performance. This paper offers an alternative explanation to success by looking at the shift in
Keywords:
Nutrition
the governments nutrition strategy after 2006 with the formation of the Child Malnutrition Initiative
Peru (CMI), a civil society working platform, and the adoption of a national poverty reduction strategy prior-
Policy change itizing nutrition interventions (known as CRECER) and conditional cash transfers (JUNTOS). The paper
Political commitment uses veto players theory to explain how these changes effectively contributed to policy change by reduc-
Intersectoral coordination ing the effective number of nutrition stakeholders involved and facilitating policy agreements around a
Service delivery common policy platform and established goals. The Peruvian case also highlights the importance of the
Accountability governments public commitment to reduce chronic malnutrition in children under ve by 5 percent in
Advocacy
5 years (5 by 5 by 5) and the accompanying role, advocacy and monitoring from civil society organiza-
Funding mechanisms
tions.
The paper looks at the success of implementing the nutrition strategy in three dimensions. Horizon-
tally, it looks at the coordination between government and non-government agencies to converge around
a common policy discourse;vertically, it looks at the implementation of the nutrition strategy across
national, regional and municipal governments;and nancially, it looks at the coordinated and conditional
allocation of nutrition funding and how this created greater incentives for horizontal and vertical coor-
dination. The paper draws some theoretical and policy implications for improving the effective and
accountable delivery of nutrition interventions in Peru and other countries outside Latin America.
2013 Elsevier Ltd. All rights reserved.

Introduction cooperate with one another to formulate adequate policies, why

Reviews explaining reductions in undernutrition have largely
focused on the role of nutrition specic (Bhutta et al., 2013) and
nutrition sensitive (Ruel and Alderman, 2013) programmes. Yet,
only marginal attention has been paid to the political and institu-
tional conditions that make these policy interventions successful.
That is slowly beginning to change. Gillespie et al. (2013) review
an emerging literature focusing on the set of enabling political con-
ditions that facilitate effective policy changes beyond the technical
design and implementation of policies. As their review notes, from
a political and organizational perspective, it is relevant to ask for
example why and when do key actors and government agencies
Corresponding author. Tel.: +44 20 7848 1514, mobile: +44 7726 152 669; fax:
+44 1273 621 202.
E-mail addresses: andres.mejia@kcl.ac.uk (A. Meja Acosta), l.haddad@ids.ac.uk
(L. Haddad).
and when do national policies become effectively implemented
at the state and local government level, and why and when does
funding becomes available and effective to nance policy changes.
Unfortunately there are too few country level analyses of these
dimensions.
This paper looks at the case of Peru to explore the role of polit-
ical and institutional factors in contributing to a dramatic reduc-
tion in child stunting since 2005. The DHS series of comparable
surveys1 show that in 1996 the rate of stunting in children under
5 years of age was 31.6%, in 2005 it was 29.8%, in 2009 it was
23.8% and in 2011 it was 18.1%. In other words, between 1996 and
2005 the rate of stunting decreased at approximately 0.2 percentage
points per year and between 2005 and 2011 it decreased at approx-
imately 1.95 percentage points per yeara ninefold decrease.
1
See the WHO Global Database on Child Growth for 1996, 2000 and 2005 and page
23 in the INEI 2012 report (in Spanish) for the 2009 and 2011 data.

0306-9192/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.foodpol.2013.10.009
 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635
This paper adopts a political economy perspective to explore
the motivations and institutional incentives of different elected
and non-elected actors to reduce undernutrition.
The Lancet framework for the reduction in child malnutrition
(Black et al., 2013) builds on the UNICEF framework (1990) and high-
lights action at three levels: immediate, underlying and enabling
environment. We acknowledge the critical role of action at the
immediate (e.g. increasing breastfeeding promotion) and underly-
ing (e.g. investments to improve household food security) levels.
Here our focus is more on the enabling factors related to economic
performance, social policy and civil society action that we suggest
contributed to the sharp decline in stunting rates observed in Peru.
From this perspective, the paper argues that government success
in reducing stunting was the result of institutional changes that bet-
ter connected economic performance to stunting performance. The
paper concludes that this connection appears to be associated with
a shift in the national Governments commitment to nutrition, the
coordinated formulation, adoption, funding and implementation
of new public policies, and the consistent support and monitoring
by civil society coalitions. Long term policy coordination in Peru is
the more surprising given that the country is known for a marked
political disconnection between the center and the periphery and
the prevalence of short term ambitions for elected politicians. Yet,
the newly elected government in 2011 renewed and strengthened
its political commitment to reduce childrens undernutrition.
The paper proposes a framework to analyze coalitions for policy
change, taking into consideration the different interests of govern-
ment and nongovernmental agencies, the integration of agencies
and programs between national, regional and municipal govern-
ments, and the allocation of government resources used to fund
the governments nutrition effort. The paper concludes by reect-
ing on the extent to which the Peruvian case has relevance for
other countries.
Approach and methodology
Producing policy change, whether is to reduce childrens under-
nutrition by distributing conditional cash transfers to mothers or
by improving the supply of micronutrients, requires the agreement
and cooperation of key decision makers over a period of time.
These critical policymakers without whose consent policies cannot
be changed or implemented, are known as veto players (Tsebelis,
2002). Veto players are individual or collective actors that need
to agree to a proposed change if it is to become a policy. As part
of the complex policy process, these players can be elected or
non-elected by popular vote (city mayors or high level
bureaucrats), they can be single individuals or be clustered in rep-
resentative bodies (Cabinet Ministers or Members of Parliament).
What is common to them is their ability to block or veto any single
policy that they oppose according to pre-established rules and
procedures.2
The institutional literature on veto players argues that there are
two complementary conditions for producing policy change: When
there is an effective reduction in the number of potential veto play-
ers and when veto players share similar policy preferences (Tseb-
elis, 2002).3 According to the rst condition, the number of
required veto players could be reduced through the adoption of a
more generous voting rule (e.g. a policy can be adopted by a simple
majority instead of by consensus) or when many individual players
2
We will not make an explicit distinction on whether veto players are critical for
the adoption or implementation of policies, although it is feasible that selected veto
players could block the implementation of a previously agreed policy.
3
The range of possible policy options that could replace the status quo is known as
a winset; the greater the magnitude of the winset, the more possibilities for producing
policy change.
27
are subsumed into a collective actor (e.g. a political party). Along the
second dimension, the ideological differences around policy choices
can be reduced through the elaboration of a common narrative that
unies multiple veto players around a shared set of values. Both con-
ditions reinforce one another. Swift policy change can take place
when policymakers delegate authority to a single leader or an agen-
da setter to propose the desired changes, but the new policy can only
be implemented and sustained when other stakeholders derive a vis-
ible benet from this change in the long run. Otherwise the policy
can be reverted in the next election (Haggard and McCubbins,
2001). In the absence of an agenda setter or policy champion, veto
players could develop a rm and cohesive consensus around main-
taining the status quo. Therefore, it is critical that a proactive agenda
setter (or policy champion) forms and sustains reform coalitions
with other (elected and non-elected) players to implement a new
policy across different levels of government.
Building on these two conditions for policy change, this paper
analyzes the extent to which a reduction in the number of veto
players and a convergence of policy preferences helped produce
policy changes that reduced childrens undernutrition rates in Peru.
This paper argues that the rst condition was achieved through the
formation of a common policy platform, the Childrens Malnutrition
Initiative (Iniciativa contra la Malnutricion or CMI) that convened
the efforts of multiple stakeholders to provide technical, nancial
and monitoring support to advance government efforts to reduce
undernutrition. The common policy platform motivated diverse
stakeholders to develop and consolidate a single narrative around
the benets of reducing childrens malnutrition. The narrative
was endorsed by a policy champion, president-elected Alan Garcia
who announced his governments commitment to reduce undernu-
trition by 5 percentage points for children under 5 years old within
5 years (5  5  5). In this paper we analyze how the convergence
of different stakeholders around a single narrative was reproduced
at different levels of policy making including the horizontal coordi-
nation across government and non government actors and across
different territories and local governments (vertical coordination).
Finally, we argue that nancial coordination of key nutrition pro-
grams at the national and subnational level was key to reinforce
the coordination incentives of diverse veto players.
In order to document success strategies, the paper relies on case
specic in-depth qualitative information regarding government ef-
forts to ght chronic malnutrition, with some comparative quanti-
tative information about trends. Qualitatively, the study builds on
stakeholder interviews conducted during a one-week visit to Lima
and Ayacucho during November 8 to 15, 2010. The interviews
sought to explore and understand the coordination efforts and
political dynamics around this successful nutrition effort (see
Meja Acosta, 2011 for questionnaire). In total, we interviewed 26
people selected from a broad range of elected and non elected gov-
ernment ofcials, non government and cooperation agencies, as
well as regional and local governments in Lima and Ayacucho
(see Meja Acosta, 2011 for a list). Some of these stakeholders were
key players in the national government (Ministry of the Presidency,
Line Ministries), elected government ofcials (legislators, regional
presidents and municipal mayors), donor and technical assistance
agencies (USAID, UNICEF, World Bank), and research and civil soci-
ety organizations such as IEP, PRISMA, IIN and CARE. In addition to
the qualitative information, the study uses secondary data on
nutrition and poverty obtained from a variety of sources.
Trends in enabling and underlying determinants
Might the rapid declines in stunting witnessed between 2005
and 2011 simply be due to trends in enabling and underlying
and factors?
28 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635

Table 1
Trends in enabling environment data and stunting data. Source: all economic data come from http://data.worldbank.org/. Rights data from various Freedom in the World annual
reports. www.freedomhouse.org.

19962005 20052011
Stunting rate, children under 5 years of age (%) 31.6 (1996) to 29.8 (2005) 29.8 (2005) to 18.1 (2011)
Decline of 6% Decline of 39%
Annual decline 0.2 percentage points Annual decline 1.95 percent
GNI/capita, PPP 4260 (1995) to 6000 (2005) 6000 (2005) to 9390 (2011)
41% Increase 57% increase
Poverty headcount $1.25 (%) 12.9 (1994) to 8.6 (2005) 8.6 (2005) to 4.9 (2010)
Decline of 33% Decline of 43%
% GDP captured by bottom 20% 4.9 (1994) to 3.9 (2005) 3.9 (2005) to 3.9 (2010)
Worsening of 20% Static
Freedom house score on the protection, respect and 4.5 (1996) to 5.5 (2005) 5.5 (2005) to 5.5 (2011)
promotion of civil and political rights (higher is better)

Table 2
Trends in underlying determinant data and stunting data.

19962005
Stunting rate, children under 5 years of age (%) 31.6 (1996) to 29.8 (2005)
Decline of 6%
Annual decline 0.2 percentage points
Safe water access% of population (WHO/UNICEF, 2013) 7883 (annual decline of 0.5 points)
Improved sanitation access% of population (WHO/UNICEF, 2013) 5967 (annual decline of 0.8 points)
Female secondary education enrollment rate (%) (World Bank, 2013) 6884 (annual decline of 1.6 points)
Calorie supply per capita (FAO/FAOSTAT) 22802423 (annual increase of 14)
20052011
29.8 (2005) to 18.1 (2011)
Decline of 39%
Annual decline 1.95 percent
8385 (annual decline of 0.4 points)
6771 (annual decline of 0.8 points)
8490 (annual decline of 1.2 points)
24232563 (annual increase of 28)

For enabling factors we explore income, poverty, inequality and
the respect for and protection of civil and political rights. We know,
for example, that income growth has signicant effects on stunting
(Haddad et al., 2003; Ruel and Alderman, 2013). Indeed, the Peru
data show improved economic conditions in the 200511 period
compared to 19962005. Table 1 shows that GNI per capita, the
percentage of GDP captured by the poorest 20%, and the poverty
rate all moved more strongly in the right direction in the second
period than in the rst. Table 1 also shows an improvement in civil
and political rights between 1996 and 2005 but not between 2005
and 2011.
However, note that in the rst period, economic growth and
poverty reduction were strong, and yet stunting rates barely
moved. What made economic performance become a driver of
stunting rates? Studies from other parts of the world show that
where stunting has declined rapidly, it has been due to a combina-
tion of rapid economic growth and improved health and nutrition
policy (ODonnell et al., 2009 and Sunil and Sagna, 2013). This is
probably what happened in Peru. Increased income at the national
level permits greater investment in public goods to improve nutri-
tion and greater income at the household level permits greater
purchases of better food, cleaner water, drugs and improved sani-
tation. But without pressure to convert that increased income into
improved nutrition, as we saw from the 19962005 period, stun-
ting rates may well have remained stuck.
Turning, then to the underlying factors, Table 2 shows how
these fared in the two time periods under investigation.
From the data in Table 2 we can see that the annual rate of
change of these variables is broadly similar across both periods:
the same for sanitation, lower for water and female secondary edu-
cation in the high stunting decline period and higher for calories in
the high stunting decline period (although these are small changes
for calories). In other words we can detect no major shift in under-
lying determinants in the high and low stunting decline periods.
The evolution of nutrition policies
If economic and political changes have provided an enabling
environment for stunting reduction without being sufcient driv-
ers, and the rates of change in underlying determinants have not
changed over the two periods, what else has helped to drive stun-
ting rates down? This paper argues that the design and implemen-
tation of effective nutrition policies after 2005 helps to explain the
signicant reduction in malnutrition rates in Peru. This section
documents two fundamental changes in the way nutrition policies
evolved over time: a gradual convergence of nutrition policy inter-
ventions towards a poverty reduction strategy and creating greater
consensus through inclusion and active participation of different
nutrition stakeholders in the ght against malnutrition. We ex-
plore these changes in detail.
Reshaping nutrition policies: from food assistance to poverty reduction
The intent of the Peruvian government to ght against malnu-
trition has been present since the seventies, but the choice and nat-
ure of approaches has changed signicantly over time. Back in
1972 the government created the National Ofce for Food Support
(ONAA), but for the most part, government efforts were weak and
inconsistent and limited mostly to coordinate donations by over-
seas aid programs. After a short lived experiment with the creation
of a Ministry of Nourishment in 1974, ONAA continued to play the
main role of coordinating food aid, but devolving the bulk of pro-
gramme implementation to NGOs. The government took a more
prominent role in food assistance in the eighties, with the creation
of the Direct Assistance Program (Programa de Asistencia Directa
PAD) for employment-based food assistance and the Glass of Milk
Program (Vaso de Leche VdL) to benet at-risk children under
6 years old. Another popular initiative was the creation of Come-
dores Populares (soup kitchens). The Comedores were neighborhood
organizations originally started by churches, parishes or NGOs and
were locally funded to feed the local population as a way to allevi-
ate the economic crises of the eighties (Aguiar et al., 2007). The
Comedores were further supported by USAIDs Proyecto de Desarr-
ollo Integral con Apoyo Alimentario (PRODIA), and by 1994 there
were 5000 Comedores in the Lima Metropolitan area and approx-
imately 13,000 elsewhere in the country, with about half of those
being self-managed. As food assistance initiatives from many other
government agencies continued to multiply in the early nineties,
the Ofce of the President took the lead to merge the main food re-
lated programmes PAD and ONAA into the National Program
 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635
for Food Assistance (PRONAA). Only the Glass of Milk program was
not integrated under PRONAA management and remained directly
funded by the Ministry of Finance and Economics and managed by
municipal governments.
Despite some early government efforts to ensure policy coordi-
nation and increase funding, there was no evidence of visible
reductions in concrete malnutrition indicators such as childrens
stunting rates. By 2002, Peru was spending $250 USD million annu-
ally on food and nutrition programs but there was no overarching
strategy to ensure the effectiveness or accountability of the
government investment. There were for example, some signicant
problems in targeting the vulnerable population. In 2000 for
example, 28% of the districts with the highest child stunting rates
received no nutrition services (from VdL and Comedores Popul-
ares), whereas 47% of districts with low prevalence of stunting
did receive services. A related issue was low access to services
and user rates. Although nutrition services from both programs
covered about 68% among the poor in 2005, only 28% of the eligible
were actually beneting from the services (Vsquez, 2007: 68,
quoted in World Bank, 2009). PRONAAs Comedores also failed to
reach many of their target beneciaries, with 97% coverage but
only 36% use (World Bank, 2009). in some cases, broader coverage
meant reduced net funding. For example, the number of Glass of
Milk beneciaries increased in the late nineties to include children
up to the age of 13 but without a corresponding increase in funding
(World Bank, 2009).
Food distribution programs were not the only source of Perus
nutrition policies as there were may other and broader policy
interventions across different sectors, including health, education,
agriculture and sanitation.4 However, food distribution initiatives
remained the governments preferred policy approach because it
was a highly visible intervention with great potential to increase
the governments political capital especially during electoral times
in the eighties and nineties. The popularity of these programs cre-
ated political and clientelistic entitlements (amongst families whose
children had aged out of the initial beneciary group) that were dif-
cult to dismantle. Many of the stakeholders interviewed during this
study corroborated that despite the reported inefciencies of the
Glass of Milk program, it was unlikely that the government would
cut funds given the powerful and inuential political lobbying
formed around it.5
Food distribution programs were also popular because they
covered the vast majority of government spending on nutrition.
According to this logic, it was unnecessary to integrate these pro-
grams with other government sectors like health, sanitation and
education to avoid further coordination problems.
The 2000 congressional removal from ofce of President Alberto
Fujimori, who ed the country to Japan from alleged corruption
charges, also signaled a dramatic shift in the direction of social pol-
icies in Peru. The interim president Valentn Paniagua (November
2000 to July 2001) created in January 2001 the Roundtable for Pov-
erty Reduction (Mesa de Concertacin para la Lucha Contra la Pobre-
za MCLCP) as a convening space where state and civil society
actors would coordinate poverty reduction initiatives.6 When
elected President Alejandro Toledo took ofce in 2001, he prioritized
the social agenda to reduce poverty and improve social justice by
4
For a broader historical analysis of Perus nutrition policies, see Politica Nacional
para la Reduccin de la Desnutricin Crnica en el Per (Instituto Apoyo, July 2001)
and the Ministry of Healths Nutrition Strategy (2001).
5
Not surprisingly, the government shift to a new articulation of social policies to
be discussed in the next section left the political structure and funding of the Glass
of Milk program untouched.
6
Paniagua (Nov-2000 to Jul-2001) had already recognized the complex nature of
the malnutrition problem in Peru, and called for the need of a state policy that
involved the participation of the private and public sectors as well as civil society in
the design, implementation and monitoring of policies.
29
bringing together government representatives, civil society, the pri-
vate sector, and international donor agencies around the MCLCP. To-
gether these agents reached an agreement on reforming social
policy, improving service delivery, and introducing greater participa-
tion by citizens in design, decision-making, and nancial planning of
social policy (World Bank, 2009). Towards the end of his administra-
tion, Toledo created the National Strategy for Food Security (Estrate-
gia Nacional de Seguridad Alimentaria ENSA) under the control of
the Ofce of the Presidency.7 Although ENSA was never imple-
mented, it established the organizational and administrative basis
for the future formulation of a national poverty reduction strategy,
CRECER (Interview # 26).
The national Strategy for Poverty Reduction (CRECER) was for-
mally created through an Executive Decree in July 2007 as a coor-
dinated poverty reduction strategy that articulates all public
ofces in the National, Regional and Local Government, as well
as the private sector, international cooperation and civil society
in general, to promote, facilitate and execute poverty reduction
and human development goals.8 The adoption of CRECER repre-
sented a signicant shift in governments thinking about nutrition
in at least three ways. First, it went beyond a food distribution ap-
proach to embrace a complementarity of interventions including
better training of health workers, improved cooking practices for
mothers, improving of hygienic conditions, access to clean water,
and use of conditional cash transfers to support reductions in malnu-
trition among some of the interventions. This diverse approach also
demanded explicit policy coordination within government agencies
and between government and non-governmental agencies to ensure
complementarity and specialization. Secondly, CRECER promoted
the decentralization of interventions so that the central state de-
volves considerable administrative, nancial and political responsi-
bilities to regional and municipal governments for the provision of
public services. Finally, there is an explicit government shift to fund
its nutrition strategy through Results Based Budgeting. This strategy
allowed government agencies to design, formulate and implement
policies according to expected results while giving the Finance Min-
istry the ability to monitor the efcient use transparency and
accountability of budgetary allocations.
An underlying and preexisting factor of success for CRECER in
Peru was the adoption of JUNTOS, a conditional cash transfer pro-
gram created during the Toledo government in 2005 as an initiative
to break the intergenerational transmission of poverty and reduce
childrens chronic malnutrition by building human capital especially
among high risk and socially excluded populations (Government of
Peru, 2011). President Toledo was inspired by the promise (drawn
from other CCT programs, particularly Progresa/Oportunidades in
Mexico) that cash transfers were less expensive but more effective
than food transfers. The adoption of JUNTOS also marked a signi-
cant shift in the governments approach to social policy because it
challenged those critics who believed that the provision of social
services could not be separated from patronage politics.
Generating consensus around nutrition: the role of civil society
A second pillar of success in Peru was the gradual convergence
and participation of different stakeholders around the importance
of reducing childrens chronic malnutrition through integrated and
coordinated policy interventions. This convergence of multiple
veto players around a single narrative was reected in the forma-
tion and development of the Child Malnutrition Initiative (CMI) in
2005. The CMI is an advocacy coalition integrated by government
and non-government agencies that organized to promote and
inuence effective government action. These agencies included
7
Supreme Decree DS 0068-2006-PCM.
8
Supreme Decree No. 055 PCM, published 8 September 2007.
30 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635

Action Against Hunger (ACH), ADRA Per, CARE Per, CARITAS del Castillo, and Virginia Borra, the Minister for Women and Social
Per, UNICEF, UN Population Fund, Future Generations, Institute Development (MIMDES). In light of the apparent success in secur-
of Nutritional Research (IIN), Mesa de Concertacin para la Lucha ing political commitment, the CMI sought to engage Perus regional
contra la Pobreza (MCLCP), FAO, Panamerican Health Organization government leaders, along with other allies such as the World
(PAHO), Plan International, PRISMA, World Food Program (WFP) Bank (who were not formally part of the CMI, but attended its
and USAID. meetings). The Presidentes Regionales (Presidents of the 25 Regions
Paradoxically, the creation of CMI was partly motivated by the in Peru) signed the Lima Declaration on Child Malnutrition that
need to articulate effective action around nutrition in the context also committed them to reducing chronic child malnutrition by 5
of diminishing funding, not due to the abundance of it. Until percentage points by 2011. According to an interviewee, the CMI
2005, several development agencies working on child malnutrition became a sort of Jiminy Cricket or an advocacy conscience
(Caritas, ADRA, PRISMA and UNICEF) benetted from USAID fund- whose role was to remind, guide and monitor government com-
ing to support mother and child health and nutrition (MCHN). By mitments to reducing malnutrition (Interview #25). Effectively,
2005, the consortium had received nearly US$50 million from when Yehude Simon replaced Premier Del Castillo in 2009, the
USAID, most of it in the form of food aid, to work in high poverty CMI swiftly moved into remind the incoming Premier of the polit-
areas such as the Peruvian Sierra and Selva. The end of USAID (Title ical commitments signed by his antecessor.
II) funding represented an opportunity to shift the agencies pre-
dominant focus on community level interventions and upscale
The politics of implementing nutrition policies in Peru
their advocacy efforts to ght poverty and malnutrition at the na-
tional level in a systematic and coordinated way.9
The previous section showed that reducing the effective num-
The CMI contributed to successful policy change because it
ber of veto players and expanding the available space for policy
helped to bridge diverse policy preferences around a similar set
consensus proved to be two key conditions for producing policy
of coordinated interventions and it offered a working platform to
change on the nutrition sector in Peru. These two conditions rein-
reduce the number of existing veto players working around nutri-
forced one another to advance the ght against malnutrition. The
tion. Regarding the rst role, the CMI developed a single narrative
CMI provided an informal policy coordination and advocacy plat-
to make nutrition the central component in the governments ght
form to aggregate (reduce) the number of nutrition stakeholders,
against poverty. To this effect, it developed alongside the Govern-
and the government promoted policy consensus around nutrition
ment of Peru a comprehensive framework to understand the con-
with the adoption of a national strategy for poverty reduction
tributing causes and negative consequences of malnutrition in
(CRECER).
Peru, and its impact on poverty reduction. Secondly, the CMI
CRECER represented a radical change in the governments strat-
helped to reduce the number of veto players by establishing an
egy for ghting malnutrition because it went beyond a classic food
informal working platform to coordinate technical and nancial
distribution approach. Instead, it promoted a series of complemen-
contributions from different cooperation agencies. Although it
tary interventions that included teaching improved cooking tech-
lacked a legal entity status (personera jurdica), it was internally
niques to mothers, facilitating better access to healthy and cheap
governed by a Board of Directors and composed by a Technical
agricultural products, improving access to clean water and sanita-
and a Communications Committee (CMI Acuerdo Interno 2006).
tion and ensuring good access to health care. A critical part of the
Through this platform, donors and cooperation agencies could
poverty reduction strategy was the adoption of the conditional
meet and discuss urgent policy issues on a monthly basis, analyze
cash transfers program (JUNTOS) to increase the purchasing power
effective mechanisms for policy inuencing, and devise cost shar-
of households and break the intergenerational poverty trap. The
ing and co funding schemes that helped advance the ght against
implementation of both strategies, JUNTOS and CRECER, required
poverty campaign. The Initiative however did not seek to share
active coordination between national policymakers, line minis-
programmatic cost or priorities, as it was perceived that coordinat-
tries, regional and locally elected leaders and front line service
ing the allocation of programmatic funds will inevitably lead to
providers.
greater controversy between the agencies involved.
This section explores in greater detail the politics of managing
A third and critical contribution of CMI was to effectively in-
and implementing the national strategy for poverty reduction
crease advocacy efforts and secure the commitment of elected of-
and its impact on reducing malnutrition. Both CRECER and JUNTOS
cials, political elites and the public at large to reduce childrens
focused on the complementarity of interventions with other sec-
malnutrition. During the 2006 presidential campaign, the CMI
tors, decentralized service provision and ensured funding levels
challenged the ten running candidates to make the ght against
that could allow a positive effect on nutrition. The government
malnutrition a national priority if elected. The specic pledge,
strategies also established clearer accountability linkages about
signed by all candidates, was to reduce chronic child malnutrition
who was responsible for policy coordination, implementation
by ve percentage points in children under 5 years old in 5 years
and funding.
(the 5  5  5 campaign). When president Alan Garcia took ofce,
CARE and the CMI drafted a policy document for action during the
rst 100 days of government. President Garcia embraced the chal- Horizontal or intersectoral coordination
lenge making a public commitment to reducing childrens malnu-
trition by 9 percentage points, to focus on children under 3 who One of the prime challenges of the National Strategy for Poverty
were the most vulnerable in terms of nutrition and poverty, and Reduction and Economic Opportunities (CRECER) was to address
to close the urbanrural gap. Garcias plan included developing hu- the problem of horizontal coordination across different government
man capital, promoting social development and co-responsibility, ministries, civil society organizations, NGOs and cooperation agen-
and reducing poverty in 1119 districts nationwide. The presiden- cies. The challenge consisted in endowing CRECER with sufcient
tial pledge also ensured the commitment from Perus Premier Jorge political and administrative leverage to coordinate policy responses
while ensuring its institutionalization away from discretionary
9
presidential authority. Some advocated for the strategy to be
Many of the stakeholders interviewed recognized the leading role of CARE-Peru,
and its National Director Milo Stanojevich in the creation of the CMI. CAREs
delegated to the Ministry of Women and Social Development (MIM-
malnutrition program in Peru had begun in 1990 and by mid 2000 they had become DES) as this would fall within the Ministrys natural policy man-
one of the leading NGOs to ght malnutrition at the regional level. date. Others, including CMI, argued against putting the National
 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635
Strategy under MIMDES given that the Ministrys limited political
clout would hinder cooperation from other social and Finance Min-
istries. The debate generated intense political interest as both the
head of MIMDES and the Ofce of the Prime Minister (Virginia Bor-
ras and Jorge del Castillo respectively) actively participated in the
technical meetings preceding the formation of the Strategy and
sought to receive this mandate from the President (Interview
#26). The President nally left the coordination, execution, moni-
toring and evaluation of the National Strategy in the hands of the
Ofce of the Prime Minister (PCM)10 through the Technical Secretar-
iat of the Inter-Ministerial Commission for Social Affairs (CT-CIAS).11
The sub secretary of MIMDES Ivan Hidalgo was a key gure to give
CRECER greater political salience within CT-CIAS, as well as facilitat-
ing the communication with the Donor led Child Malnutrition Initia-
tive (CMI). The decision to give the National Strategy CRECER
sufcient political leverage to convene other government entities
was welcomed by CMI members. The Executive Committee was
formed by the Technical Secretary of the Inter-Ministerial Commis-
sion for Social Affairs, and convened representatives from the Woman
and Development Ministry, Health, Education, Work and Job Crea-
tion, Transport and Communications, Agriculture, and Finance Minis-
tries. The Finance Ministry representative usually chaired the CIAS
(Interview #24).
The management of JUNTOS shared CRECERs similar challenge
of encouraging multisectoral cooperation across multiple nutrition
stakeholders. But it also had to confront or minimize some of the
previous challenges associated with the delivery of social programs
in Peru: service overload, political capture of program benets, cli-
entelist networks affecting beneciary populations, and failure to
successfully target poor populations. To overcome these gover-
nance barriers, JUNTOS was centrally managed by a directorate
based at the PCM with mechanisms to promote inter-sectoral coor-
dination such as the compliance of mothers of a multiple condi-
tionality, and a strong M&E system with its own managing
committee and community facilitators. The JUNTOS directorate is
composed of a president, four civil society representatives from
the National Accord, and individuals from the Ministries of Educa-
tion, Health, MIMDES and MEF. The directorate practices consen-
sus decision-making and transparency to stress the legitimacy of
JUNTOS. Coordination across government sectors is managed by
Multisectoral Technical Committees (MTCs) which are charged
with linking the program to different government sectors and the
Roundtable for Poverty Reduction (MCLCP).
An initial evaluation of JUNTOS impact based on its operation
in 2006 and 2007 (Perova and Vakis, 2009) concluded that JUNTOS
increased the utilization of health services for women and children
and improved the nutrition intake of program households but did
not have a demonstrated impact on stunting, probably due to an
insufcient provision (in quantity and quality) of health services.
A later and even more rigorous study (Snchez and Jaramillo,
2012) used data from 2008 to 2010 to conclude that JUNTOS did
contribute to the reduction of early chronic malnutrition. A subse-
quent evaluation of JUNTOS (Perova and Vakis (2012) (although
not looking at its stunting impacts) concluded that the duration
of exposure to the program mattered for impact: longer was better.
In terms of its governance structure however, this paper argues
that the success of JUNTOS in reducing stunting is due to combina-
tion of a centralized and diverse management structure that
enhances both direct accountability but also multisectoral cooper-
ation across different nutrition stakeholders.
While the governments multisectoral approach to nutrition is
associated with an effective reduction in malnutrition rates, there
10
Executive Decree No. 002-2003-PCM (02.01.2003).
11
CT-CIAS had been created in under Legislative Decree No. 560 of the Executive
Branch (28.03.1990).
31
are key political actors that were marginalized from the policy-
making process. With very few exceptions, Members of Congress
maintained very limited discussions or interactions with represen-
tatives from the Health, Social Development (MIMDES) or Educa-
tion Ministries, and only recently they became aware of the
existence of ST-CIAS as the government entity in charge of social
policies. Beyond the individual level, political parties have also
maintained no or very limited inuence on the process of policy
formulation and implementation in Peru. The exclusion of Con-
gress as a legitimate policymaking arena is largely explained by
the chronic fragmentation of its political parties. The initial moti-
vation for marginalizing congressional representatives was to
reinforce the Presidents agenda setting power and avoid political
bargaining with multiple coalition partners that could undermine
the coherence or cost of required policy reforms (Meja Acosta,
2009). In the long run however, the absence of national political
parties and congressional committees may compromise the
long-term sustainability of the governments strategy to tackle
malnutrition. Congress has several roles to ensure the success of
government policies in the long run, such as: (a) producing quality
legislation to advance and institutionalize government efforts in
the ght against malnutrition, (b) playing an active role in the
monitoring and oversight of government initiatives, and (c) estab-
lishing direct accountability linkages between legislators and their
constituents when it comes to reducing malnutrition.
Vertical coordination and policy implementation across different tiers
The challenge of effective vertical coordination refers to the gov-
ernments ability to coordinate, implement and monitor its poverty
reduction strategy across different government tiers at the na-
tional, regional and municipal level. What are the cooperation
incentives of sub national governments (regional and municipal),
to adopt, advance and benet from the policy interventions estab-
lished by the national central government? This is a particularly
difcult cooperation dilemma in the context of the highly discon-
nected and fragmented Peruvian political landscape. After the
2006 presidential election, only two out of 25 elected regional gov-
ernments belonged to the governments political party, the APRA.
At local levels, in the 195 provinces and 1831 districts, the picture
is even more fragmented, with the proliferation of local elites and
movements with little or no connection to national political
parties.
The stakeholders interviewed for this paper conrmed that the
vertical articulation of the National Strategy CRECER from the PCM
promoted an effective coordination between the central and regio-
nal governments, but there were signicant gaps when it came to
linking poverty reduction policies between the regional and muni-
cipal levels. The CMI played a crucial role to ensure policy coordi-
nation and political commitment from national and regional
authorities. After the ofcial launch of CRECER in March 2007
signed by the President and the regional governors, the CMI and
the World Bank mobilized the countrys regional governments to
sign the Lima Declaration on Child Malnutrition, thus securing their
political commitment to reducing chronic malnutrition by 5 per-
centage points before 2011.
The actual (regional) implementation of CRECER was far from
smooth in practice. Legislation was passed in 2008 (Norma 001-
2008) to decentralize the local implementation of CRECER to muni-
cipal and regional governments. Decentralization was crucial to
encourage regional presidents to gradually take over the CRECER
agenda and put their own regional stamp on it, such as Ayacuchos
CRECER-Wari program. The success of the Ayacucho experience
shows how the nutrition strategy started as a regional priority
but it gradually morphed to adopt region specic programs to im-
prove human capital, to promote economic growth and improve
32 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635
provision of social services (Interview #14).12 To implement the
strategy, Regional President Molina set up an intersectoral commit-
tee (mirroring the national coordination structure) to facilitate hor-
izontal alignments in the ght against poverty.13 At a personal level,
the regional president had direct contact with the National Director
of CT-CIAS Ivn Hidalgo and the Minister for Women and Social
Development Virginia Borra, and the congresswoman for the Ayacu-
cho region, Elizabeth Leon (Interview #16). Yet this type of leverage
in the Peruvian context was more an exception than a rule.
In contrast to CRECER, the implementation of the JUNTOS pro-
gram triggered greater political conicts between the central gov-
ernment and local authorities over ownership and control of
resources. In principle, the conditional cash transfer scheme di-
rectly allocated central government transfers to eligible house-
holds in selected municipalities based on needs assessments,
poverty lines and a local peer review process. Government critics
argued that the selection and allocation of transfers beneted
recipients who were sympathetic to local authorities (Government
of Peru, 2011). Mayors resented the fact that they were not in
charge of directly managing funds or social priorities even though
they were elected representatives (Interview # 6). Although there
are no dedicated studies to look at the political impact of CCTs in
Peru, it is highly unlikely that the allocation of JUNTOS funding
helped to advance the careers of local politicians given the low
reelection rates of incumbent mayors.
One recurrent theme in Peru was the chronic coordination
problems between municipal governments and the regional and
national levels. Part of this was explained by the political fragmen-
tation and coordination challenges between the regional presi-
dency and the 111 municipal districts. After the 2010 municipal
election for example, it emerged that less than 20% of municipal
districts had direct partisan alignment with the newly elected re-
gional president. In other words, more than 80% of districts lacked
clear political incentives to collaborate with and implement the
poverty reduction strategy led by another party. In the case of Re-
gional President Molina, this minoritarian situation inuenced his
decision not to run for reelection in the 2010 regional elections, but
from a broader policy perspective, the lack of political continuity is
a serious problem to ensure the success and stability of social pol-
icies. A second challenge of implementing nutrition policies at mu-
nicipal level is their lack of technical and administrative capacity to
administrate central government funds. This is space where exter-
nal cooperation agencies can and have step up training of project
coordinators and bring expertise and technical assistance to
municipalities (Interview #16).
After an initial evaluation of the government initiative in the
ght against chronic malnutrition conrmed the lack of political
incentives and administrative weaknesses of local governments,
there were some effective government responses. First, in 2008 a
12
Ayacucho offers an excellent success case that posted a dramatic reduction in
chronic malnutrition of more than 6% points, and a reduction of poverty rates of 15.6%
during the 20052009 period. Success in Ayacucho is remarkable because political
violence destroyed the social fabric, undermined civil society and dismantled the
economic productivity during the eighties and nineties. Ayacucho also achieved
success without beneting from rents and transfers from the export of natural
resource unlike other regions.
13
The CRECER-Wari strategy reproduced the same instances of policy coordination
to facilitate intersectoral and political dialogue at the regional level between the
National Coordination of CRECER and representatives from the ministries of Health,
Education, Housing and Labor, regional government entities (including the Presidency
of the Regional Council for the Fight against Poverty and Child Malnutrition, and
Regional Managers of JUNTOS, PRONAA and FONCODES), elected authorities including
the Regional President of Ayacucho, and mayors from 12 municipal districts.
Representatives of the National Agreement for Poverty Alleviation, and the Poverty
Alleviation Roundtable also contributed to policy coordination and implementation of
the CRECER-Wari strategy through their regional ofces in Ayacucho (Interviews #
13, #14 and #16).
law (Norma 001-2008) was passed to decentralize the local imple-
mentation of CRECER to municipal and regional governments, so
that 12 regional governments signed up formally to indicate their
commitment to the program.14 Secondly, the central government
trained and deployed JUNTOS program managers to build adminis-
trative and executive capacity in more than 100 local governments.
Costing nutrition strategies through results based budgeting
The previous two sections argued that effective implementation
of nutrition policies took place in the context of effective horizontal
and vertical coordination. This section claims that the nutrition
funding mechanism was the glue that made horizontal and vertical
coordination stick together. In the case of Peru, the decision to de-
sign and fund the national strategy against malnutrition through
Results Based Budgeting15 (Presupuesto por Resultados) or RBB
was a critical factor for success. The choice of nutrition as a pilot area
to adopt RBB was a natural decision since effective nutrition inter-
ventions required the coordination of several government ministries
and social programs (Health, Education, Housing, Labor, JUNTOS,
PRONAA) to provide public services and attain complementary goals.
The RBB strategy had a double advantage: (a) it helped calculate and
secure the necessary funds for accomplishing nutrition targets and
thus protect social spending, and (b) it created direct incentives for
government bureaucrats and elected authorities to make govern-
ment spending more transparent and visible to the public and to
one another (Interview #26).
The Ministry of Finance and Economy (MEF) was directly in-
volved in the budgeting process through its executive units (unid-
ades ejecutoras) in charge of calculating and collecting the
appropriate budget estimates for the following year, and conveying
that information to the central level for a proper forecast of next
years budget. This was a fundamental change because it shifted
budgeting from an input oriented approach to a product oriented
approach that focused on delivery of services. It also allowed for
project coordination between the administrative and logistical per-
sons in charge of providing the service, with the technocrat in
charge of executing the budget, with the government planner in
charge of signing the checks (Interview #1). JUNTOS budget was
established by Law No. 28562 in 2005, which provided 120 million
soles (c. $40 million USD) to nance the pilot phase of the program.
In 2009, the JUNTOS budget allocation (through results based bud-
geting) represented 8.2% of the total budget assigned to social
programs.
The decision to cost nutrition efforts through RBB highlighted
important differences between the MEF that placed emphasis
on results and value for money and members of the social sector
such as the Poverty for Poverty Reduction (MCLCP) that focused on
social outcomes and processes. An important compromise
achieved was the inclusion, thanks to the advocacy of MCLCP, of
specic social targets to be achieved as part of macroeconomic
goals set by the MEF (Interview #11). While MEF has made good
progress in the allocation of budgets according to outputs, it has
been more difcult to monitor the disbursement and effective
spending according to results and this remains one of the pending
challenges (Interview #26).
At the micro level, it is not clear that the introduction of RBB
completely eliminated the political lobbying and bargaining of
ministries to obtain greater budgetary allocations. With the adop-
tion of RBB, it is more controversial to try to break up and identify
14
At the time of writing, there were 21 regional governments and 650 local
governments that adopted and institutionalized the National Strategy CRECER.
15
Although the initial proposal for adopting a results-based system of public
budgeting was rst considered during the Toledo Administration in 2001, the idea
only gained political momentum with President Alan Garca in 2006.
 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635
operating expenditure rather than capital expenditure (Interviews
#3 and 11). As a result, the same political motivations to reshufe
funding between capital and operating expenditure remains under
the RBB scheme (Interview #11), but it is argued that under the
RBB scheme it is difcult to overestimate spending, thus reducing
motivations for rent seeking (Interview #26).
The growing predominance of the Executive and the MEF in the
RBB process triggered mixed reactions among stakeholders and
beneciaries. On the one hand, many recognize the organizational
and technical advantages of MEF to forecast and transfer budgetary
allocations, which has enabled continuity of funds to advance gov-
ernment nutrition efforts. By the same token it is important that
MEF allows districts some autonomy and spending exibility to
adapt to unexpected circumstances such as food price increases
or windfall revenues (Interview #6). As one of the interviewees
warned, if MEF ofcials continue to have an excessive control of
spending decisions from the capital city Lima, they run the risk
of asphyxiating the planning process and undermining the innova-
tive capacity of regional ofcers (Interview #6).
At the sub national level, the RBB scheme has not solved the
conict over budget allocations between regions and municipali-
ties. On the one hand, regional governments have the capacity to
absorb and use scal transfers in a more accountable manner than
municipal governments. In terms of long term sustainability how-
ever, municipal governments need to improve their planning abil-
ities to make the most use of scal transfers. Currently, most
stakeholders recognize the need to improve investment at the mu-
nicipal level, but the central government insists in promoting
spending at the regional level because municipal governments
are not ready yet, they lack the technical capabilities and we can-
not afford to waste our social investment. . . (Interview #20).
Conclusions and research agenda
The acceleration in the decline of stunting rates witnessed in
Peru post 2005 is unlikely to have been solely due to economic fac-
tors or changes in underlying determinants. GDP growth and pov-
erty reduction did accelerate post 2005, but not to the extent that
they alone can explain the ninefold acceleration in stunting de-
clines. The economic context was conducive but not conclusive.
Similarly, improvements in factors such as access to improved san-
itation and safe water, girls secondary school enrollment and food
supply cannot account for the dramatic acceleration in stunting
reduction.
This paper argued that social policies in Peru adopted between
1990s and 2005 played an important role in this acceleration by
going beyond food provision to promote effective coordination
across sectors, to decentralize implementation at local level while
maintaining design at central level, and to focus on funding mea-
surable outcomes through results based budgets. While many
challenges remain in the Peruvian context to fully eradicate mal-
nutrition, there are a few success factors that appear to be impor-
tant to consolidating and focusing on the social sector, including a
high level political commitment from elected authorities and an
active involvement and coordination from civil society groups in
the design and effective implementation of the two key govern-
ment strategies to reduce malnutrition CRECER and JUNTOS.
From a theoretical perspective, this paper has built on veto
players theory to help explain the existence of two key conditions
leading to favorable policy change in terms of nutrition. The ght
against childrens malnutrition in Peru shows a considerable
reduction in the number of relevant stakeholders through the for-
mation of a formal coordination platform, the Initiative Against
Child malnutrition (CMI) that convened nearly two dozen govern-
ment and non government agencies, civil society and research
organizations. Secondly, different policy differences merged
33
around the need to go beyond food distribution and frame the ght
against malnutrition in the context of a broader poverty reduction
strategy that required coordinated action on many other fronts.
The Peruvian CMI conrms the theoretical prediction that increas-
ing the number of veto players will not have an adverse impact on
policy change if the new preferences are aligned with or absorbed
by the preferences of preexisting players (Tsebelis, 2002: 2628).
While the original theoretical framework is able to explain the
institutional conditions leading to policy change, the Peru case
illustrates the importance of political leadership when it comes
to crafting coalitions around a common policy goal. Political lead-
ership was key to gather consensus around a common discourse
before and after the 2006 elections, ensuring that malnutrition re-
mained a salient issue in the policy agenda. Many experts inter-
viewed agreed that government efforts became more credible
when the ght against malnutrition became a visible issue in the
public agenda (Interviewees # 3 and #22). Not only national and
regional candidates were keen to sign public declaration in subse-
quent elections, but the increased public awareness was echoed
and validated by independent (non government) printed media
such as Revista Caretas and other media like Radio Programas del
Peru (RPP) (Interview # 3).16
The paper has also developed an explicit notion of nutrition
governance by looking at three interrelated dimensions of the gov-
ernments ght against chronic malnutrition: the coordination
across different sectors, the implementation at the subnational le-
vel and the coordination of funding mechanisms. We have found
this framework to be useful for understanding the political incen-
tives for adopting and implementing nutrition policies in other
countries (Mejia Acosta and Fanzo, 2012).
There are also implications for future comparative research.
First, more analysis is needed to assess the linkage between fund-
ing mechanisms and greater policy coordination and government
responsiveness across different agencies and government tiers. In
Peru, we argued that the presence of pooled funding mechanisms
that granted conditional transfers to beneciaries (JUNTOS) was
the glue that stimulated horizontal and vertical coordination of
government agencies around service delivery. Looking outside
Peru, the question is whether other sources and mechanisms for
channeling nutrition funding are likely to produce more or less
effective government responses.
Secondly, it is worth exploring the conditions that account for
effective civil society participation in other countries. The Peru
experience suggests that civil society activism is necessary but
not sufcient to trigger government action. As active members of
CMI, CSOs contributed to the formulation and implementation of
CRECER and JUNTOS alongside government actors and agencies.
They helped to identify realistic policy targets, facilitated coordina-
tion efforts across different government ministries, promoted
greater integration of policies, training and technical assistance be-
tween the central and the regional and municipal levels, and con-
tinued to oversee the work and commitment of elected politicians
and government ofcials.
A nal question that deserves further research is to better
understand the political incentives that elected politicians have
(Mayors or members of congress) to invest in the ght against mal-
nutrition. The Peruvian experience shows that strong executive
leadership was crucial to coordinate and implement the nutrition
strategy at the national and regional level but many interviewees
16
The CMI was one of the promoters of this campaign that brought together
different coalitions and organizations working on child rights to develop concrete
targets across seven main areas of rights including nutrition. The model of the CMI
campaign around the 2005 elections was inuential in determining this focus on
obtaining commitments from candidates to specic changes in key indicators, and on
ensuring follow-up and monitoring afterwards on their fulllment.
34 A. Meja Acosta, L. Haddad / Food Policy 44 (2014) 2635
were also quick to point out that the success of government efforts
to reduce malnutrition was possible thanks to the absence of politi-
cal parties at the local level (Interviews #3, 9 and 11). The argu-
ment defended the need to protect the strategys technical
nature and the allocation of antipoverty transfers from the (nega-
tive) inuence of political parties. This apparent contradiction (to
depoliticize in order to ensure political commitment) needs to be
better understood. In practice, it would be relevant to explore
why and when incumbent politicians and their parties prefer to in-
vest and ensure the long-term success of poverty reduction strate-
gies in addition to promoting the short-term interests of their
constituents. In Peru, this question is particularly relevant to
understand the prospects for policy continuity when very few
incumbent mayors and legislators were brought back to ofce after
the 2011 election.
Comparative policy recommendations
Keeping in mind the limitations of generalizing from a single
case study, we outline four lessons that emerge from the Peruvian
success story that could inform nutrition strategies in another con-
text. First, is the design of an overarching nutrition and poverty
reduction strategy such as CRECER and JUNTOS, to reduce the
number of players and effectively integrate nutrition responses
across sectors. Without specic nutrition objectives and compo-
nents, social policy is less likely to reduce stunting. Secondly, the
collective role played by civil society groupsnational and interna-
tionalin the formation of a policy coordination platform, the CMI,
and its strategic inuence in the political process (in the context of
an election, a large international event, in the aftermath of a crisis
or when a regime changes) contributed to progressive change.
Thirdly, the changes were made possible with the support of strong
executive leadership, to articulate a single narrative around the
need to reduce stunting, to coordinate effective action across dif-
ferent agencies and to ensure a continuous and committed funding
effort. Finally, the regular availability of credible data on nutrition
outcomes is vital to sustaining government enthusiasm and civil
society activismthe relative frequency of surveys observed in
Peru is missing in many countries. Civil society in other countries
could take a more prominent role to monitor and report on govern-
ments commitments and progress by demanding regular reports
on the nature and size of the nutrition budget, by comparing na-
tional progress with global efforts to monitor government commit-
ment on nutrition, especially at local level, or by introducing
community scorecards to evaluate the implementation and local
level impact of government programs.
The success in ghting childrens chronic malnutrition in Peru
validates and expands the validity of veto players theory to under-
stand the adoption of social policies, and it offers an analytical
framework to understand the governance, political and institu-
tional dimensions of scaling up nutrition efforts in other parts of
the world.
Funding disclaimer
The Analysis of success in ghting nutrition in Peru was com-
missioned by CARE Peru. The funders did not have a role in the
analysis and interpretation of data, but have given feedback to
the report at several stages of writing. Care Peru has authorized
the decision to submit the article for publication.
Acknowledgements
Linnet Taylor provided invaluable research assistance. We wish
to thank and acknowledge the support of the staff at CARE, espe-
cially Jay Goulden, Carlos Rojas, Walter Vilchez and Fiorella Onee-
glio without whom this work would have not been made possible.
We would also like to thank the 2 anonymous referees for their
valuable comments and suggestions. All omissions and errors are
ours.
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