Infant Mortality and Social Context

Roelfien Haak; Héctor Bejar
CEDEP

Mortality of children in Latin American is not isolated from the economic and social context of the region. In fact, infant mortality is a result of the living conditions experienced by a majority of the population.

Latin America is currently undergoing the implementation of so–called "structural adjustment", a type of program recommended to the countries’ governments by international financial organizations as a condition for receiving loans. Gaining control of inflation, a primary objective of structural adjustment, is indeed positive and necessary. In itself, however, structural adjustment cannot guarantee that control of inflation can be sustained, nor does it put Latin American societies on the road to being less discriminatory and exclusionary than they already are.

Latin American productive employment has still not managed to move out of recession, with 2% GDP growth continuing to be less than the 3% growth of its economically active population. Unemployment has moved above 7% throughout the region, and under–employment continues to grow steadily. With 15 million new "jobs" in the region from 1993 through 1995, 13 million are in the informal sector. In Latin America, this is a form of survival at the most basic level of existence. Poverty is growing. It is increasingly affecting the middle classes; it is primarily threatening women; it is seriously affecting the well–being of the children of Latin America.

This regional reality is dramatic in Peru. Despite the publication of official figures showing spectacular growth of the gross national product as compared to 1990, when viewed from a longer historical perspective, the country is at 1984 production levels in real terms. Peru has paid a high social cost for a result that is still insufficient and precarious. Social inequities have worsened and wealth has become more concentrated, with Peruvian and multinational companies capturing 42% of the national income in 1994.

Consequent to the structural adjustment programs, poverty is now a mass phenomenon in Peru. Though official figures speak of an encouraging decrease in poverty in specific areas, at the current pace it would take hundreds of years for the social phenomenon of increasing poverty to disappear. While 60% of the population already lives in extreme poverty, underemployment continues to expand. At the present time, almost 80% of the economically active population is experiencing increasing poverty.

The government’s acknowledgment of the detrimental social consequences of its structural adjustment program has been slow and insufficient. Payment of the foreign debt continues to command the majority of public funds. While special funds to fight poverty, particularly FONCODES, have been growing, these funds are allocated primarily for the development of infrastructure. The average spending for essential basic services continues to be low and flagging, as measured against population growth and the unmet needs of the people, especially in health and education. Funds which are available are allocated in a centralized and undemocratic manner, without real participation of local governments and communities. In the best of circumstances, local recipients are put in the role of applicants and beneficiaries; they are not actors and decision–makers.

Following is data which supports these assertions.

Deceleration of GDP Growth in Latin America and the Caribbean

Latin America’s economic growth has been decelerating and continues to be less than would be necessary to recoup the preceding "lost decade" of the l980s. The International Labor Organization has defined 1995 in Latin America as "a year of fragile economies with setbacks in employment".¹

The vulnerable economic recovery that began to control inflation through so–called structural adjustment has been interrupted.

Further adjustments had to be made to deal with the volatility of short–term capital fostered, in part, by those same programs.

Product growth has fallen off and is now in the area of 1.5% to 2.%. This is approximately half the average recorded in the 1990–1994 period and lower than the growth of the economically active population, which is in excess of 3% per year.

Graphic 1. Latin American GDP

ILO. Official Statistics

Growth of EAP Exceeds GDP Growth

The growth in employment has been less than the expansion of the non–farm economically active population, which was 3.3% per year during the 1990–1995 period. Outpacing growth in employment, this has generated a continuing employment gap. The increase in open unemployment averages 6.4% in 1994; the increase in underemployment and the informal sector is shown in other charts.

Graphic 2.EAP in Latin American

ILO. Based on household surveys.

New Jobs are in Low Productivity Categories and Provide Low Income

An insufficient number of new jobs have been created in Latin America. This has been caused by economic policies which discourage production and favor the decline of local industrial initiatives.

The jobs which have been created are, for the most part, low in productivity and low in income generation. The correlation is the expansion of the informal economic sector. Out of every 100 new jobs, 94 are in the informal sector, accounting for 57% of the persons with jobs in the region.

As a result, while it is true that inflation fell from 73% to 18% in 1995, real income has decreased by –2.4% in the region as a whole.²

Graphic 3. Latin American new jobs

Source: ILO

Social Inequity in the Distribution of National Income

The distribution of national income in Peru is one of the most uneven in Latin America. While company income represented 42% of national income in 1994, worker income from wages amounted to only 19%. The chart shows that this practice has continued through recent years (see Graphic 4).

Poverty Affects the Majority of the Peruvian Population

As a result of unequal distribution of national income, aggravated by the structural adjustment program currently underway, a majority of the Peruvian people are poor. According to 1994 official figures, 63.5% of the population lives in poverty conditions, with 17.7% being extremely poor.³ In spite of this, official figures describe a relative decrease in poverty. These figures, in part, reflect changes which have been made in the criteria and methods for measuring poverty and extreme poverty (see Graphic 5).

Graphic 4. Distribution of national income. 1992-1994 period.

Sources: INEI, BCR, GRUPO PROPUESTA

Graphic 5.Evolution of poverty in Peru. 1990-1994 period.

Source: ENNIV, FONCODES

Massive Underrmployement

The massive layoffs caused by the structural adjustment programs, coupled with an insufficient and diminishing supply of jobs in private industry, have resulted in increasing under–employment. In 1995, almost 80% of the economically active population made an income well under the minimum living wage.⁴ This trend toward massive un– and under–employment has been advancing since the start of the 1990 structural adjustment program (Graphic 6).

Graphic 6. Unemployment and underemployement. 1992-1995 period.

Sources: INEIV, BCR

Graphic 7.Types of spending in Peru (As percentage of GDP)

Source: BCR/Prepared by: Eduardo O´Brien.

Social Spending in Peru’s 1996 Budget

The public spending budget totals 22,898 million Peruvian soles, equivalent to US $9,955 million. This is a contraction in real terms of 6% compared to the previous year. Earmarked for the social sector is 8,160,460 thousand soles (U.S. $3,556,721). In relative terms, this is 35.7% of total public spending. This sum includes bureaucratic remunerations and infrastructure costs.

Budget allocations for payment of the foreign debt continues to exceed social spending, currently totalling 48.3% of the federal budget.⁵

Graphic 8. Concentrated budget execution. Percentage structure by sector.

Peru´s Budget 1995-1996

Concentration in the Ministry of the Presidency

The power for budget allocation is concentrated in the Ministry of the Presidency. This makes the 1996 budget even more critical.

In 1996, this Ministry accounts for 23% of central government resources –more than double its percentage in 1995. The high proportion of resources concentrated in the Ministry of the Economy is explained by the fact that foreign debt payments are made by that Ministry.

Social Spending Deaggregated for Bureaucracy and Infraestructure

Official Peruvian government figures show a considerable increase in social spending in the General Budget for the Republic.

Nevertheless, it should be taken into account that:

1. The official definition of social spending is extremely broad, including all expenses of the Judiciary and of the Ministry of Labor, Education (including higher education, which is not accessed by the poorest) and Health, plus expenditures for special programs to alleviate poverty.

2. Specific programs geared to poverty alleviation have grown since 1990, but they have done so at the expense of education and health, which have not grown significantly.

3. In 1995, no less than 70% of poverty program spending was allocated to bureaucratic support and the financing of infrastructure development. Basic services remained at their low traditional averages (see Graphic 9).

Infant Mortality Trends in Peru

The infant mortality rate in Peru is the third highest in the region after Bolivia and Haiti. The 1994 rate was estimated to be 52 per one thousand live births. This means 34,000 deaths per year of infants under one year of age.

At the outset of this decade, reduction of infant mortality was one of the goals which moved civil society and the state to undertake significant joint action at both national and international levels.

The Declaration of the World Summit for Children held at United Nations headquarters on September 30, 1990 sealed these agreements with commitments for targets to be reached between 1990 and the year 2000. One of these targets is the reduction of the mortality rate for children under one year of age (IMR) and children under five years of age by one–third—cutting the figures to 50 and 70 per 1000 live births, respectively.

Peru signed this agreement and each year holds "Children’s Week" to follow up on the achievement of the goals set forth in the National Action Plan for Children.

The infant mortality rate has been reduced by 50% nationally over the past 20 years, with a 1993 estimate of 58.3 per thousand live births. This trend, however, which on the whole continues to be high, is not evenly distributed over the entire country.

In 1993 the risk of dying during the first year of life was more than double in rural areas as compared to urban areas. The IMRs by department or province reveal that while Callao had a rate of 21, in Cusco, Puno and Huancavelica the average varied from 82 to 96 per thousand live births. This unequal dispersion of infant mortality rates is not reflected in the national averages.

Moreover, the behavior of these indicators showing health improvements was not the same over time in the country’s different population centers. The difference between the provinces and the national average during the 1972–81 decade was much lower than that found for 1981–93.⁶

The more significant differences in the health status of extreme population groups, i.e., the broadening of epidemiological gaps, show that the national indicators fail to express a heterogeneous health reality. Three health indicators have improved in the long term: the infant mortality rate, the fertility rate, and life expectancy.

Nevertheless, health indicators expressed as national averages mask the enormous differences existing within the country. Various factors have been involved in the reduction of infant mortality in Peru over the past decades, including a drop in fertility, an increase in women’s education, mass communications, migration to urban areas where the supply of health institutions and professionals is greater, and an increase in access to health services.

Graphic 9.Operation, bureaucracy and infrastructure, percentages for total of each sector in 1995 public spending.

Preparation: Eduardo O´Brien

The Causes of Infant Mortality

Being a child was risky in Peru in 1994.

* Deaths of infants under 1 year of age were caused by perinatal origin, acute respiratory infections, diarrheic illnesses, nutritional deficiencies, and congenital anomalies.
* Deficient pre–natal care and inadequate care in deliveries caused perinatal problems such as low birth weight, which is estimated at 8.8% nationally.
* Recently the incidence of immuno–preventible diseases has dropped significantly, due to the high immunization coverages attained.
* In the 1–4 years of age group, acute respiratory infection (ARI) (6 to 12 episodes per year, first cause for consultation, pneumonia chief cause of death) and diarrheic illness were the chief causes of illness and death.
* Caloric–protein malnutrition constitutes an important cause of death and disability in this group and is projected to the 6–9 years of age group, where chronic malnutrition affects 48% of the population. Anemia due to iron deficiency affects 20% of children. Among the chief determinants of malnutrition are: short duration of lactation, food insecurity of poor families, maternal illiteracy, lack of nutrition education, and high prevalence of diarrhea and ARI.

It is important to note the changes that have taken place in this situation over the last 20 years.⁷

Primary causes of mortality in children under five years of age:

* diarrheic diseases
* respiratory illnesses
* illnesses associated with prenatal period
* severe malnutrition

Primary causes of mortality in children under one year of age:

* immuno–preventible diseases
* diarrheic diseases
* respiratory illnesses

The reduction in the mortality rate was accompanied by modifications in the structure of causes. Among the latter was the effect of broadening immunization coverages, supported by a program organized by the government, international cooperation organizations and grassroots social organizations, in particular omen organized by neighborhood and through collective survival endeavors ("Glass of Milk" Committees, Mothers Clubs, people’s kitchens) and NGOs.

Among children under five years of age, mortality causes linked to poverty become more acute, particularly nutritional insecurity and low provision of mother–child care.

Mother and Child Health

* Being a mother is a health risk.
* 50% of the female population are women in the fertile age group (15–49).
* The maternal mortality rate in 1991 was 261 per 100,000 live births.
* Approximately 15% of maternal deaths are of adolescent mothers, among whom there is also 20% of deaths due to abortion.
* 65% of expectant mothers receiving prenatal care have not had any tetanus vaccine.

IMF Comments on Peruvian Social Policy

In 1994, the technical assistance mission of the Public Finance Department of the International Monetary Fund prepared a diagnosis of poverty situation, public policies and public spending management in Peru, in response to a request made by the President of the Republic. The mission indicated, among other things, that:

* the data on budget execution are very poor;
* there is a need to improve the quality of education services, as well as to improve access to same by the poor;
* in health and nutrition there is considerable duplication of functions among the different agencies of the central government, non–governmental organizations and regional and municipal governments in the provision of health services and nutrition programs. Despite this, the coverage of same is still very limited;
* the nutrition programs do not cover the most vulnerable and highest risk groups;
* most of the food assistance programs do not reach the most needy groups;
* the extreme budgetary weakness of the line ministries contrasts with the strength and power of the ministry of the Presidency?⁸

The Role of Multilateral Agencies

Multilateral finance agencies promote, support and finance the economic structural adjustment program currently underway and try to downplay its negative social effects by financing special and focused programs to combat extreme poverty. The real effect of these programs is still very much open to debate, since no assessment of their impact has yet been made.

On the other hand, non–financial technical multilateral agencies, such as the UNDP, ILO or UNICEF, maintain different viewpoints, but their role is far from decisive.

"It is very clear, even from a superficial examination of social policy in Peru, that agencies like the World Bank, IFM and IDB play an important role in the formulation of those policies," indicates the specialist Rosemary Thorp, who made an assessment of Peruvian socio–economic reform.

"There are some problems, however, with this dependence on multilateral agencies. One is that policy making may become passive and dependent on the recommendations of foreign agencies. Another is the creation of external islands within the line ministries, not entirely under ministerial control and with higher salaries than the majority of ministry employees. There is also the possibility of a lack of coordination among the agencies themselves and duplication of efforts, as well as application of contradictory policies...

... Although the resources provided by multilaterals may very well be necessary at the initial stages of the reform process, there is a limit as to how far or how much it is desirable for Peru to increase its level of external indebtedness with loans for social development.

... We have frequently emphasized ... the weakness of the Peruvian State and society. But there are also strengths. There is a broad network of community and local organizations that represents a powerful potential force in a coordinated strategy. There are also growing signs of the potential for cooperation with the private sector. Such coordination and cooperation can only be achieved if the central government acknowledges the strength of those organizations and of NGOs, and consciously involves them in a comprehensive national effort."?⁹

Participation of Civil Society

In Peru there are no formal or institutionalized linkages between government agencies and civil society organizations. Efforts along this line are isolated or exceptional. Grassroots or citizen orgnizations have no participation in the on–going designing of policy, its definition or application, and the government fails to take advantage of their rich and varied experiences. Decision–making and monetary resources are centralized in the ministry of the Presidency.

The Inter–sectorial Commission on Social Affairs has had a very secondary and almost nonexistent role. This Commission has a Technical Secretariat whose basic work has been the Plan for Improved Social Spending or the focusing of such spending on pockets of extreme poverty. Civil society organizations do not have any type or representation on this Commission.

TABLES

1 ENDES II.1991–92, INEI, page 89.
2 1993 National Census, INEI.
3 CUANTO, Perú en Números 95. Projected rate, page 240, August 1995, Lima, Peru.

Source: UNICEF - Estado Mundial de la Infancia, 1992 and 1995, taken from Estadísticas para América Latina y el Caribe. UNICEF, Regional Office for Latin America and the Caribbean. May 1995.
* 1993 National Census, INEI, Peru.

Source: Social Investment Map, FONCODES - UNICEF, 1994: En. page 23.

Source: Statistics for Latin America and the Caribbean, UNICEF, Regional Office. May 1995, page 24. Preparation: FOVIDA, January 1996.
* The three highest and three lowest maternal mortality rates in Latin America and the Caribbean.

Notes:

Charts prepared by Eduardo O'Brien.
1 ILO. Panorama laboral 1995, Avance del panorama laboral de 1995, primer semestre.

2 Ibid.

3 Encuesta Nacional de Niveles de Vida, ENNIV 1994.

4 National Statistics Institute, Central Bank.

5 O’BRIEN Eduardo and SIERRA Juan. Análisis y alternativas del gasto social para 1996. Grupo PROPUESTA.

6 Lineamientos de Política de Salud 1995–2000: Un sector Salud con equidad, eficacia y calidad. Ministerio de Salud. December 1995. Lima, Peru.

7 Tavera, Mario: "La mortalidad infantil, estructura, tendencias e implicaciones para la situación de salud", paper presented at the Seminar on Infant Mortality in Peru and analysis of the health situation. INEI, MINSA, UNICEF. September 1994.

8 AHMAD Ehtisman et al. Peru: pobreza, politicas publicas y gestión del gasto publico (Aide memoir). Department of Public Finance of the International Monetary Fund. April 1994.

9 THORP, Rosemary et al. Challenges for Peace. Towards Sustainable Social Development in Peru. Report of the Pilot Mission on Socio–Economic Reform of the Inter–American Development Bank. Social Agenda Policy Group, April 1995.