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How COVID-19 is tragically exposing systemic vulnerabilities in Peru

Despite early assessments that Peru was faring well in the COVID-19 pandemic and that its preparedness was due to its strict application of austerity and reforms over the last 30 years, these quickly turned out to be tragically premature as the country emerged over the summer as one of the worst impacted globally in terms of confirmed deaths per capita. While much of the blame has been focused on people’s behaviour, the crisis ultimately points to deep overlapping structural inequalities within the social protection, employment, and health systems, which austerity and reform have not resolved and in some cases worsened.

COVID testing in Peru
COVID-19 testing in Peru. Credit: Ministerio de Defensa del Perú on Flickr.

Precocious optimism followed by demise

Peru was one of the first countries to adopt strict measures to cope with COVID-19 in Latin America. A week after the first COVID-19 case was reported on 6 March, the country closed its borders on 13 March and declared a mandatory immobilization, allowing the population to go out only for acquiring essential services. At the same time, it launched an economic plan equivalent to 12% of the GDP, considered by experts as unprecedented – the greatest economic stimulus in Latin America against COVID-19. The plan included cash transfers for the vulnerable population, subsidies for services and salaries, food provisioning, financial aid for companies, and a large budget allocation for the health system, among other measures.

The current Minister of Economy and Finance, Maria Antonieta Alva, argued that the last 30 years of good fiscal behaviour – as a result of the strict application of austerity measures – allowed the country to face this health and economic crisis. These statements and international news coverage created a positive narrative that seemed to vindicate the country’s economic and social policies in recent decades. Even as recently as 21 July, an article in the Financial Times presented Peru as better prepared for the crisis compared to other countries in the region that were in worse fiscal and macroeconomic positions, such as neighbouring Ecuador.

However, this congratulatory assessment was tragically premature, as has now become evident. As of 24 August, Peru has the highest number of confirmed COVID-19 deaths per capita in Latin America and second only to Belgium globally (and soon to overtake), at 842 per million people, versus 542 for Brazil or 468 for Mexico. It also has the sixth largest number of confirmed cases in the world, with 600,438 confirmed cases. Per capita, it has slightly more confirmed cases than Brazil and more than four times than Mexico.

After initially controlling a sharp spike in cases in late May, daily confirmed cases first plateaued at between 3,000 to 4,000 per day, and after removing the nationwide quarantine on 30 June, they again surged since the beginning of August to surpass the peak levels reported in May (see Figure 1). Confirmed deaths have been running at about 200 deaths a day since July after a peak of about 300 a day in June (see Figure 2).1

Confirmed daily new COVID-19 cases, Peru
Figure 1: Confirmed daily new cases, Peru
Confirmed daily COVID-19 deaths, Peru
Figure 2: Confirmed daily deaths, Peru

Source of both figures: (last accessed 24 August 2020).

The dire comparison with its neighbours is partly due to a much higher level of testing (besides Chile), which is also reflective of at least one aspect of greater capacity in the health system (and it also underscores the certain underestimation of the severity of the crisis in Mexico and Ecuador). However, this statistic is also problematic because the Peruvian numbers include both PCR as well as serology tests, with the large majority being serological, whereas other countries only include PCR tests. As a result, the numbers are not comparable, although this being said, Peru’s positivity rate is also one of the highest in the world, meaning that far more testing is needed relative to the current prevalence of infection.2

Proximate explanations of failure: mobility and behaviour

The lack of success in controlling the pandemic was partially due to an inability to restrict peoples’ mobility despite the lockdown, which has been widely reported in media and noted by commentators. This became more evident following the initial 15-day quarantine period, even despite the extension of this initial period. As in many parts of the world, migrant workers in places such as the capital city of Lima began returning to their places of origin by foot. Specialists also noted that the lack of refrigerators in households and the habit of buying fresh products caused people to go out to markets frequently. Social protection measures to help vulnerable people ironically made this situation worse. For instance, a monetary grant of 760 soles (about 214 USD) was one of the measures intended to help people without a formal income and who lost their job because of COVID-19. However, the payment of the grant caused people to crowd in the banks. Indeed, markets and banks became the main hot spots of infection.

As a result, many experts claimed that people’s behaviour was the main factor that undermined the COVID-19 response, that lack of education about health care and respect for rules was aggravating the spread of the virus, especially among poor people. However, the discussion generally revolves around proximate reasons rather than highlighting fundamental structural inequalities that in fact point back to the legacy of social and economic policies over the last 30 years.

More fundamental structural reasons

Although the COVID-19 response at first seemed to be strong and promising, it actually quickly exposed the deep and overlapping structural problems within the social protection system, the employment structure, and the health system, which 30 years of reform did not resolve and in some cases worsened.

One crucial problem, as noted above, is the high degree of informality, which is estimated at 72.5% of the economically active population (16.511 million people), with no access to any formal social security. Poverty was estimated at about one-fifth of the national population in 2018, based on a money-metric poverty line of 344 soles (roughly 98 USD) per person per month (the extreme poverty line was 183 soles). This means that about half of employed people were informal but not considered poor by this metric, even though they might have been just above the poverty line.

Moreover, only a fraction of those deemed poor receive assistance. For instance, before the lockdown, only about 725,000 households were affiliated with the main cash transfer programme (Juntos), or less than 9% of households in the general household register that is used for poverty targeting. Those uncovered and working informally become part of the ‘missing middle’ given that they are also not covered by any social protection.

As noted above, the government has created different monetary subsidies and adapted the existing cash transfer programmes to address the vulnerability of these uncovered populations. As of 21 August, these have been extended in principle to more than 8.5 million households, with transfer values from 160 soles to 760 soles (it is unclear whether these are monthly or one-off payments). However, the government has not yet completed paying many of these households and for many it would amount to only one transfer within the six-month period from March to August. Beyond such limited support and facing unemployment with little or no savings, adhering to mobility restrictions were quite simply unrealistic or impossible for a large majority of the population.

In addition, although Peru is in a better fiscal or financial position compared to other Latin American countries, this position was achieved by austerity and reforms that have undermined the public health system. Health specialists have noted the lack of historical investment in this system, as well as fragmentation and inequality, all of which have hampered the COVID-19 response effectiveness.3

Austerity clearly contributed to critical deficiencies in terms of infrastructure, human resources and medical supplies, and also constrained the composition of health spending, producing inefficient combinations of spending and thus impacting negatively on the implementation of services. For instance, Peru has a higher number of beds per capita compared with Ecuador and Mexico, but a lower number of doctors (see here). The distribution has also been historically uneven among the regions.4

Acknowledging this situation, the lockdown helped the government to gain time to increase the supply of beds, intensive care units, personal protective equipment, health staff, and to improve the infrastructure and also allocate financial resources to the sector. It has also generated alliances between the different health subsystems (public and private) to improve the availability of beds and intensive care units.

Despite the efforts, the number of cases exceeds the capacity of hospitals, the number of health personnel is insufficient, and there is a scarcity of essential supplies. Health professionals and local authorities have recently reported the collapse of the health system in different regions including Loreto, Piura, Lambayeque, Ucayali, Ica, Lima, Huánuco and Arequipa due to lack of human resources and key medical supplies, including scarcity of medicinal oxygen.5

Realities exposed

In sum, COVID-19 has exposed a reality that is distant from what the government and the international news media celebrated at the beginning of the pandemic. In a short period of time, Peru went from being heralded as better prepared to having the world’s worst performance in coping with the crisis. This has been in large part because of deep structural inequalities in Peruvian society, exacerbated by the high cost of austere policy choices that, despite producing strong economic performance according to conventional measures, did not solve the most pressing social problems of the last decades and exacerbated the crisis.

COVID-19 exposed an illusion. A political commitment to redefine the last 30 years of policies is required, alongside an allocation and distribution of resources to make it happen.

About the authors:

Kattia Talla CornejoKattia Liz Talla Cornejo lives in Lima, Peru. She has been working as a consultant monitoring a health project aimed at strengthening the COVID-19 response in Ancash, one of the Peruvian regions most impacted by the pandemic. This allows her to observe the critical situation of the health system and the COVID-19 response from the inside. She holds an MA in Development Studies from ISS with a major in Social Policy, and degree in Economics and International Business. She has experience in public finance, policy advocacy and monitoring within the fields of social policy, health and childhood, and has worked in governmental and non-governmental organizations in Peru.

Andrew FischerAndrew M. Fischer is Associate Professor of Social Policy and Development Studies at the ISS and the Scientific Director of CERES, The Dutch Research School for International Development. His latest book, Poverty as Ideology (Zed, 2018), was awarded the International Studies in Poverty Prize by the Comparative Research Programme on Poverty (CROP) and Zed Books and, as part of the award, is now fully open access ( Since 2015, he has been leading a European Research Council Starting Grant on the political economy of externally financing social policy in developing countries. He has been known to tweet @AndrewM_Fischer

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COVID-19: Should Europe embrace frugality?

The Covid-19 pandemic, emerging in the aftermath of the recent global financial crisis, could potentially further shake the confidence that Europeans have in their institutions. Rigid and slow decision-making processes and an excessive institutional reliance on super-specialisation and protocol-driven scientific evidence can at least partly explain why Europe finds it so difficult to predict disruptions and why it adapts its institutional machineries so slowly. Greater flexibility, including space for experimentation and improvisation, can help Europe to adapt more quickly to future contingencies, write Saradindu Bhaduri and Peter Knorringa.

Drawing of doctors wearing masks

Europe has offered a historically unprecedented degree of stability, prosperity, comfort and reliability to most of its citizens in recent decades. Many of its citizens have grown to take these benefits for granted, even when all this makes Europe a very high-cost economic system. Two recent disruptions, the earlier financial crisis and the Covid-19 pandemic, are unprecedented in the history of Europe, at least since World War II. The pandemic has caused more than 150,000 deaths so far, with a mortality rate in Europe far exceeding that of countries outside the continent. Potentially, these two events could shake the faith of people in the institutional mechanisms of the continent developed brick by brick over the last half a century, especially if such disruptions are expected to recur more frequently in the future.

Understanding the European system

Few would disagree that the present European production and innovation system, inter-country variations notwithstanding, relies extensively on the super-specialisation of work and an overwhelming reliance on strongly protocolised ‘hard scientific evidence’. Together, they are supposed to uphold quality and transparency in economic decision making, even at the cost of being expensive and sticky, i.e. slow in its ability to adapt to changing circumstances. While specialisation and protocols are in themselves indispensable and desirable elements in a modern economy, too much of it creates its own challenges.

In this blog we argue that the excessive institutional reliance on super-specialisation and protocol-driven scientific evidence in all its decision-making processes can, at least partly, explain why Europe finds it so difficult to predict disruptions and is not able to quickly adapt its institutional machineries in the face of a crisis1. A remedy in our view lies in reducing over-formalisation in its decision-making processes and creating more space for experimentation and judicious improvisation. These steps can help Europe to adapt quicker to future contingencies2.

A discourse which has begun highlighting the importance of such experimentations and judicious improvisations is the one on frugality and frugal innovations. They suggest ways to re-introduce such experimentations and improvisations in innovation processes to reduce ‘over-engineering’ and costs while maintaining basic functionality and affordability3. A concurrently emerging discourse on frugality in policy making emphasises the need for improvised decision making based on seasoned, practical, context-specific experience and the importance of ‘experimenting while deciding’4.

Does Covid-19 challenge protocolised hard evidence-driven decision-making?

Indeed, the pandemic struck, and struck hard while the system often continued to wait for a ‘formal go-ahead’ informed by ‘hard evidence’ to be gathered by ‘super-specialised’ actors and processes, to take policy decisions on (i) whether to test ‘asymptomatic patients’, (ii) whether ‘to wear a mask’, (iii) whether it is okay ‘to use hydroxychloroquine’, or (iv) whether ‘to impose a lockdown’. Waiting for ‘hard evidence’ has often been given a priority over also making clever use of readily available ‘soft evidence’ by seasoned practitioners, presumably also not to disturb the comfort of its citizens 5,6,7,8. Moreover, this denial to act upon soft evidence is not specific to the context of the current pandemic; it is rather the routine. Incidentally, later more systematic studies seem to validate the soft evidence of wearing masks, and practising social distance9.

Is the system adapting?

Going beyond ‘super-specialised actors?’

While Europe initially responded slowly to the arrival of Covid-19, we do now observe quite a few deviations from the routine reliance on ‘super-specialisation’ and formal protocols surrounding innovation, production, and validation. Such improvisations are particularly visible in products and services related to public health deliveries, arguably to ensure their timely and affordable access at the time of the pandemic. Examples include the open-source development of a ventilator, where so-called lay persons can also contribute and participate. Similarly, many informal organisations have sprung up across the continent to produce open-source medical equipment and protection gear for patients and healthcare workers10. These organisations are not taking the routine protocolised path of regulatory approval. Instead, in order to ensure timely affordable access, they are relying on the viewpoints of physicians and clinical administrators on ‘whether it works’ in the ‘actual’ environment of their use11.

Going beyond ‘protocolised’ hard evidence?

A sizeable section of physicians and clinical researchers of repute have vouched for including hydroxychloroquine (HCQ) in the treatment protocol of Covid-19 based, once again, only on soft evidence of clinical acumen, ‘prudent observations’, and targeted, non-randomised, small-sample clinical studies121314. While the opposition to rely on such soft evidence may be rational, the issue remains that we need fast decisions and therapies to deal with the pandemic, and ‘hard evidence’ of randomised controlled trials does not come fast, nor do they come cheap. Indeed, more than four months into the pandemic, we have conflicting evidence of its (non-) efficacy for advanced-stage treatment. While the WHO has stopped its randomised controlled clinical trial (RCT) citing ‘no benefit’[20], a recent ‘retrospective study’ by the Henry Ford Health System reports significant benefits.[21] For early-stage treatment or as a prophylactic, we are still guided by softer evidence of ‘clinical observations’ and ‘retrospective studies’15.

The evidence of low rates of mortality in places and countries using this therapy have triggered a diverse set of responses from scientists, politicians, and regulatory authorities16,17. Some of them have rejected it outright due to non-availability of ‘gold standard’ evidence from RCTs. Other responses have ranged from agreeing to conduct more elaborate studies (RCTs or otherwise), to continuing with the therapy based on ‘prudent clinical acumen’. Indeed, an emerging view in this context invites us to explore ‘doing while learning’ by integrating the urge of clinical practitioners to use untested therapies, while designing, if necessary, full-fledged protocolised clinical trials to evaluate efficacy of the therapy better18. These propositions challenge the sharp division of super-specialisations between clinical research and clinical practice: “clinical practice and clinical research are addressed by separate institutions, procedures, and funding”19. The crisis has underlined the necessity to adapt this structure.

So, is a new pattern emerging?

Many of the presently successful experiments can be defined as frugal innovations: they are affordable, retain basic functionalities, and are developed through extensive polycentric interactions, involving super-specialised experts as well as seasoned lay practitioners. Similarly, in line with the arguments of the frugality discourse in policy making, decisions are being made by localised, practical experiences of people in the field, focusing more on ‘what works’ rather than ‘what ought to work’, to ensure faster access to protective gear, medical equipment, as well as medicine therapies. Such a process of decision making arguably gives priority to arriving at ‘good-enough’, faster decisions, rather than waiting for a zero-error solution. Of course, we need to be careful here; most of these experiments show that results are contextual, local in their scope and feasibility, and difficult to scale up.

Still, an exclusive reliance on super-specialisation and protocols would hold fort only in an environment where lives and livelihoods are stable, prosperous, comfortable, and reliable. But now that the illusion of a zero-risk and fully controllable society is fading, we propose a more nuanced future orientation that creates space for experimentation and improvisation based on localised knowledges. Recent EU efforts to pay more attention to citizen science and frugal innovation, for example in a Horizon 2020 call, are promising stepping stones in this direction, i.e. to develop rigorous science that is also built on the bottom-up knowledge, practices, and the creativity of EU citizens. This will help make the society more resilient to future contingencies.

1. See for an elaborated account of Europe’s early response to COVID -19 ‘Coronavirus Europe failed the test’, Politico.Last accessed on 1 June 2020.
2. See ‘Better luck next time? How the EU can move faster when disaster strikes’,Sciencebusiness
Last accessed on 10 June 2020.
3. Knorringa, P., Peša, I., Leliveld, A. et al. Frugal Innovation and Development: Aides or Adversaries?. Eur J Dev Res 28, 143–153 (2016). . Last accessed on 1 June 2020.
4. Patil, K., Bhaduri, S. ‘Zero-error’ versus ‘good-enough’: towards a ‘frugality’ narrative for defence procurement policy. Mind Soc 19, 43–59 (2020). Last accessed on 1 June 2020.
5. ‘Italy, Pandemic’s New Epicenter, Has Lessons for the World’, New York TImes, especially the section on local experiments. Last accessed on 1 June 2020.
6. ‘Report on face masks’ effectiveness for Covid-19 divides scientists’, The Guardian Last accessed on 6 June 2020.
7. ‘In one Italian town, we showed mass testing could eradicate the coronavirus’, The Guardian Last accessed on 6 June 2020.
8. ‘Up to 30% of coronavirus cases asymptomatic’, DW Last accessed on 6 June 2020.
9. ‘Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis’  Last accessed on 6 June 2020.
10. Digital Response to COVID-19Last accessed on 3 June 2020.
11. ‘Open-Source Medical Hardware: What You Should Know and What You Can Do’, Creative Commons
12. ‘Hydroxychloroquine for COVID-19: What’s the Evidence?’, Medscape Last accessed on 1 June 2020.
13. ‘Hydroxychloroquine prophylaxis for high-risk COVID-19 contacts in India: a prudent approach, The Lancet’. Last accessed on 1 June 2020.
14. See ‘He Was a Science Star. Then He Promoted a Questionable Cure for Covid-19’, The New York TimesLast accessed on 1 June 2020.
15. ‘Preventive use of HCQ in frontline healthcare workers: ICMR study’, The Indian ExpressLast accessed on 10 June 2020.
16. ‘A Look at COVID Mortality in Paris, Marseille, New York and Montreal’,
Last accessed on 10 June 2020.
17. ‘Coronavirus: How Turkey took control of Covid-19 emergency,’ BBC. Last accessed on 10 June 2020.
18. ‘Chloroquine and hydroxychloroquine in covid-19′, the BMJ. Last accessed on 1 June 2020.
19. ‘Optimizing the Trade-off Between Learning and Doing in a Pandemic’, JAMA network. Last accessed on 1 June 2020.



This article was originally published by the Centre for Frugal Innovation in Africa (CFIA). This article is part of a series about the coronavirus crisis. Read all articles of this series here.

Saradindu BhaduriSaradindu Bhaduri held the Prince Claus Chair in Frugal Innovation for Development and Equity (2015-17) at ISS (EUR). He is Associate Professor at the Centre for Studies in Science Policy, at JNU New Delhi, and the Coordinator of the proposed JNU-CFIA Transdisciplinary Research Cluster on Frugality Studies.Saradindu Bhaduri

Peter Knorringa is a Professor of Private Sector & Development at the International Institute of Social Studies (ISS) at Erasmus University Rotterdam. Since 2013, Professor Knorringa is the academic director of the Centre for Frugal Innovation in Africa (CFIA).

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