Learning from Perú: Why a macroeconomic star failed tragically and unequally on Covid-19 outcomes

Peru’s macroeconomic success and moderate health security rating paradoxically combined with amongst the highest levels of reported COVID-19 mortality globally, and significant inequality in pandemic health outcomes. A thematic analysis of evidence from desk review of online publications and databases was used to examine determinants of this outcome for national and global policy dialogue on pandemic preparedness, prevention and protection. The paradox relates to a concentration of risk and vulnerability in low income, urban households, associated with differentials in social conditions, and in a failure to address deficits in primary care and community systems, or in social protection of vulnerable households. Deeper causes in the political economy, state-society relations and the interests driving policy choices underlie the inequity in the immediate drivers. Neoliberal policy choices generated socio-economic insecurity and informality, which with state underinvestment in social protection and primary health care during early pandemic waves generated a society with elevated risk, disaffected by the state and surviving largely outside formal rule systems. Pandemic responses need to connect with such realities, invest in social conditions and local health systems, (re)connect people to public services and social protection, and regenerate public trust to tackle drivers of and prevent excessive, inequitable pandemic-related mortality.