A Tale of Two Crashes: Pandemic Politics in Brazil and Peru

Abstract

Health care system preparedness did not correlate consistently with policy performance during the COVID-19 pandemic. In Brazil and Peru, the preparedness of health care systems was inversely related to the perceived political risks associated with the spread of COVID-19. Lack of preparedness of the Peruvian health care system heightened fears of a system crash and thus encouraged a more stringent initial response by President Martín Vizcarra, the political actor both most accountable and able to act. In Brazil, the combination of a robust health care system and the highly fragmented political system enabled President Jair Bolsonaro to politicize the pandemic and prioritize economic growth while blaming his opponents for what he considered excessively costly public health measures.

La preparación del sistema de atención de salud no se correlacionó de manera consistente con el desempeño de las políticas durante la pandemia de COVID-19. En Brasil y Perú, la preparación del sistema de salud estaba inversamente relacionada con los riesgos políticos percibidos asociados a la propagación de COVID-19. La falta de preparación del sistema de salud peruano aumentó los temores de un colapso del sistema de atención médica y, por lo tanto, dio lugar a una respuesta inicial más estricta por parte del presidente Martín Vizcarra, el actor político más responsable y capaz de actuar. En Brasil, la combinación de un sistema de salud robusto y un sistema político altamente fragmentado permitieron que el presidente Jair Bolsonaro politizara la pandemia y priorizara el crecimiento económico mientras culpaba a sus oponentes por lo que consideraba medidas de salud pública excesivamente costosas.

Keywords

COVID-19 Health care systems Brazil Peru Politics

Indicators of health care system preparedness (Global Health Security Index, 2019) did not correlate consistently with policy performance during the COVID-19 pandemic (Abbey et al., 2020; Kaiser, Chen, and Gluckman, 2021), and researchers turned to politics and political institutions to explain variation in pandemic policy performance (Greer et al., 2020; Greer, King, and Massard da Fonseca, 2021: 24–26; Brubacher et al., 2022). In Latin America, the preparedness of health care systems was often inversely related to the perceived political risks associated with the spread of COVID-19. The lack of preparedness heightened fears of a health care system crash and thus encouraged more stringent initial responses. In this article, we analyze the performance of political leadership and institutions in response to the first wave of COVID-19 in two cases, Brazil and Peru. Given that political leadership strategies often depend on opportunities to seek credit or avoid blame (Greer et al., 2022b), we find that politicians who were unable to avoid responsibility for the pandemic response tended to be more vigorous in their approach. In Peru, swift and stringent policies were adopted because the health care system was perceived to be vulnerable and the president, Martín Vizcarra, was the only political actor in a position to respond effectively. In Brazil, the combination of a robust health care system and the highly fragmented political system enabled President Jair Bolsonaro to politicize the pandemic and prioritize economic growth while blaming his opponents for what he considered excessively costly public health measures.

In the following sections, we first introduce our theoretical framework and justify our selection of cases, which was based on our assessment of pandemic politics in the region as a whole. We then analyze the policy responses to the pandemic in Brazil and Peru. To understand the policy process from the perspective of the principal actors, we conducted semistructured interviews with senior bureaucrats and politicians and experts in public health who were consulted by governments.¹ We explore the theoretical implications of our analysis of the cases and conclude that both political institutions and leadership matter, albeit in often unexpected ways.

Explaining Variation in Responses to the Pandemic

Early in the pandemic, it was argued that high levels of pandemic preparedness in health care systems and the strength of the welfare state prior to the spread of the COVID-19 virus would explain variation in responses (Tessema et al., 2021; Giraudy, Niedzwiecki, and Pribble, 2020; Murillo and Quijano, 2020; Garcia et al., 2020; Benitez et al., 2020). At the same time, the literature suggested the importance of political and institutional factors like leadership, political incentives, and perceptions of decisionmakers (Obaid et al., 2020; Moon, 2020; Lee, Huang, and Moon, 2020; Rocha et al., 2021; Can Kavakli, 2020), and centralization of decision-making authority (Ringe, Rennó, and Rovira, 2022; Giraudy, Niedzwiecki, and Pribble, 2020; Riccardo, 2020; Alon, Farrell, and Lee, 2020; Laage-Thomsen and Lund, 2022; Frey, Chen, and Presidente, 2020). It was argued that presidents facing reelection would prioritize speedy economic recovery at the expense of rigorous public health measures (Pulejo and Querubín, 2021; Murillo and Quijano, 2020; Desierto and Koyama, 2020).

We offer a counterintuitive argument. First, preparedness does not always have the expected effect. Presidents in countries with ill-prepared health care systems may respond more vigorously because of a heightened perception of vulnerability. Second, a key political consideration was the opportunity to shirk responsibility and shift blame. Presidents may take less stringent measures when they can elude blame for the pandemic mismanagement while seeking credit for avoiding the negative consequences of stringent health policy measures. Countries with vulnerable health care systems were more likely to implement more stringent and earlier social distancing measures (Table 1). The response is measured using the Stringency Index created by Oxford COVID-19 Government Response Tracker (Hale et al., 2020).² The countries’ performance is measured in terms of deaths during the first year of the pandemic (World Health Organization, 2022). Preparedness is measured using data on investments in public health systems (World Health Organization, 2020), hospital capacities, and social programs (World Bank, 2020). Political conditions are measured with descriptive data.

Table 1

Pandemic Response of Latin American Countries

Country	Response	Performance	Social Welfare Coverage	Health Care Investment	Health CareCapacities		Institutional Design		Electoral Incentives
Country	Stringency Index (10 days after first case)	Cumulative total deaths (per 100,000 population)	% of the population	per capita(US$ PPP)	Nurses(per 1,000 population)	Hospital Beds(per 1,000 population)	Unitary State	Single- Chamber Congress	Presidential Reelection
Argentina	25.0	60,082	31	1,917	9.7	5	No	Yes	Yes
Bolivia	93.5	12,041	8	462	1.6	1.1	Yes	Yes	Yes
Brazil	11.1	290,314	31	1,472	9.7	2.2	No	Yes	Yes
Chile	11.1	22,180	45	2,229	12.1	2.2	Yes	Yes	No
Colombia	50.9	61,771	9	1,039	1.3	1.5	Yes	Yes	No
Costa Rica	63.0	2,896	16	1,237	3.4	1.2	Yes	No	No
Cuba	30.6	414	n.a.	2,486	7.6	5.2	Yes	N.A.	Yes
Dominican Rep.	11.1	3,269	6	986	1.4	1.6	Yes	Yes	No
Ecuador	8.3	16,435	11	959	2.8	1.5	Yes	No	Yes
El Salvador	88.9	1,975	6	583	1.8	1.3	Yes	No	No
Guatemala	93.5	6,685	4	475	0.1	0.6	Yes	No	No
Haiti	75.9	251	0	146	0.7	0.7	Yes	No	No
Honduras	100.0	4,422	3	395	0.7	0.7	Yes	No	Yes
Mexico	2.8	221,165	42	1,036	2.4	15.2	No	Yes	No
Nicaragua	8.3	176	14	506	1.5	0.9	Yes	No	Yes
Panama	59.3	6,035	18	1,795	3.1	2.3	Yes	No	No
Paraguay	74.1	3,662	14	867	0.7	1.3	Yes	Yes	No
Peru	90.7	135,241	12	681	2.2	1.6	Yes	No	No
Uruguay	57.4	760	37	2,102	1.9	2.8	Yes	Yes	No
Venezuela	82.4	1,475	10	141	0.9	0.8	No	No	Yes
Average	51.9	42,562	16.7	1,075.7	3.3	2.5	–	–	–

Latin American countries displayed a wide range of COVID-19 policy responses, from relatively lax social distancing to strict lockdowns with military surveillance. Countries with broader social programs coverage—and, arguably, a legacy of strong social welfare—introduced less stringent responses during the early stages of the pandemic. Countries with higher expenditure per capita and with better hospital and workforce capacities seem to have been more confident in the resilience of their health care systems, while governments in countries with greater deficiencies may have been more constrained by the emergency and prompted to introduce more stringent policies.

Where authority was less centralized—for example, in bicameral congresses and federal systems—less stringent containment measures tended to be adopted. This may be because presidents in unitary and centralized systems have greater capacity to respond in an emergency, but it could also be because presidents in federal systems with more checks and balances can pass responsibility on to the legislature or subnational authorities. In addition, presidents in countries where reelection is allowed implemented more relaxed measures than others. Strong containment measures impose economic costs that may threaten reelection. Therefore a strong and quick reaction in pandemic management at the beginning of the crisis seems to have been informed by long-standing structural and infrastructural pressures that became more salient in the face of a health emergency, but only when there were no opportunities for diffusing political responsibility.

As shown in Table 1, pandemic mismanagement has a heavy cost. Countries such as Brazil, Mexico, and Peru far exceed the Latin American average for deaths caused by the pandemic. Peru is notable, above all, because, in contrast to Brazil and Mexico, the executive decided to introduce strong and rapid responses to the pandemic, but the mortality rates were staggering. Brazil fared worst among the countries that took more lax measures.

Brazil: Denial and Polarization of the Pandemic Response

Under the presidency of Jair Bolsonaro (2019–2022), Brazil became a COVID-19 epicenter. It had a publicly supported, universal, and decentralized health care system with high levels of technical expertise and experience among the staff in the Ministry of Health and a more-than-four-decade-old consolidated national vaccines plan (Fleury and Fava, 2022). Bolsonaro ignored these resources, rejected scientific and technical advice, and appointed a parallel advisory body, which met between February 2020 and March 2021, to provide the alternative advice he wanted. He played down the seriousness of the virus in February and March 2020, defended early-treatment measures not supported by science in May and June of that year, created unnecessary contention over the vaccine rollout from October 2020 to January 2021, and left federal states to manage the pandemic on their own (Greer et al., 2022a). Despite a comparatively high level of preparedness in its health care system, Brazil’s executive refused to accept responsibility for the pandemic response.

From 2003 to 2016, Brazil was governed by Luiz Inácio Lula da Silva and Dilma Rousseff of the Partido dos Trabalhadores (Workers’ Party—PT). The PT pursued equity-enhancing measures and improvements in the health system.³ During Lula’s administration, federal spending on public health increased by 16.8 percent (Soares and Santos, 2014). Brazil’s Sistema Único de Saúde (Unified Health System—SUS) was largely responsible for improvements in health outcomes in the years preceding the pandemic (Rich, 2020; Barberia and Gómez, 2020: 2). Of all the nations of Latin America, Brazil was best positioned to detect, prevent, and mitigate the spread of an epidemic (Global Health Security Index, 2019), and it was so recognized by the WHO. Indeed, as Smith (2020: 81) writes,

One might have expected the health system to respond with unusually high competence. Brazil’s democratic constitution of 1988 had established a universal right to health, and in the ensuing decades, Brazil constructed a universal healthcare system. Brazil’s public-health and social services systems had won international renown for their effective responses to wide-ranging public-health crises such as AIDS, dengue fever, and childhood malnutrition. Indeed, in the early days of the pandemic, the Ministry of Health appeared to be springing into action once again.

Brazil also had an innovative strategy for the health of families (Gombata, 2016) to strengthen primary care and create contacts between public health officials and communities. This system could have been an effective vehicle for responding to the pandemic and ensuring prevention measures.

Despite these resources and public investments, the health care system suffered from weaknesses that the pandemic exposed, including “chronic underfunding, lack of truly universal access, and inequalities between public and private systems” (Urbinatti et al., 2021: 50). Before the pandemic, Brazil had 382,352 doctors, but only 6,500 (1.7 percent) were intensive-care doctors. The Brazilian Intensive Care Medicine Association estimated that 40,000 ICU doctors were needed to tackle the pandemic. According to data from the World Bank (2018), in 2018 Brazil had 9.7 nurses per 1,000 inhabitants and 2.2 hospital beds per 1,000 inhabitants. Per capita spending on health was US$853 in 2019 (World Bank, 2019).

Early in January 2020, public health officials began updating their 2009 influenza protocols in response to what was then called a pneumonia of unknown origin in China. An emergency operation center was created at the end of January to serve as a decision-making body of the first instance and articulate a network of policy actors including the Brazilian Health Regulatory Agency and the SUS. Decision-making was largely centered in the Ministry of Health, where there were five secretariats responsible for the pandemic response (including medical attention, surveillance, and logistics). The emergency operation center held weekly meetings with representatives of ministries of foreign affairs and defense and the Presidency. It also communicated with states and municipalities through a series of technical reports (former director of immunizations and infectious diseases in the Department of Health Surveillance at the Ministry of Health, Zoom interview, May 10, 2021).

Given the relative robustness of the public health system in Brazil, many analysts were puzzled by the unwillingness of the government to rely on its in-house expertise. “We have a huge list of public health rock stars in Brazil,” noted one health policy adviser, but many were marginalized because of their outspoken criticism of the government. Much of the learning from earlier public health crises caused by HIV/AIDS and Zika—epidemics that were addressed with active tracking of cases and provided experience relevant to COVID-19—was not transmitted. Health workers were not properly trained and supported; no coherent social distancing measures were implemented; testing and contact tracing were dismissed as infeasible. Key informants we interviewed agreed that the executive was the source of these problems.

President Bolsonaro was elected in October 2018 and took office on January 1, 2019. A far-right outsider candidate who professed admiration for Brazil’s military dictatorship of the 1960s–1980s and who promised to undo many of the reforms implemented by the PT in the interests of business, large landowners, and the middle class, Bolsonaro was a polarizing figure (Smith, 2020). His response to COVID-19 would also be polarizing, but initially it was merely flat-footed. Faced with growing evidence of a pandemic, Bolsonaro was at first indecisive. In February 2020 he appeared not to have a clear view on how best to respond. In his initial speeches on the subject, he expressed a concern about keeping the economy open, but he was not yet defying public health recommendations. During the first critical months of the pandemic, Brazil’s COVID-19 policy response can best be called tepid—not because of negligence among public health officials but rather because of presidential indecision.

As Ministry of Health technicians became increasingly worried about the disease and its potential impact on Brazil’s health care system, the president continued to dither. Then-Health Minister Luiz Henrique Mandetta (2020) indicated that disagreements between Bolsonaro and the ministry began as early as February 2020 over an operation to rescue Brazilians in Wuhan. When Wuhan went into lockdown and Hubei Province imposed restrictions on 60 million people, reported the ministry’s former public health emergency coordinator (Zoom interview, May 11, 2021), “we thought that was not something ordinary, and the alert level went up.” Tensions with the president continued when Mandetta asked for quarantines for everyone entering Brazil from abroad (Presidência de la República Secretaria-Geral, 2020).

Public health officials were alarmed by the collapse of the Italian health system in early March. Their main concern was securing ICU beds, recalled a senior government official (Zoom interview, May 31, 2021):

We wanted people in primary care units. Everything was bought from China. Brazilian industries had gone out of business. There was no global leadership. We needed more ICUs: 2,000 beds to start. Then 30 days later, in March, we needed 6,000. Then with numbers rising in New York and Florida, we went to 15,000 new ICUs just for COVID. We went after the Brazilian suppliers because we could not get supplies from China.

At the same time, in the first week of March, a key decision-point was reached when Bolsonaro traveled to Mar-a-Lago in Florida to meet with U.S. President Donald Trump. Upon returning from this visit—during which half the Brazilian delegation contracted COVID-19—Bolsonaro sought to play down the pandemic with denial, lies, and conspiracy theories that echoed Trump’s views. He minimized the risks of COVID-19 and pushed aggressively for economic reopening.⁴ He followed Donald Trump’s playbook by promoting unproven therapies,⁵ attacking China, criticizing the WHO, assailing his political opponents (Lotta et al., 2002: 366), and minimizing the pandemic by calling COVID-19 a “little flu.”

Although Bolsonaro was influenced by Trump, his strategy was a domestic political gamble. He calculated that his base cared more about the economic consequences of the pandemic than about the public health impact.⁶ As a senior official who worked closely with the president put it (Zoom interview, May 31, 2021):

He was thinking, “This disease is going to pass; we are going to get through it and . . . in the future they’ll say, ‘I was the one who didn’t let the market or your business fail.’” He’s not dumb, he’s not crazy. He’s just making his political choices, and if someone says he is wrong he’s going to say: “I’ll give you hydroxychloroquine for your health, but I don’t want to close anything. I want people to go back to work.” And some people wanted that and they gave their support to him. It’s no sickness, it’s just a political choice.

Bolsonaro’s views put the minister of health in a difficult position. He was compelled to counter the president by holding daily press conferences to warn of the public health risk posed by COVID-19. Technical staff from the ministry fanned out to speak with legislators, judges from the Supreme Court, the governor of the Central Bank, and other key decision-makers. They even met with cabinet officials, who were generally sympathetic. The president, however, refused to meet to talk about COVID-19 with his minister of health. Ministry officials lamented that precious time was wasted seeking to convince the president of the need for public health measures. This was a clear contrast with previous administrations, according to the ministry’s former public health emergency coordinator (Zoom interview, May 11, 2021). He compared Bolsonaro’s reluctance to hear experts’ advice with the openness of President Rousseff during the Zika crisis in 2016: “During the Zika crisis, I used to meet with President Rousseff and members of the council of ministers twice a week.” The government launched a broad strategy to control the mosquito Aedes aegypti vector through a national campaign. The presidential decrees to establish a federal situation room for the health crisis and the creation of situation rooms at the state and municipal levels also helped to avoid a deepening problem. The coordination among the three spheres of the Brazilian health system—federal, state, and municipal—contrasted with the lack of leadership during the COVID-19 crisis. The same is true of the involvement of the other ministries, the armed forces, and public companies.⁷

Fearing that he would be blamed for the impending catastrophe, Mandetta insisted on meeting with the president and conveying his ministry’s estimate that as many as 180,000 people could die between March and December 2020 unless stringent measures were taken.⁸ This blunt warning seemed not to alarm the president. Instead, he turned to nonexperts whose views aligned with his own (Mandetta, 2020). In February 2020, he created a parallel emergency operation center that reported directly to him staffed by people who played down the seriousness of the virus, advocated early treatment, and recommended a herd immunity strategy. Backed by these faux experts, the president promoted his unscientific views on social media. One such view, according to the above-mentioned former director of immunizations and infectious diseases (Zoom interview, May 10, 2021), was that “vertical distance” was needed, meaning that “only the elderly should stay at home.”

In late March the Ministry of Health released a report warning that ICU occupancy would exceed 80 percent capacity unless stringent measures were taken, sparking a debate that went all the way to the Supreme Court (former member of the ministry’s Department of Health Surveillance, Zoom interview, May 10, 2021). In defiance of the minister’s public health guidance, Bolsonaro took highly publicized walks with crowds in the streets of Brasilia and tweeted that people should go about their lives as though everything was normal. This resulted in confusion, with many people thinking that the health policy restrictions had been lifted, and forced the minister to contradict the president again.

Pro-Bolsonaro states followed the president, adopting early-treatment policies and avoiding restrictive measures (Dunn and Laterzo, 2021). Other state governments attempted to fill the leadership vacuum created by Bolsonaro and implement WHO-recommended public health measures, and their authority to do so was upheld by the Supreme Court (Greer et al., 2022a: 9). For this, however, they were attacked by the president.⁹ As Greer et al. (2022a: 9) put it, “Bolsonaro took advantage of the division of authority over the COVID-19 epidemic to adopt a blame-avoidance strategy. . . . Polling suggests Bolsonaro was able to pass the blame on to state governors, whilst claiming credit for social policies (particularly cash transfers).”

On April 16, Mandetta was removed, clearing the way for Bolsonaro to pursue his agenda unfettered. At the time, Mandetta was more popular than Bolsonaro, and most Brazilians opposed his dismissal. He was replaced by Nelson Teich, who tried to avoid criticizing the president. Ministry efforts to combat the spread of disinformation through daily press conferences were scaled back. An army general, Eduardo Pazuello, was appointed to the post of executive secretary—the number two job in the ministry.¹⁰

Despite catching COVID-19 in May, Bolsonaro continued to play down the seriousness of the pandemic, even under pressure from state and local governments, and he continued to peddle hydroxychloroquine, which he administered to himself. Consequently, Teich resigned in mid-May, less than a month after his appointment, giving Bolsonaro the chance to place Pazuello in charge of the ministry despite his lack of medical expertise. Pazuello, in turn, appointed more military officers to key ministry posts. Many scientists and technical experts objected to the presence of military officers in senior positions in the Ministry of Health and left the ministry.

Bolsonaro’s posture also created conflict between the central government and the states, which were forced to assume the burden of managing the pandemic response. The conflict was especially intense with the governor of São Paulo, João Doria, whom Bolsonaro called a “lunatic.” Yet the Supreme Court backed Doria’s claim that he had the jurisdiction to implement public health measures to contain the pandemic.

Bolsonaro also politicized the vaccine program. “Although the country has a national immunization program with a consolidated trajectory, associated with a well-structured epidemiological surveillance system,” Fleury and Fava (2022) note, this did not prevent a “delay in immunizing the population.” An inquiry by Congress revealed that between July and September 2020, the Butantan Institute, a local public research center in São Paulo state, had offered the Ministry of Health millions of doses that could be delivered if the purchase were completed expeditiously.¹¹ In October Bolsonaro said, “My minister of health already said that this vaccine will not be mandatory. Full stop” (Farias, 2020). In August, Pfizer offered 70 million doses to the Ministry of Health but got no answer.

Rather than encouraging people to get vaccinated, Bolsonaro sought to allay the concerns of some citizens that they would be forced to be vaccinated. When Pazuello announced that Brazil would be purchasing a vaccine from China in partnership with Butantan Institute, Bolsonaro tweeted that he would not make Brazilians guinea pigs for “João Doria’s Chinese vaccine.” Without Doria’s insistence on the vaccine partnership with China, Brazil would have been further delayed in its immunization campaign. Fortunately for many Brazilians, the partial autonomy of the SUS—in which decision-making authority was shared among federal, state, and municipal levels of government—enhanced Brazil’s policy response in anti-Bolsonaro states.

In summary, Bolsonaro’s refusal to take advantage of Brazil’s public health system exacerbated the human toll of the pandemic. As one public policy expert put it, “Political leadership really matters. The leadership we had made very bad decisions. They chose not to make policies that were costly for them politically” (confidential Zoom interview, April 30, 2021).

Peru: Structural Limitations with Few Blame-shifting Options

In Peru, President Martín Vizcarra took office following the resignation of his predecessor, Pedro Pablo Kuczynski, in March 2018. His government enjoyed high levels of public approval, at least compared with that of the legislature that had recklessly deposed Kuczynski. When legislative-executive tension escalated again in September 2019, the president constitutionally dissolved Congress and called for new elections in January 2020. The measure was backed by 84 percent of Peruvians, most of whom believed that the legislature had been obstructionist. Meanwhile, Vizcarra’s popularity rose from 48 percent to 79 percent (Paredes and Encinas, 2020). The result of this process was an empowered president with a crisis-solving mandate who enjoyed ample room for policymaking. The new Congress was sworn in on March 19, 2020, 13 days after the first case of coronavirus was identified in Peru.

In contrast to Bolsonaro, Vizcarra was not a directly elected president, nor was reelection constitutionally permitted. His political calculations, in the midst of a crisis caused by a divided government, revolved around surviving the congressional attacks and connecting with citizens to build support in public opinion (Requena, 2019; Meléndez, 2019; Camacho and Sosa-Villagarcia, 2021). His presidency was born of the crisis, and his leadership was sustained by the need for national unity. His populist rhetoric focused mainly on criticizing the political class not with the aim of concentrating power but rather to advance political, electoral, and anticorruption reforms. To achieve these goals, Vizcarra had already summoned independent experts to a commission on political reform (Campos, 2019; Sosa-Villagarcia and Camacho, 2019). He would do the same with COVID-19.

The Vizcarra government did not, however, have the benefit of a functional universal public health care system that would provide room for policy innovation. The Peruvian system was fragmented and formally divided into three major organizations: the Ministerio de Salud (Ministry of Health—MINSA), the Seguro Social de Salud (Health Social Insurance—EsSalud), and private sector clinics. These organizations represented different groups of medical professionals and health care providers, and they received funding from diverse sources. MINSA was funded through the central government as part of the health sector in the national budget, EsSalud through the contributions of citizens enrolled in this health insurance plan, and the private sector clinics through direct payment or insurance. As a result, the system was hobbled by jurisdictional overlaps, disparities in the quality of service, and a lack of coordination.

Territorially, the system was decentralized in a way that contributed to further fragmentation and weakened the pandemic response. In 2005, regional health directorates (known in Peru as DIRESAS) were created in the 25 departments of Peru, each of which was intended to report to MINSA. The government transferred the equivalent of US$25 million to regional governments on March 27, 2020, to improve the capacity of subnational health care. However, the directorates often became bottlenecks undermining central-government policy. Regional governors were the main authority over them, and lack of coordination with the central government delayed or prevented the implementation of policy decisions. A senior official from MINSA mentioned that when central government officials attempted to work with directorates they found themselves wasting valuable time negotiating with governors and subnational bureaucracies: “The Minister of Health is the minister for Lima. His power vanishes beyond the intersection of La Marina and Faucett Avenues—each region handled its health policy differently” (confidential Zoom interview, May 21, 2021).¹² In addition to MINSA, EsSalud, the private sector clinics, and the 25 health directorates, there is a health system for the National Police and the armed forces.

Not only was this fragmentation inefficient but it favored corruption because of difficulties in tracking state purchases (member of the cabinet, confidential Zoom interview, May 21, 2021). Several senior officials noted that this was a problem exacerbated by the fact that the types of goods purchased favor micro-level corruption (confidential Zoom interviews, April 3 and May 21, 2021). For example, it is very difficult for Peruvian state officials to track the use of small resources such as syringes, gauze pads, or medicines. These, in general, are lost in the dynamics of small-scale corruption in which doctors and nurses use them for their private practices or give them to relatives and acquaintances. Senior health officials noted that mafia groups had been discovered selling these goods on the black market to private pharmacies or individuals (confidential Zoom interviews, April 3 and May 21, 2021). There are, therefore, incentives for established networks of corruption to limit the implementation of new policies and prevent policy reforms.

The system was put to the test after March 6, when the first active case of coronavirus was identified in the country. President Vizcarra took charge of both the policy response and the communication strategy, assembled an emergency cabinet, and spoke to the nation to highlight the importance of social distancing (see Office of the Presidency of Peru, 2021). Ten days later, with the full support of his minister of the economy and finance, he announced a nationwide lockdown, travel restrictions, work-from-home orders, and limitation of social gatherings. Shortly thereafter he removed his minister of health, who had been naively optimistic that Peru would be spared the worst of COVID-19 as had been the case of H1N1 and Zika and who had decided that US$1 million was sufficient to fund a plan to manage any future contagion (government officials in the health ministry, confidential Zoom interviews, April 3 and 9 and May 21, 2021).

Vizcarra’s policies were influenced by both the new minister of health, Victor Zamora, and his minister of the economy and finance, Maria Antonieta Alva, who was strongly influenced by the advice of her former professors at Harvard University (León, 2021; former senior policy advisers and government officials, confidential Zoom interviews, April 2 and May 21, 2021). They met with the cabinet every day and prioritized direct coordination with subnational authorities in the implementation of pandemic policies.

On March 14 the president declared a national lockdown following the identification of the first COVID-19 case. The dramatic decision to lock down Peru was not easy. Minister Alva was well aware of the potential damage that the shutdown of the economy would do to the country’s finances. However, supported by the director of the Central Reserve Bank, she prioritized the containment plan for the pandemic as “the best plan to protect the economy in the long term” (León, 2021; former senior policy advisers and government officials, Zoom interviews, April 2 and May 21, 2021). It was thus with the full support—indeed, on the initiative—of the Ministry of Finance that the government implemented its initial pandemic management measures. During the following months, the discussion of the balance between health and the economy would continue in the public debate and within the cabinet. However, the Ministry of the Economy was in a crucial way injecting resources to strengthen the health system (former senior official, confidential Zoom interview, May 21, 2021).

In this crucial stage, public health advisers and policy experts played a leading role in the government’s pandemic response. President Vizcarra and his cabinet also sought the support and assistance of experts outside the public sector. Along with the creation of a COVID-19 task group led by a doctor and former health minister, Pilar Mazzeti, Vizcarra created two advisory groups to plan the pandemic response in the first months. The first consisted of epidemiologists and statisticians and the second of social scientists. According to members of those advisory groups, the president was deeply invested in the process: he participated in the meetings, seeking to receive constant information about the policy recommendations and integrate them into the response plan proactively (Zoom interviews, February 27 and April 9, 2021). Vizcarra was a president who wanted his policies to be consistent with the available science and evidence.

While Vizcarra’s advisory groups were working behind the scenes, he took center stage. His communication strategy was not limited to providing information about social distancing and mobility restrictions; it also included a daily noon-hour press conference in which he updated the public on the spread of the virus and the status of health care institutions and took questions from the media. These conferences usually ended with the president pleading with Peruvians to stick together in the fight against their common enemy, the virus. The appeals to unity paid off politically; Vizcarra’s popularity increased to 87 percent, with 83 percent of Peruvians supporting the containment measures (Sosa-Villagarcia and Hurtado, 2021).

Vizcarra was able to take stringent measures, including effectively shutting down the economy, in part because Peru had achieved an annual growth rate of 3.6 percent in the 10 years prior to the crisis, one of strongest records in Latin America, and was therefore in a strong macroeconomic position. Previous governments had, however, squandered the opportunity to make major investments in welfare policies or improve working conditions, public transportation, public hygiene, and housing. As a result, many Peruvians were simply unable to comply with health policy directives. Most of Peru’s labor force found employment in the informal economy, and many households lacked running water or refrigeration.¹³ Low-income families relied on daily visits to crowded markets and used unregulated and crowded public transportation to get to school and work. Working remotely was not an option, and, lacking any form of social security, living close to the margin of survival, many workers simply could not stop income-earning activities. Much of the social policy expansion that occurred in recent years happened during the 2011–2016 government of President Ollanta Humala, but it took the form of conditional cash transfers and capacity-building programs. In principle, these programs should have expanded social policy coverage considerably, but serious problems in implementation such as underregistration, insufficient coverage, and corruption diminished their effectiveness.

Oxygen was in short supply—an oligopoly of two firms controlled the market thanks to a corrupt and anticompetitive price-fixing scheme adopted under the government of Alan García (2006–2011). There were only 500 ICU beds, a number that quickly increased to 2,400 but still fell well short of the 7,000 it was estimated Peru needed at the time. The 20,000 regular hospital beds fell short of the 80,000 needed. Laboratory capacity for testing was extremely limited: whereas Peru needed to conduct 50,000 tests per day, it had the capacity for only 500. Whereas Peru needed 20,000 intensive-care doctors, only 700 were available; 40 percent of the primary care units lacked doctors, 30 percent lacked water, and 75 percent had no Internet. There was no central registry for all the hospitals in the country, making it hard to determine the number of beds and health care workers. Former senior policy advisers and officials confirmed that pervasive corruption meant that supplies sent to the provinces would often wind up sold on the streets (Zoom interviews, April 3 and May 21, 2021).

As the limitations of the health care system became apparent and the opposition gained strength, Vizcarra’s capacity to mobilize citizens around policy would crumble. A former cabinet official noted that the new Congress started to find weaknesses in the pandemic response and impatience mounted with the message that the “pandemic was not over yet” (confidential Zoom interview, May 21, 2021), the opposition began to engage in constant criticism, repeatedly summoning ministers to vexatious plenary meetings (former senior officials, Zoom interview, May 21, 2021).

While Vizcarra called his policies science-based, some of his decisions did not follow the updates of international public health recommendations and resulted in mixed messages. Although his government criticized misinformation campaigns about the origin of the pandemic and the efficacy of vaccines—indeed, it was actually among the governments with lower levels of misinformation spread in the region (Edgell et al., 2021)—Vizcarra nonetheless included unproven drugs in the list of official COVID-19 treatments (RM 315-2020-MINSA). Even though these drugs had not been fully tested and there is no reliable evidence of their efficacy, the government designed a program called Plan Tayta dedicated to the redistribution of these medicines throughout the nation. In October 2020 MINSA dropped the use of such drugs given the publication of an internal report on the negative effects of their use on COVID-19 patients.

The government also mixed messages around COVID-19 testing. Vizcarra pushed for mass rapid testing, but these tests carried a high cost. Serology or “rapid” testing was the cheaper and available option, but it is designed to detect antibodies and does not detect the early stages of the infection. As a result, it is not a fully reliable tool for detecting early cases and isolating them. Moreover, the government systematically rejected the use of contact-tracing instruments recommended by the scientific community. However, interviewees agreed that instead of being arbitrary decisions, these actions were predetermined. Contact-tracing requires a primary-care capacity that Peru does not have, while the use of rapid tests was hindered by the government’s initial delay in taking the pandemic seriously.

Finally, the tensions between the executive and legislative branches of government escalated during the pandemic and politicized containment measures (Hidalgo, 2021). Members of the opposition warned about the economic consequences of stringent measures and called for an economic recovery plan. However, they were also actively undermining the efforts of the executive, denying votes of confidence to the cabinet and questioning the economic measures taken to fight the pandemic in the media. The impeachment of Vizcarra in November 2020 sparked massive mobilization in the country against the legislature, but it also disrupted vaccine acquisition and the implementation of the long-term policy response to COVID-19. While the curve was eventually flattened, political instability and the relaxation of the containment measures led to a devastating second wave.

Preparedness and Diffusion of Responsibility

The greater preparedness of the Brazilian health system could have led to a swift response under a leadership different from Bolsonaro’s, which gambled that his electoral base preferred economic openness to stringent public health measures. He was able to cast himself as an opponent of governors, members of Congress, and even his own ministers. This reflected and fostered fragmentation and division across levels of government and within the bureaucracy. In Peru, the fragility of the health system impressed leaders with the need for a more energetic central-government response, while the absence of alternative actors (members of Congress, subnational authorities) forced the executive to assume responsibility. As a result, the Peruvian response was stringent and expedited by the executive until the opposition forces were able to build power in a newly constituted legislature.

We have focused on leadership not only as a reflection of the personality or ideology of the president but as contingent upon strategic goals and institutional capacity. Our interviews have revealed the motivations behind leaders’ decision-making. While President Vizcarra took office with a mandate to resolve a crisis resulting from a confrontation between political parties, Bolsonaro did so after winning a polarized election. For the same reason, Vizcarra had incentives to project a unifying mandate, seeking to appeal to national unity, while Bolsonaro built his leadership prior to the pandemic by dividing and radicalizing his constituents.

Our interviews show that presidents centralized or decentralized the response according to the existence of opportunities for the centralization or diffusion of responsibility or blame. The centralized Peruvian response is explained not only by its unitary constitution but, above all, by the need of the executive to assume decision-making authority in order to coordinate a coherent response in the absence of alternative actors. By contrast, the critical role that states’ governments and municipalities played in the Brazilian pandemic response reflected the abdication of presidential authority and the capacity of subnational units to act where the president would not.

Drawing on our cases, we advance new hypotheses for future research. The level of preparedness of the health care system determines the degree of room for maneuver that the authorities will have to respond. Central governments have less room to sidestep decisions where the health system is deficient. The threat of an imminent catastrophe reduces the opportunities to deflect or abdicate responsibility and increases the need for a centralized response (Blofield, Hoffman, and Llanos, 2020; Bennouna et al., 2021; Dunn and Laterzo, 2021; Velasco-Guachalla et al., 2021; Ramirez et al., 2020; Massard da Fonseca, 2021). At the same time, in those countries where the health system is more prepared, there are greater opportunities to improvise less urgent responses. In other words, the possibility of a diffusion of responsibility is greater when the preparedness of the country offers a protective cushion against the crisis.

In times of crisis, it is possible to observe a greater demand for strong leadership, but this is conditioned by ongoing political dynamics and partisan identities (Sosa-Villagarcia and Hurtado, 2021; Pignataro, 2021; Ayala, 2021; Kritzinger et al., 2020). In contexts where leadership has been built on the basis of polarization, the incentives to reproduce this type of relationship during the crisis remain. Rather than consolidate a unifying leadership, presidents tend to focus on responding to their electoral and social bases, especially when they are willing to accept the politicization of the crisis (Velasco-Guachalla et al., 2021; Cyr et al., 2021; Ramirez et al., 2020). When presidents face a crisis with a call to national unity and there is no one to blame, there are greater incentives to respond to the pandemic without catering to extreme positions.

Conclusion

Our study was motivated by an interest in understanding different policy responses to the pandemic. We have identified variation in two features of the policy process that merit further analysis. The first is the need to introduce strong and urgent responses due to the lack of preparedness in the face of a national emergency. The second is whether executive leaders are forced to assume responsibility in such emergencies and bring decision-making under central authority or have the option of ducking responsibility and shifting blame onto others.

Our findings reinforce the importance of the interaction between health care institutions and political opportunities. State capacity clearly matters (Kavanagh and Singh, 2020). Decision-making processes and incentives explain why there is not a direct or one-to-one relationship between the apparent preparedness of public health systems and policy outcomes (Greer et al., 2020). Institutional factors alone would not have predicted Brazil’s response. The political process and political leadership also matter (Blofield, Hoffman, and Llanos, 2020). However, Peru also demonstrates that even a vigorous response to the crisis may founder on a fragmented health care system, especially when broader social conditions make compliance with public health measures difficult or impossible for much of the population.

Although the two cases are different in critical respects, both are cautionary tales that underscore the costly legacies and negative human impact of policies that weaken the role of government in the supply of public goods. In the case of Brazil, considerable investments in universal public health care were squandered by a leader who valued the economy over the health and safety of the public. The best-prepared country in Latin America performed extremely poorly. In Peru, decades of neglect of the health care system handicapped a vigorous effort to respond to the pandemic. The hubristic assumption that strong macroeconomic fundamentals would be sufficient to enable the country to weather the storm proved dangerously misleading. Without sustained investments in public health care and efforts to provide basic public goods such as sanitary conditions for work, housing, and transportation, a country with a supposedly strong economy suffered the world’s worst impact of COVID-19.

Footnotes

Notes

Maxwell A. Cameron is a professor in the Department of Political Science and the School of Public Policy and Global Affairs at the University of British Columbia. Veronica Hurtado is a Ph.D. candidate in the Department of Political Science at the University of British Columbia. Paolo Sosa-Villagarcia is a Ph.D. candidate in the Department of Political Science at the University of British Columbia and a researcher at the Instituto de Estudios Peruanos. Marsílea Gombata works at the International Relations Institute and the International Relations Research Center at the Universidade de São Paulo. The authors acknowledge the collaborative work of the UBC Working Group on Health Systems Responses to COVID-19. Funding was provided by the Social Sciences Research Council of Canada (GR002109) and the Faculty of Arts at UBC. Paolo Sosa-Villagarcia gratefully acknowledges the funding of the Public Scholars Initiative program at UBC. The research was approved by the Behavioral of Research Ethics Board at UBC (H20-02136).

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