LIMA Ė Insufficient health care investment over decades, a fragmented health system, a shortage of doctors and hospital beds, a large informal sector and an overweight and rule-defying populace have created a perfect storm in Peru, which now has the worldís highest coronavirus case fatality rate (CFR) after the tiny European microstate of San Marino.
The South American country has thus far attributed more than 29,000 deaths to COVID-19, or 88 per 100,000 inhabitants; it also ranks fifth worldwide and second in Latin America after Brazil in terms of total confirmed coronavirus cases (around 652,000, or 2 percent of its population).
This scenario would have been hard to imagine in mid-March when the Andean nation, then with just 71 confirmed cases, became the first Latin American country to enact a mandatory nationwide stay-at-home policy.
What led to the current situation and why did the governmentís rapid response not have the desired effect?
Before the onset of the health emergency, Peru had earmarked 18.5 billion soles (around $5.2 billion) for health-care spending in 2020, an amount that at 2.2 percent of its gross domestic product was one of the lowest rates in Latin America.
Public spending on health care in Peru as a share of GDP has for decades fallen below the minimum 6 percent level recommended by the World Health Organization and far below the 10.1 percent average for the 37 Organization for Economic Co-operation and Development member states (of which it is not a member).
The budget allocation not only is insufficient, but the funds also are not effectively employed and at times are not even fully spent due to bureaucratic red tape. Amid the pandemic, for example, some doctors are now owed several months of back pay.
According to an analysis by Peruís Foreign Trade Society, more than 8.7 billion soles allocated in different annual health sector budgets went unspent between 2015-2019.
Public hospitals typically lack the equipment needed for even the simplest procedures, forcing patientsí family members Ė or even the patients themselves Ė to provide it themselves.
Furthermore, Peruís badly fragmented health system is divided up among large and small entities that have their own hospital networks and medical centers and operate in a parallel and uncoordinated fashion.
Peruís Comprehensive Health Insurance (SIS), administered by the Health Ministry to provide universal coverage to people below the poverty line and in vulnerable situations, covers more than 20 million people.
Separately, EsSalud (Peruís equivalent of a social security program) is overseen by the Labor Ministry and provides coverage to nearly 12 million people, including the formally employed and retirees.
But Peruvian police and military personnel also have their own separate health coverage and exclusive hospitals. And municipal clinics exist in some cities, such as the Metropolitan Municipality of Limaís Metropolitan Solidarity System (Sisol), which has 26 hospitals Ė seven of which are located in cities outside the capital Ė and 11 medical centers.
Prior to the pandemic, Peru had a deficit of 24,000 health professionals, according to former Health Minister Victor Zamora.
The country in March had just 13 doctors per 10,000 inhabitants, one of the lowest densities in Latin America; and the number of doctors stood at just half that level in regions such as the Amazon department of Loreto.
Amid the health emergency, the situation became more acute because a substantial number of medical professionals who were part of the at-risk population stopped treating patients. The government has tried to resolve the problem by hiring foreign doctors and recent medical school graduates.
A shortage of intensive-care beds equipped with artificial respirators has been an additional problem. Only 276 fully equipped ICU beds were available to treat COVID-19 patients at the start of the pandemic, according to the OECD, although that number has since increased to more than 1,500.
That initial scarcity was particularly evident in regions such as the northwestern department of La Libertad, where there was just one mechanical ventilator per 200,000 inhabitants, according to a report in April by the National Ombudsmanís Office.
Many Peruvians also failed to do their part to prevent the collapse of the public health system and flouted the nationís strict stay-at-home orders.
More than 50,000 people were arrested in the first two months of the health emergency for defying the strict quarantine and nighttime curfews. Although some acted out of economic necessity, many others arranged social gatherings even though they are expressly prohibited.
The most notorious example was a clandestine party that ended tragically when a police raid triggered a stampede that left 13 dead.
Peruís high level of informality also has been a factor in the high death rate.
The majority (around 70 percent) of Peruís economically active population works in the informal sector and does not pay taxes, a state of affairs that deprives the state of the revenue it needs to provide broader health coverage.
Accustomed to living hand to mouth, informal workers also tend to self-treat at home or resort to private health care Ė and incur enormous costs Ė if they become seriously ill.
The virus furthermore has spread in part due to inter-provincial transport, which has operated virtually without safety measures since domestic travel restrictions were lifted in mid-July.
The general poor health of Peruís population also has been a major contributor to the countryís high CFR, which differs from the infection fatality rate, or the proportion of deaths among all infected individuals.
(The IFR is invariably lower than the CFR but is difficult to calculate because, according to the World Health Organization, a substantial proportion of COVID-19 cases are asymptomatic or very mild and therefore go undetected)
In early August, the Health Ministry said 85 percent of those who succumbed to the coronavirus were obese, 43 percent were diabetics and 27 percent suffered from hypertension Ė three of the main risk factors for severe COVID-19 outcomes.
That is no coincidence.
In Peru, at least one in five people over the age of 15 is obese, according to the latest figures from the National Institute of Statistics and Informatics. Meanwhile, a whopping 70 percent of the population is regarded as overweight or obese (compared with an average for all of Latin America of 59.5 percent).
Peruís obesity rate is slightly below the average for the region (24 percent), which is nearly double the global rate.