Exploring Barriers and Enablers to Peru's COVID-19 Pandemic Response, and the Local, Regional, and Global Implications

Background: Peru had more COVID-19 deaths per capita than any other country. Despite delayed vaccine procurement, Peru achieved an 80% two-dose vaccination rate for its adult population (18 years and older) by December 2021. This study aimed to understand the barriers and enablers to Peru’s pandemic response and offer policy recommendations for health system strengthening and improved pandemic response capacity in Peru, Latin America, and globally. Methods: Thirty-one semi-structured in-depth interviews were conducted with 35 individuals from the public, private, and other sectors across Peru’s Lima and Amazonian regions. Participants were recruited through purposeful and snowball sampling, based on the inclusion criteria of being involved in Peru’s pandemic response decision-making. A content analysis was conducted to identify patterns across interviews, and a force field analysis was applied to understand which factors most negatively and positively impacted Peru’s pandemic response. Findings: Participants identified political instability and corruption, lack of experienced leaders and organized decision-making, cross-sector competition, a fragmented health system, and regulatory challenges as barriers to Peru’s pandemic response. In contrast, participants identified experience with vaccination campaigns, high vaccine acceptance, community-based donations and support, and cross-sector collaboration as facilitators to Peru’s pandemic response. Interpretation: While Peru did institute some effective response measures to COVID-19, these were overshadowed by large-scale systemic and political issues that hindered the country’s capacity for a timely and effective pandemic response. Funding: This study was funded by the Duke Global Health Institute, the Duke Margolis Center for Health Policy, and the Duke Global Health Innovation Center.Declaration of Interest: SS, EJO, and JH declare no competing interests. GY received a grant from the Carnegie Corporation of New York (International Peach & Security Program) for his center to fund a two-year study on reimagining multilateralism, including design of a new pandemic vaccine finance facility. GY was a member of the COVID-19 Vaccine Development Taskforce, hosted by the World Bank, and participated as an academic unpaid adviser in the consultation process that led to the launch of COVAX. GY is a signatory to the People’s Vaccine campaign and is a funding member of Amnesty International, one of the members of the People’s Vaccine Alliance. KU received a grant from the Bill & Melinda Gates Foundation to Duke University for independent research; grants or contracts from USAID, Grand Challenges Canada, Bill & Melinda Gates Foundation, The Rockefeller Foundation, The Open Society Foundations, and Conrad N. Hilton Foundation in agreements with Duke University; grants or contracts from BroadReach and Results 4 Development in agreements with Duke University as a sub-award on the USAID award; received non-financial support from the World Economic Forum for Innovations in Healthcare (Duke-controlled non- profit); non-financial support from McKinsey & Company for Innovations in Healthcare; grants or contracts from Amgen, AstraZeneca, Bayer, Bayer Cares Foundation, Johnson & Johnson Foundation, Medtronic, Pfizer, Incl, Pfizer Foundation, Takeda, and Vynamic in agreements with Innovations in Healthcare; received an honorarium for a lecture from Weber Shandwick; received payment for travel expenses for a speaking engagement from Roche; received travel expenses for client meetings in England, UK from Duke Cooperate Education; received travel expenses to attend a meeting in Doha, Qatar from the World Innovation Summit for Health (WISH); received travel expenses to attend a meeting in England, UK from Bill & Melinda Gates Foundation; was a member of Hewlett Foundation’s time-limited Advisory Committee to support development of new strategy; participated in a meeting planning committee for Africa CDC’s International Conference on Public Health in Africa; was a paid member of the Rockefeller Foundation’s time- limited Advisory Board on global vaccination; is the President and a Member of Board of Directors for Innovations in Healthcare, Inc.; is a Member of Board of Directors for Duke Global Incl, Duke Medicine Global Support Corporation, Duke Medicine Asia Pte. Ltd. (Singapore), and Duke India Service Private Limited (India); is the Owner and Sole Manager of MAK Advisors, LLC.; and is a stock owner in Amazon and Cree.Ethical Approval: All study procedures were approved by the Duke University Campus Institutional Review Board (IRB) and received an IRB exemption. The study bypassed a Peruvian IRB because of the IRB exemption and because we did not have a partner site or institution in Peru and that the study presented minimal harm to participants given that in-depth interviews sought solely to capture personal opinions and perspectives on Peru’s pandemic response, and we omitted participant names and identifiers from publications.