Poverty, precarious work, and the COVID-19 pandemic: lessons from Bolivia

Bolivia is one of the poorest countries in Latin America with a gross domestic product of around US$3500 per capita, health spending of approximately$220 per capita, a labour market dominated by informal work, and a weak health system. However, in the response to COVID-19, Bolivia has fared better than other health systems in the region and provides insight with regard to the implementation of subnational nonpharmaceutical interventions and supporting workers without social protection. The Bolivian Government confirmed the first case of COVID-19 in the country on March 10, 2020, and responded quickly by cancelling events, closing schools and borders, and implementing a national lockdown on March 22, 2020. However, the Bolivian Government was under pressure to open the economy in an election season. In response, the Bolivian Government shifted responsibility for most non-pharmaceutical interventions to departmental and municipal governments on June 1, 2020. The Bolivian Government maintained a mask mandate, school and border closures, and a nightly curfew, while allowing departmental and municipal governments to set workplace, social gathering, population mobility, and public transit policies. Daily deaths from COVID-19 increased markedly from 20 on June 1, 2020, to 96 on Aug 1, 2020. Subnationally, the first outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred in the wealthy, politically conservative department of Santa Cruz, followed by the poor, politically moderate department of Beni in May, 2020. These two departments maintained strict confinement policies in June, 2020, to manage outbreaks. Strict policies were also maintained in the wealthy, politically conservative department of Tarija, while the other six departments relaxed restrictions quickly in June, 2020, and subsequently a surge in cases was observed. In response to an increase in deaths in June and July, 2020, Chuquisaca and Cochabamba reinstated some restrictions and the other departments shifted to a policy of isolating municipalities with outbreaks. Daily deaths began to decline in August, 2020, decreasing to 35 per day by Sept 15, 2020. The Bolivian Government announced a postconfinement phase on Sept 1, 2020, and subsequently all departments began to relax containment strategies. A national mask mandate, nightly curfew, school closure, event ban, and border closure were maintained while allowing most workplaces and transportation to open with restricted hours and distancing protocols. Departments differed with regard to opening hours of businesses, the level of intermunicipal transportation, the size of gatherings, and local enforcement. The relaxation of restrictions in some departments coincided with the nationwide surge in COVID-19 deaths in June and July, 2020. However, deaths declined in September and October, 2020, despite the post-confinement relaxation. Informality, inequity, and overlapping health disparities and pre-existing conditions of specific groups are systemic and persistent issues that amplified the impact of the pandemic and explain outcomes observed across the country. In the poorest departments, deaths in July, 2020, were more than seven times higher than that in July, 2019. In comparison, the peak of deaths in the wealthiest departments were only two times higher than that in the same period in 2019. More than 70% of working Bolivians do not have employment contracts or employer-based social security making strict containment especially difficult to achieve. National and departmental containment laws designated market, transportation, and agricultural labourers as essential workers, despite informal, openair, street markets being identified as sites of contagion. Employment in these sectors continued amid a shortage of personal protective equipment (PPE) and testing. Departmental and municipal governments implemented mask and glove mandates, but these low-income workers were expected to source and purchase their own PPE and tests. COVID-19 cases were concentrated in these informal workplaces. In Cochabamba, market and transportation workers and their families account for 40–50% of confirmed COVID-19 cases despite low levels of testing among these groups. The national government expanded benefits for existing cash transfer programmes in late March, 2020, and extended income transfers to Lancet Glob Health 2021