Scientific Papers

National governance and excess mortality due to COVID-19 in 213 countries: a retrospective analysis and perspectives on future pandemics | Globalization and Health

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Based on the analysis of the years 2020 and 2021, it was found that among the three main components examined, only the “Control of Corruption, Government Effectiveness, Regulatory Quality and Rule of Law” component had a significant impact (p < 0.0001). In other words, the component represented by the variable PRIN1 was found to be inversely related to the daily estimated cumulative excess deaths per 100 thousand inhabitants in the year 2020. On the other hand, the “Voice and Accountability” component and the “Political Stability and Absence of Violence/Terrorism” component did not show any correlation with the daily estimated cumulative excess deaths per 100 thousand inhabitants. These findings are consistent with previous studies that have shown that countries with good governance, including trust in government, have lower excess mortality rates due to COVID-19 [35,36,37] and lower mortality rates and infection-fatality ratio and infection attack rates of COVID-19 [38,39,40].

Few studies have examined the link between governance indicators and excess mortality caused by COVID-19. This study has a strength in that it utilized the more robust outcome of excess mortality caused by COVID-19. Comparing the number of deaths due to COVID-19 may not be the most suitable method for comparing different countries [41]. It is challenging to discuss the results of studies that have examined different outcomes of COVID-19.

An ecological study revealed a link between worse governance indicators and lower COVID-19 mortality among 54 African countries. However, the authors of the study believed that the high number of patients aged 65 or older and the use of the total number of deaths instead of weekly averages may have affected the results [42]. Another research found that the World Bank governance indicators were not related to the number of cases and deaths from COVID-19 [43]. Although these studies focused on the mortality rate due to COVID-19, the analysis of the association between governance and COVID-19 outcomes still seems debatable and requires further research.

A previous study that evaluated three dimensions of the governance indicator, namely Government Effectiveness, Regulatory Quality, and Rule of Law found that countries with high levels of these dimensions had better performances during the COVID-19 pandemic, such as lower mortality rates [44]. This suggests that the governance indicator, even if it lacks all six dimensions, still played a significant role in the performance of countries during the pandemic.

The rule of law has, among its dimensions, legality, proportionality, transparency and the participatory process in the drafting and implementation of laws and regulations. Government communication in a transparent manner helps individuals to understand the reason for implementing the government measures adopted [45]. Therefore, in a country with a strengthened rule of law, this understanding may have influenced citizens’ perception that their rights and freedoms were not being violated [46]. The rule of law provides legitimacy to the government’s restrictive measures. The limitations of some rights must be proportional. That is, the least restrictive measures should be implemented to deal with the situation. Adherence to rule of law principles, when adopting emergency measures, is expected to strengthen public trust in the institutions. Therefore, compliance with measures and effectiveness of actions can be reinforced [47].

It is interesting to note that the results of the current research indicate that in the years 2020 and 2021, the components “Voice and Accountability” and “Political Stability and Absence of Violence/Terrorism” did not have any correlation with the excess mortality rate caused by COVID-19. However, in 2022, the “Political Stability and Absence of Violence/Terrorism” component was directly and significantly associated with the excess mortality rate due to COVID-19. It is important to understand that the World Bank’s interpretation of the “Political Stability and Absence of Violence/Terrorism” and “Voice and Accountability” indicators [5] is related to the citizens’ engagement in the government’s selection process, freedom of expression, and the media’s ability to function freely.

A study conducted in 203 countries aimed to identify the possible predictors of mortality due to COVID-19 found that the “Voice and Accountability” indicator was a positive predictor. The researchers argued that this could be due to better governance leading to a better reporting system for deaths [48]. However, the results of the present research contradict this finding. The lack of transparency in data reporting may have affected the reporting of cases and deaths. This may have been a factor that influenced the present study’s results, which found no significant association between excess mortality and the “Voice and Accountability” indicator.

Another study analyzed data from 185 countries to investigate the relationship between pandemic spread namely the COVID-19 positive rate and the COVID-19 growth rate i.e., the quantity of testing being done in a country relative to the magnitude of the outbreak, and all six dimensions of governance also analysed in the present study, including the “Voice and Accountability” indicator and the “Political Stability and Absence of Violence/Terrorism” indicator. The study found that these indicators had a smaller influence on COVID-19 positive rates compared to the other dimensions of governance. The researchers suggested that the “Voice and Accountability” and “Political Stability and Absence of Violence/Terrorism” indicators are more specific and may not strongly influence the quality of governance as the “Government Effectiveness” indicator does [49].

A recent study analyzing data from 226 countries found that the effectiveness of non-pharmaceutical interventions to mitigate the spread of COVID-19 was negatively impacted by two factors – “Voice and Accountability” and “Political Stability and Absence of Violence/Terrorism”. Countries that value freedom of expression and free media, which are some aspects of “Voice and Accountability”, may have faced more challenges in implementing non-pharmaceutical interventions, especially when such interventions were imposed [6].

By 2022, some countries had made more progress in distributing and using the COVID-19 vaccine than others. However, vaccine acceptance was affected by social unrest and crime. A study has shown that people who were most concerned about these issues were 3% points less likely to accept the vaccine against COVID-19 [50]. This influence of violence may explain the increase in excess mortality associated with COVID-19, as vaccination is a protective measure against the disease.

Although there was no statistically significant association between “Political Stability and Absence of Violence/Terrorism” and excess mortality in 2020 and 2021, there was a significant and direct association in 2022. One study found that politically stable countries reported more deaths, tests, and cases per capita, as well as higher vaccination coverage compared to corrupt countries. This could be because the most corrupt countries face challenges in registering cases and have lower testing rates, as corruption may have affected the availability of resources and inputs [51].

Greater government effectiveness and less “Political Stability and Absence of Violence/Terrorism” before the pandemic were associated with faster initial responses from the government. This may suggest that “Political Stability and Absence of Violence/Terrorism” function differently from other governance dimensions. However, it is not clear how this dimension affects decision-making in times of crisis [52].

Despite political stability, countries responded differently to the pandemic. Politically stable nations conducted more testing and had higher numbers of cases and deaths due to COVID-19 compared to countries with political instability. Countries with worse governance indicators and more corruption were associated with decreased reporting of cases, deaths, and testing [51]. This may be related to the result of the present research, which showed a direct and significant association between “Political Stability and Absence of Violence/Terrorism” and excess mortality in 2022.

The results of the current study suggest that the covariates of vaccination were not linked to increased mortality in 2021 and 2022. A previous study indicated that countries that achieved more efficient vaccination rates in the initial phase of the pandemic had a reduction in the number of people infected [53]. The difference between these results may be due to the type of outcome analyzed by the studies, which was excess mortality versus the number of people infected. Additionally, vaccination efficiency may be linked to other factors such as the logistical capacity to store and distribute vaccines, and proper communication of the importance of vaccination to the target population.

Surprisingly, countries that made vaccination available to the entire population later had a lower rate of accumulated infection compared to countries that made it available earlier. It was expected that the sooner universal availability of vaccines was achieved, the lower the infection rate would be. The period considered for the accumulated infection rate was from January 1, 2020, to September 30, 2021. In 2020, none of the countries had achieved the availability of vaccines for the entire population, which may have influenced the results. Countries that achieved universal availability of vaccines from January to June 2021 may have had a higher accumulated infection rate in 2020.

A study assessing eight countries, selected based on the criteria of vaccine doses (60 doses per 100 people) and a population of over one million individuals, matched the results of the present research, showing that infection rates in all countries were reduced after vaccination [54].

Our findings showed that the variables related to vaccination were significant and inversely proportional. This means that both the “Vaccination Policies” variable in 2022 and the “Administration of first dose” variable in 2021 were inversely correlated with governance indicators. Countries that adopted vaccination policies or administered the first dose later had lower governance indicators. However, this relationship between governance and vaccination is influenced by several factors such as distribution capacity and hesitation to receive. The availability of vaccines to certain groups, such as frontline healthcare workers, the vulnerable, and the elderly, and achieving universal availability are related to vaccination policies. Moreover, throughout the pandemic, countries with low levels of governance, which initially had low levels of vaccination, achieved approximately half the doses per 100 people of countries with better governance [55]. The present study did not consider the factors related to the storage, transport, and distribution of vaccines as possible confounding factors, which may have influenced the results.

Another study analyzing data from 204 countries showed that good governance was associated with earlier administration of the first dose by 9.1 days. Government effectiveness followed by political stability were the indicators with the largest association [56]. The findings of the present study indicate that while the other vaccination indicators were positively associated with good governance, the “Vaccination Policies” indicator showed a significant and inverse correlation with the governance indicators. The inverse association of the vaccination policies indicator with governance was unexpected, given that this indicator reflects a country’s ability to provide universal access to the COVID-19 vaccine, especially for vulnerable groups such as the elderly, frontline workers, and clinically vulnerable individuals and to the entire population. It is important to investigate further the relationship between governance and vaccine availability, as this can help us prepare better for future pandemics. Our findings corroborate a previous study including 172 countries showing that good governance is associated with higher rates of vaccination against COVID-19 [57]. However, different indicators weighed differently in that study i.e., “Voice and Accountability,“ (22%) “Political Stability and Absence of Violence/Terrorism” (19%) and “Regulatory Quality” (16%) were the indicators that weighed most in vaccination performance, approximately three months after the first vaccine against COVID-19. In our study, “Government Effectiveness” had a stronger correlation with the governance indicators while “Voice and Accountability” had a weaker correlation.

The governance indicators that were associated with lower excess mortality due to COVID-19 were those related to the quality of public services provided, the formulation and implementation of solid policies and regulations, and trust and respect for society’s rules. So, improving and strengthening these aspects can help us face future pandemics better. Controlling corruption can also improve public trust in politicians and the government’s credibility [58, 59]. In other words, strengthening national governance can improve our level of preparation and response to future pandemics.

Our study has some limitations that should be acknowledged. The cross-sectional nature of the study makes it difficult to draw any causal conclusions. The confounding factors considered in this research needed to be limited to a manageable number and do not pretend to represent the hole complexity of the topic. It has to be emphasized that our analysis did not take into account relevant socioeconomic indicators and cultural [60], social and societal values. The research results may have been impacted by missing data and temporal variation in COVID-19 outcomes. It is also important to note that the correlation coefficient analysis does not imply a cause-and-effect analysis.

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