Association between democratic governance and excess mortality during the COVID-19 pandemic

Background 

Excess mortality has been used to assess the overall health impact of COVID-19 across countries. Democracies aim to build trust in government and enable checks and balances on decision making, which may be useful in a pandemic. But during the pandemic, they have been criticised as being hesitant to enforce restrictive public health measures.

Methods 

Through linking open-access datasets we constructed univariable and multivariable linear regression models investigating the association between country V-Dem Liberal Democracy Indices (LDI), representing strength of democratic governance and excess mortality rates, from January 2020 to September 2021. We adjusted for several important confounders and conducted a range of sensitivity analyses to assess the robustness of our findings.

Results 

Across 78 countries, 4.19 million deaths million excess deaths were recorded. On multivariable regression, a one-point increase in V-Dem LDI was associated with a decrease in excess mortality of 2.18 per 100 000 (p=0.004), after accounting for age, gender, wealth and universal health coverage. This association was only partially attenuated by COVID-19 vaccination rates and remained robust in all sensitivity analyses.

Conclusions 

Democratic governance may have played an important role in mitigating the overall health impact of COVID-19 across countries. This study strengthens the case to broaden the scope of traditional pandemic risk assessment and discussions on preparedness.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Previous studies have found that as countries become more democratic they experience a decline in rates of infant and child mortality, infections such as tuberculosis and non-communicable diseases.
• Within Europe, more democratic countries were initially more reluctant to adopt restrictive COVID-19 measures that could conflict with democratic principles, including lockdowns.
• Existing studies have investigated the relationship between governance and COVID-19 deaths across countries, but these studies fail to capture the indirect impact of epidemics, by excluding deaths not recorded as being due to COVID-19.
• It is not yet clear whether on balance, democratic governance has been beneficial or detrimental to the impact of COVID-19 across countries.

WHAT THIS STUDY ADDS

• Across 78 countries and 4.19 million deaths, stronger democratic governance was significantly associated with fewer excess deaths during the COVID-19 pandemic.
• The robustness of deliberative decision-making processes was the only specific feature of democratic governance found to be associated with fewer excess deaths.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Given the omission of sociopolitical considerations from outbreak risk assessment tools, this study builds the case to broaden of the scope of traditional pandemic risk assessment and discussions on preparedness.
• Future research into the mechanisms underlying our findings will help to understand and address the complex vulnerabilities countries face in a protracted public health emergency.

an observational study