Democratic governance and excess mortality during the COVID-19 pandemic
Authors: Jain Vageesh , Clarke Jonathan , Beaney Thomas 
Published: August 2021

AbstractBackgroundExcess mortality has been used to assess the 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. On the other hand, democratic governments have been criticised as slow to enforce restrictive policies and being overly influenced by public opinion. This study sought to understand whether strength of democratic governance is associated with the variation in excess mortality observed across countries during the pandemic.MethodsThrough linking open-access datasets we constructed univariable and multivariable linear regression models investigating the association between country EIU Democracy Index (representing strength of democratic governance on a scale of 0 to 10) and excess mortality rates, from February 2020 to May 2021. We stratified our analysis into high-income and low and middle-income country groups and adjusted for several important confounders.ResultsAcross 78 countries, the mean EIU democracy index was 6.74 (range 1.94 to 9.81) and the mean excess mortality rate was 128 per 100,000 (range -55 to 503 per 100,000). A one-point increase in EIU Democracy Index was associated with a decrease in excess mortality of 26.3 per 100,000 (p=0.002), after accounting for COVID-19 cases, age ≥ 65, gender, prevalence of cardiovascular disease, universal health coverage and the strength of early government restrictions. This association was particularly strong in high-income countries (β -47.5, p<0.001) but non-significant in low and middle-income countries (β -10.8, p=0.40).ConclusionsSocio-political factors related to the way societies are governed have played an important role in mitigating the overall health impact of COVID-19. Given the omission of such considerations from outbreak risk assessment tools, and their particular significance in high-income countries rated most highly by such tools, this study strengthens the case to broaden the scope of traditional pandemic risk assessment.Key MessagesWhat is already known?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.In Europe, more democratic countries were initially more reluctant to adopt restrictive COVID-19 measures that could conflict with democratic principles, including lockdowns.What are the new findings?We found that a one-point increase in EIU Democracy Index was associated with a decrease in excess mortality of 26.3 per 100,000 (p=0.002), after accounting for several confounders including demographics, numbers of cases and the strength of early government responses.This association was particularly significant in high-income countries (β - 47.5, p<0.001), suggesting that way societies are governed has played an important role in mitigating the impact of COVID-19.What do the new findings imply?Given the omission of social, political and cultural considerations from outbreak risk assessment tools, and criticisms of such tools that have failed to accurately reflect the observed impact of the pandemic across high-income countries, this study builds on the case to broaden of the scope of traditional pandemic risk assessment.Future research into the mechanisms underlying our findings will help to understand and address the complex and deep-rooted vulnerabilities countries face in a protracted and large-scale public health emergency.