The underlying factors of excess mortality in 2020: a cross-country analysis of pre-pandemic healthcare conditions and strategies to cope with Covid-19

BACKGROUND: Government responses to the pandemic varied in terms of timing, duration, and stringency, seeking to protect healthcare systems, whose pre-pandemic state varied significantly. Therefore, the severity of Covid-19 and, thus, excess mortality have been unequal across counties. This paper explores the geography of excess mortality and its underlying factors in 2020, highlighting the effects of health policies pre-pandemic and strategies devised by governments to cope with Covid-19. METHODS: Excess mortality is estimated for 79 high, medium and low-income countries. The factors of excess mortality are examined employing median quantile regression analysis. RESULTS: Health privatization, healthcare underfunding, and late implementation of containment and mitigation strategies were powerful drivers of excess mortality. By contrast, the results suggest a negative association of excess mortality with health expenditure, number of doctors and hospital beds, share of population covered by health insurance and test and trace capacity. CONCLUSIONS: The evidence highlights the importance of sufficiently funded healthcare systems with universal access and strong primary healthcare in the battle against the pandemic. An early response to Covid-19, including borders’ controls and a strong test and trace capacity, could improve epidemiological surveillance and minimize excess mortality, with stringent and lengthy lockdowns not providing a significant benefit.