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.
- HEALTH POLICY
Data availability statement
Data are available on reasonable request. The data underlying this article are all available through open-access datasets online. The data file used for analysis will be shared on reasonable request to the corresponding author.
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Contributors All authors contributed to all stages of this study, including inception, design, data analysis, data interpretation, illustrations, write-up and discussion, editing and revisions. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: VJ, TB: Drafting the work or revising it critically for important intellectual content: VJ, TB, JC: Final approval of the version to be published: VJ, TB, JC: Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: VJ, TB, JC. Guarantor: VJ.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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