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Original research
Association between democratic governance and excess mortality during the COVID-19 pandemic: an observational study
  1. Vageesh Jain1,
  2. Jonathan Clarke2,
  3. Thomas Beaney3
  1. 1 Institute for Global Health, University College London, London, UK
  2. 2 Department of Surgery and Cancer, Imperial College London, London, UK
  3. 3 Department of Primary Care and Public Health, Imperial College London, London, UK
  1. Correspondence to Dr Vageesh Jain, Institute for Global Health, University College London, London WC1E 6JB, UK; vageeshjain{at}gmail.com

Abstract

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.

  • MORTALITY
  • COVID-19
  • HEALTH POLICY
  • EPIDEMICS

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.

This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

https://bmj.com/coronavirus/usage

https://doi.org/10.1136/jech-2022-218920

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    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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    Footnotes

    • 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.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.