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Medical staff in Belgium in PPE transferring a man from an ambulance to a hospital

Why countries best placed to handle the pandemic appear to have fared the worst

During the first year of the pandemic, it was wealthier countries, with their comparatively stronger health systems, civil services, legal systems and other public services, that suffered the highest rates of COVID-19. Indeed, countries rated to be best prepared to respond to public health threats such as pandemics – those with the greatest “global health security” – had the most COVID-related fatalities.

On the face of it, this makes no sense. Poorer countries with weaker, less effective state institutions wouldn’t be expected to fare better in a pandemic. So in a recent working paper, we took a deep dive into the statistics to find out what might explain this unusual situation.

We looked at three core dimensions that tend to describe how effective states are at doing things. If states are effective, they usually have greater authority to provide order and security, greater capacity to provide public services, and greater legitimacy (which is a measure of how accepting citizens are of the state’s fundamental right to rule over them). So when preventing or dealing with COVID-19, we expected states with high authority (such as China), high capacity (Finland) and high legitimacy (Canada) to have an advantage over those with low authority (Honduras), low capacity (Liberia) and low legitimacy (Uzbekistan).

But this wasn’t the case. Simple correlations between these three core dimensions of the state and COVID-19 health outcomes are puzzling: countries with higher state effectiveness – no matter the dimension used to measure it – have had higher rates of COVID-19 infections and fatalities. And an initial look at national policies to contain the disease similarly reveals the unexpected: greater state effectiveness seems to be linked, weakly but still, to lighter restrictions.

Moreover, countries rated as having high authority and high capacity have also been slower than those with lower assessments to enact containment policies. Some “weaker” states – for instance, the Central African Republic, Somalia and Yemen – closed and cancelled public events more quickly than states considered to be more effective.

Data can be deceptive

At a first look, then, the data seems to confirm that typically more effective states were generally less effective in their pandemic response. However, drawing such conclusions from simple correlations is misleading.

There are several factors that can explain differences in pandemic outcomes. For instance, countries bordering others with high infection rates are at a higher risk. This made southern Europe, made up of typically highly effective states, a high-risk area during the first wave of the pandemic, as it was an early place the virus took hold.

Health volunteers in Myanmar being briefed
Myanmar has kept deaths low, despite having a weak health system and relying on volunteers to counter COVID-19. Lynn Bo Bo/EPA-EFE

And because the elderly are more vulnerable to the virus, countries with older populations are also more susceptible to COVID-19. In some countries with highly effective state institutions, like Japan and Germany, over 20% of the population is 65 and above. In Uganda or Mali, for instance, it’s only around 2%.

We also know that with higher rates of COVID-19 testing, more infections and deaths are detected – and this detection typically happens more in countries with stronger health systems and public services. To get an accurate picture of the relationship between the state and COVID-19, such factors must be controlled for.

A completely different picture emerges once economic development, the age structure of the population, population density, testing rates, and proximity to badly affected countries are taken into account. When these relevant factors are analysed, it appears more effective states have mounted more effective pandemic responses. There are, though, some differences in outcomes according to the three different dimensions of the state that we mentioned previously.

When controlling for the above factors, states with a greater capacity to provide public services have had fewer COVID-19 infections and deaths, as well as a lower ratio of infections leading to deaths (what’s known as the case-fatality rate). States with greater authority have also had lower case-fatality rates – consistent with our expectations – though not infections and deaths. On the other hand, there is no clear relationship between state legitimacy and pandemic outcomes.

A Polish woman being vaccinated against COVID-19.
Stronger health systems and other public services will become more of an advantage as vaccines are rolled out. Maciej Kulczynski/EPA-EFE

Weaker states remain vulnerable

Such findings should remind us that having strong state institutions does really matter – even if on the surface it looks like these institutions have failed.

This isn’t to say that many countries with “weaker” and less well-funded state institutions have not performed admirably in the pandemic. Prior experience with infectious diseases, public support for restrictions, and strong community action, among other factors, have all been important.

But admiring the resilience of communities and the skill and resourcefulness of (some) public officials should not distract us from the fact that those who live in weaker states remain, on average, more vulnerable to the pandemic in health and economic terms. As the COVID-19 crisis continues, we mustn’t let deceptive data hide the fact that those living in countries with less effective state institutions remain at a huge disadvantage, and that truly the pandemic has both reflected and exacerbated existing inequalities.

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