Explaining covid-19 performance: what factors might predict national responses?

Limited consideration of globalisation, geography, and global governance

The GSHI measures the performance of individual nations. However, given the increasingly globalised and interconnected social and economic world, viruses can spread rapidly despite seemingly good preparedness. The GHSI did not consider the importance of geography. For example, islands nations such as Australia, New Zealand, and Pacific island states could close their borders in an attempt to prevent the virus from entering the country. Major air transport hubs in particular posed risks for increased disease transmission. The GSHI also did not consider the contribution of regional organisations (eg the European Union) or global organisations (eg the G20) to coordinating national responses. Failure to coordinate efforts to stem the spread and impact of the virus has yielded considerable chaos, including shortages of critical commodities such as personal protective equipment, poorly managed population movements, and lack of standardisation of key trade policies. Thus, disease control may be only as effective as practices within the poorest performing countries.4

Bias to high income countries

Researchers in US institutions developed the GHSI, advised by a panel of international experts. Critics of the GHSI argued the experts’ emphasis on biosafety over other capacities reflects a bias to high income countries.456 For example, there is tension between biosecurity focused, authoritarian approaches to public health and more comprehensive, social determinants driven, participatory and rights based approaches, which require effective community participation.7 The pandemic has highlighted the importance of the latter and the need to involve a broad range of experts from different backgrounds, including civil society, to develop and implement an effective response to a public health crisis.

Failure to assess health system capacity

Nations with universal publicly funded health systems that were not financially distressed and had strong public health capacity seem to have been relatively well prepared for covid-19: these include Thailand, Vietnam, Australia, and New Zealand. Conversely, the pandemic highlighted the weaknesses of fragmented systems relying on for-profit healthcare providers, such as in the US. Covid-19 exposed fragile and chronically underfunded public health systems and weak pandemic preparedness activities. England outsourced testing and tracing to private companies with no relevant experience, which created a fragmented system separate from existing health service, university, and veterinary laboratories and from those experienced in contact tracing in local government or sexual health clinics. The tracing system in particular performed poorly, using a telephone based system that ignored the importance of the local knowledge of contact tracers, termed “shoe leather epidemiology.”8 The result was an ineffective and fragmented programme which hampered efforts to control the outbreak. These factors also highlight the importance of being able to draw on a well functioning public health system.9 Vietnam, whose public health system emphasises care, solidarity, and community responsibility, has had low covid-19 cases and death rates although it scored low on the GHSI (50th place; score 49.1).

Role of political leadership

The GHSI measures trust in government, but it overlooked the role that political leadership and ideology plays in shaping public health responses.10 The GHSI rated New Zealand lower than many other high income countries (35th place; score 54.0). Yet many praise Prime Minster Ardern’s strong political leadership during the covid-19 crisis, especially her empathic and clear communication to the public and evidence based response. By contrast, other leaders, including in the US and Brazil, failed to accept scientific public health advice, including mask wearing and social distancing, promoted unproved therapies, and criticised the World Health Organization. In the UK, rated second highest on the GHSI, the covid-19 response was hampered by the process of leaving the European Union, which dominated the attention of politicians and efforts of civil servants.11 The perils of populist leaders in pandemic responses have been previously highlighted.12

Assessing political leadership and philosophy may risk politicising the index and opening it to criticism from countries with low scores. However, existing frameworks for assessing the quality of a country’s governance,13 effectiveness,14 and transparency can be drawn on.15 Examples of poor governance during covid-19 include the growing concern about corruption in the procurement of essential equipment and the absence of transparency when contracting with private companies.16 Given the vital importance of trust during a pandemic, political leaders who promote transparent government are more likely to mount a more effective response.

Importance of context overlooked

Consideration of context is key to the accurate assessment of health interventions.1718 Yet to allow for cross country comparisons, indices often reduce complex systems to a standard set of measures that overlook important differences, such as dynamic political, economic, and social structures and systems6

The context can include the degree of centralisation of power. New Zealand and Vietnam have centralised governments, and both fared well in response to covid-19. Some federated states including India, the US, Belgium, Australia, and South Africa have pandemic responses that have varied in effectiveness across the country and point to the value of national coordination. Italy’s regional structure allowed it to largely contain the pandemic in the north of the country during the first wave.19 However, this containment broke down in the summer as Italians went on holiday20 and exposed weaknesses in the regional health infrastructure and preparedness in regions that had escaped the initial wave.21 Future predictive work would benefit from a qualitative, context assessment of each country, informed by a range of expertise.

Limits of national wealth as predictive factor

The GHSI report noted a positive correlation between gross domestic product (GDP) (0.37) and GDP per capita (0.44) and the GHSI score.1 But national wealth may not be the only or main determinant of health security. Lower income countries may allocate their scarce resources more appropriately and tailored to context.56 In Rwanda, a strong health system, rapid lockdown, and effective contact testing and testing of staff at national borders and those working in public spaces, such as banks and bars, have kept cases low and no deaths have been recorded.22 Similarly, despite Vietnam’s low GDP it has had a highly effective pandemic response. Such outcomes confirm earlier analyses that low income countries can use their resources efficiently and innovatively to achieve good health.23

No examination of inequalities within countries

The covid-19 pandemic has heightened pre-existing inequalities in many countries. Most nations reported minority populations being most vulnerable. In the US, black, Hispanic, and Native American people were more susceptible to infection, severe illness, hospitalisation, and death.242526 In Australia, recently arrived migrants faced greater risk,27 while minority ethnic groups bore a high burden in the UK.28 In South Africa most infection hot spots arose in high density, overcrowded settlements with poor access to water and other basic services and heavy reliance on cramped private taxi transport in the absence of any public transport.29 In Brazil, social inequities and structural racism placed pregnant and postpartum black women at higher risk of death.30 Everywhere, marginalised people and those living in precarious situations tend to fall through the cracks in the social safety nets, find it harder to isolate when required, and cannot avoid settings where the risks of infection are high. Marginalised people also face the risk of losing their jobs and housing, fail to qualify for social security, and face food insecurity. Future iterations of the GHSI should include measures of the scale and nature of inequalities within a country.

Importance of social security provisions

The covid-19 pandemic has highlighted the importance of social security provisions to protect people from losing their jobs and homes, yet the GHSI does not consider them in its assessment. Government support to people and businesses affected by covid-19 has been important. For example, in many high income countries, unemployment benefits and job and income support schemes have protected many from extreme poverty, whereas in most low and middle income countries such income protection does not exist. In India the absence of government support forced tens of thousands of migrant workers to return to their home villages. Some died and many faced police harassment and hunger. In many countries the availability of sick leave has been an effective public health measure as people without this provision have found it difficult to follow public health advice to self-isolate. Including measures of social protection would improve future indices.

Civil society capacity not assessed

The GHSI did not assess the capacity of civil society organisation to assist in pandemic responses. Social solidarity built on civil society engagement can offer protection even where trust in government is weak. For example, in South Africa, Cape Town’s community action networks are working to both ameliorate the consequences of lockdown and reduce local transmission. Using social media, they built local relationships based on trust and challenged divisive individualism by creating a collective consciousness for responses to covid-19 related issues.31 Societies can also create political space for civil society and social movement activists to protest human rights abuses, which often increase under the cover of exceptional or emergency pandemic measures.32 Future exercises should include civil society perspectives and their potential to respond to pandemics.

Gap between capacity and its application not assessed

Although the GHSI assessed the theoretical capacity of a country to respond to a pandemic it did not examine the actual capacity and willingness to respond. For example, the US scored high on applied epidemiology training programmes (indicators 2.3.1) but political intervention prevented the Centres for Disease Control and Prevention from applying epidemiological science to responses to the pandemic. A complex system is only as strong as its weakest point. Preparedness assessments based on system critical components discussed here work best.