Measuring the COVID-19 Policy Response Around the World
In an analysis of 31 high-income nations, Asian countries have performed the best.
The COVID-19 pandemic has been a challenge for the entire world. But, clearly, some countries are performing better than others. What can we learn from those that have done well — and also from those who have done poorly?
These questions animated the pandemic response measure in the FREOPP World Index of Healthcare Innovation, a comprehensive look at health care systems in 31 high-income countries.
Measuring fatalities, restrictions, vaccinations, & isolation from foreigners
There are many places to look for raw statistics on COVID-19 cases, hospitalizations, and deaths. But we wanted to go a level deeper.
Focus on fatalities. First, we only looked at COVID-19 fatalities per million residents, not cases or hospitalizations. While fatalities are counted in different ways by different people in different countries, death remains the most objective measure of pandemic severity, especially in comparison to “cases,” which require either symptoms of COVID-19 or a positive test for the SARS-CoV-2 virus. (Since COVID-19 infections can be asymptomatic, cases are not a reliable indicator of pandemic severity.) Excess deaths are perhaps the most reliable way of comparing COVID-19 fatalities across countries, though even excess death counts are imperfect, because they do not distinguish between deaths caused by the coronavirus and those caused by lockdown-related policies.
Compare economic restrictions. We wanted to examine if any countries had been successful at reducing mortality rates with a relatively light touch in terms of economic restrictions. We captured monthly data from the Oxford Government Response Stringency Index beginning on April 15, 2020 in order to compare how aggressive they were in their economic policy responses to the pandemic. The scores from each month were added to create the lockdown stringency score in the table below.
Vaccine distribution. The most significant recent development has been the regulatory approval of several COVID-19 vaccines, a process that was rapidly accelerated by the Trump administration’s Operation Warp Speed program, which funded up-front the costs of manufacturing the vaccines, even before we knew whether or not they were going to work. However, there has been wide variation in the success of countries—and even within countries—at distributing and administering COVID-19 vaccines. As of March 31, 2021, Israel and the United Arab Emirates stand out as success stories, while much of Europe and the Pacific Rim is in disarray, risking a prolonged pandemic in those regions.
How susceptible were countries to COVID-19 pandemic spread?
Purely examining mortality rates and lockdown stringency does not capture the susceptibility that various countries had to pandemic spread. Some countries have had an inherent advantage in combating COVID-19 in that their economies and societies were more isolated from other parts of the world, especially other parts of the world where the pandemic was already spreading.
In attempt to account for this relative integration or isolation, we added a third measure, based on 2019 passenger travel and tourism volume from the International Air Transport Association and the World Tourism Organization. These measures do not perfectly capture global economic integration or isolation, but they provide some indication of which countries were most susceptible to transmission from elsewhere.
Another question is how much to weight raw travel volume vs. the population of a given country. The U.S. has the most travel volume in our survey, but is also the largest country by population. The exponential nature of COVID-19 transmission argues for overweighting raw volume relative to population; that is, all it takes is one infectious person to transmit the disease to dozens of his acquaintances. Hence, we used the following formula to capture economic isolation: (2019 tourism & travel volume) ^ 1.5 / population. As with fatalities per million and lockdown stringency, this figure was then standardized into a 0–100 scale and then weighted at 15% relative to 35% for mortality and 25% each for economic stringency and vaccinations per 100 residents. (An earlier version of this analysis weighted each measure equally, but a lighter weighting for the isolation measure is warranted, given its imprecision.)
Asian countries top the rankings
The top three countries in our analysis were Asian: the United Arab Emirates (#1), Taiwan (#2), and Singapore (#3). New Zealand and Hong Kong, two more Pacific Rim territories, ranked fourth and fifth, respectively.
In our previous survey from August 2020, the top five countries were Taiwan, Japan, Hong Kong, Norway, and New Zealand.
Taiwan, Singapore, and New Zealand have enjoyed remarkably low mortality rates from COVID-19, but the U.A.E. took the top spot in our rankings due to their fairly low death rates combined with terrific success at administering COVID vaccines: 84 doses per 100 residents as of March 31, 2021. Many of the countries where the pandemic death toll has been low have not yet successfully distributed the vaccine, prolonging the risk of COVID deaths in the future.
On the other hand, Hong Kong stands out for its high global integration, as measured by travel volume, and both Hong Kong and Taiwan for their close proximity to China, where the virus originated. The results of Hong Kong and Singapore (#9) are especially impressive when one considers that both places are small city-states with high population density: a problem that has driven a severe outbreak in New York City.
Eastern & central European nations have fared poorly
Most people are familiar with the images of Italian hospitals being overwhelmed with COVID-19 patients. But much less attention has been paid to central and eastern Europe, which has the highest mortality rate in the world.
The bottom seven countries in our pandemic rankings—the Czech Republic (#31), Hungary (#30), Belgium (#29), Slovakia (#28), Italy (#27), Portugal (#26), and Poland (#25)— reflect a combination of high mortality rates, poor vaccination rates, and ineffective economic lockdowns.
In comparison to the United States (#17), Italy and the United Kingdom (#24) are notable comparators, because these countries experience a high degree of international travel, like the U.S., and imposed lockdowns that are stricter than those in America. But they both have also seen significantly higher mortality rates from COVID-19.
Another important factor in evaluating the U.S. — one that is not part of our evaluation — is the geographic variation in pandemic severity. If the northeastern United States from Virginia to New Hampshire were examined as a separate country, it would rank much worse on both mortality and lockdown severity. By the same token, the rest of the U.S. would rank higher.
Single-payer health care is not correlated with pandemic success
Some have argued that if the U.S. had a single-payer health care system, it would have fared better in its COVID-19 response. But there is no correlation between the format of a country’s health insurance system and its ranking in our analysis. Taiwan (#2) has a single-payer system and has performed extremely well, but Italy (#27) and the U.K. (#24) also have single-payer systems and performed poorly.
Similarly, countries with private insurance and/or consumer-driven models models are also all over the rankings. Japan (#7), Hong Kong (#5), and the Czech Republic (#31) all have public-private hybrid systems; so do Ireland (#19) and Belgium (#29).
U.S. ranking improved from 27th to 17th
The ranking of the United States in our pandemic response index has gone down and up over time. In the June 2020 version of our analysis, the U.S. ranked 20th. In August, it sank to 27th. In the March 2021 rankings, the U.S. is back up to 17th, thanks to its relatively successful vaccine rollout, and rising death tolls in Europe.
The SARS ‘muscle memory’ hypothesis
While insurance systems do not appear to have any correlation to success in combating COVID-19, another factor does: experience with the original SARS-CoV-1 pandemic in 2002–3. Hong Kong, Taiwan, and Singapore experienced the second, third, and fifth-most fatalities from that previous coronavirus pandemic.
Two phenomena could explain why these countries have had success with SARS-CoV-2 and the 2020 pandemic. The first is that citizens in these countries were acutely aware of the threat posed by COVID-19 due to this past experience, and that they were therefore more prepared and quicker in their response (e.g., by wearing masks) as a result of reports out of Wuhan. Similarly, Asian governments took the threat more seriously early on, and enacted aggressive contact tracing measures and had already built up stockpiles of personal protective equipment.
The second — and most intriguing — possibility is that SARS-CoV-1 spread widely in Asian countries in 2002–3, leading many individuals in those countries to have immunity to SARS-CoV-2. While it would be unusual for coronavirus immunity to last 17 years, it cannot be completely ruled out.
In the 1918 influenza pandemic that killed as many as 100 million people around the world, an unusually high number of young adults were killed, while an unusual proportion of elderly individuals was spared. Researchers in Canada have postulated that those who survived a previous influenza pandemic from 1889–90 were largely immune to the 1918 flu; those who were not yet alive in 1889 were most susceptible to the 1918 version.
Are the West and the East facing different strains of SARS-CoV-2?
There may be an entirely different explanation for the difference between the performance of Pacific and Atlantic nations during the COVID-19 pandemic: that the strain of SARS-CoV-2 that spread through Europe and the eastern United States was more virulent than the one that spread eastward from China to the Pacific Rim and the western United States.
New research from a group of American and English researchers and from Zhejiang University in China indicates that a single point mutation — the substitution of glycine for aspartic acid at position 614 — increases the ability of the SARS-CoV-2 spike protein to attach to human cells, significantly increasing its virulence.
This more virulent G614 strain spread through Italy and the West, while the less virulent D614 form remained more common in China, Japan, and the East. “The transition from D614 to G614 occurred asynchronously in different regions through the world, beginning in Europe, followed by North America and Oceania, then Asia,” write the Los Alamos researchers in Cell.
This difference suggests that relative prevalence of D614 vs. G614 in a given country should be accounted for in international comparisons of COVID-19 performance.
The contribution of long-term care facilities
In the U.S., 38% of all deaths from COVID-19 have occurred in nursing homes and assisted living facilities that house only 0.6% of the U.S. population. The failure to protect this population is not only a problem in the U.S., however; a survey of international countries found similar results.
Indeed, among 22 countries reporting care home fatalities, the U.S. sits squarely in the middle in terms of the share of fatalities occurring in care homes. Among WIHI countries, Canada (80%) and Australia (75%) had the highest concentration of fatalities in nursing homes, whereas Singapore (11%) and Hungary (23%) the lowest.
While Ireland reported a care home fatality share of 56%, its true share is closer to Canada’s, because Ireland, Finland, New Zealand, and Norway do not report deaths of care home residents who die outside of long-term care facilities. In other countries, roughly one-quarter of COVID-19 deaths of care home residents occur in hospitals and other external locations.
Not all COVID success stories are created equal
If we are to improve our policy response to future pandemics, it will be important to distinguish true successes from illusory ones, in which illusory successes are those that were not the result of superior policy decisions but rather due to isolation, immunity, or past experience with coronavirus pandemics. This work will continue, but we hope that we have made an initial contribution to the field.
