Drivers of COVID-19 policy stringency in 175 countries and territories: COVID-19 cases and deaths, gross domestic products per capita, and health expenditures

ABSTRACT

ObjectiveTo understand the associations of COVID-19 cases and deaths with policy stringency globally and regionally. MethodsWe modeled the marginal effects of new COVID-19 cases and deaths on policy stringency (scored 0-100) in 175 countries and territories, adjusting for gross domestic product (GDP) per capita and health expenditure (% of GDP). Time periods examined were March-August 2020, September 2020- February 2021, and March-August 2021. ResultsPolicy response to new cases and deaths was faster and more stringent early in the COVID-19 pandemic (March-August 2020) compared to subsequent periods. New deaths were more strongly associated with stringent policies than new cases. In an average week, 1 new death per 100,000 people was associated with a stringency increase of 2.1 units in March-August 2020, 1.3 units in September 2020-February 2021, and 0.7 units in March-August 2021. New deaths in Africa and the Western Pacific were associated with more stringency than in other regions. Higher health expenditure was associated with less stringent policies. GDP per capita did not have consistent patterns of associations with stringency. ConclusionsOur findings demonstrate the need for enhanced mortality surveillance to ensure policy alignment during health emergencies. Countries that invest less of their GDP in health are inclined to enact stringent policies during health emergencies than countries with more significant health expenditure.