A country’s pre-existing socio-economic and health service capacity may influence its overall ability to effectively respond to the pandemic and may account for differences in COVID-19 CFRs across countries and regions. Earlier studies at the outset of the COVID-19 pandemic identified and/or projected socio-economic factors such as median age, life expectancy, GDP per capita and health indicators such as current health expenditure, number of hospital beds and medical doctors to be associated with COVID-19 CFR (9, 12, 25–26). In this study, current COVID-19 data was used to investigate the effect of inequalities in human development, population median age, pandemic preparedness, vaccination rates, and clinical capacity on COVID-19 CFRs across countries and regions. Geospatial analysis was also used to highlight regional differences in COVID-19 CFRs. We were especially keen to examine what influence socioeconomic inequalities (IHDI) and vaccination rates exerted on COVID-19 CFRs across countries and regions. It is important to add that, the use of current COVID-19 data allowed us to compare the current COVID-19 case fatality burden in the context of cross-country and regional variations of the selected indicators against projections made for various regions in the early days of the COVID-19 pandemic.
Descriptive data for specific regions showed the African region reported the lowest scores for all the selected indicators included in the study. Surprisingly, Mean CFR was highest in the South American region, though the African region followed closely. Africa and South America had the lower average median ages compared to Europe and Oceania. This result may give credence to the argument that low resourced countries, particularly those in Africa and South America, may have significantly younger populations in comparison to more economically developed regions like Europe and Oceania. Similarly, Africa and Asia reported the lowest regional scores for GHSI and COVID-19 vaccination compared to Europe and North America. This supports the need for innovative public health interventions for resource poor regions.
Regional variations in GHSI, IHDI, ICU bed capacity and vaccination rates may be a reflection of variations in pre-existing socio-economic and health resources, and these findings suggest that health care capacity in low resourced regions may be poor in comparison to more economically developed regions. Consequently, it is expected that these low resourced regions may be inadequately prepared to respond to the COVID-19 pandemic resulting in a higher vulnerability to fatalities from COVID-19. A close look at the choropleth map (Fig. 1) generated for all countries depicts wide variations in COVID-19 CFR across all regions of the world, without a clear and consistent pattern in any specific region.
Country median age, IHDI, and vaccination rate emerged as statistically significant predictors of COVID-19 CFR from the regression analysis. Specifically, for median age, the results from the regression analysis revealed that higher country median age is predictive of higher COVID-19 CFR. This finding suggests that countries located in Europe, Oceania and North America with higher rates of older populations may experience higher COVID-19 CFRs than countries with younger populations, such as those in Africa, South America, and Asia. These findings are consistent with earlier studies that found that higher COVID-19 CFR among higher age groups in multiple regions (12, 25, 26). A possible explanation for this result is that many older adults may have pre-existing comorbidities such as diabetes, cardiovascular diseases,, or hypertension (27). Consequently, older adults with comorbidities have the highest susceptibility to COVID-19 fatality (28).
Regarding the emergence of the IHDI as a statistically significant predictor of COVID-19 CFR, the results indicate higher inequalities in human development is predictive of higher COVID-19 CFR. In other words, countries with wide inequalities in human development would have higher fatality rates from COVID-19, while countries with lower inequalities in human development would have lower fatality rates from COVID-19. To be clear on the importance of this finding, IHDI evaluates inequalities in human development by factoring in a measure of the dispersion in the distribution of the measures of health, education, and income used in estimating HDI within a population (22). Individuals in the lower socioeconomic brackets are more likely to have limited access to preventive and treatment opportunities for COVID-19 for various reasons including financial constraints, leading to higher vulnerabilities to COVID-19. This finding is a strong reflection of the effect of underlying inequalities in socioeconomic factors, leading to a disproportionate burden of COVID-19 case fatalities on individuals and communities in the lower socioeconomic brackets and is consistent with the findings of earlier studies that showed worse COVID-19 outcomes for poorer communities (11). This reinforces the urgency for a concerted effort of global investments to support all countries, but especially economically disadvantaged countries.
Vaccination rate emerged as the final predictor of COVID-19 CFR from the regression analysis, with a direction suggesting countries with higher vaccination rates recorded lower overall mortality from COVID-19. This finding is consistent with extant public health recommendations on the efficacy of COVID-19 vaccinations in significantly reducing the risk and associated burden of severe disease, hospitalization, and mortality from COVID-19 (20–21). It is essential to add this finding also underscores the importance of COVID-19 vaccines in the crusade against the pandemic on the global stage. This is especially important in the face of existing inequalities in the distribution and access to COVID-19 vaccines across countries, a situation if allowed to continue, may inevitably lead to the emergence of new COVID-19 variants that may further prolong the pandemic (29) along with the many disruptions to human life that come with it. Concerted efforts among countries and regions in the global community including equitable distribution of resources, such as COVID-19 vaccines, will therefore be critical to the success of the fight against the pandemic.
This study is not without its limitations. First, many countries differ in their definition of COVID-19 related deaths. Subsequently, there may be much variability in recording COVID-19 CFR between countries (30). Additionally, this variability in recording may also be attributed to the distribution of resources in low resource countries compared to high resource countries. High resource countries may implement more strategies for correctly classifying whether or not a death was COVID-19 related (26). Conversely, low resourced countries may have missed deaths attributable to COVID-19 resulting from lack of testing and surveillance (31). Both of these factors may contribute to an overestimation or underestimation of COVID-19 CFR respectively. There is also additional difficulty in assessing COVID-19 CFR rates because of the dynamic nature of the COVID-19 pandemic. Finally, the lack of data on some of the variables of interest across some of the countries is considered a limitation in this study. These limitations notwithstanding, we consider the use of current COVID-19 data from the World Health Organization, inclusion of only countries with data on all the variables of interest as well as the use of geospatial analysis, to highlight regional differences in COVID-19 CFR as strengths in this study.