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Background  Government responses to the pandemic varied in terms of timing, duration, and stringency, seeking to protect healthcare systems, whose pre-pandemic state varied significantly. Therefore, the severity of Covid-19 and, thus, excess mortality have been unequal across counties. This paper explores the geography of excess mortality and its underlying factors in 2020, highlighting the effects of health policies pre-pandemic and strategies devised by governments to cope with Covid-19.    Methods  Excess mortality is estimated for 79 high, medium and low-income countries. The factors of excess mortality are examined employing median quantile regression analysis.    Results  Health privatization, healthcare underfunding, and late implementation of containment and mitigation strategies were powerful drivers of excess mortality. By contrast, the results suggest a negative association of excess mortality with health expenditure, number of doctors and hospital beds, share of population covered by health insurance and test and trace capacity.    Conclusions  The evidence highlights the importance of sufficiently funded healthcare systems with universal access and strong primary healthcare in the battle against the pandemic. An early response to Covid-19, including borders’ controls and a strong test and trace capacity, could improve epidemiological surveillance and minimize excess mortality, with stringent and lengthy lockdowns not providing a significant benefit.

bmc health services research

The underlying factors of excess mortality in 2020: a cross-country analysis of pre-pandemic healthcare conditions and strategies to cope with Covid-19