Data, et cetera



Country vulnerability to pandemics

March 30, 2020

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The novel coronavirus, COVID-19, was declared a global pandemic on March 11, 2020. As of March 2020, more than 600,000 people have been diagnosed with the virus. Since no country has reliable data on the prevalence of COVID-19, the actual number of people impacted is certainly much higher.

As the pandemic continues to grow, significant differences in country responses and viral epidemiology have emerged. For instance, the proportion of diagnosed patients that ultimately die from the infection varies monumentally between countries. As of the end of March, the case fatality rate varies from about one death for every nine diagnoses in Italy to one in 150 cases in Germany.

To explain these differences, some have noted that the German patients are overall younger, and the country has successfully protected its elderly citizens. By contrast, Italy has an older population, with great intergenerational cohabitation. South Korea has experienced low fatality rates, despite eschewing quarantine measures in favor of extensive contact tracing, a rigorous triage system developed during the MERS outbreak, and public and transparent sharing of epidemiological data.

Treatment, food, and vaccine: measures of readiness

Of course, the public health efforts taken to contain a pandemic are only part of the story. The second part of the question is how resilient countries are when containment measures fail and a virus becomes widespread. At this stage, other factors become important in preventing broader harm. We examine several indicators to assess country vulnerability to pandemic.

First, we compared each country's ability to deliver healthcare in a pandemic scenario. We use two metrics: the number of hospital beds per capita and the percent of each country's health expenditures that are paid out-of-pocket. The first indicator captures the ability for a healthcare system to absorb a large number of patients requiring intensive care, while the second measures the likelihood of a population experiencing financial hardship as a result of escalating healthcare needs.

Second, we note that in periods of quarantine, rising unemployment (due to layoffs or medical illness), and public anxiety, the ability for a country to continue to feed its population may be tested. We use The Economist's Global Food Security Index, a composite metric that evaluates the affordability, availability, and quality of food and food delivery. In countries with weak food security, a pandemic may tip the scales toward increased hunger and malnourishment.

Four metrics of pandemic resilience

Select a metric:

Source: Out-of-pocket expenditure (% of current health expenditure) (2016) and hospital beds per 1,000 population (most recent year of data) are from the World Bank. The Global Food Security Index is from The Economist Intelligence Unit (December 2019 model). Vaccine coverage data are the average coverage rate for diphtheria and tetanus toxoid with pertussis containing vaccine (DTP, third dose), measles containing vaccine (MCV, second dose), and pneumococcal conjugate vaccine (PCV, last dose in the schedule). Data are from the WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) (2018).

Finally, we consider that the current COVID-19 pandemic may only end with the development of a vaccine or curative treatment. In this scenario, countries will need to rapidly deliver the new treatment throughout their populations, testing their healthcare supply chains and delivery systems. As a proxy for this, we evaluate the current vaccination coverage of three childhood vaccines. Although a COVID-19 vaccine would be delivered to a different (i.e. not pediatric) population, we consider it reasonable that a country with barriers to delivering other vaccines may experience the same challenges with a novel cure.

Ready or not? A metric of pandemic resilience

For the capacity to deliver inpatient care, Japan, South Korea, and Belarus rate the highest: each country has more than ten inpatient hospital beds per 1,000 people. Globally, countries in Europe have the highest number of per-capita beds, with the notable exceptions of Sweden, the United Kingdom, Italy, Spain, and Portugal. The lowest rates of hospital beds are in Africa (with the lowest rates in Mali, Madagascar, Niger, Sengal, Guinea, and Ethiopia) and South Asia (notably Nepal, Pakistan, and India).

Regardless of health system capacity, the ability for patients to financially afford care rates highest in Botswana, Oman, Rwanda, Mozambique, South Africa, Qatar, and France: each countries where out of pocket payments constitute less than 10% of total healthcare expenditures. The United States similarly has low out of pocket spending (11%). By contrast, in Azerbaijan, Nigeria, Myanmar, Sudan, and Bangladesh, more than 70% of all healthcare spending is paid out of pocket. In countries such as these, choosing to go to a hospital to seek care has the potential to be unaffordable or cause significant financial hardship.

Top ten most vulnerable countries

Source: Out-of-pocket expenditure (% of current health expenditure) (2016) and hospital beds per 1,000 population (most recent year of data) are from the World Bank. The Global Food Security Index is from The Economist Intelligence Unit (December 2019 model). Vaccine coverage data are the average coverage rate for diphtheria and tetanus toxoid with pertussis containing vaccine (DTP, third dose), measles containing vaccine (MCV, second dose), and pneumococcal conjugate vaccine (PCV, last dose in the schedule). Data are from the WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) (2018).

Using the Global Food Security Index (GFSI) as a proxy for the affordability and stability, we find that the most secure food systems are in Singapore, North America (United States, Canada), and Europe (Ireland, Switzerland, Finland, Norway, and Sweden). By contrast, the weakest countries for food access, quality, and affordability are Venezuela, Burundi, the Democratic Republic of Congo, Chad, and Madagascar. In these countries, fluxuations in access or cost of foods may tip countries into a food crisis.

Finally, national coverage of childhood vaccines is highest in several Middle Eastern countries (United Arab Emirates, Kuwait, Oman), Malaysia, Hungary, and China. Very low (lower than 50%) vaccination coverage is observed in Venezuela, Haiti, Chad, Guinea, and the Philippines. These countries may struggle to deliver a novel pandemic cure to its population, as a result of health system capacity, supply chain systems, or other barriers.

Top ten most resilient countries

Source: Out-of-pocket expenditure (% of current health expenditure) (2016) and hospital beds per 1,000 population (most recent year of data) are from the World Bank. The Global Food Security Index is from The Economist Intelligence Unit (December 2019 model). Vaccine coverage data are the average coverage rate for diphtheria and tetanus toxoid with pertussis containing vaccine (DTP, third dose), measles containing vaccine (MCV, second dose), and pneumococcal conjugate vaccine (PCV, last dose in the schedule). Data are from the WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) (2018).

To unify each of these indicators into one metric, we standardized and combined each metric (using a sum of z-scores). In this way, we are able to compare the entire planet using one unified measure of pandemic resilience.

We find that the countries most resilient to an infectious disease outbreak are Japan, Germany, South Korea, Belarus, and France. In each of these countries, the country has a proportionately high number of hospital beds, patients pay a low proportion of healthcare expenses (with the notable exceptions of South Korea and Belarus), have resilient food systems, and successfully deliver vaccines to the vast majority of children.

By contrast, Chad, Venezuela, Haiti, Nigeria, and Guinea are the most vulnerable countries, according to this metric. Each has limited capacity to deliver inpatient care, patients bear a large proportion of the costs of healthcare, the food access, quality, and affordability are poor, and vaccination coverage is low. In a pandemic scenario, each of these countries may be unable to deliver lifesaving care, patients may face large financial barriers in seeking care, food may become scarce or unaffordable, and patients may struggle to get access to any novel curative treatment.

What does it mean for COVID-19?

There are many reasons that a country may struggle with the response to COVID-19. These include (but are not limited to) weak or delayed testing, insufficient contact tracing, healthcare system barriers, socioeconomic factors, or demography. The four indicators described here are just four of these potential factors, and may or may not be the ones that matter in the COVID-19 response.

Nonetheless, as COVID-19 continues its spread across the globe, this analysis provides a clue at which countries may be the ones to experience the greatest devastation and long-term harm.




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