Structural gradients in excess mortality during and after the COVID-19 pandemic: economic development, preparedness,...

Excess mortality has emerged as a comprehensive indicator of overall mortality burden of the COVID-19 pandemic, reflecting both direct and indirect deaths beyond officially reported COVID-19 fatalities. However, the substantial cross-national variation in excess mortality remains incompletely explained, particularly in relation to structural heterogeneity across countries. This study examines whether pandemic mortality differs according to economic development and national preparedness.

We analysed 59 countries from 2020 to 2024. Excess mortality ratios were estimated based on pre-pandemic mortality trends (2015-2019). Countries were classified as advanced or emerging market economies based on the International Monetary Fund criteria. National preparedness was assessed by the 2021 Global Health Security (GHS) Index. Associations between preparedness and excess mortality were evaluated using regression models and interpreted using SHapley Additive exPlanations (SHAP)-based analysis to quantify domain-level contributions to predict mortality.

Excess mortality peaked globally in 2020 and 2021 and declined thereafter. During the early period of the pandemic, emerging market economies experienced consistently higher total and non-COVID (excluding officially reported COVID-19 deaths) excess mortality than did advanced economies. Using the pooled analyses during the early pandemic period (2020-2021), higher overall GHS Index scores were significantly associated with lower excess mortality. However, this association weakened after stratification by economic development stage, indicating that the pooled associations were largely driven by structural differences between economic groups. Early detection and risk environment as preparedness domains were strongly associated with reduced excess mortality.

Cross-national differences in pandemic mortality were primarily shaped by structural capacity gradients rather than preparedness scores. Therefore, preparedness indices might function better as indicators of broader structural capacity than predictors of mortality outcomes in comparable economic contexts. Strengthening pandemic resilience should prioritise surveillance capacity and institutional robustness to enhance baseline preparedness capacity.