State Capacity and Post-COVID-19 Recovery in Avoidable Mortality and Life Expectancy: A Panel Time-series Analysis Across 38 OECD Countries

Understanding how quickly health systems recover from shocks is essential for strengthening resilience. We examined post-COVID-19 recovery in life expectancy and avoidable mortality across 38 Organization for Economic Co-operation and Development (OECD) countries and whether state capacity was associated with recovery pace.

We analyzed a 2010-2023 country-year panel using OECD and World Bank data, with avoidable mortality through 2022. State capacity was represented by the first principal component of government effectiveness, regulatory quality, and rule of law. Interrupted time series analysis quantified the 2020 shock, hierarchical linear models assessed whether pre-pandemic state capacity moderated recovery slopes, and dynamic panel generalized method of moments estimation addressed potential reverse causality. Because peak impact varied by country, sensitivity analyses used 2021 as the intervention year.

In 2020, life expectancy fell by 1.191 years and avoidable mortality increased by 45.4 deaths per 100 000 population relative to counterfactual trends (both p<0.001). Recovery slopes varied across countries (p<0.001). Higher state capacity was associated with faster avoidable mortality recovery (β=-6.334; p<0.001), persisting after adjustment for healthcare infrastructure, vaccination coverage, and system type and under a 2021 intervention-year specification (β=-6.120; p<0.001). No comparable association was observed for life expectancy.

State capacity was associated with avoidable mortality recovery but not life expectancy recovery. Despite effective early containment, Korea was among the slowest to recover in avoidable mortality, suggesting that outbreak response and essential healthcare continuity may depend on different capacities. Avoidable mortality may warrant monitoring as a health system resilience indicator.