Why COVID-19 infection and death rates were so high in Eastern Europe | Popgen Tech


Two years ago, we examined where Canada stands compared to similar countries on COVID-19 rates. It was part of a larger study that looked at COVID-19 infections based on a country’s welfare regime: liberal, social democratic or conservative/corporatist.

Welfare systems use income redistribution, sick pay, pensions, maternity leave, unemployment support and social assistance to address inequalities in society.

Liberal, social democratic or conservative/corporatist welfare regimes do not always reflect electoral politics. For example, liberal democracies can elect conservative governments. Welfare descriptions deal with how states provide health care, old age or social security to ensure the well-being of their citizens.

Strong welfare, healthier citizens?

Liberal states that include Canada, the United States, Ireland, the United Kingdom, Australia, New Zealand and Japan have modest systems of welfare provision. They rely on minimum government interference.

Social democracies in countries such as Sweden, Norway, Denmark, Finland, Iceland and the Netherlands focus heavily on the provision of state benefits. They also offer universal health coverage.

The conservative/corporatist states that include Italy, Greece, France, Germany, Austria, Switzerland and Belgium offer means/income tested benefits. Their welfare provisions have a low impact in reducing social inequality.

Social epidemiology, which particularly focuses on the impact of social factors on health, has long used welfare state variables to analyze differences in population health. Strong welfare provisions were generally associated with lower mortality rates.

COVID-19 and Eastern Bloc democracies

However, welfare regime theory has paid little attention to Eastern European nations.

Before the fall of communism in Eastern Europe in 1989, the absence of a private market made the state the primary agent in the distribution of resources. After 1989, however, Eastern Europe transitioned to capitalism.

For our research, we expanded our sample to include the former communist states. We divided them into three groups.

The first group includes the former Soviet republics of Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Latvia, Lithuania, Moldova, Russia and Ukraine.

The second group includes the Central and Eastern European countries Bulgaria, Estonia, Hungary, Poland, Romania, Slovakia and the Czech Republic.

The third group includes the southeastern European countries that emerged from the former Yugoslavia: Bosnia-Herzegovina, Croatia, Kosovo, Montenegro, North Macedonia, Serbia and Slovenia. To this we added Albania.

We assumed that the former communist and socialist states had built on their former state-centric approaches to health care and benefit provision—and that this would lead to lower COVID-19 infections and death rates. But contrary to our expectations, the Eastern European states fared worse than Western democracies in the number of cases and deaths from COVID-19.

A smiling man and woman with gray hair are being vaccinated by someone wearing a mask and blue scrubs.
An Albanian couple is vaccinated against COVID-19 in their village of Sukth in Albanian in November 2021.
(AP Photo/Franc Zhurda)


We examined COVID-19 cases and deaths per 100,000 people during the first three waves of the pandemic.

Excess deaths per 100,000 are also included. Excess deaths represent the difference between the number of reported deaths in a country from all causes and the number of deaths that would have been expected if there had been no pandemic.

Health care variables included the number of doctors, nurses and hospital beds, as well as variables related to health coverage – COVID-19 vaccination rates, testing and the provision of universal health care.

Policy variables include public trust in government, stringency of government cuts and income relief.

We found that Western liberal, social democratic, and conservative/corporatist states have lower COVID-19 infections than Central, Eastern, and Southeastern European countries and former Soviet nations.

This was the case even when accounting for differences between countries in testing, reporting, healthcare resources, pandemic policy and economic factors.

A dark-haired woman in an animal-print dress walks past a line of riot police holding the hands of two blond children.
A woman with her children walks past riot police after an anti-vaccination protest in Vilnius, Lithuania, in September 2021.
(AP Photo/Mindaugas Kulbis)

Situation worsened with COVID-19 waves

All countries started the first wave of the COVID-19 pandemic with statistically similar cases, deaths and excess deaths.

By the second wave, Eastern European countries had significant increases in cases and deaths compared to liberal and social democratic states. Southeast European countries, once part of Yugoslavia, had the highest number of cases of any other group.

By the third wave, Central and Eastern European states had more than four times the number of cases than liberal states and 10 times the number of COVID-19 deaths than social democratic states. In general, Eastern and Southeastern Europe had excess mortality rates that were two to three times higher than those in the West.


Our analysis indicates that Western liberal states spend the most on health care, around 10 percent of their GDP. Southeast European states spend almost eight percent of their GDP, while their neighboring Central and Eastern European countries and former Soviet states spend even less, close to seven percent and six percent respectively.

Despite spending less on health, countries in Central and Eastern Europe had lower numbers of COVID-19 cases and excess deaths than Southeastern European countries and former Soviet states.

A graph shows the relationship between GDP spent on healthcare and COVID-19 deaths
Relationship between GDP spent on health care and COVID-19 deaths.
(Authors supplied)

This can be explained as an after-effect of capitalism. Albania and Kosovo are experiencing what some call catastrophic out-of-pocket health expenditures — the term used when payments for health services exceed 40 percent of household disposable income.

Looking at COVID-19 deaths per million people, Southeastern Europe recorded the highest numbers, even when accounting for GDP spent on health. South-Eastern European countries also have the lowest numbers of hospital beds compared to the other groups, and the smallest number of nurses and doctors per 10,000 people.

A graph shows the relationship between the number of hospital beds and COVID-19 deaths by type of welfare state
Relationship between number of hospital beds and COVID-19 deaths by type of welfare state.
(Authors supplied)

Privatized health care to blame?

Inadequate numbers of hospital beds are a symptom of the overstretched healthcare system in the region, a serious problem in those countries emerging from the dissolution of Yugoslavia.

Most former Yugoslav states enacted health care reforms that shifted state-based health delivery to the free market. It was modeled after the UK’s competitive hospitals approach under one-time prime minister Margaret Thatcher.

Health care financing in former Yugoslav countries followed an insurance model subsidized by payroll and government contributions. It was much more decentralized than in the former Soviet states, which relied mainly on state funding when they were part of the Soviet Union.

Throughout the 1990s, various conflicts in the former Yugoslavia also contributed to the deterioration of the population’s health. These conflicts have also hampered the government’s capacity to build and strengthen their systems of health provision and delivery.

Some have argued that the fall of communism, the liberalization of trade, and the privatization of health care have moved former Eastern Bloc countries toward Western-style welfare regimes.

However, our data shows that the erosion of their health care systems by the private market has put these states in an impossible situation in terms of managing COVID-19 infections and mortality rates. The fall of communism was in fact detrimental to the health and well-being of Eastern Europeans.


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