Country Risk to Face Global Emergencies: Negative Effects of High Public Debt on Health Expenditures and Fatality Rate in COVID-19 Pandemic Crisis

Abstract

Risk is a variation of performance in the presence of events and it can negatively impact socioeconomic system of countries. Statistical evidence here shows that high public debt reduces health expenditures over time and increases the vulnerability and risk of European countries to face health emergencies, such as COVID-19 pandemic crisis. Overall, then, findings suggest that high public debt weakens healthcare and socioeconomic system of countries to cope with crises, such as COVID-19 pandemic, conflicts, natural disasters, etc.

JEL Codes: I18; H12; H51; H60; H63

Introduction

In contemporary economies, more and more countries have high levels of public debt that force to budget constraints with policies of public finance based on austerity measures (including spending cuts and/or tax increases), which impact funding for health, education and other public sectors [11Alesina A, Favero C, Giavazzi F. Austerity: When it works and when it doesn’t. Princeton University Press; 2019. Available from: https://doi.org/10.2307/j.ctvc77f4b-55Crivelli E, Leive A, Stratmann MT. Subnational health spending and soft budget constraints in OECD countries. International Monetary Fund; 2010. p. 1-25. Available from: https://www.imf.org/external/pubs/ft/wp/2010/wp10147.pdf]. Studies suggest that high levels of public debt may restrict government expenditure, especially in critical sectors like healthcare and education [66Bacchiocchi E, Borghi E, Missale A. Public investment under fiscal constraints. Fiscal Studies. 2011;32(1):11-42. Available from: https://ec.europa.eu/economy_finance/events/2017/20170124-ecfin-workshop/documents/missale_en.pdf,77Souliotis K, Papadonikolaki J, Papageorgiou M, Economou M. The impact of crisis on health and health care: Thoughts and data on the Greek case. Arch Hell Med. 2018;35(1):9-16. Available from: http://mail.mednet.gr/archives/2018-sup/9abs.html]. Moreover, high level of public debt has significative effects on socio-economic system and it can decrease a government’s ability to respond to complex emergencies and social problems [88Agoraki MK, Kardara S, Kollintzas T, Kouretas GP. Debt-to-GDP changes and the great recession: European Periphery versus European Core. Int J Finance Econ. 2023;28:3299-3331. Available from: https://www2.aueb.gr/conferences/Crete2018/Papers/Kouretas.pdf-1010Essers D, Cassimon D. Towards HIPC 2.0? Lessons from past debt relief initiatives for addressing current debt problems. JGD. 2022;13(2):187-231. Available from: https://www.degruyter.com/document/doi/10.1515/jgd-2021-0051/html]. Research paper here explores the relationship between the public debt and healthcare expenditures for assessing country risk, measured with fatality rates, in the presence of pandemic crises, such as COVID-19. Findings can suggest effective long-run policies to face next global emergencies, such as pandemics similar to COVID-19, conflicts, natural disasters, etc., in various countries.

Case study of European countries to face COVID-19 and study design

The literature about COVID-19 has a lot of studies on manifold topics [1111Abel JG, Gietel-Basten S. International remittance flows and the economic and social consequences of COVID-19. Environ Plan A. 2020;52(8):1480-1482. Available from: https://ideas.repec.org/a/sae/envira/v52y2020i8p1480-1482.html-6767Growing healthcare capacity to improve access to healthcare. Available from: https://www.roche.com/about/strategy/access-to-healthcare/capacity/. Accessed June 27, 2023.]. However, how the relationship between the public debt and healthcare expenditures affects fatality rates in the presence of pandemic crises, such as COVID-19, it is hardly known. This study focuses on a group of 27 European nations having comparable socioeconomic systems: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, and Sweden [6868Johns Hopkins University. Johns Hopkins Center for System Science and Engineering, 2023-COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Available from: https://www.arcgis.com/apps/dashboards/bda7594740fd40299423467b48e9ecf6. Accessed May 18, 2023.].             

The study examines variables of the economic and health system in European countries in 2009 and 2019 to assess the level and change before the COVID-19 pandemic crisis and their relationship with case fatality rates of the COVID-19 in 2020 and 2022. Variables under study are:

• Health expenditures per capita in 2009 and 2019 [6969Organisation for Economic Co-operation and Development (OECD). Health expenditure and financing. Available from: https://stats.oecd.org/Index.aspx?DataSetCode=SHA. Accessed June 15, 2024.]
• Government consolidated gross debt, as a share of GDP, in 2009 and 2019 [7070Database. Available from: https://ec.europa.eu/eurostat/data/database. Accessed July 2024.]
• Case fatality rate (CFR) on 30 December 2020 and 2022 [6868Johns Hopkins University. Johns Hopkins Center for System Science and Engineering, 2023-COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Available from: https://www.arcgis.com/apps/dashboards/bda7594740fd40299423467b48e9ecf6. Accessed May 18, 2023.]

The average COVID-19 fatality rate in the year 2020, the starting year of the COVID-19 pandemic crisis, is used to categorize the sample of European countries under study into two groups:

• Group 1, Countries with lower COVID-19 fatality rates in 2020 than the sample arithmetic mean.
• Group 2, Countries with higher COVID-19 fatality rates in 2020 than the sample arithmetic mean.

The arithmetic mean and the change from 2009 to 2019 (ten years) of general government gross debt and of health expenditures in countries of group 1 and 2, with a comparative analysis, assess the evolution of public debt and health expenditures between these categories before the emergence of COVID-19 pandemic crisis. The rate of change ∆ for variable x is given by: x in 2019 minus x in 2009 divided by x in 2009. Statistical analyses are based on descriptive statistics, independent sample T-test to assess the significance of the difference of means between group 1 and 2, correlation analyses of basic relation between health expenditure and COVID-19 fatality rate and a simple regression analysis with log-log model given by the following equation [11Alesina A, Favero C, Giavazzi F. Austerity: When it works and when it doesn’t. Princeton University Press; 2019. Available from: https://doi.org/10.2307/j.ctvc77f4b]:

COVID-19 fatality rates 2022

(y_i ) = α + β healthcare expenditures per capita 2019 (x_i)+ u_i           [11Alesina A, Favero C, Giavazzi F. Austerity: When it works and when it doesn’t. Princeton University Press; 2019. Available from: https://doi.org/10.2307/j.ctvc77f4b]

α = constant

β = coefficient of regression

u_i = error term

i (subscript) = countries

Estimated relationship is calculated with Ordinary Last Squares (OLS) method that determines the unknown parameters. Statistical analyses are performed with the IBM SPSS Statistics 26^®.

Results

Table 1 reveals that Group 1 with a lower COVID-19 fatality rate in 2020 and 2022 than group 2 has in the year 2009 and 2019 higher levels of health expenditure per capita (> $3,100 per capita). From 2009 to 2019 this group 1 has a rate of growth of health expenditure per capita of 0.19. Instead, countries with a higher COVID-19 fatality rate in 2020 had in 2009 and 2019, levels of health expenditure per capita lower than previous group 1 (about $2,530 in 2009 and $2,600 in 2019). Moreover, this group 2 has a lower rate of growth of health expenditure per capita from 2009 to 2019 and equal to 0.09. If we consider government gross debt as % of GDP, Table 1 reveals that in group 1 is lower both in 2009 (46.8%) and 2019 (50.9%) than group 2, which had 67.2% in 2009 and 81.49% in 2019. In addition, group 1 has from 2009 to 2019 a lower growth of government gross debt (% of GDP) given by 0.12 compared to group 2 that has experienced a high growth of government gross debt (% of GDP) of 0.29, generating a high burden for socioeconomic system, such that public finance had to reduce health expenditures  with negatively effects on overall health system. Statistical significance of differences in arithmetic means (Table 1) is verified with independent sample T-test and results are in Table 2: the independent samples T-test compares the means of groups 1 and 2 to determine whether the associated population means are significantly different. Since the p-value is higher than significance level α = 0.05, we can reject the null hypothesis of similarity of arithmetic means between groups 1 and 2, except for the COVID-19 fatality rate in 2020 and 2022.

Table 1: Descriptive statistics categorized per groups.

Table 2: Independent Samples T-Test based on average mean and change of variables from 2009 to 2019 in European countries of group 1 (Countries with LOWER COVID-19 Fatality in 2020) and group 2 (Countries with HIGHER COVID-19 Fatality in 2020).

Pearson’s coefficient of correlation is −0.67, which indicates a strong negative correlation. The more resources that European nations spend in health sector, the better they are likely to reduce the case fatality rates of COVID-19. The one-tailed significance value – which in this case has p - value < 0.001, considering that the standard alpha value is 0.05, means that correlation analysis here is highly significant (Table 3).

Table 3: Bivariate correlation between health expenditure and COVID-19 fatality rates.

Table 4 presents the results of the regression analysis using the OLS method. The findings clearly indicate that when countries experience a 1% increase in healthcare expenditure per capita in 2019, it leads to a 1.2% reduction in the COVID-19 fatality rate. The R² coefficient of determination explains approximately 45% of the variance in the data, whereas the F - value is statistically significant (p - value < 0.001), indicating that the independent variable reliably predicts the dependent variable, namely the reduction in the COVID-19 fatality rate.

Table 4: Estimated relationship of COVID-19 fatality rate in 2022 on Healthcare Expenditure per Capita $ 2019, log-log model.

Figure 1 illustrates the estimated relationship between COVID-19 fatality rate in 2022 and healthcare expenditures per capita, whereas bar graphs in Figure 2 confirm empirical analyses with a comparison of COVID-19 fatality rate in 2022, health expenditure per capita in 2019 and level of public debt in European countries of group 1 (Countries with LOWER COVID-19 Fatality in 2020) and group 2 (Countries with HIGHER COVID-19 Fatality in 2020).

Figure 1: Regression line of the COVID-19 fatality rate in 2022 on healthcare expenditures per capita in 2019.

Figure 2: Comparison of COVID-19 fatality rate in 2022, health expenditure per capita in 2019 and level of public debt in European countries of group 1 (Countries with LOWER COVID-19 Fatality in 2020) and group 2 (Countries with HIGHER COVID-19 Fatality in 2020).

Discussion and public policy implications to face next emergencies

Studies about COVID-19 discuss manifold implications about health and other socioeconomic effects [7171Sanyaolu A, Okorie C, Marinkovic A, Patidar R, Younis K, Desai P, et al. Comorbidity and its Impact on Patients with COVID-19. SN Compr Clin Med. 2020;2(8):1069-1076. doi: 10.1007/s42399-020-00363-4. Epub 2020 Jun 25. PMID: 32838147; PMCID: PMC7314621.-8484Zhang N, Jack Chan PT, Jia W, Dung CH, Zhao P, et al. Analysis of efficacy of intervention strategies for COVID-19 transmission: A case study of Hong Kong. Environ Int. 2021 Nov;156:106723. doi: 10.1016/j.envint.2021.106723. Epub 2021 Jun 18. PMID: 34161908; PMCID: PMC8214805.]. What this study adds is that countries with higher fatality rates had previous high levels of public debt (0.29% of GDP), resulting in a decline in overall health expenditures over time for healthcare system. Conversely, countries with lower fatality rates, despite a lesser increase in public debt (0.12% of GDP), had a notable escalation in health expenditures per capita, totaling 0.19% of GDP. Results suggest that countries with lower levels of public debt over time are associated with greater resilience in healthcare system and consequential lower-case fatality rate of COVID-19 [3535Coccia M. High potential of technology to face new respiratory viruses: mechanical ventilation devices for effective healthcare to next pandemic emergencies. Technol Soc. 2023;73:102233. Available from: https://doi.org/10.1016/j.techsoc.2023.102233,85-8885-88Aboelnaga S, Czech K, Wielechowski M, Kotyza P, Smutka L, Ndue K. COVID-19 resilience index in European Union countries based on their risk and readiness scale. PLoS One. 2023 Aug 18;18(8). doi: 10.1371/journal.pone.0289615. PMID: 37540717; PMCID: PMC10403121.]. The susceptibility of the health system stems from the high level of public debt in certain countries, often resulting from political economy strategies based on austerity measures aimed at alleviating the burden of government debt, such as the Stability and Growth Pact (SGP) in Europe, that also reduces health expenditures over time; several studies indicate that European nations striving to reduce their public debt levels adhere to the rules outlined in the SGP, also reducing the spending in health and education [88Agoraki MK, Kardara S, Kollintzas T, Kouretas GP. Debt-to-GDP changes and the great recession: European Periphery versus European Core. Int J Finance Econ. 2023;28:3299-3331. Available from: https://www2.aueb.gr/conferences/Crete2018/Papers/Kouretas.pdf,8989Theodoropoulou S. Recovery, resilience and growth regimes under overlapping EU conditionalities: the case of Greece. CEP. 2022;20:201-219.]. However, findings here show that when European countries have a 1% increase in healthcare expenditure per capita, they experienced a 1.2% reduction in the COVID-19 fatality rate. The European Central Bank [9090European Central Bank (ECB). Government debt reduction strategies in the Euro area. Econ Bull. 2016;4:1-20.] affirms that excessive government debt leads economies to be less resilient to unforeseen shocks, crises, emergencies, etc. and the trimming of health and social expenditures is frequently a response to initiatives aimed at addressing high level of public debt. Iwata and Iiboshi [9191Iwata Y, IIboshi H. The nexus between public debt and the government spending multiplier: fiscal adjustments matter. Oxf Bull Econ Stat. 2023;85:830-858. https://doi.org/10.1111/obes.12547] argue that fiscal adjustments seems to be the primary factor contributing to the diminishing government spending multipliers, rather than the accumulation of debt itself. Hence, financial strategies and public finance policies that impose limitations in various European countries with significant high level of public debt tend to heighten systemic fragility and diminish the ability of health systems to effectively respond to crises and complex emergencies [9292Benati I, Coccia M. Effective Contact Tracing System Minimizes COVID-19 Related Infections and Deaths: Policy Lessons to Reduce the Impact of Future Pandemic Diseases. J Public Adm Governance. 2022;12(3):19-33. https://doi.org/10.5296/jpag.v12i3.19834]. Undoubtedly, these governmental strategies fail to take into account the impact of elevated public debt on a nation’s systemic ability to withstand crises and socio-economic shock. The fundamental implications of economic policy of findings here are that countries must decrease public debt with good governance and institutions [9393Coccia M. Comparative Institutional Changes. In: Farazmand A, editor. Global Encyclopedia of Public Administration, Public Policy, and Governance. Springer; 2019. https://doi.org/10.1007/978-3-319-31816-5_1277-1] and steer clear of austerity measures in order to allocate more resources to the healthcare sector and enhance readiness to address unforeseen emergencies like the COVID-19 pandemic, natural calamities, conflicts, and other environmental disruptions [9494Barro RJ. Non-pharmaceutical interventions and mortality in U.S. cities during the great influenza pandemic, 1918-1919. Res Econ. 2022 Jun;76(2):93-106. doi: 10.1016/j.rie.2022.06.001. Epub 2022 Jun 25. PMID: 35784011; PMCID: PMC9232401.-135135Núñez-Delgado A, Bontempi E, Zhou Y, Álvarez-Rodríguez E, López-Ramón MV, Coccia M, Zhang Z, Santás-Miguel V, Race M. Editorial of the Topic “Environmental and Health Issues and Solutions for Anticoccidials and other Emerging Pollutants of Special Concern”. Processes. 2024; 12(7):1379. https://doi.org/10.3390/pr12071379].

Concluding remarks

One of the main problems for managing global crises is to clarify the drivers of systemic weakness or strength in countries to face emergencies. This study here analyzes how the level of public debt can affect healthcare expenditures and fatality rates in the presence of pandemic crises, such as COVID-19.

Main findings of the empirical evidence are that:

• High public debt over time reduces health expenditures and increases the vulnerability of countries to face complex emergencies, such as COVID-19 pandemic crisis.
• High public debt weakens healthcare and socio-economic system of countries in the presence of crises.
• More economic resources the nations spend in health sector, the better they are likely to face emergencies and reduce the case fatality rates.
• When countries experience a 1% increase in healthcare expenditure per capita, in general they have a 1.2% reduction in the COVID-19 fatality rate.
• Countries must reduce public debt with good governance and institutions without reducing the allocation of economic resources to the healthcare sector in order to improve the preparedness to unforeseen complex emergencies and crises, such as pandemics, natural disasters, conflicts, and other environmental catastrophes.

These conclusions are of course tentative. There is need for much more detailed research with additional data and different methods into the relations of socioeconomic factors to reduce country risk and improve the resilience of  nations in the presence of emergencies and global crises.

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47. Núñez-Delgado A, Zhang Z, Bontempi E, Coccia M, Race M, Zhou Y. Editorial on the Topic “New Research on Detection and Removal of Emerging Pollutants.” Materials (Basel). 2023 Feb 27;16(2):725. Available from: https://doi.org/10.3390/ma16020725

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52. Coccia M. Probability of discoveries between research fields to explain scientific and technological change. Technol Soc. 2022 Feb;68:101874. Available from: https://doi.org/10.1016/j.techsoc.2022.101874

53. Coccia M. COVID-19 Pandemic Crisis: Analysis of origins, diffusive factors and problems of lockdowns and vaccinations to design best policy responses Vol.2. KSP Books; 2023. ISBN: 978-625-7813-54-9.

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56. Kargı B, Coccia M, Uçkaç BC. Findings from the first wave of COVID-19 on the different impacts of lockdown on public health and economic growth. Int J Econ Sci. 2023;12(2):21-39. Available from: https://eurrec.org/ijoes-article-117076

57. Kargı B, Coccia M, Uçkaç BC. How does the wealth level of nations affect their COVID19 vaccination plans? Econ Manage Sustain. 2023;8(2):6-19. Available from: https://www.ceeol.com/search/article-detail?id=1213042

58. Kargı B, Coccia M, Uçkaç BC. The Relation Between Restriction Policies against Covid-19, Economic Growth and Mortality Rate in Society. Migration Letters. 2023;20(5):218-231. Available from: https://migrationletters.com/index.php/ml/article/view/3538

59. Khan JR, Awan N, Islam MM, Muurlink O. Healthcare capacity, health expenditure, and civil society as predictors of COVID-19 case fatalities: a global analysis. Front Public Health. 2020;8:347. Available from: https://pubmed.ncbi.nlm.nih.gov/32719765/

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61. Coccia M, Bontempi E. New trajectories of technologies for the removal of pollutants and emerging contaminants in the environment. Environ Res. 2023 Jul 15;229:115938. doi: 10.1016/j.envres.2023.115938. Epub 2023 Apr 20. PMID: 37086878.

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121. Coccia M. Effects of the spread of COVID-19 on public health of polluted cities: results of the first wave for explaining the dejà vu in the second wave of COVID-19 pandemic and epidemics of future vital agents. Environ Sci Pollut Res Int. 2021 Apr;28(15):19147-19154. doi: 10.1007/s11356-020-11662-7. Epub 2021 Jan 4. PMID: 33398753; PMCID: PMC7781409.

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123. Coccia M. Meta-analysis to explain unknown causes of the origins of SARS-COV-2. Environ Res. 2022 Aug;211:113062. doi: 10.1016/j.envres.2022.113062. Epub 2022 Mar 5. PMID: 35259407; PMCID: PMC8897286.

124. Coccia M. COVID-19 Vaccination is not a Sufficient Public Policy to face Crisis Management of next Pandemic Threats. Public Organization Review. 2022a; 1-15. https://doi.org/10.1007/s11115-022-00661-6

125. Coccia M. Effects of strict containment policies on COVID-19 pandemic crisis: lessons to cope with next pandemic impacts. Environ Sci Pollut Res Int. 2023 Jan;30(1):2020-2028. doi: 10.1007/s11356-022-22024-w. Epub 2022 Aug 4. PMID: 35925462; PMCID: PMC9362501.

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133. Coccia M, Benati I. Comparative Studies. Global Encyclopedia of Public Administration, Public Policy, and Governance –section Bureaucracy (edited by Ali Farazmand). Springer, Cham. 2018a; Chapter No. 1197-1:1-7. https://doi.org/10.1007/978-3-319-31816-5_1197-1

134. Coccia M, Benati I. Effective health systems facing pandemic crisis: lessons from COVID-19 in Europe for next emergencies, International Journal of Health Governance. 2024a. DOI 10.1108/IJHG-02-2024-0013

135. Núñez-Delgado A, Bontempi E, Zhou Y, Álvarez-Rodríguez E, López-Ramón MV, Coccia M, Zhang Z, Santás-Miguel V, Race M. Editorial of the Topic “Environmental and Health Issues and Solutions for Anticoccidials and other Emerging Pollutants of Special Concern”. Processes. 2024; 12(7):1379. https://doi.org/10.3390/pr12071379

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Coccia M. Country Risk to Face Global Emergencies: Negative Effects of High Public Debt on Health Expenditures and Fatality Rate in COVID-19 Pandemic Crisis. IgMin Res. Jul 06, 2024; 2(7): 537-545. IgMin ID: igmin214; DOI:10.61927/igmin214; Available at: igmin.link/p214

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