Governance in Crisis: A Mixed-Methods Analysis of Global Health Governance During COVID-19

Background: The COVID-19 pandemic exposed major structural deficiencies in global health governance, including stark inequities in vaccine access, intervention timing, and mortality outcomes. While economic resources played a role, the influence of governance performance remains insufficiently examined. This study addresses a significant gap by integrating governance metrics with pandemic response data to assess how governance quality, independent of income level, affected national outcomes. Although the Oxford COVID-19 Government Response Tracker (OxCGRT) dataset has been widely used to document policy responses, this study offers a novel contribution by linking these policy interventions with governance performance and evaluating their joint effect on health outcomes and vaccine equity. Methods: This mixed-methods study combines quantitative analysis of global datasets with a qualitative literature review. Quantitative data were mainly obtained from the Oxford COVID-19 Government Response Tracker (OxCGRT), the World Bank’s Worldwide Governance Indicators (WGIs), and World Bank/WHO databases. A governance performance index was constructed using two WGI components: Government Effectiveness and Regulatory Quality. Countries were grouped into high, medium, or low governance categories. Statistical tests included ANOVA, Kaplan Meier survival analysis, and multivariable OLS regression. The qualitative component reviewed 45 academic and institutional sources on governance performance during COVID-19. Results: Countries with high governance performance had earlier public health interventions, lower mortality, and broader vaccine coverage, independent of income level. Kaplan Meier analysis revealed faster school closures in these countries ( p < 0.01). Multivariable regression showed governance remained a significant predictor after adjusting for income and health spending. Qualitative findings highlighted recurring weaknesses in legal enforceability, intergovernmental coordination, and global financing mechanisms. Conclusions: Governance performance had a decisive impact on pandemic outcomes. The COVID-19 crisis revealed the need for robust governance systems capable of responding to complex emergencies that extend beyond the health sector into institutional, economic, and social spheres.