Abstract / Summary
Background The COVID-19 pandemic exposed critical vulnerabilities in African health systems, revealing that pandemic preparedness is determined not merely by technical capacity but by the complex interplay of health expenditure, governance quality, and economic context. The paper investigates the implications of pandemic preparedness on health system resilience in African countries, the mediating role of health expenditure and the moderating influence of economic development. Methods The study first undertook an analytical situational analysis followed by a cross-country analysis of data from 195 countries the study employed multivariate linear regression models with robust standard errors, incorporating the Global Health Security (GHS). The study tested mediation pathways, interaction effects between preparedness and income, and conducted multiple robustness checks including alternative outcomes and outlier adjustment. Results Globally, the GHS Index showed a strong positive association with reported COVID-19 mortality (β = 43.14, p < 0.001), even after extensive controls the preparedness paradox. However, health expenditure per capita demonstrated a consistent protective effect (β = -0.15 to -0.18, p < 0.01), while governance was protective for excess mortality (β = -60.24, p < 0.01). Critically, a significant negative interaction between preparedness and income emerged (β = -0.37 standardized, p < 0.001), indicating that the positive preparedness-mortality relationship weakens as income rises. In Africa, preparedness effects were weaker and not robust across specifications; only life expectancy consistently predicted mortality (β = 0.12, p < 0.001 in log model). VIF diagnostics confirmed no severe multicollinearity (mean VIF = 2.43 global, 2.36 Africa). Conclusion Pandemic preparedness as measured by the GHS Index does not translate into lower mortality; rather, its association with outcomes is context-dependent, moderated by economic development. In Africa, structural and demographic factors outweigh formal preparedness metrics. Policy should prioritize sustained health financing and institutional capacity.