This chapter focusses on the impact of COVID‑19 on health and societies, as the most recent among emerging pandemics. It starts by outlining the health burden of COVID‑19, both direct and indirect through disruptions in care pathways. It then explores the social burden and effects on key risk factors for non-communicable diseases (NCDs). Recognising the significant societal disruptions, the chapter, then, presents an analysis estimating the long-term impact of COVID‑19 on NCDs across 28 OECD and 5 non-OECD European Union/European Economic Area countries, using the OECD Strategic Public Health Planning for NCDs model.
The Economic Case for Pandemic Preparedness and Response
Beyond Lockdowns
Abstract
Key messages
COVID‑19 has had an enormous impact on health and societies
COVID‑19 claimed the lives of nearly 7 million people worldwide by the end of its emergency phase in 2023, and placed immense strain on healthcare systems, societies and economies. Globally, the estimated full death toll associated directly or indirectly with the pandemic was approximately 14.9 million excess deaths by the end of 2021. During its peak period between 2020 and 2022, OECD countries alone recorded an additional 6 million deaths compared to the years prior to the COVID‑19 pandemic. Countries with higher reported COVID‑19 death rates also typically had larger increases in excess deaths, more pronounced reductions in life expectancy and larger contractions in gross domestic product (GDP).
COVID‑19 also had a significant negative impact on the mental health and well-being of populations. For example, modelled estimates from the Institute for Health Metrics and Evaluation indicate that the share of the population with major depressive disorders and anxiety increased by around 25% and 19%, respectively, on average across OECD countries in 2021 compared with 2019 levels and has remained elevated or continued to rise in some countries in 2023.
The broader morbidity from COVID‑19 continues, with around 5% to 15% of people who contracted COVID‑19 exhibiting symptoms corresponding to long COVID – a chronic condition that develops following SARS‑CoV‑2 infection and lasts for at least three months. The impacts of long COVID vary across countries yet recent OECD analysis suggests that it could continue to cost health systems around USD 11 billion per year across OECD countries over the next decade, with annual GDP losses expected to range between 0.1 and 0.2%.
COVID‑19 negatively impacted care pathways for chronic diseases. In the first months of the crisis, hospital admissions for cardiovascular diseases temporarily declined in many OECD countries, and even when patients reached hospitals, care was often delayed. Cancer care was similarly affected, with major interruptions to screening and diagnosis likely to worsen prognoses and excess cancer deaths in the coming years. Cancer surgeries also declined, and waiting times lengthened as hospitals struggled with backlogs and staff services. While healthcare systems adapted to preserve access for patients with chronic conditions, postponed elective procedures and medical appointments created a backlog, disproportionately affecting older patients with multimorbidity and potentially increasing long-term health burdens.
The overall burden of COVID‑19 extends well beyond health. The COVID‑19 pandemic has exacerbated socio‑economic inequalities, job insecurity, negative educational outcomes and beyond. The pandemic also had significant employment and labour impacts; for example, unemployment across OECD increased by 32% on average between 2019 and 2020, while GDP reduced by 5%.
COVID‑19 had mixed impacts on lifestyle factors that influence the burden of non-communicable diseases (NCDs)
The COVID‑19 pandemic led to significant social, behavioural, and economic disruptions, altering some lifestyle‑related risk factors associated with the burden of NCDs. To better understand the pandemic’s potential impact, observed post-pandemic trends in major NCD risk factors were compared with projections based on pre‑pandemic linear trends. On average across 28 OECD countries, the prevalence of tobacco use was around 10% higher than predicted, suggesting that COVID‑19 slowed the decline in overall smoking prevalence. By contrast, in the same period and set of countries, per capita alcohol consumption was 4% lower than predicted. The impact on obesity was marginal, less than 1% higher than expected on average, possibly due to the lag between changes in energy balance and observable weight shifts, compounded by the short assessment period.
COVID‑19 could have lingering impacts on the NCD burden, healthcare spending and the economy
Potential shifts in major NCD risk factors, together with disruptions in the healthcare pathway for chronic disease patients during COVID‑19, raise concerns about an increased long-term risk of developing NCDs such as cardiovascular disease, cancer and diabetes. To capture the long-term consequences of COVID‑19, the OECD modelled two hypothetical pandemic scenarios reflecting the changes in lifestyles and healthcare delivery. Both scenarios assume changes in exposure to key risk factors (i.e. tobacco use, alcohol consumption and obesity) and temporary declines in cancer survival. In the temporary shock scenario, these disruptions are short-lived: risk factors change through 2021, remain stable until 2023 and return to pre‑pandemic levels by 2024. From a practical standpoint, this scenario implies that individuals who had altered their habits during the COVID‑19 pandemic would revert to their previous lifestyles by 2024. The second scenario (i.e. a permanent shock) assumes persistent shifts: risk factors change through 2021 and remain permanently at that level through 2050, assuming that lifestyle changes adopted during the pandemic would persist throughout the duration of the simulation.
COVID‑19 could have lingering impacts on the NCD burden, healthcare spending and the economy:
In the short term (i.e. between 2020 and 2024), COVID‑19‑related lifestyle changes are estimated to have reduced life expectancy and healthy life expectancy by 2.4 months and 2.5 months, respectively, across the 28 OECD countries analysed. This health burden translates into an average 0.4% increase in annual health expenditure and annual GDP losses of 0.1%.
In the long term (i.e. between 2025 and 2050), the detrimental impact of COVID‑19 on health and the economy fades over time if risk factors and behaviours gradually return to pre‑pandemic levels. However, if changes in risk factor prevalence levels observed during COVID‑19 persist permanently, life expectancy could remain, on average, 1.9 months lower in 28 OECD countries by 2050 compared to a scenario where no COVID‑19 occurred. Annual health expenditure could remain 0.6% higher, and GDP could be as much as 0.2% lower, each year, on average, across 28 OECD countries in 2025-2050.
COVID‑19 was the latest reminder of the disruptive capacity of pandemics. By the end of its emergency phase in 2023, it had directly claimed nearly 7 million lives worldwide (WHO, 2025[1]). Health systems across the globe were stretched far beyond capacity, and routine services for non-COVID‑19 patients were severely disrupted. Across OECD countries, the immense strain placed on healthcare systems, societies and economies resulted in an estimated additional 6 million deaths between 2020 and 2022 compared with pre‑pandemic years (Morgan et al., 2023[2]). COVID‑19 disrupted nearly every step of the care pathway for patients with chronic conditions such as cardiovascular diseases and cancer, leading to delayed care and worsening health outcomes that may persist for years. Mental health also deteriorated, with an estimated 25% and 19% increase in the prevalence of depressive disorders and anxiety across OECD countries in 2021 compared to pre‑pandemic levels, with prevalence remaining elevated in subsequent years (IHME, 2025[3]). The broader morbidity of COVID‑19 continues, with around 5% to 15% of people who contracted the virus exhibiting symptoms of long COVID – a chronic condition that can last for at least three months after infection (OECD, 2026[4]). The overall burden of the pandemic extends well beyond health, deepening social inequalities and driving economic losses, with unemployment across OECD countries by 32% on average between 2019 and GDP falling by around 5% (OECD, 2021[5]).
The chapter is organised as follows: Section 2.1 outlines the health burden of COVID‑19, from its impact on mortality, to mental health and well-being, and the continuing broader morbidity of long COVID – a chronic condition that develops following SARS‑CoV‑2 infection and lasts for at least three months. It then explores the impact on care pathways for non-communicable diseases, such as cardiovascular diseases and cancer, before touching on the social burden. Section 2.2 presents an analysis of the COVID‑19 impact on key risk factors for non-communicable diseases (NCDs). Recognising the significant societal disruptions, Section 2.3, then, presents an analysis estimating the long-term impact of COVID‑19 on NCDs across 28 OECD and 5 non-OECD European Union (EU)/European Economic Area (EEA) countries, using the OECD Strategic Public Health Planning for Non-Communicable Diseases (SPHeP-NCDs) model.
2.1.1. Mortality burden
COVID‑19 has been the latest among several large‑scale disease outbreaks over the last century, claiming the lives of nearly 7 million people worldwide by the end of the emergency phase of the pandemic in May 2023, and placing immense strain on healthcare systems, societies and economies (WHO, 2025[1]). Between 2020 and 2022, more than 3 million COVID‑19 deaths were recorded across OECD countries, with COVID‑19 accounting for almost 1 in 5 of all weekly deaths in the OECD at the peak of the pandemic in 2021. Across this same three‑year period OECD countries recorded an additional 6 million deaths (i.e. excess deaths) compared to the years prior to the pandemic (Box 2.1) (Morgan et al., 2023[2]). The number of additional all-cause deaths and COVID‑19 deaths peaked in early 2021, followed by a steep decline and several spikes during the following two years (Figure 2.1). A 7‑month fall in OECD-average life expectancy was seen in 2020 alone (OECD, 2021[5]), with life expectancy still below pre‑pandemic levels in 13 OECD countries in 2023 (OECD, 2025[6]).
Excess mortality is defined as the difference between the observed number of deaths (either from all causes or a specific cause of death) over a defined period (ranging from a week to a multi-year period) compared to an estimate of the expected numbers of deaths for the same period (Morgan et al., 2023[2]). The excess mortality indicator is often used to reflect the magnitude of a crisis, such as an infectious disease outbreak or pandemic, by quantifying the number of additional deaths observed in comparison to the expected rate (WHO, 2025[7]). As an estimate of the overall COVID‑19 mortality burden, it is a more comprehensive measure compared to the confirmed COVID‑19 death count alone, as it additionally captures COVID‑19 deaths that were not correctly diagnosed and reported, as well as deaths from other causes that can be attributed to the over-arching crisis condition (Eurostat, 2025[8]). It is considered a more objective and comparable measure that accounts for both the direct and indirect impacts of the pandemic.
Source: Morgan et al. (2023[2]), Examining recent mortality trends: The impact of demographic change, https://dx.doi.org/10.1787/78f69783-en; WHO (2025[7]),Global Excess Deaths Associated with the COVID‑19 Pandemic, https://www.who.int/news-room/questions-and-answers/item/global-excess-deaths-associated-with-the-COVID-19-pandemic, Eurostat (2025[8]), Statistics Explained, https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Glossary:Excess_mortality.
Total weekly deaths above the 2015‑2019 average and total reported COVID‑19 deaths, 34 OECD countries, 2020-2022
Note: Weekly data unavailable for Ireland, Japan, Korea and Türkiye. Additional deaths compared to the weekly deaths during 2015‑2019.
Source: Morgan et al. (2023[2]), Examining recent mortality trends: The impact of demographic change, Figure 2.2, https://dx.doi.org/10.1787/78f69783-en.
Globally, estimates from the World Health Organization (WHO) indicate that the full death toll associated directly or indirectly with the COVID‑19 pandemic by the end of 2021 was approximately 14.9 million excess deaths (range 13.3 million to 16.6 million) (WHO, 2022[9]). Geographically, most of the excess deaths (84%) were distributed across Southeast Asia, Europe and the Americas. Lower-middle‑income and upper-middle‑income countries carried the highest burden, accounting for 53% and 28% of the total 14.9 million excess deaths accordingly (ibid). Moreover, the COVID‑19 pandemic disproportionately affected men compared to women in terms of excess mortality (OECD, 2021[5]). Statistics on the excess mortality from 29 OECD countries show that deaths for men increased by 15% over the first year of the pandemic, compared to 2015‑2019 averages, compared to only 12% for women (ibid). Furthermore, individuals with chronic conditions, such as cardiovascular disease, cancers and diabetes, tended to have worse and more long-term COVID‑19 outcomes leading to higher rates of hospitalisation and death (Box 2.2).
During the COVID‑19 pandemic, patients with chronic, non-communicable diseases, such as cancer, cardiovascular diseases (CVDs) and diabetes, were at a greater of risk of becoming infected, experiencing severe outcomes and dying from COVID‑19. The relative susceptibility and vulnerability towards COVID‑19 was therefore unevenly distributed among population groups based on the presence of health risks and comorbidities.
COVID‑19 and cancer
Scientific literature demonstrates a strong positive correlation between having a cancer diagnosis and increased vulnerability of being infected, developing severe complications, requiring mechanical ventilation or intensive care unit (ICU) admission, and dying from COVID‑19. For COVID‑19 infections, a cohort study including more than 4.5 million adults in Catalonia found that cancer was associated with an 8% higher risk of COVID‑19 infection (adjusted hazard ratio = 1.08) (Roel et al., 2022[10]). Moreover, after being infected, patients with active or recently diagnosed and/or treated cancer were at a much higher risk of developing severe COVID‑19 disease, often requiring emergency medical interventions and at times hospitalisation. Data from a systematic review and meta‑analysis by Han et al. (2022[11]) showed that patients with cancer had a 49% higher risk of severe COVID‑19 outcomes compared to other COVID‑19 patients (pooled relative risk [RR] of 1.49). Another systematic review, which included 34 studies found that cancer was associated with a 2.84 times higher risk of severe COVID‑19 disease (Gao et al., 2020[12]).
COVID‑19 and cardiovascular disease
Cardiovascular disease (CVD) is one of the most well-known risk factors for COVID‑19, contributing to a large portion of the overall COVID‑19 health burden. Patients diagnosed with cardiovascular diseases, including hypertension, acute cardiac injury, arrhythmia, and coronary artery disease, among other CVDs, are predisposed to a higher risk of mortality and are more likely to suffer greater complications after the onset of the COVID‑19 infection. Findings from a systematic review by Hessami et al. (2021[13]) found that the pooled risk odds of being admitted to an intensive care unit were much greater for patients with arrhythmia (Odds Ratio [OR]: 7.03, 95% confidence interval [CI] 2.79‑17.69), acute cardiac injury (OR: 15.58, 95% CI 5.15‑47.12), coronary heart disease (OR: 2.61, 95% CI 1.09‑ 6.26), cardiovascular disease (OR: 3.11, 95% CI 1.59‑6.09), and hypertension (OR: 1.95, 95% CI 1.41‑ 2.68) compared to the general population. In terms of risk of mortality, a large‑scale systematic review by Luo et al. (2020[14]) suggests that CVDs are associated with 2.65 times higher odds of mortality from COVID‑19. Additionally, a systematic review by Harrison et al. (2021[15]) found that patients with hypertension (OR: 2.50, 95% CI 2.02‑3.11) and cardiovascular disease (OR: 2.65, 95% CI 1.86‑3.78) had higher mortality compared to the general population, as well as a higher likelihood of developing severe COVID‑19.
Source: Roel et al. (2022[10]), “Cancer and the risk of coronavirus disease 2019 diagnosis, hospitalisation and death: A population‐based multistate cohort study including 4 618 377 adults in Catalonia, Spain”, https://doi.org/10.1002/ijc.33846; Han et al. (2022[11]), “Impact of cancer diagnoses on the outcomes of patients with COVID-19: a systematic review and meta-analysis”, https://doi.org/10.1136/bmjopen-2020-044661; Gao et al. (2020[12]), “Cancer is associated with the severity and mortality of patients with COVID-19: a systematic review and meta-analysis”, https://doi.org/10.1101/2020.05.01.20087031; Hessami et al. (2021[13]), “Cardiovascular diseases burden in COVID-19: Systematic review and meta-analysis”, https://doi.org/10.1016/j.ajem.2020.10.022; Luo et al. (2020[14]), “The potential association between common comorbidities and severity and mortality of coronavirus disease 2019: A pooled analysis”, https://doi.org/10.1002/clc.23465; Harrison et al. (2021[15]), “Cardiovascular risk factors, cardiovascular disease, and COVID-19: an umbrella review of systematic reviews”, https://doi.org/10.1093/ehjqcco/qcab029.
At its peak in 2021, COVID‑19 was the fourth highest cause of mortality across OECD countries, accounting for 7% of all deaths, following diseases of the circulatory system (28%), cancers (21%), and diseases of the respiratory system (9%) (OECD, 2023[16]). Since then, the effects of COVID‑19 have decreased yet it still accounted for around 5% of all deaths across OECD countries in 2023 (OECD, 2025[6]). A significant proportion of COVID‑19 deaths are understood as “avoidable deaths” – deaths from preventable or treatable diseases that can be avoided through timely and effective healthcare interventions. It is estimated that across 26 OECD countries with available data for 2020 and 2021, over 3 million premature deaths among people aged under 75 years could have been avoided (OECD, 2023[16]). Largely explained by the immense pressures placed on healthcare systems, insufficient availability of personal protective equipment and vaccination, avoidable mortality spiked during the early stages of the COVID‑19 pandemic. As a result, the pandemic reversed the trend of gradually declining mortality across the OECD, reaching a 900 deaths per 100 000 population age‑standardised mortality rate in 2021 compared to 810 deaths per 100 000 in 2019 (Morgan et al., 2023[2]).
Countries with higher reported COVID‑19 death rates also typically had larger increases in excess deaths, more pronounced reductions in life expectancy and larger contractions in Gross Domestic Product (GDP) (OECD, 2023[17]). One study found that in the first year of the pandemic the highest case fatality rate was observed in Mexico (8.51%), followed by China (5.17%) and Bulgaria (4.12%) (Ngatu et al., 2022[18]). However, contractions in GDP were particularly pronounced in Spain (‑10.8%), the United Kingdom (‑9.3%) and Greece (‑9.0%) (OECD, 2023[17]).
2.1.2. Mental health and well-being
COVID‑19 had a significant negative impact on the mental health and well-being of populations at a global level. More specifically, scientific literature highlights increasing trends in rates of anxiety, depression and suicide during the pandemic period (Wang et al., 2022[19]). Spikes in feelings of loneliness, division and disconnection from society continued to grow between mid-2020 and the first half of the 2021 (OECD, 2021[5]). Largely attributed to physical distancing, social and economic uncertainty – many adults reported experiencing “stress, anxiety or sadness that was difficult to cope with alone”, including 33% of people in the United States, and between 23% and 26% of people in Canada, Australia, New Zealand and France, (ibid). Modelled estimates from the Institute for Health Metrics and Evaluation (IHME) indicate that the share of the population with major depressive disorders and anxiety increased by around 25% and 19%, respectively, on average across 38 OECD countries in 2021 compared with 2019 levels, and has remained elevated or continued to rise in some countries in 2023 (Figure 2.2).
Source: (IHME, 2025[3]), GBD Results, https://vizhub.healthdata.org/gbd-results/.
Whilst mental health deteriorated for almost all population groups on average in 2020, women’s, young people’s, unemployed and migrants’ mental health outcomes proved to be more vulnerable in times of the pandemic (OECD, 2021[5]). Across OECD countries, 15 to 24‑year‑olds, full-time students and unemployed people were at the highest risk of experiencing depression in 2020, averaging around 40% (OECD, 2021[5]) Furthermore, a representative survey of 13‑ to 19‑year‑olds in the United States found that more than one in four young people nationally reported losing sleep because of worry, feeling depressed or constantly under the strain (Margolius, 2020[20]). Exacerbated by higher rates of unemployment, job disruption and insecurity, racial and ethnic minorities from lower-income backgrounds in some cases experienced the biggest declines in mental health (OECD, 2021[21]). Data on the long-term mental health impacts of the COVID‑19 pandemic remains largely fragmented, although this is expected to become clearer as additional research emerges.
2.1.3. Long COVID
The wider health impact of COVID‑19 persists through cases of long COVID – a chronic condition that develops following SARS‑CoV‑2 infection and lasts for at least three months. Approximately 5% to 15% of people who contract COVID‑19 exhibit symptoms corresponding to long COVID (OECD, 2026[4]). According to data from the OECD’s 2023‑2024 Patient-Reported Indicator Survey (PaRIS) of more than 107 000 primary care patients aged 45 and older in 19 countries, around 7% reported ever having long COVID and 5% were still experiencing persistent symptoms at the time of the survey (OECD, 2025[22]). Among those who reported experiencing COVID‑19, almost 14% reported persistence of long COVID symptoms beyond three months, and 6.5% reported persistence beyond 12 months. Long COVID patients consistently reported poorer self-rated physical and mental health than those without long COVID (OECD, 2025[22]). Women also tend to experience higher rates of long COVID (OECD, 2021[5]; OECD, 2025[22]).
The impacts of long COVID vary across countries and evidence is still emerging. According to recent OECD modelling, an estimated 5.3% of people across OECD and EU countries were living with long COVID on average in 2021, with healthcare costs amounting to between 0.6% and 0.8% of total health expenditure (OECD, 2026[4]). Long COVID significantly affected labour markets, reducing the OECD and EU workforce by approximately 1% on average in 2021. In the coming decade, prevalence is projected to level off at between 0.6% and 1.0% of the OECD population, although long COVID may continue to cost health systems roughly USD 11 billion each year, with annual GDP losses expected to range between 0.1% and 0.2% (ibid).
2.1.4. Impact on care pathways for non-communicable diseases
Care pathways for patients with chronic conditions were significantly disrupted due to COVID‑19. In OECD and EU countries, the health burden of NCDs has been of utmost concern for decades, with diseases of the circulatory system and cancer remaining the leading causes of mortality in 2021, accounting for 32% and 22% of all deaths in the EU (OECD/European Commission, 2024[23]), and 28% and 21% of all deaths across OECD countries (OECD, 2023[16]), respectively. In response to the emerging SARS‑CoV‑2 virus, most countries imposed far-reaching non-pharmaceutical interventions, including an extensive restructuring of health systems, stay at home orders, quarantine mandates, among others (WHO, 2020[24]). The disruption of health systems and daily life brought by the COVID‑19 pandemic had unforeseen circumstances in the management and prevention of NCDs (Table 2.1).
Source: OECD analysis based on review of the literature.
Cardiovascular care pathways
The first months of the COVID‑19 pandemic brought an abrupt and dramatic decline in hospital admissions for life‑threatening cardiovascular conditions. Across 17 OECD countries, admissions for several cardiovascular conditions fell by an average of 26% between March and May 2020 compared with the same period in 2019 (Figure 2.3), ranging from more moderate levels in Japan (‑9.5%) (Arai et al., 2022[25]) to steeper levels in Italy (‑43%) (Severino et al., 2020[26]). Admissions for acute stroke followed a similar pattern, decreasing nearly 24% on average across 11 OECD countries (Figure 2.3), with reductions exceeding 50% in Greece (Katsouras et al., 2021[27]) and 6% in Japan (Yoshimoto et al., 2022[28]).
The reductions in hospital admissions were compounded by declines in cardiovascular procedures. Across 8 OECD countries, cardiovascular interventions fell by an average of 22% during the early months of 2020 compared to the 2019 levels (Figure 2.3), with the steepest decline in the United Kingdom (Leyva et al., 2021[29]). Delays in treatment also lengthened. In Belgium, the median interval between hospital arrival and reopening a blocked artery (i.e. door-to-ballon time) increased by around 15% (Claeys et al., 2020[30]) and in France care management time for some patients with acute coronary events increased by over 40% (Lesaine et al., 2022[31]). Increases of around 11% were seen with total treatment delay for myocardial infarction patients in the Netherlands and door-to-needle times for stroke patients in Australia (Sturkenboom et al., 2022[32]; Cadilhac et al., 2021[33]). Median length of stay during March and May of 2020 for various cardiovascular patients decreased in several countries, including the United States, the United Kingdom, Israel and Germany, compared to the same period in 2019 (Bhatt et al., 2020[34]; Mafham et al., 2020[35]; Kobo et al., 2020[36]; Ueberham et al., 2021[37]).
Percent change during the first months of the pandemic compared with pre‑pandemic reference period
Note: Whiskers represent the minimum and maximum reduction in cardiovascular care across OECD countries. Data come from different studies across various time periods in 2020 compared to 2019 reference periods and are not necessarily directly comparable.
Acute cardiovascular admissions (including cute coronary syndromes [ACS] and heart failure): Chart displays percentage change of hospital admissions in the first months of the COVID‑19 pandemic compared to pre‑pandemic reference periods (Severino et al., 2020[26]; Aldujeli et al., 2021[38]; Piuhola et al., 2020[39]; Sung et al., 2021[40]; Plat et al., 2023[41]; Lavie et al., 2022[42]; Claeys et al., 2020[30]; Rodríguez-Leor et al., 2020[43]; Mohammad et al., 2020[44]; Zeymer et al., 2023[45]) (Mafham et al., 2020[35]; Mefford et al., 2021[46]; Arai et al., 2022[25]; Kempers et al., 2023[47]; Gellert et al., 2023[48]; Kubica et al., 2021[49]). Data from Denmark is an average of four different studies focussing on ACS and atrial fibrillation admission rates from Mar‑20 to May‑20 (Østergaard et al., 2021[50]; Lauridsen et al., 2020[51]; Andersson et al., 2020[52]; Holt et al., 2020[53]). Data from Greece is an average of three studies focussing on ACS admissions (Papafaklis et al., 2020[54]; Katsouras et al., 2021[27]; Katsouras et al., 2021[55]).
Acute stroke admissions. Chart displays percentage change of hospital admissions in the first months of the COVID‑19 pandemic compared to pre‑pandemic reference periods (Yoshimoto et al., 2022[28]; Douiri et al., 2021[56]; Kempers et al., 2023[47]; Raymaekers et al., 2021[57]; Miękisiak et al., 2022[58]; Libruder et al., 2021[59]; Campanile et al., 2021[60]; Katsouras et al., 2021[27]; the Swiss Stroke Registry Investigators, 2022[61]). Data from Germany is an average from studies by (Richter et al., 2021[62]; Hoyer et al., 2020[63]; Dengler et al., 2022[64]). Data from the United States is an average from studies by (de Havenon et al., 2021[65]; de Havenon et al., 2021[66]; Sheng et al., 2021[67]; Schirmer et al., 2020[68]; Rodrigues, Jin and Pendharkar, 2022[69]; Nogueira et al., 2021[70]; Myers et al., 2022[71]).
Cardiovascular interventions: Data shows averages from different cardiovascular interventions from the first months of the COVID‑19 pandemic compared to pre‑pandemic reference periods (Cai, Fisher and Loa, 2021[72]; Benali et al., 2022[73]; Wood-Kurland et al., 2023[74]; Zeymer et al., 2023[45]; Connolly et al., 2021[75]; Legutko et al., 2020[76]). Data from the United States is an average of data from (Varghese et al., 2022[77]; Nogueira et al., 2021[70]; Maraey et al., 2023[78]). Data from the United Kingdom is an average of data from (Leyva et al., 2021[29]; Kwok et al., 2020[79]; Mafham et al., 2020[35]).
Source: OECD review of academic literature as above.
These care disruptions had clinical repercussions. Mortality from cardiovascular causes increased sharply in several OECD countries. For example, Israel reported a 66% rise in in-hospital mortality from acute stroke (Libruder et al., 2021[59]), the United States saw a 44% increase in acute myocardial infarction deaths (Mefford et al., 2021[46]) and Spain a 47% rise in ACS (Rodríguez-Leor et al., 2020[43]). Broader cardiovascular mortality also rose by 8% in the United Kingdom (Wu et al., 2020[80]) and by as much as 46% in Lithuania (Čelutkienė et al., 2022[81]). Beyond hospitals, out-of-hospital cardiac arrest outcomes worsened across multiple countries (Katasako et al., 2023[82]; Hosomi et al., 2022[83]; Chan et al., 2021[84]; Baert et al., 2020[85]).
Cascade of cancer care
The cascade of cancer care, from screening and diagnosis to treatment and follow-up, was also strained. At the outset of the pandemic, 16 out of a group of 21 countries temporarily paused cancer screening programmes (Fujisawa, 2022[86]). The number of cancer screening procedures declined by roughly 26% on average across 6 OECD countries over several months in 2020 compared to the prior year’s levels (Figure 2.4). Although most programmes resumed later in the year, the backlog proved difficult to recover. From 2020 to 2022, breast and cervical screening participation remained below 2017-2019 levels in the majority of OECD countries (Figure 2.5). The long-term impact on colorectal cancer screening is less pronounced, with just over half of OECD countries (11 of 20) reporting lower screening rates in 2020‑2022 versus 2017-2019, although the OECD average remains stable.
The diagnostic pathway also faltered. In the early months of the pandemic, studies showed a substantial reduction in diagnoses in many OECD countries and every cancer type compared to the same periods in 2019, ranging from a 58% reduction in the United Kingdom (Rutter et al., 2021[87]) to an 11.5% reduction in France (Blay et al., 2021[88]). Some recovery occurred later in the year, but by the end of 2020, many countries still reported fewer diagnoses than expected (Greene et al., 2022[89]; Nogueira et al., 2023[90]; Drescher et al., 2021[91]; Johansson et al., 2022[92]; Peacock et al., 2021[93]; Zagar et al., 2022[94]; Okuyama et al., 2022[95]). Emerging evidence also suggests that cancers were being diagnosed at later stages. The number of new early-stage cancer diagnoses declined by about 10% on average across 6 OECD countries (Figure 2.4), while the proportion of metastatic cancers increased in some countries such as France (Blay et al., 2021[88]), Italy (Rottoli et al., 2022[96]; Cantini et al., 2022[97]) and the Netherlands (Eijkelboom et al., 2021[98]; Deukeren et al., 2022[99]; Toes-Zoutendijk et al., 2022[100]).
Treatment was similarly disrupted. During the first months, the number of patients treated decreased according to several studies (Eijkelboom et al., 2021[98]; Blay et al., 2021[88]; Amador et al., 2021[101]; Gathani et al., 2021[102]; Morris et al., 2021[103]; Kleemann et al., 2022[104]). The number of surgical cancer procedures fell by roughly 15% across 5 OECD countries in which there are data for several cancer types, with the estimated reductions ranging from 1% in New Zealand (Gurney et al., 2021[105]) to 27% in the United Kingdom (Nossiter et al., 2022[106]) (Figure 2.4). Time from diagnosis to intervention lengthened in several systems (Kripalani et al., 2022[107]; Deukeren et al., 2022[99]), reflecting bottlenecks in testing, surgical capacity and staff availability. The few studies examining survivorship signalled a 26.5% decline in median overall survival among metastatic colorectal cancer patients in France from May to September 2020 (Thierry et al., 2021[108]), and by around three months for esophagogastric cancer patients from March to September 2020 in Scotland (Baxter et al., 2023[109]). Although the overall impact of the pandemic on cancer mortality remains uncertain due to limited long-term data, evidence suggests that COVID‑19 likely led to a substantial increase in cancer-related deaths resulting from delays in diagnosis and treatment (Lai et al., 2020[110]; Hanna et al., 2020[111]; Sud et al., 2020[112]; Jabbal et al., 2023[113]; Blay et al., 2021[88]).
Percent change during the first months of the pandemic compared with pre‑pandemic reference period
Note: Whiskers represent the minimum and maximum reduction in cancer care across OECD countries. Data come from different studies across various time periods in 2020 compared to 2019 reference periods, and are not necessarily directly comparable.
Average number of cancer screening procedures reflect oesophagogastric, breast, respiratory, gynecological, urological and colorectal cancers in 2020 compared to 2019 reference periods. For France, data average reflects oesophagogastric, breast, respiratory, gynecological, urological and colorectal cancers in 2020 compared to 2019 (Le Bihan Benjamin et al., 2022[114]). Netherlands reflects faecal test invitations for colorectal screening in 2020 compared to 2018 and 2019 average (Domper-Arnal, Hijos-Mallada and Lanas, 2022[115]). Australia reflects the number of colonoscopies in Jan-Sept 2020 compared to same period in 2019 (Williams et al., 2021[116]). Austria reflects mean rate of colonoscopies per week in Mar-Sept 2020 compared with same period 2019 (Domper-Arnal, Hijos-Mallada and Lanas, 2022[115]). Korea reflects number of breast screening in 2020 compared with 2019 (Kang et al., 2021[117]) and the United States average reflects colorectal and breast cancer screenings from Apr-Jun 2020 compared with same period in 2019 (Jabbal et al., 2023[113]; Oakes et al., 2023[118]).
Average for the number of new diagnosis of stage 0/I/II/III cancers reflect the following: Data from Iceland, Sweden, Norway and Denmark refer to the proportion of all cancers diagnosed at in situ stage (Stage 0) in March – Dec 2020 compared to same period 2019 (Johansson et al., 2022[92]). Data from Italy average the proportion of colorectal, lung and breast cancers diagnosed at Stage I to III from 2020 to 2021 compared to 2018 to Feb 2020 (Mentrasti et al., 2022[119]; Rottoli et al., 2022[96]; Cantini et al., 2022[97]; Mentrasti et al., 2022[120]). Data from the Netherlands averages the proportion of breast, prostate and colorectal cancers from March to October 2020 compared with same periods in 2018 and 2019 average (Eijkelboom et al., 2021[98]; Deukeren et al., 2022[99]; Toes-Zoutendijk et al., 2022[100]).
Majority of data on the number of surgical procedures refers to all cancers from whole 2020/from March onwards, compared to same periods 2019 (Le Bihan Benjamin et al., 2022[114]), except the following: data from Italy refers to colorectal surgeries only (Rottoli et al., 2022[96]), the Netherlands shows data from cervical cancers from the whole 2020 period (Algera et al., 2022[121]), New Zealand averages data from prostate, colorectal and lung cancers (Gurney et al., 2021[105]) and the United Kingdom shows data from prostate cancers from Mar – Dec 2020 compared with same period 2019 (Nossiter et al., 2022[106]).
Source: OECD review of academic literature as above.
Percent change in screening programmes 2020-2022 average compared to 2017-2019 (or nearest years) average
Note: Based on programme data for all countries except the United States, Spain, Switzerland and Japan that refer to survey data. Data represent the percentage differences between the averages over the 3‑year period 2020 to 2022 (post-COVID‑19) compared to 2017 to 2019 (pre‑COVID‑19). For some countries, data are available for only one or two years. Breast cancer includes to mammography screening in women aged 50‑69 within the past two years; cervical cancer includes cervical cancer screening in women age 20‑69 within the past three years; colorectal cancer includes colorectal cancer screening coverage of the population aged 50‑74.
Source: (OECD, 2024[122]), Screening (indicator), https://data-explorer.oecd.org/s/3gp.
Health services for NCD patients
The reorganisation of health services during the COVID‑19 pandemic largely succeeded in maintaining access to care and preserving quality, but it also created a substantial backlog due to postponed elective procedures and medical appointments. This backlog disproportionately affected patients with chronic conditions, particularly older individuals with comorbidities, who are already at higher risk of severe complications and mortality (Box 2.2). On average, across 27 OECD countries, in-person consultations decreased from 2019 to 2020 by ‑1.1 per capita, with Italy and Lithuania seeing the most significant drops at ‑5.2 and ‑3.2 consultations per capita, respectively (OECD, 2023[17]). However, a rapid shift toward virtual care helped offset some of the pressure on hospitals (Zachrison, Yan and Schwamm, 2021[123]; Cantor et al., 2023[124]), ensuring that patients could still access healthcare remotely while reducing overcrowding of health systems.
Despite efforts to adapt, the significant pressure on health services led to widespread unmet needs and disruptions to routine care. On average, across 22 OECD countries with comparable data, over one in five people (22%) reported skipping a necessary medical examination or treatment during the first year of the pandemic, ranging from 10% in Denmark, to 35% in Hungary (OECD, 2023[17]). Projections done by (Fotopoulou et al., 2022[125]) showed that if the number of COVID‑19 patients remained high, delays in elective surgeries would lead to significant unmet medical care needs for non-COVID‑19 patients who rely on routine care and elective procedures for the management of their conditions. A study by (Sarzynski et al., 2024[126]) showed that there was a substantial decrease in patient transfers during high-surge periods, while COVID‑19‑related transfers accounted for a majority of transfers, reflecting the tendency to maintain care for non-COVID patients and vital elective procedures in their respective locations. Moreover, a study by (Crombez and De Staelen, 2024[127]) found that the challenges in reorganising healthcare during the pandemic – such as maintaining quality and access to care – were influenced by each country’s level of preparedness and health system resilience before the pandemic. Additionally, pre‑pandemic conditions may have also impacted the severity of COVID‑19 in different countries (ibid).
Those with chronic conditions were hit hardest. During the first year of the pandemic, an average of 37% of individuals with one or more chronic conditions across 21 OECD countries reported missing or delaying appointments or clinical procedures, compared to approximately 25% of those without chronic conditions (Figure 2.6) (OECD, 2023[17]). Furthermore, the percentage of older adults with multimorbidity – defined as having two or more chronic conditions – reporting cancelled or postponed care due to COVID‑19 ranged from 37% in the United States to 11% in Germany, with the OECD average among 11 countries at 11% (OECD, 2023[17]).
Percentage of people aged 50 years and over who reported forgoing or postponing medical care due to COVID‑19, with and without a self-reported chronic health condition, 21 OECD countries
Note: Chronic conditions include: acute myocardial infarction/heart failure, high blood pressure or hypertension, high cholesterol, stroke or vascular disease, diabetes or high blood sugar, chronic lung disease, Parkinson’s disease, Alzheimer’s disease, dementia or other serious memory problems, rheumatoid arthritis, osteoarthritis or other rheumatism or chronic kidney disease. Data collected between June and August 2020.
Source: OECD (2023[17]), Ready for the Next Crisis? Investing in Health System Resilience, Figure 6.3, https://doi.org/10.1787/1e53cf80-en.
2.1.5. Social impact
The overall burden associated with the COVID‑19 pandemic extends well beyond health, with profound social and economic impacts that disproportionately affected disadvantaged populations. The pandemic exacerbated socio‑economic inequalities, job insecurity, and negative educational outcomes and led to spikes in discrimination (Berchet, Bijlholt and Ando, 2023[128]). Chapter 7 provides a brief overview of the impact on children and young people through temporary school closures. The onset of the COVID‑19 crisis led to the closure of many activities and businesses, resulting in a varied impact on the unemployment rate across OECD countries and substantial rises in overall labour underutilisation rates (OECD, 2021[5]). Between 2019 and 2020, the average unemployment rate across OECD countries increased by around 32% (1.7 p.p.), reaching 7.1% in 2020, with particularly sharp rises in the United States and Canada (Figure 2.7). Over the same period, labour underutilisation across OECD countries rose by nearly 37%, reaching 17% in 2020 (an increase of 4.5 p.p.) (Figure 2.7), and the share of 15‑29 year‑olds not in employment, education or training (NEET) grew by nearly 6% (OECD, 2021[5]). GDP declined across almost all OECD countries, falling by an average of around 5% between 2019 and 2020 (Figure 2.7).
Percent change 2020 compared to 2019
Note: The OECD area unemployment rate is calculated as the total number of unemployed people in all OECD countries as a percentage of the total labour force (i.e. the unemployed plus those in employment); this is equivalent to an average of unemployment rates of all OECD countries weighted by the labour force of each country. Data for Germany in 2020 are provisional and might be subject to low reliability due to technical issues with the introduction of the new German system of integrated household surveys.
Source: Adapted from OECD (2021[5]), COVID‑19 and Well-being: Life in the Pandemic, Figures 2.1 and 2.7, https://doi.org/10.1787/1e1ecb53-en.
In terms of broader labour impacts, 14% of workers in 19 European OECD countries felt it was “likely they would lose their job” within three months, and nearly 1 in 3 people in 25 OECD countries reported financial difficulties (OECD, 2021[5]). Greece and Latvia saw some of largest changes in job security, with roughly 10% more people fearing job loss between April-June 2020 and February-March 2021, whereas Denmark and Slovenia reported the smallest changes. Socially disadvantaged populations, including younger, less educated and individuals belonging to racial/ethnic minority groups, faced greater financial strain – often occupying low income, part-time jobs and working in more precarious working conditions. Commonly over-represented in the leisure and hospitality, tourism and retail industries these population groups faced a higher risk of job loss due to limited teleworking opportunities. Consequently, at the peak of the pandemic almost one in five OECD households struggled to make ends meet (OECD, 2021[5]).
The COVID‑19 pandemic led to significant social, behavioural, and economic disruptions, altering some lifestyle‑related risk factors associated with the burden of non-communicable diseases (NCDs) (WHO, 2020[129]). To better understand the pandemic’s impact, observed post-pandemic trends in major NCD risk factors were compared with projections based on pre‑pandemic linear trends. Table 2.2 shows estimated changes in tobacco use, alcohol consumption, and obesity across 28 OECD and 5 non-OECD EU/EEA countries during the COVID‑19 period (2020-2022), relative to projected levels. On average across the 28 OECD countries included, the prevalence of tobacco use among the population aged 15 years and older was estimated to be +1.41 p.p. higher (around a 10.9% increase) than predicted, with all countries reporting higher-than-predicted smoking prevalence despite variations in magnitude. This suggests that COVID‑19 slowed the decline in overall smoking prevalence. By contrast, in the same period and set of countries, calendar year per-capita alcohol consumption among persons aged 15 years and older was lower than predicted, averaging 0.40 litres lower (around a 3.8% decrease) compared to projections. The impact on obesity was marginal, with overall prevalence, on average, +0.11 p.p. higher (around a 0.5% increase) than predicted, possibly due to the lag between changes in energy balance and observable weight shifts, compounded by the short assessment period.
Estimated average change in major risk factor levels in 2020‑2022 (or available years) compared to what would have been expected in those years if following a linear pre‑pandemic trend, based on data from 28 OECD and 5 non-OECD EU/EEA countries
Note: Tobacco: Age‑standardised prevalence of current tobacco use among the population aged 15 years and older. Alcohol: Total (recorded and unrecorded) alcohol consumption per capita among persons aged 15 years and older within a calendar year (in litres (L) of pure alcohol). Obesity: Age‑standardised prevalence of obesity in persons aged 18 and over (defined as body mass index (BMI) ≥ 30 kg/m². Data show the difference between the average of observed values in 2020-2022 (or available years) and the average of values predicted for 2020-2022 based on a pre‑pandemic linear trend for years 2010-2019 for alcohol and obesity and 2000-2015 for tobacco. For each risk factor, increases are coloured in red, and decreases are coloured in blue.
Increases
Decreases
Source: OECD analysis using data from The WHO’s Global Health Observatory, 2024.
The overall changes in lifestyle‑related risk factors relative to expected levels presented in Table 2.2 may be over- or underestimated and reflect the heterogeneous behavioural responses of populations during the pandemic, as highlighted in the sections below.
2.2.1. Tobacco consumption
Even before the COVID‑19 pandemic, tobacco exposure was the second leading global risk factor for early death and disability, responsible for over one‑fifth of all NCD-related deaths, including a substantial share of cardiovascular and respiratory diseases as well as cancers (WHO, 2023[130]).
During the pandemic, smoking behaviours shifted in complex and sometimes contradictory ways across OECD countries. In 11 OECD countries with survey data, current smokers generally reported no change in their smoking habits, but whose who did change their behaviour generally reported smoking more rather than smoking less (Figure 2.8). Across OECD countries, reductions in smoking behaviour were observed among some population groups in some countries such as Italy and Denmark, but among those who continued to smoke, daily use increased in some countries such as France and Germany (Odone et al., 2020[131]; Fosgaard, Pizzo and Sadoff, 2022[132]; Guignard et al., 2021[133]; Koopmann et al., 2021[134]).
Note: Data come from national survey responses to smoking habits during the first months of the COVID‑19 pandemic and are not necessarily directly comparable. Italy data corresponds to regional data in Northern Italy; all other data correspond to national samples in periods ranging from March to June 2020.
Source: Australia, Canada, the United Kingdom and the United States April to June 2020: (Gravely et al., 2021[135]); France 30 March to 1 April 2020: (Guignard et al., 2021[133]); Germany 8 April to 11 May 2020: (Koopmann et al., 2021[134]); Ireland 23 April to 1 May 2020: (Reynolds et al., 2021[136]); Italy March to May 2020: (Munarini et al., 2022[137]); New Zealand 15 to 18 April 2020: (Gendall et al., 2021[138]); Poland 17 April to 1 May 2020 (Sidor and Rzymski, 2020[139]).
Smoking patterns also varied by age group. Among adolescents and young adults, studies reported mixed results, with some studies showing reduced tobacco use (Villanueva-Blasco et al., 2023[140]; Rogés et al., 2021[141]) and others showing no change or even increases (Barrera-Núñez et al., 2022[142]; Jackson et al., 2023[143]). Among adults, smoking generally declined (Guignard et al., 2021[133]; Koyama et al., 2021[144]). Increased use was most often linked to stress, anxiety, unemployment and income loss, as well as remote work and higher education levels, all of which are factors that may have shaped daily routines and coping mechanisms (Guignard et al., 2021[133]; Wiley et al., 2022[145]; Loui et al., 2023[146]; Koyama et al., 2021[144]).
2.2.2. Harmful alcohol use
Similar to tobacco use, harmful alcohol consumption is also a major risk factor for NCD morbidity and mortality, directly linked to liver cirrhosis, pancreatitis, multiple cancers, haemorrhagic stroke, and hypertension (WHO, 2024[147]). A small group of heavy drinkers, between 4% and 14% of adults, consume between 31% to 54% of all alcohol consumed, bearing a disproportionate share of its health and social harms (OECD, 2021[148]).
The pandemic disrupted drinking patterns, but not uniformly. One OECD analysis showed that during the first wave of the COVID‑19 pandemic, 44% of people across 11 OECD countries reported drinking more frequently in comparison to 25% reporting drinking less and 32% reporting no change (OECD, 2021[149]). Other findings reveal a more nuanced picture. In 8 OECD countries with survey data, most respondents reported no change in their alcohol consumption during COVID‑19, but the picture was mixed for those who did change their behaviour (Figure 2.9).In terms of prevalence and average weekly use, several countries reported decreases in alcohol consumption from April 2020 to July 2020 compared to before the pandemic (Rossow et al., 2021[150]; Quadri et al., 2023[151]; Rossow et al., 2021[152]), although the United States and the United Kingdom were exceptions to this trend (Barbosa, Cowell and Dowd, 2021[153]; Rossow et al., 2021[152]).
Despite this mixed picture, the first few months of the pandemic saw an overall increase in alcohol consumption among heavier drinkers across eight European countries (defined in this study as those in the top 10% of alcohol consumption pre‑pandemic), using data from the European Survey on Alcohol use and COVID‑19 (Rossow et al., 2021[152]). In contrast, only small average changes in consumption were reported among other drinkers. Moreover, 7 of these countries reported a statistically significant increase in the proportion of heavy drinkers (those who drink more than 28 units per week) during the pandemic (Rossow et al., 2021[152]). This trend is consistent with emerging evidence showing an 18% pandemic-related increase in alcohol-attributable mortality across 19 EU countries compared with 2019, despite declining population-level consumption over this same time period (Rehm et al., 2025[154]). As with tobacco, factors commonly associated with increased alcohol use during the pandemic included psychosocial and economic stressors such as anxiety and depression, unemployment, reduced income, remote work, and a history of substance use disorder (Weerakoon, Jetelina and Knell, 2021[155]; Barrera-Núñez et al., 2022[142]; Booth et al., 2023[156]; Quadri et al., 2023[151]).
Note: Data come from national survey responses to alcohol consumption during COVID‑19 and are not necessarily directly comparable.
Source: Data from Spain corresponds to local hospital alcohol use disorder patients (Arias Horcajadas et al., 2022[157]) but results are consistent with average weekly use rates shown by (Rossow et al., 2021[152]). Rest of data corresponds to national samples from different studies in periods ranging through 2020 and 2021: Australia 16 to 30 September 2020 (Booth et al., 2023[156]); Germany 8 April to 11 May 2020 (Koopmann et al., 2021[134]) Ireland 23 April to 1 May 2020 (Reynolds et al., 2021[136]) Italy 3 to 15 April 2020 (Scarmozzino and Visioli, 2020[158]) Norway 15 to 20 April 2020 (Alpers et al., 2021[159]) Poland 8 to 18 April 2020 (Szajnoga, Klimek-Tulwin and Piekut, 2020[160]) Spain March to May 2020 (Arias Horcajadas et al., 2022[157]) United States March to April 2020, August 2020, December 2020 and April 2021 (Wittenberg et al., 2022[161]; Weerakoon, Jetelina and Knell, 2021[155]).
2.2.3. Diet and physical activity
Unhealthy diets and physical inactivity, and their associated impacts on body mass index, are important risk factors for cardiovascular disease, diabetes, and cancers, among other NCDs (WHO, 2024[162]; OECD/WHO, 2023[163]). Unfavourable shifts in eating behaviours and physical activity patterns were accentuated by the mobility restrictions during the pandemic, potentially counteracting the gains made by policies promoting healthier lifestyles and accentuating the prevalence of overweight and obesity. Despite limited evidence, it appears that the majority of people in several countries reported a decrease in general activity levels during the initial months of the pandemic (Di Renzo et al., 2020[164]; Catucci, Scognamiglio and Rossi, 2021[165]; Granero et al., 2023[166]; Ochi et al., 2023[167]; Fearnbach et al., 2021[168]; Romero and Lv, 2022[169]). The effect on levels of physical activity among children and adolescents remains unclear, with some studies reporting a decline and others reporting no significant changes (OECD/European Commission, 2024[23]). Furthermore, studies have found that during there was an apparent trend towards more frequent, healthier, home‑cooked meals during the early COVID‑19 periods, but with more variable and conflicting results in regard to the increase or decrease in unhealthy snacking (Wdowiak-Szymanik et al., 2022[170]; Bennett et al., 2021[171]).
The COVID‑19 pandemic acted as both a stress test and a mirror for societies’ health behaviours. For some, it reinforced positive habits, while for others, it deepened risk factors for NCDs. Changes in the risk factors combined with severe disruptions in screening, diagnosis and treatment have created the conditions for a possible rise in NCDs over the coming years (Xu et al., 2024[172]). The OECD has developed the Strategic Public Health Planning for Non-Communicable Diseases (SPHeP-NCDs) model to quantify the impact of major risk factors on population health and the economy (see Annex 2.A for more details). The remainder of this chapter uses the SPHeP-NCDs model to estimate the impact of COVID‑19 on the long-term health and economic burden of NCDs across 28 OECD and 5 non-OECD EU/EEA countries included in the analysis.
The impact of COVID‑19 on the burden of NCDs – hereafter referred to as the “COVID-19-impact” – is estimated by comparing outputs of two different scenarios against a common baseline. The “baseline” scenario represents a counterfactual world without COVID‑19, assuming that pre‑COVID‑19 risk factor levels remain unchanged and health systems continue to perform at pre‑COVID‑19 levels in treating NCDs. The two “COVID‑19” scenarios represent alternative worlds in which exposure to key risk factors (i.e. tobacco use, alcohol consumption and obesity) are altered to reflect lifestyle changes during the COVID‑19 pandemic and assume temporary declines in cancer survival due to diagnostic delays during the pandemic. This modelling exercise does not include other impacts of COVID‑19, including on mental health or long COVID, and can be considered a conservative estimate with a certain degree of uncertainty. While Section 2.3 provides two illustrative scenarios, the true range of future impacts is likely to be broader, reflecting underlying uncertainties and the potential for additional economic effects, including those arising from changes in mental health and labour force participation.
The following two scenarios of “COVID‑19” are modelled (see Figure 2.10):
Scenario 1 (temporary shock): The pandemic is assumed to produce only a short-lived disturbance in the population risk factors. Levels of the modelled risk factors are assumed to be altered linearly from the 2020 levels through 2021, remain stable until 2023 and return to pre‑pandemic levels by 2024. Cancer survival rates are assumed to decline temporarily to reflect diagnostic and treatment delays but subsequently recover by end of 2024. From a practical standpoint, this scenario implies that individuals who had altered their habits during the COVID‑19 pandemic would revert to their previous lifestyles by 2024. This scenario represents a more conservative estimate and can be interpreted as an upper-bound approximation of the NCD-related impact of COVID‑19, as, even if risk factors return to pre‑pandemic levels, individuals may still face an elevated long-term risk of developing NCDs.
Scenario 2 (permanent shock): The effect of the pandemic is assumed to endure through persistent shifts in risk factors. As in Scenario 1, risk factor levels are altered linearly through 2021, but remain permanently at that level through 2050, assuming that lifestyle changes adopted during the pandemic would persist throughout the duration of the simulation. Cancer survival rates are still assumed to dip temporarily, with complete recovery by end of 2024. This scenario represents a less conservative estimate and can be interpreted as an upper-bound approximation of the NCD-related impact of COVID‑19.
Modelled changes to the risk factors that impact the burden of NCDs under each scenario
Note: Illustrative, not based on real data. The green line denotes the theoretical changes to the risk factors that may influence the burden of NCDs. Under each scenario, cancer survival rates are also assumed to temporarily decline in the short-term with complete recovery by end of 2024.
The choice was made to present two scenarios of “COVID‑19” to provide a hypothetical range of estimates, based on different assumptions regarding the projected duration of the impact of the pandemic while keeping the magnitude of the shock constant. These scenarios are projected into the future to be able to see the impact on NCDs, which takes time to materialise (e.g. tobacco consumption does not cause lung cancer immediately but may do so after several years). The impacts are measured over two time periods, 2020 to the end of 2024 (i.e. short-term impact) and 2025 to 2050 (i.e. long-term impact). These two time periods were chosen as Scenario 1 likely has a greater impact in the short-term than the long-term, with its impact diminishes over time, while Scenario 2 has the same impact as Scenario 1 in the short-term but has a sustained impact over the long-term. The model accounts for population ageing to avoid any misleading conclusion from demographic change.
The analysis models the impact of COVID‑19‑related changes to three major risk factors: tobacco smoking, harmful alcohol consumption, and obesity. The magnitude of the modelled shock to risk factors in the COVID‑19 scenarios is based on the analysis presented in Section 2.2 in Table 2.2, which estimates the pandemic’s impact by comparing post-pandemic trends in major NCD risk factors with projections from pre‑pandemic linear trends. The overall impact on alcohol consumption in Table 2.2 was applied to moderate drinkers, while the impact applied to hazardous and harmful drinkers was extrapolated from Rossow et al. (2021[152]). It is important to note that the numbers used in the model are only estimates, and the real impact of COVID‑19 on risk factor levels in some countries may be over or underestimated.
Beyond changes in risk factors, COVID‑19 significantly affected care pathways for people with chronic conditions, as described in Section 2.1.4. Disruptions to cancer care, in particular, may have long-term consequences for cancer morbidity and mortality. Accordingly, in each “COVID‑19” scenario the model assumes a temporary shock to 5‑year cancer survival, using figures extrapolated from Sud et al.’s (2020[112]) modelling study in the United Kingdom, which estimates the impact of 3‑month delays in cancer diagnosis on longer-term survival. The same shock was applied to all countries for a period of several years.
2.3.1. COVID‑19s indirect effects on NCDs could shorten life expectancy
The indirect impacts of COVID‑19 on NCDs is likely to have led to people living shorter lives, adding to the deaths directly caused by the virus. In the short term (i.e. between 2020 and 2024), changes in NCDs attributable to COVID‑19 are estimated to have reduced life expectancy and healthy life expectancy (HALE) – a measure combining mortality and morbidity by quantifying the average number of years a person can expect to live in full health, accounting for years lived with illness or injury – by 2.4 months and 2.5 months, respectively, on average across the 28 OECD countries analysed, compared to a scenario where the pandemic never occurred (Figure 2.11). This is likely primarily driven by an increase in premature mortality from cancers and CVD over this time period. These indirect effects are considerable, representing about 20% of the overall impact of COVID‑19, given that during the period 2019 to 2021 life expectancy at birth across the 28 OECD countries studied declined by around 11 months (i.e. from 81.1 years in 2019 to 80.2 years in 2021) (Eurostat, 2025[173]; OECD, 2025[174]).
In the long term (i.e. between 2025 and 2050), the detrimental impact of COVID‑19 on life expectancy fades over time if risk factors and behaviours gradually return to pre‑pandemic levels (i.e. the temporary shock in Scenario 1). However, if changes in risk factor levels observed during COVID‑19 continue permanently (Scenario 2), life expectancy and HALE could remain lower over the long term, averaging 1.9 months and 2.4 months less, respectively, across 28 OECD countries by 2050 compared to a scenario where no COVID‑19 occurred (Figure 2.11). It is important to note that changes in the modelled risk factors will also affect other NCDs not included in the model, so the estimated impact is therefore an underestimation of the overall effect.
Impact on life expectancy (LE) and health life expectancy (HALE) in months, average over 2020-2024 (short-term impact) and 2025-2050 (long-term impact)
Note: The “short-term impact” estimates the NCD-related impact of COVID‑19 over the period 2020-2024, assuming disruptions to several key risk factors and declines in cancer survival over this time. The “long-term impact” estimates the NCD-related impact of COVID‑19 over the period 2025-2050 under two scenarios, a “temporary shock” in which disruptions to risk factors are short-lived until 2024 and a “permanent shock” which assumes persistent shifts for the duration of the model to 2050. The temporary shock can be interpreted as a lower-bound approximation of the NCD-related impact of COVID‑19, while the permanent shock can be interpreted as an upper-bound approximation.
Source: OECD SPHeP NCDs model, 2025.
It is likely that COVID‑19 may have lasting negative consequences on mental health, not only as a direct consequence from the pandemic itself (Section 2.1.2) but also indirectly through an expected rise in NCDs associated with changes in risk factors in the future. For example, analysis suggests that people with NCDs are at a higher risk of experiencing depression (Everard et al., 2025[175]). Having cancer is associated with a 15% increased risk of depression, people living with heart disease have an 18% increased risk, with diabetes an 18% increased risk, with stroke a 23% increased risk and with chronic lung disease a 27% increased risk of depression relative to those without. Multimorbidity further worsens mental health: one NCD increases the risk of depression by 21%, two by 42% and three or more by 50%.
2.3.2. The lasting impacts of COVID‑19 could also increase the future costs associated with NCDs
The lasting impacts of COVID‑19 are expected to place additional pressure on health systems by increasing the future costs associated with NCDs. In the short term, an additional USD 11 per capita (adjusted for purchasing power parity – PPP) is projected to be spent per year, on average, across 28 OECD countries between 2020 and 2024 compared to a no-COVID baseline (Figure 2.12). This is equivalent to an increase of about 0.4% of overall annual health expenditure over this period. This can be viewed alongside the direct toll of the virus, with total health spending rising by around 8% on average across OECD countries at the peak of the pandemic in 2021, compared with a steady pre‑pandemic annual growth rate of 3% (OECD, 2024[176]). The largest spending in Figure 2.12 is predicted to happen in countries with high treatment costs, greater baseline prevalence of risk factors, and larger estimated COVID‑19‑related risk factor changes. While in other countries, such as Türkiye, where both the level of some risk factors such as alcohol consumption, and the treatment costs are relatively low, the spending may remain broadly comparable to the baseline.
If lifestyle trends return to pre‑pandemic levels by the end of 2024, the impact on health expenditure in the longer term becomes insignificant for many countries by 2050 (Figure 2.12). This is likely the result of less NCDs and a gain in a more resilient population. However, if risk factor trends observed during COVID‑19 persist permanently, additional medical costs equal to 0.6% of total annual health expenditure on NCDs are projected on average across 28 OECD countries between 2025 and 2050. Higher health expenditure in the future is driven by increased morbidity as well as increasing population size.
Impact on overall health expenditure of non-communicable diseases, in USD PPP 2022 per capita and as a percentage of total health expenditure, per year, average over 2020-2024 (short-term impact) and 2025-2050 (long‑term impact)
Note: Health expenditure includes curative care, rehabilitative care, preventative care, ancillary services and medical goods; and does not include long-term care. The estimates take into account the cost of other diseases as well as population dynamics. The “short-term impact” estimates the non-communicable‑disease NCD-related impact of COVID‑19 over the period 2020-2024, assuming disruptions to several key risk factors and declines in cancer survival this time. The “long-term impact” estimates the NCD-related impact of COVID‑19 over the period 2025-2050 under two scenarios, a “temporary shock” in which disruptions to risk factors are short-lived until 2024 and a “permanent shock” which assumes persistent shifts for the duration of the model to 2050. The temporary shock can be interpreted as a lower-bound approximation of the NCD-related impact of COVID‑19, while the permanent shock can be interpreted as an upper-bound approximation.
Source: OECD SPHeP NCDs model, 2025.
On a macro level, the combined impact of NCDs on premature mortality and less people in the workforce affect a country’s gross domestic product (GDP). In the short term, the indirect impact of COVID‑19 on NCDs could see OECD countries experience an average 0.1% annual GDP loss between 2020 and 2024 (Figure 2.13). In the longer term, if COVID‑19 trends persist permanently (Scenario 2), GDP could be as much as 0.2% lower each year, on average, across 28 OECD countries.
Impact on the average annual GDP over 2020-2024 (short-term impact) and 2025-2050 (long-term impact), in percentage of GDP
Note: The “short-term impact” estimates the NCD-related impact of COVID‑19 over the period 2020-2024, assuming disruptions to several key risk factors and declines in cancer survival this time. The “long-term impact” estimates the NCD-related impact of COVID‑19 over the period 2025-2050 under two scenarios, a “temporary shock” in which disruptions to risk factors are short-lived until 2024 and a “permanent shock” which assumes persistent shifts for the duration of the model to 2050. The temporary shock can be interpreted as a lower-bound approximation of the NCD-related impact of COVID‑19, while the permanent shock can be interpreted as an upper-bound approximation.
Source: OECD SPHeP NCDs model, 2025.
This chapter outlined the enormous impact COVID‑19 has had on health and societies, as only the latest among several large‑scale disease outbreaks over the last century (Chapter 3). Millions of people lost their lives worldwide. Populations saw declines in mental health and well-being, care pathways for chronic diseases were severely disrupted, and there were also major impacts on employment and labour. Although available data is mixed, COVID‑19 also altered the trajectory of lifestyle‑related risk factors, with increases in tobacco consumption and rises in harmful alcohol use.
This chapter also assessed the potential health and economic consequences of the indirect impact of COVID‑19 on NCDs. In the short term, life expectancy across 28 OECD countries is estimated to be 2.4 months lower compared to a scenario where the pandemic never occurred, with additional medical costs equalling 0.4% of overall annual health expenditure. The detrimental impact of COVID‑19 on health and the economy fades over time if risk factors and behaviours gradually return to pre‑pandemic levels. However, if changes in risk factors during COVID‑19 continue permanently, life expectancy could remain, on average, 1.9 months lower in 28 OECD countries by 2050 compared to a scenario where no COVID‑19 occurred, translating into increased medical costs equal to 0.6% of total health expenditure and annual GDP losses of 0.2%. These estimates are likely conservative, as they do not take into account other impacts of COVID‑19 such as on mental health or long COVID.
The findings of the chapter highlight the need to strengthen pandemic preparedness and response capacities, not only to address immediate health needs but also to anticipate the longer-term consequences for NCDs. People living with NCDs face heightened risks of mortality and morbidity during pandemics, while, at the same time, the crises themselves can intensify the burden of NCDs, further straining health systems and economies. Future research could further explore these longer-term dynamics, including the potential for permanent health and behavioural shocks, the impact of pandemic-driven changes in ICU capacity on healthcare workforce resilience and the implications of unmet mental health needs for life expectancy and health system costs across OECD countries.
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The OECD Strategic Public Health Planning for Non-Communicable Diseases (SPHeP-NCDs) model is an advanced systems modelling tool for public health policy and strategic planning. It is used to predict the health and economic outcomes of the population of a country up to 2050. The model analyses a comprehensive set of key risk factors (e.g. obesity, alcohol use, tobacco, diet, air pollution and physical activity) and their associated non-communicable diseases (NCDs). The model covers 51 countries, including OECD Member countries, G20 countries, EU27 countries and OECD accession and selected partner countries. Note that the model does not take into account the impact of risk factors on communicable diseases.
For each of the countries, the model uses demographic and risk factor characteristics by age‑ and sex-specific population groups from international databases. These inputs are used to generate synthetic populations, in which each individual is assigned demographic characteristics and a risk factor profile (see Annex Figure 2.A.1). Based on these characteristics, an individual has a certain risk of developing a disease each year. These relative risks are based on a Global Burden of Disease study, amongst others, and only consider the direct relation between the risk factor and the disease. Note that the model uses population predictions to adjust the size and demographic profile of country populations in the future but maintains current (age‑ and gender-specific) rates for risk factors. In other words, it does not predict any future trends in risk factor prevalence, with the exception of those caused by demographic changes.
Note: This schematic is highly simplified and focusses on the disease component – it does not reflect some other components of the model (including births, immigration, emigration, death, remission and fatality).
Source: OECD (2019[177]), SPHeP-NCDs Technical Documentation.
For each year modelled, a cross-sectional representation of the population can be obtained, to calculate health status indicators such as life expectancy, disease prevalence, mortality, and disability-adjusted life years using disability weights. The disease and demographic profile of the population also form the basis for the healthcare cost and labour market outputs. The impact of demographic changes and labour force participation and productivity are translated into a change in GDP using the Cobb-Douglas production function, consistent with the OECD long-term economic forecast model (Guillemette and Turner, 2017[178]) and other established long-term models such as the World Bank Long Term Growth Model (Pennings and Loayza, 2022[179]).
The model consolidates previous OECD work into a single platform. It covers a set of key risk factors, including harmful alcohol consumption (OECD, 2021[149]), tobacco consumption (Devaux et al., 2024[180]), overweight and obesity (OECD, 2019[181]), physical activity (OECD/WHO, 2023[163]), air pollution and diet. For each risk factor, individuals in the model can develop associated categories of disease, including those that are directly linked to the risk factor through a relative risk. Categories of disease include type 2 diabetes, stroke, ischaemic heart disease, chronic obstructive pulmonary disorder, musculoskeletal disorders (e.g. rheumatoid arthritis, low back pain), cirrhosis, chronic kidney disease, depression, dementia, several cancers (OECD, 2024[182]), injuries and dependence disorders.
As described in Section 2.3 in the main text, the analyses presented in this chapter models the impact of COVID‑19 related changes to three major risk factors – tobacco smoking, harmful alcohol consumption, and obesity – as well as cancer mortality on NCDs. Results are presented as annual averages or cumulative numbers for two time periods: 2020 to 2024 and 2025 to 2050. Single‑year estimates are not used as they are affected by noise in the model. Since the scenario is introduced as a “shock” from COVID‑19, rather than gradually over time, the annual average over the time periods reflects the impact in any of the years covered.
The results presented here are subject to limitations. First, the impact of each risk factor is limited to a set of major diseases that are linked directly or indirectly to the prevalence of the risk factor. However, there is emerging evidence of the impact of each risk factor on a wider range of diseases and other health and well-being outcomes. Second, some data on risk factors is self-reported, which may over- or under-estimate results. Thirdly, the data on risk factors during the COVID‑19 pandemic are mixed and sometimes conflicting. Fourth, the model does not include other impacts from COVID‑19 such as on mental health or long COVID.
For more information see OECD (2019[177]).