Health system quality and COVID-19 vaccination: a cross-sectional analysis in 14 countries

The social and behavioral determinants of COVID-19 vaccination have been previously described. However, little is known about how vaccinated people use and rate their health system. We used surveys conducted in 14 countries to study the health system correlates of COVID-19 vaccination. Country-specific logistic regression models were adjusted for respondent age, education, income, chronic illness, COVID-19 infection, urban residence, and minority ethnic, racial, or linguistic group. Estimates were summarized across countries using random effects meta-analysis. Vaccination with at least two or three doses ranged from 29% in India to 85% in Peru. Greater health care utilization, having a regular and a high-quality provider and receiving other preventive health services, were positively associated with vaccination. Confidence in the health system and government also increased the odds of vaccination. In contrast, having unmet health care needs or experiencing discrimination or a medical mistake decreased the odds of vaccination. Associations between health system predictors and vaccination tended to be stronger in high-income countries and in countries with the most COVID-related deaths. Access to quality health systems may affect vaccine decisions. Building strong primary care systems and ensuring a baseline level of quality– that is affordable for all – should be central to pandemic preparedness strategies