Background: This study aims at analyzing the efficiency of the health systems of 31 European countries in treating COVID-19, for the period January 1, 2020 - January 1, 2021, by incorporating some factors from a multidimensional perspective. Methods: The methodology used in the research was Data Envelopment Analysis (DEA), through which efficiency scores for health systems have been calculated. The research was performed considering three stages: the first wave (January 1-June 15), the relaxation period (June 15-October 1) and the second wave (October 1-December 31). In evaluating the determinants of the efficiency of health systems, six major fields of influence were taken into account: health care, health status, population, economic, cultural/societal and governmental issues, all covering 15 indicators. After measuring the efficiency, we used the Tobit type regression to establish the influencing elements on it. Results: The results for the public health systems of European states were determined for each country and period. We evaluated the efficiency of health systems in Europe against COVID-19, starting from health inputs (COVID-19 cases, physicians, nurses, hospital beds, health expenditure) and output (COVID-19 deaths). The obtained outputs show that, especially in the first phase of the pandemic, the inefficiency of the health systems was quite high, mainly in Western countries (Italy, Belgium, Spain, UK). In the relaxation phase and in the second wave, the Western states, severely affected at the beginning of the pandemic, began to take adequate measures and improve the efficiency of their sanitary systems. Instead, Eastern European countries were hit hard by the inefficiency of health systems (Bulgaria, Greece, Hungary, Romania). After Tobit regression, results of the study show that the influencing elements are different for the three stages: concerning the first wave, comobirdities, population age, and population density are important; for relaxation period a great influence have government effectiveness and power distance; with respect to second wave, the relevant factors are education and population density. Conclusions: The results obtained could serve as starting points for health policymakers to perform comparative analyzes in terms of good practices in the health system and to develop national plans to better deal with health crises. At the same time, they can be used internationally to achieve a coherent and effective community response to the pandemic.
