The health benefits of democracy — 170-country study

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HandsLife expectancy improved more quickly in countries that switched to democracy over the past 50 years and there were fewer deaths from cardiovascular disease, diseases such as cancer and cirrhosis, and even road traffic accidents, a major study of 170 countries has concluded.

The Guardian reports that the study said it was not just that democracies tended to be richer: the “democracy effect” was far stronger than any GDP effect. “Free and fair elections appear important for improving adult health … most likely by increasing government accountability and responsiveness,” the study said. “Democracies are more likely than autocracies to lead to health gains.”

The report says the study comes at a time when democracy is being challenged perhaps as never before. A majority of the world’s population lives in democracies, but more than 2bn people live in countries where democracy has been on the back foot in recent years, such as India, Turkey, Brazil and the US. The rise of populism attests to disillusionment in much of the democratic world, and the relative success of autocracies from China to Rwanda, and Vietnam to Singapore, has raised questions as to whether political freedom is the best system of government for everyone.

The study concludes that, as far as health is concerned, it is.

Thomas Bollyky, the lead author, from the US Council on Foreign Relations, said: “This is good news at a time when the news around democracy has been fairly depressing. Health and elections are inevitably linked.”

Researchers used existing measures of democratic experience compiled in the V-Dem database and plotted them against a range of metrics such as government health spending and disease outcomes. The report says they then compared trends in countries that had transitioned from autocracy to democracy since 1970 with 55 states that had not. The impact of HIV was factored out, because the huge amount of foreign aid devoted to the virus would have skewed the findings.

The conclusions were stark, the report says. Life expectancy at age 15 was 3% higher in countries 10 years after their transition to democracy than in counterparts that had not changed government type. Cardiovascular disease, tuberculosis, transport injuries and non-communicable diseases also fell as democracy bedded in. These four health dangers cause a quarter of the total death and disability in people under 70 in low and middle-income countries. The implication for further democratisation across the autocratic world is clear.

“We estimate that, between 1994 and 2014, the increases in democratic experience resulted in 16m fewer deaths from cardiovascular disease globally,” Bollyky is quoted in the report as saying. He added that if China had experienced the same democratic transition that a country such as Poland achieved over that period, it would have saved 10m lives of people who died from that one illness.

Researchers believe free societies achieve better outcomes not because of prosperity but public pressure. “Countries where government is not subject to free and fair democracy doesn’t have the same pressure from voters” to deliver better health services, Bollyky said.

Dr Joseph Dieleman, a co-author of the paper, from the Institute for Health Metrics and Evaluation, said: “Efforts to improve the health of adults might benefit from funding programmes that help countries to strengthen their democratic processes.”

The report says the study is the biggest of its kind to make such a broad correlation between democracy and adult health: others have focused more narrowly on democracy’s impact on early years health.

The work was conducted by the US Council on Foreign Relations and the Institute for Health Metrics and Evaluation. It was funded by Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Abstract
Background: Previous analyses of democracy and population health have focused on broad measures, such as life expectancy at birth and child and infant mortality, and have shown some contradictory results. We used a panel of data spanning 170 countries to assess the association between democracy and cause-specific mortality and explore the pathways connecting democratic rule to health gains.
Methods: We extracted cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and information on regime type from the Varieties of Democracy project. These data cover 170 countries and 46 years. From the Financing Global Health database, we extracted gross domestic product (GDP) per capita, also covering 46 years, and Development Assistance for Health estimates starting from 1990 and domestic health spending estimates starting from 1995. We used a diverse set of empirical methods—synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression—which together provide a robust analysis of the association between democratisation and population health.
Findings: HIV-free life expectancy at age 15 years improved significantly during the study period (1970–2015) in countries after they transitioned to democracy, on average by 3% after 10 years. Democratic experience explains 22·27% of the variance in mortality within a country from cardiovascular diseases, 16·53% for tuberculosis, and 17·78% for transport injuries, and a smaller percentage for other diseases included in the study. For cardiovascular diseases, transport injuries, cancers, cirrhosis, and other non-communicable diseases, democratic experience explains more of the variation in mortality than GDP. Over the past 20 years, the average country’s increase in democratic experience had direct and indirect effects on reducing mortality from cardiovascular disease (−9·64%, 95% CI −6·38 to −12·90), other non-communicable diseases (−9·14%, −4·26 to −14·02), and tuberculosis (−8·93%, −2·08 to −15·77). Increases in a country’s democratic experience were not correlated with GDP per capita between 1995 and 2015 (ρ=–0·1036; p=0·1826), but were correlated with declines in mortality from cardiovascular disease (ρ=–0·3873; p<0·0001) and increases in government health spending (ρ=0·4002; p<0·0001). Removal of free and fair elections from the democratic experience variable resulted in loss of association with age-standardised mortality from non-communicable diseases and injuries.
Interpretation: When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases.

Authors
Thomas J Bollyky, Tara Templin, Matthew Cohen, Diana Schoder, Joseph L Dieleman, Simon Wigley

The Guardian report
The Lancet abstract


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