‘ Democracies Linked To Greater Universal Health Coverage Compared With Autocracies, Even In An Economic Recession. Health Affairs (2021) (with T. Templin, J. L. Dieleman, J.E. Mumford, S. Kiernan, M. Miller-Petrie, and T. Bollyky). [Full text] [Annex]
Abstract: Despite widespread recognition that universal health coverage is a political choice, the roles that a country’s political system plays in ensuring essential health services and minimizing financial risk remain poorly understood. Identifying the political determinants of universal health coverage is important for continued progress, and understanding the roles of political systems is particularly valuable in a global economic recession, which tests the continued commitment of nations to protecting their health of its citizens and to shielding them from financial risk. We measured the associations that democracy has with universal health coverage and government health spending in 170 countries during the period 1990–2019. We assessed how economic recessions affect those associations (using synthetic control methods) and the mechanisms connecting democracy with government health spending and universal health coverage (using machine learning methods). Our results show that democracy is positively associated with universal health coverage and government health spending and that this association is greatest for low-income countries. Free and fair elections were the mechanism primarily responsible for those positive associations. Democracies are more likely than autocracies to maintain universal health coverage, even amid economic recessions, when access to affordable, effective health services matters most.
‘Autocratisation and universal health coverage: a synthetic control study. The BMJ (2020) (with J. L. Dieleman, T. Templin, J.E. Mumford, and T. Bollyky). [Full text] [Annex]
Abstract: We assess the relation between autocratisation—substantial decreases in democratic traits (free and fair elections, freedom of civil and political association, and freedom of expression)—and countries’ population health outcomes and progress toward universal health coverage (UHC). We find that autocratising countries had worse than estimated life expectancy, effective health service coverage, and levels of out-of-pocket spending on health. These results suggest that the noticeable increase in the number of countries that are experiencing democratic erosion in recent years is hindering population health gains and progress toward UHC. Global health institutions will need to adjust their policy recommendations and activities to obtain the best possible results in those countries with a diminishing democratic incentive to provide quality healthcare to populations.
‘Is women’s political empowerment affecting COVID-19 mortality? Efil Journal · 3(10-11): 8-19 · 2020 (with A. Akkoyunlu). [Full text] [tweet summary]
Abstract: Much of the research on the ongoing pandemic has focused on the health and economic policies required to slow the spread of the disease and minimize its impact on the economy. The focus of this study is the political factors that influence policy-making. Specifically, we examine whether there is an association between women’s political empowerment and COVID-19 mortality. We use data for 168 countries, ordinary least squares regressions, and an instrumental variables approach to assess this relationship. Our results show that political equality by gender and participation by women in civil society associations are negatively associated with cumulative COVID-19 deaths.
‘The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis’ The Lancet · 393(10181): 1628-1640 · 2019 (with T. Bollyky, T. Templin, M. Cohen, D. Schoder, and J.L. Dieleman) [Full text] [Annex]
- Explainer – Washington Post.
- Opinion piece – CNN.
- Commentary – click here.
- Entry in the UK Chief Medical Officer’s annual report.
- Media coverage – Guardian, NPR, Bloomberg, Hindustan Times, BMJ, BBC World News and PBS.
- Data visualization – click here.
- Video of panel discussion to launch the article, at the Council on Foreign Relations – click here.
Abstract: 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.
‘The Impact of Democracy and Media Freedom on Under-5 Mortality, 1961-2011’ Social Science & Medicine 190: 237-246 · October 2017 (with Arzu Akkoyunlu) [full text]
Abstract: Do democracies produce better health outcomes for children than autocracies? We argue that (1) democratic governments have an incentive to reduce child mortality among low-income families and (2) that media freedom enhances their ability to deliver mortality-reducing resources to the poorest. A panel of 167 countries for the years 1961-2011 is used to test those two theoretical claims. We find that level of democracy is negatively associated with under-5 mortality, and that that negative association is greater in the presence of media freedom. These results are robust to the inclusion of country and year fixed effects, time-varying control variables, and the multiple imputation of missing values.
‘The Impact of Regime Type on Health: Does Redistribution Explain Everything?’ World Politics 63(4): 647-77 · 2011 (with Arzu Akkoyunlu) [full text] [data]
Abstract: Many scholars claim that democracy improves population health. The prevailing explanation for this is that democratic regimes distribute health-promoting resources more widely than autocratic regimes. The central contention of this article is that democracies also have a significant pro-health effect regardless of public redistributive policies. After establishing the theoretical plausibility of the nondistributive effect, a panel of 153 countries for the years 1972 to 2000 is used to examine the relationship between extent of democratic experience and life expectancy. The authors find that democratic governance continues to have a salutary effect on population health even when controls are introduced for the distribution of health-enhancing resources. Data for fifty autocratic countries for the years 1994 to 2007 are then used to examine whether media freedom—independent of government responsiveness—has a positive impact on life expectancy.
‘Do Electoral Institutions Have an Impact on Population Health?’ Public Choice 148(3-4): 595-610 · 2011 (with Arzu Akkoyunlu) [full text]
Abstract: There is an emerging political economics literature which purports to show that legislatures elected based on proportional electoral rules spend more and redistribute more than legislatures elected based on majoritarian electoral rules. Going a step further the authors of this paper consider whether degree of electoral proportionality has an impact on population health and, in particular, the health of the least advantaged members of society. A panel of 24 parliamentary democracies for the years 1960–2004 is used to examine the relationship between electoral institutions and health. The authors find that greater electoral proportionality is positively associated with overall population health (as indicated by life expectancy) and with the health of the poorest (as indicated by a reduction in infant mortality). A panel of 17 countries for the years 1970–2004 is then used to show to that electoral permissiveness modifies the impact of health spending on infant mortality.