Democracy linked to global health gains in low-, middle-income countries

Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases -- such as malaria, diarrheal illnesses and pneumonia -- which relies heavily on foreign aid.

A new study led by Stanford Medicine and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases.

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

"The results of this study suggest that elections and the health of the people are increasingly inseparable," the authors wrote.

A paper describing the findings will be published March 13 in The Lancet. Tara Templin, a graduate student in health research and policy at Stanford Health Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

"Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases," the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

"As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health care infrastructure and resources to provide chronic care that weren't as critical in providing childhood vaccines or acute care," Templin said.

Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy -- cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases -- were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

"Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness," the study said.

The researchers used data from the Global Burden of Diseases, Injuries and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health care investments.

HIV-free life expectancy at age 15, for example, improved significantly -- on average by 3 percent every 10 years during the study period -- after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

And yet, this connection between fair elections and global health is little understood.

"Democratic government has not been a driving force in global health," the researchers wrote. "Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid."

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

"Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements," the authors wrote, "most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation."

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations' health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

"There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults," Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.

The researchers hypothesize that democracy improves population health because:

When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population.

• Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs.
• Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country's increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

"This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health," the study said. "Pretending otherwise is akin to believing that the solution to a nation's crumbling roads and infrastructure is just a technical schematic and cheaper materials."

Other researchers from the Council on Foreign Relations, as well as researchers from the University of Washington-Seattle and Bilkent University in Turkey, also contributed to the study.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Stanford's Department of Health Research and Policy also supported the work.