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Democracy tied to health improvements in developing countries, new research suggests

Free and fair elections and a democratic government are linked with decreases in adult mortality in developing countries, a new study has found.

Stanford health policy graduate student Tara Templin was brainstorming with colleagues about how to achieve the U.N. Sustainable Development Goals — you know, as health policy scholars are wont to do.

“There’s a lot of interest in how external aid is spent, and how to achieve sustainable health improvements, so we wanted to investigate the link between governance and population health,” Templin told me. “Every day I get to work on these big questions that I’m passionate about.”

That passion led to a new study published in The Lancet. Templin shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations. The research is featured in a Stanford Health Policy article.

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.

Templin and Bollyky suggest 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. “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.”

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,” she told me.

In 2016, the four causes of mortality 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.

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.

This is the kind of stuff that gets Templin charged up.

“As part of my work, I have the privilege to investigate questions about improving population health and to contribute to policy discussions,” she told me. “Isn’t that just great?”

Photo by Getty Images

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