In developing countries, democratic governments are more likely than autocratic governments to have better health gains for causes of mortality (eg, cardiovascular diseases and transport injuries), which might further enhance efforts to improve population health, according to a new study published in The Lancet.

In this study, the investigators extracted the following data: (1) cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) and information on regime type from the Varieties of Democracy project, which covered 170 countries and 46 years; (2) gross domestic product (GDP) per capita from the Financing Global Health database, also covering 46 years; (3) Development Assistance for Health estimates starting from 1990; and (4) domestic health spending estimates starting from 1995. To analyze the association between democratization and population health, the investigators used empirical methods such as synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression.

The first analysis found that HIV-free life expectancy at age 15 improved significantly during the study period (1970-2015) in countries after they transitioned to democracy (on average, 3% after 10 years). The second analysis found that democratic experience explained 22.27% of the mortality variance within a country from cardiovascular diseases, 16.53% for tuberculosis, 17.78% for transport injuries, and a smaller percentage for other diseases. For these 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 -12.9), non-communicable diseases (-9.14%, -4.26 to -14.02), and tuberculosis (-8.93%, -2.08 to -15.77).

The third analysis found that an increase in a country’s democratic experience was not correlated with GDP per capita between 1995 and 2015 (P =-.1036; P =.1826), but were correlated with declines in mortality from cardiovascular disease (P =-.3873; P <.0001) and increases in government health spending (P =.4002; P <.0001).

The fourth analysis found that removing free and fair elections from the democratic experience variable resulted in a negative association between that variable and age-standardized mortality from cardiovascular diseases, transport injuries, tuberculosis, and non-communicable diseases no longer being statistically significant (P =.052, P =.075, P =.263, and P =.497, respectively).

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The investigators noted 2 limitations in their study: First, the link between democracy and population health is difficult to measure because of the association of democracy with other factors, such as country income or total health expenditure and the lack of randomized data. Second, although GBD 2016 provides the only comprehensive data on cause-specific mortality and burden in all countries, this effort relies on modeling estimates when data are sparse. Data are more likely to be sparse in low-income countries, particularly for cardiovascular and non-communicable diseases.

The investigators concluded that “[i]nternational health agencies and donors might increasingly need to consider the implications of regime type in their efforts to [maximize] health gains, particularly in the context of [aging] populations and the growing burden of non-communicable diseases.”


Bollyky TJ, Templin T, Cohen M, Schoder D, Dieleman JL, Wigley S. The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis [published online March 13, 2019]. Lancet. doi: 10.1016/s0140-6736(19)30235-1