Browsing by Author "Bollyky, T. J."

Now showing 1 - 4 of 4

Open Access
Autocratisation and universal health coverage: synthetic control study
(BMJ Publishing Group, 2020) Wigley, Simon; Dieleman, J. L.; Templin, T.; Mumford, J. E.; Bollyky, T. J.
Objective: To 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). Design: Synthetic control analysis. Setting and country selection: Global sample of countries for all years from 1989 to 2019, split into two categories: 17 treatment countries that started autocratising during 2000 to 2010, and 119 control countries that never autocratised from 1989 to 2019. The treatment countries comprised low and middle income nations and represent all world regions except North America and western Europe. A weighted combination of control countries was used to construct synthetic controls for each treatment country. This statistical method is especially well suited to population level studies when random assignment is infeasible and sufficiently similar comparators are not available. The method was originally developed in economics and political science to assess the impact of policies and events, and it is now increasingly used in epidemiology. Main outcome measures: HIV-free life expectancy at age 5 years, UHC effective coverage index (0-100 point scale), and out-of-pocket spending on health per capita. All outcome variables are for the period 1989 to 2019. Results: Autocratising countries underperformed for all three outcome variables in the 10 years after the onset of autocratisation, despite some improvements in life expectancy, UHC effective coverage index, and out-of-pocket spending on health. On average, HIV-free life expectancy at age 5 years increased by 2.2% (from 64.7 to 66.1 years) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 3.5% (95% confidence interval 3.3% to 3.6%, P<0.001) (from 64.7 to 66.9 years) in the absence of autocratisation. On average, the UHC effective coverage index increased by 11.9% (from 42.5 to 47.6 points) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 20.2% (95% confidence interval 19.6% to 21.2%, P<0.001) (from 42.5 to 51.1 points) in the absence of autocratisation. Finally, on average, out-of-pocket spending on health per capita increased by 10.0% (from $4.00 (£3.1; €3.4) to $4.4, log transformed) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by only 4.4% (95% confidence interval 3.9% to 4.6%, P<0.001) (from $4.0 to $4.2, log transformed) in the absence of autocratisation. Conclusions: 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.
Open Access
Democracies linked to greater universal health coverage compared with autocracies, even in an economic recession
(Project HOPE, 2021-08) Templin, T.; Dieleman, J. L.; Wigley, Simon; Mumford, J. E.; Miller-Petrie, M.; Kiernan, S.; Bollyky, T. J.
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.
Open Access
Democracy and implementation of non-communicable disease policies
(Elsevier, 2020) Wigley, Simon; Dieleman, J. L.; Templin, T.; Kiernan, S.; Bollyky, T. J.
In their Article in The Lancet Global Health, Luke Allen and colleagues1 found weak evidence for a positive association between democracy and the implementation of polices recommended by WHO to reduce the burden of premature non-communicable disease mortality.1 As Allen and colleagues note, that finding is in contrast with our research on the positive association between democracy and population health outcomes on non-communicable diseases.2 Accordingly, here we build on the important analysis of Allen and colleagues by closely examining the association between democracy and implementation of non-communicable disease policy.
Open Access
The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis
(Elsevier, 2019) Bollyky, T. J.; Templin, T.; Cohen, M.; Schoder, D.; Dieleman, J. L.; Wigley, Simon
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. Funding Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.