Democracy and health

Abstract

Scholars of population and global health have grappled for decades with the complex relationship between health and its determinants. This growing literature has taught us much about proximal and distal health determinants, especially those in the socio-economic realm. Economics as it relates to health, in particular, has received considerable and recent investigation,1 but mounting evidence suggests that a country's economic status alone cannot entirely explain differences in health and health policy.2–8 Thus, societies with similar levels of economic development, such as Afghanistan and the Indian state of Kerala, can have radically different levels of health and health system development. It is therefore important to extend our analysis to broader structural factors, such as political institutions, to better understand global health inequalities. A country's political structure affects virtually every aspect of society, including health. There are few studies on the relationship between political institutions and health, at both theoretical and empirical levels9–11. One reason must certainly stem from the complexity of the health-politics nexus and the difficulty of identifying independent and interactive influences in both directions. The relationship can be defined in many ways, ranging from the study of political systems (e.g. democratic or authoritarian, legislative and executive governance, proportional or majoritarian electoral systems, constitutional structure); culture (e.g. political values); institutions (e.g. centralized or fragmented, presidential or parliamentary, responsiveness to citizenry, political parties); state capacity (technical and administrative capacity, level of corruption); and philosophy, to more nuts-and-bolts political process factors, such as personal politics (e.g. political leadership, powerful personalities, presidential tactics), political strategy and interest group representation (e.g. its strength or weakness in a political system). More recent influences on health policy include re-election incentives, financial contributions (e.g. in the US), and the depth and range of public opinion.12,,13 A recent issue of the …