Regime Type and Data Manipulation: Evidence from the COVID-19 Pandemic.

CONTEXT: This study examines whether autocratic governments are more likely to manipulate health data than democratic governments. The COVID-19 pandemic presents a unique opportunity to examine this question owing to its global impact. METHODS: Three distinct indicators of COVID-19 data manipulation were constructed for nearly all sovereign states. Each indicator was then regressed on democracy and controls for unintended misreporting. A machine learning approach was then used to determine whether any of the specific features of democracy are more predictive of manipulation. FINDINGS: Democracy was found to be negatively associated with all three measures of manipulation, even after running a battery of robustness checks. Absence of opposition party autonomy and free and fair elections were found to be the most important predictors of deliberate undercounting. CONCLUSIONS: The manipulation of data in autocracies denies citizens the opportunity to protect themselves against health risks, hinders the ability of international organizations and donors to identify effective policies, and3 makes it difficult for scholars to assess the impact of political institutions on population health. This suggests that health advocates and scholars should use alternative methods to estimate health outcomes in countries where opposition parties lack autonomy or must participate in uncompetitive elections.

Non-communicable disease policy implementation from 2014 to 2021: a repeated cross-sectional analysis of global policy data for 194 countries.

BACKGROUND: Non-communicable diseases (NCDs) are the world's leading cause of death and disability. Global implementation of WHO-recommended NCD policies has been increasing with time, but in 2019 fewer than half of these policies had been implemented globally. In 2022, WHO released updated data on NCD policy implementation, on the basis of surveys conducted in 2021 during the COVID-19 pandemic. We sought to examine whether the trajectory of global policy implementation changed during this period. METHODS: In this repeated cross-sectional analysis, we used data from the 2015, 2017, 2020, and 2022 WHO progress monitors to calculate NCD policy implementation scores for all 194 WHO member states. We used Welch's ANOVA and Games-Howell post-hoc pairwise testing to examine changes in mean implementation scores for 19 WHO-recommended NCD policies, with assessment at the global, geographical, geopolitical, and country-income levels. We collated sales data on tobacco, alcohol, and junk foods to examine the association between changes in sales and the predicted probability of implementation of policies targeting these products. We also calculated the Corporate Financial Influence Index (CFII) for each country, which was used to assess the association between corporate influence and policy implementation. We used logistic regression to assess the relationship between product sales and the probability of implementing related policies. The relationship between CFII and policy implementation was assessed with Pearson's correlation analysis and random-effects multivariate regression. FINDINGS: Across the 194 countries, in the years preceding publication of each progress monitor, mean total policy implementation score (out of a potential 18·0) was 7·0 (SD 3·5) in 2014, 8·2 (3·5) in 2016, 8·6 (3·6) in 2019, and 8·6 (3·6) in 2021. Only the differences in mean implementation score between 2014 and the other three report years were deemed statistically significant (pairwise p<0·05). Thus the steady improvement in mean global NCD policy implementation stalled in 2021 at 47·8%. However, from 2019 to 2021, we identified shifts in individual policies: global mean implementation scores increased for policies on tobacco, clinical guidelines, salt, and child food marketing, and decreased for policies on alcohol, breastmilk substitute marketing, physical activity mass media campaigns, risk factor surveys, and national NCD plans and targets. Six of the seven policies with the lowest levels of implementation (global mean score <0·4 out of a potential 1·0) in both 2019 and 2021 were related to tobacco, alcohol, and unhealthy food. From 2020 onwards, we identified weak or no associations between sales of tobacco, alcohol, and junk foods and the predicted probability of implementing policies related to each commodity. Country-level CFII was significantly associated with total policy implementation score (Pearson's r -0·49, 95% CI -0·59 to -0·36), and this finding was supported in multivariate modelling for all policies combined and for all commercial policies except alcohol policies. INTERPRETATION: NCD policy implementation has stagnated. Progress in the implementation of some policies is matched by decreased implementation of others, particularly those related to unhealthy commodities. To prevent NCDs and their consequences, and attain the Sustainable Development Goals, the rate of NCD policy adoption must be substantially and urgently increased before the next NCD progress monitor and UN high-level meeting on NCDs in 2024. FUNDING: None.

Study protocol: assessing the association between corporate financial influence and implementation of policies to tackle commercial determinants of non-communicable diseases: a cross-sectional analysis of 172 countries.

INTRODUCTION: There are many case studies of corporations that have worked to undermine health policy implementation. It is unclear whether countries that are more exposed to corporate financial influence are systematically less likely to implement robust health policies that target firms' financial interests. We aim to assess the association between corporate financial influence and implementation of WHO-recommended policies to constrain sales, marketing and consumption of tobacco, alcohol and unhealthy foods. METHODS AND ANALYSIS: We will perform a cross-sectional analysis of 172 WHO Member States using national datasets from 2015, 2017 and 2020. We will use random effects generalised least squares regression to test the association between implementation status of 12 WHO-recommended tobacco, alcohol and diet policies, and corporate financial influence, a metric that combines disclosure of campaign donations, public campaign finance, corporate campaign donations, legislature corrupt activities, disclosure by politicians and executive oversight. We will control for GDP per capita, population aged >65 years (%), urbanisation (%), level of democracy, continent, ethno-linguistic fractionalisation, legal origin, UN-defined 'Small Island Developing States' and Muslim population (%) (to capture alcohol policy differences). We will include year dummies to address the possibility of a spurious relationship between the outcome variable and the independent variables of interests. For example, there may be an upward global trend in policy implementation that coincides with an upward global trend in the regulation of lobbying and campaign finance. ETHICS AND DISSEMINATION: As this study uses publicly available data, ethics approval is not required. The authors have no conflicts of interest to declare. Findings will be submitted to a peer-reviewed journal for publication in the academic literature. All data, code and syntax will be made publicly available on GitHub.

Assessing the association between Corporate Financial Influence and implementation of policies to tackle commercial determinants of non-communicable diseases: A cross-sectional analysis of 172 countries.

OBJECTIVE: Non-communicable diseases (NCDs) are the leading cause of global death and disability. Tobacco, alcohol, and unhealthy foods are major contributing risk factors. WHO Member States have unanimously endorsed a set of 12 policies designed to constrain the sale of these commodities, however, there are myriad case studies of commercial entities seeking to undermine effective legislation in order to protect their profits. We set out to quantify the association between corporate financial influence and implementation of commercial policies. METHODS: We generated policy implementation scores for all 194 WHO Member States using data from the 2015, 2017, and 2020 WHO NCD Progress Monitor Reports. We used publicly available data to create a novel Corporate Financial Influence Index (CFII) that quantifies the opportunity for corporations to use their financial resources to directly influence policymaking in each country. We reported policy implementation trends over time and used random effects multivariate regression to test the association between policy implementation and CFII for each country, while controlling for broad set of economic, cultural, historical, geographic, and demographic factors. FINDINGS: Implementation of the 12 WHO-backed commercial policies has risen over time, but remains low at approximately 40%. Progress is reversing for alcohol policies. CFII explains around a fifth of the variance in global implementation. For every 10% rise in CFII, implementation falls by approximately 2% (95%CI 0.90 to 3.5, p < 0.001). CONCLUSION: Our quantitative global analysis suggests that financial corporate influence is negatively associated with implementation of policies that seek to restrict the marketing, sale, and consumption of unhealthy (but profitable) commodities. In the context of anemic international progress tackling NCDs, greater attention should be paid to managing regulatory opportunities for overt and covert corporate financial influence as a core plank of the global NCD response.

Implementation of non-communicable disease policies from 2015 to 2020: a geopolitical analysis of 194 countries.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality globally. We aimed to analyse trends in implementation of WHO-recommended population-level policies and associations with national geopolitical characteristics. METHODS: We calculated cross-sectional NCD policy implementation scores for all 194 WHO member states from the 2015, 2017, and 2020 WHO progress monitor reports, and examined changes over time as well as average implementation by geographical and geopolitical region and income level. We developed a framework of indicators of national characteristics hypothesised to influence policy implementation, including democracy, corporate permeation (an indicator of corporate influence), NCD burden, and risk factor prevalence. We used multivariate regression models to test our hypotheses. FINDINGS: On average, countries had fully implemented a third (32·8%, SD 18·2) of the 19 policies in 2020. Using aggregate policy scores, which include partially implemented policies, mean implementation had increased from 39·0% (SD 19·3) in 2015 to 45·9% (19·2) in 2017 and 47·0% (19·8) in 2020. Implementation was lowest for policies relating to alcohol, tobacco, and unhealthy foods, and had reversed for a third of all policies. Low-income and less democratic countries had the lowest policy implementation. Our model explained 64·8% of variance in implementation scores. For every unit increase in corporate permeation, implementation decreased by 5·0% (95% CI -8·0 to -1·9, p=0·0017), and for every 1% increase in NCD mortality burden, implementation increased by 0·9% (0·2 to 1·6, p=0·014). Democracy was positively associated with policy implementation, but only in countries with low corporate permeation. INTERPRETATION: Implementation of NCD policies is uneven, but broadly improving over time. Urgent action is needed to boost implementation of policies targeting corporate vectors of NCDs, and to support countries facing high corporate permeation. FUNDING: The National Institutes for Health Research, the Swedish Research Council, the Fulbright Commission, and the Swedish Society of Medicine.

Democracies Linked To Greater Universal Health Coverage Compared With Autocracies, Even In An Economic Recession.

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.

Autocratisation and universal health coverage: synthetic control study.

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.

The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis.

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.

The impact of democracy and media freedom on under-5 mortality, 1961-2011.

Do democracies produce better health outcomes for children than autocracies? We argue that (1) democratic governments have an incentive to reduce child mortality among low-income families and (2) that media freedom enhances their ability to deliver mortality-reducing resources to the poorest. A panel of 167 countries for the years 1961-2011 is used to test those two theoretical claims. We find that level of democracy is negatively associated with under-5 mortality, and that that negative association is greater in the presence of media freedom. These results are robust to the inclusion of country and year fixed effects, time-varying control variables, and the multiple imputation of missing values.

The resource curse and child mortality, 1961-2011.

There is now an extensive literature on the adverse effect of petroleum wealth on the political, economic and social well-being of a country. In this study we examine whether the so-called resource curse extends to the health of children, as measured by under-five mortality. We argue that the type of revenue available to governments in petroleum-rich countries reduces their incentive to improve child health. Whereas the type of revenue available to governments in petroleum-poor countries encourages policies designed to improve child health. In order to test that line of argument we employ a panel of 167 countries (all countries with populations above 250,000) for the years 1961-2011. We find robust evidence that petroleum-poor countries outperform petroleum-rich countries when it comes to reducing under-five mortality. This suggests that governments in oil abundant countries often fail to effectively use the resource windfall at their disposal to improve child health.

The impact of regime type on health: does redistribution explain everything?

Many scholars claim that democracy improves population health. The prevailing explanation for this is that democratic regimes distribute health-promoting resources more widely than autocratic regimes. The central contention of this article is that democracies also have a significant pro-health effect regardless of public redistributive policies. After establishing the theoretical plausibility of the nondistributive effect, a panel of 153 countries for the years 1972 to 2000 is used to examine the relationship between extent of democratic experience and life expectancy. The authors find that democratic governance continues to have a salutary effect on population health even when controls are introduced for the distribution of health-enhancing resources. Data for fifty autocratic countries for the years 1994 to 2007 are then used to examine whether media freedom­independent of government responsiveness­has a positive impact on life expectancy.