THE IMPACT OF REGIME TYPE
ON HEALTH
Does Redistribution Explain Everything?
By SIMON WIGLEY and ARZU AKKOYUNLU-WIGLEY*
In t r o d u c t I o n
T
HERE is a small but growing number of cross-national studies
that purport to show that democracies produce healthier popula-
tions than autocracies.
1
This denotes an interesting departure from the
usual focus in the political economy literature on the effects of political
institutions on economic outcomes. More direct measures of human
well-being, such as the ability to avoid preventable illness and prema-
ture death, promise to provide a more meaningful basis for assessing
institutional arrangements. However, the prevailing explanation for the
association between regime type and health focuses on the effect of
policy-making on the distribution of material resources. It is argued
that democratic societies are healthier than their autocratic counter-
parts because elected representatives must satisfy a wider range of sup-
porters and, therefore, ensure that health-enhancing resources such as
health and education services reach a broader segment of the popula-
tion. In this article we consider whether democratic governance also
has a pro-health effect regardless of its impact on public redistributive
policies. In other words, does a country that transitions from autocratic
to democratic rule undergo an improvement in population health even
if its public redistributive policies remain unchanged?
The article is composed of two parts. In the first section we briefly
review the political economy literature on the link between regime type
*Earlier versions of this paper were presented at the 2009 American Political Science Association
annual meeting and at Australian National University’s 2008 Economics and Democracy conference.
We thank the attendees at both events for their insight and criticism. We are also grateful to the Sci-
entific and Technological Research Council of Turkey for its financial support of this project.
1
See Besley and Kudamatsu 2006; Álvarez-Dardet and Franco-Giraldo 2006; Franco, Álvarez-
Dardet, and Ruiz 2004; Gerring, Thacker, and Alfaro 2007; Zweifel and Navia 2000.
World Politics 63, no. 4 (October 2011), 647–77
Copyright © 2011 Trustees of Princeton University
doi: 10.1017/S0043887111000177
https://doi.org/10.1017/S0043887111000177
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648 w o r l d p o l I t I c s
2
Dahl 1971. See also McGuire and Olson 1996; Bueno de Mesquita, Smith, Siverson, and Mor-
row 2002; Ghobarah, Huth, and Russett 2003, 191; Lake and Baum 2001, 593–96.
3
Meltzer and Richard 1981. See also Acemoglu and Robinson 2005, and Boix 2003.
and health. We then outline the various ways in which regime type may
nondistributively influence population health. In the second section we
use a panel of 153 countries for each year from 1972–2000 to test the
hypothesis that democratic governance alone, irrespective of its impact
on the distribution of health-promoting resources, has a positive in-
fluence on health. More specifically, we examine whether regime type
continues to have an effect on life expectancy when controls are intro-
duced for the distribution of health-promoting resources such as health
care, education, welfare transfers, and food. We then use a panel of
fifty autocratic countries for the years 1994–2007 to examine whether
media freedom by itself, regardless of government responsiveness, has
a positive impact on life expectancy. We find that the health dividend
of democratic rule and media freedom is not erased when controls are
introduced for, respectively, government spending and government re-
sponsiveness.
t
h e dI s t r I b u t I v e ef f e c t s o f re g I m e ty p e
In theory at least, democratic countries tend to produce healthier so-
cieties by virtue of the fact that elected representatives are accountable
to voters, subject to pressure by autonomous interest groups, and vul-
nerable to public criticism. People who live in a democratic polity are
able to penalize governments whose policies fail to adequately prevent
or treat ill health. As a corollary to bottom-up pressure by voters and
interest groups, there is also a competitive struggle between political
elites for votes. As result of that competition candidates have an incen-
tive to capture previously ignored votes in order to be elected to office.
Thus, the number of citizens who benefit from public provisioning in-
creases as candidates seek to broaden their support base. In autocra-
cies, however, the cost of political participation in order to change the
leadership is high due to the threat of reprisals. Thus, because there is
little or no competition for votes, there are typically fewer incentives
for autocrats to redistribute income or provide social services.
2
Allan Meltzer and Scott Richard present perhaps the most influen-
tial political economy model of the distributional effects of democratic
versus autocratic governments.
3
The basic claim underpinning their
model is that redistribution and investment in public services increases
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I m p a c t o f r e g I m e t y p e o n h e a l t h 649
4
Sen 1999, 152–53.
5
See, for example, Brown and Hunter 1999; Deacon 2009; Ghobarah, Huth, and Russett 2004;
Kaufman and Segura-Ubiergo 2001; Lake and Baum 2001; Lindert 2004, chaps.15–17; Przeworski,
Alvarez, Chiebub, and Limongi 2000; Stasavage 2005.
6
Ross 2006. See also Mulligan, Gil, and Sala-i-Martini 2004, and Nelson 2007.
7
Gwatkin 2004, 5–6.
8
See, for example, Bidani and Ravallion 1997; Filmer and Pritchett 1999; McGuire 2005.
9
Striking evidence to the contrary is presented by Kudamatsu 2010. Using demographic health
surveys from twenty-eight sub-Saharan African countries, Kudamatsu finds that the mortality rate of
infants born from the same mother was reduced by 1.2 percentage points following the democratiza-
tion that took place in those countries during the 1990s.
in democracies when the income of the median voter—whose prefer-
ences determine public policy—is below the mean. In contrast, auto-
cratic governments need only serve the interests of the wealthy elite;
therefore redistribution is less likely to take place.
In keeping with that theoretical prediction, there is some empirical
evidence in support of the claim that the desire to win votes coupled
with exposure to interest-group pressure and public criticism helps to
ensure the adequate provisioning of social services and thus improves
the health of the population. Amartya Sen, for example, notes that
famine has not occurred in an independent country where there are
regular and competitive elections and a relatively free press.
4
There are
also a number of cross-national studies that show that democracies de-
vote more resources to health and education than autocracies.
5
Nevertheless, Michael Ross presents evidence that leads to questions
regarding the linkage between democracy and the delivery of resources
to the neediest.
6
The poorest segment of the population is typically
afflicted by higher rates of infant and child mortality.
7
Moreover, the
causes of mortality among the very youngest are typically easier to pre-
vent than the causes of mortality in the adult population. Furthermore,
mortality among the very young can be prevented by inexpensive inter-
ventions such as oral rehydration therapy, antibiotics, or immunization.
Yet Ross finds that in an area where public provisioning can have the
most significant impact on mortality, democracies appear to perform
no better than autocracies. Thus, while democratic governance may
increase overall social spending (and, therefore, the life expectancy of
the overall population), it may not ensure that social services reach the
poor (and, therefore, does not increase the life expectancy of the least
advantaged). As has been often noted, much depends on how well each
government targets public spending rather than on how much is spent.
8
Ross’s study suggests that democracies are no better than autocracies at
targeting public services to the least advantaged.
9
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650 w o r l d p o l I t I c s
One explanation for this apparent failure is that the poor comprise a
comparatively small constituency. The seminal Meltzer-Richard model
introduced above predicts that the middle-income classes represent the
decisive voters and so the low-income classes may not necessarily be
targeted by those competing for political power. Thus, a growing num-
ber of scholars argue that the extent to which the poor in democracies
actually benefit from social spending depends on the electoral rules that
have been adopted.
10
A further explanation for this failure is that young democracies are not
as good as more established democracies at targeting social services.
11
In new democracies, political leaders are not sufficiently accountable
until the formal procedures of democratic rule become entrenched, vot-
ers become accustomed to exercising their newfound political and civil
rights, and a network of voluntary associations (such as political parties,
pressure groups, and trade unions) has had time to emerge. This sug-
gests that the pro-health effect of democracy is dependent on the stock
of democracy accumulated over an extended period of time, rather than
on the flow of democracy at any given time. In support of that claim,
Timothy Besley and Masayuki Kudamatsu present evidence that the
pro-health effect of democracy is primarily dependent on whether
democratic institutions have persisted over time.
12
Similarly, John Ger-
ring and colleagues find that long-term democratic experience—but
not short-term democratic experience—is a significant determinant
of infant mortality.
13
We assume that the extent to which democratic
rule is entrenched is equally important for the nondistributional ef-
fects that we now introduce. As such, the regime variable we include
in our empirical models is constructed to reflect the accumulated stock
of democracy.
t
h e no n d I s t r I b u t I v e ef f e c t s o f re g I m e ty p e
According to the distributional thesis, political institutions influence
population health because they determine access to resources that are
crucial for avoiding preventable morbidity and premature mortality
10
Iversen and Soskice 2006; Persson and Tabellini 2003, 17–18. Elsewhere we find that greater
electoral proportionality is negatively associated with infant mortality and positively associated with
life expectancy, and that proportionality conditions the impact of aggregate health spending on infant
mortality. See Wigley and Akkoyunlu-Wigley, forthcoming.
11
Gerring, Thacker, and Alfaro 2007; Keefer 2007; Keefer and Khemani 2005; Persson and Tabel-
lini 2006.
12
Besley and Kudamatsu 2006.
13
Gerring, Thacker, and Alfaro 2007.
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I m p a c t o f r e g I m e t y p e o n h e a l t h 651
(for example, health care, schooling, income, and food). Our primary
contention is that the distributional thesis does not fully capture the
impact of democratic governance on health. If that hypothesis turns
out to be correct, then, everything else being equal, we expect a country
that transitions from autocratic to democratic rule to eventually ex-
perience an improvement in population health even if its social and
economic policies remain unchanged. It is incumbent upon us, there-
fore, to provide a theoretically plausible account of what the nondistri-
butional effect might entail as well as empirical evidence for such an
effect.
We contend that democratic governance will have salutary effect on
health regardless of public policy because it permits active participa-
tion in the decision-making process, and because of the protection af-
forded to the individual by civil and political rights. We consider four
pathways—autonomy, social capital, collective action, and informa-
tion diffusion—through which active participation and rights protec-
tion can have a nondistributive effect on health. While both aspects
of democratic rule are crucial to the first two pathways, autonomy and
social capital, rights protection alone is the key feature of the second
two, collective action and information diffusion.
a
u t o n o m y
Epidemiological research into the social determinants of health sug-
gests that being subordinate to the authority of another can have a
negative effect on mental and physical health. Perhaps the most strik-
ing evidence for the pro-health effect of autonomy is provided by the
Whitehall studies of health differentials among British civil servants.
Those longitudinal cohort studies find that individuals in the least se-
nior job position (junior office support staff) have a mortality rate three
times higher than individuals in the most senior job position (senior
administrators).
14
Significantly, that result followed even when the re-
searchers controlled for income, access to medical care, lifestyle choices
(smoking, high cholesterol, diet, etc.), genetic predisposition, and up-
bringing.
15
These studies show that even among individuals who are
not impoverished, relative status is a significant determinant of in-
equalities in health. The researchers conclude that the extent to which
individuals perceive they have control over their lives plays a significant
role in determining their health.
16
14
Marmot et al. 1997; van Rossum et al. 2000.
15
Marmot 2004a, 38–58.
16
Marmot 2004b, 52–54.
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