Democracy and implementation of non-communicable disease policies

Correspondence

www.thelancet.com/lancetgh Vol 8 April 2020 e482

Democracy and

implementation of

non-communicable

disease policies

In their Article in The Lancet Global

Health, Luke Allen and colleagues

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.

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.

_{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.

First, we expanded Allen

and colleagues’ analysis of the

association between the Economist

Intelligence Unit measure of

democracy and implementation of

non-communicable disease policy

to include data for both 2015 and

2017 and for 144 to 149 countries,

depending on the democracy

indicator. Allen and colleagues used

2017 data for 144 countries. Second,

we considered three additional

democracy indicators produced by

the Varieties of Democracy project,

Freedom House, and the World Bank.

The Economist Intelligence Unit

democracy indicator, which Allen

and colleagues use, relies heavily

on polling data. Little empirical

support exists for the claim that

ordinary citizens can assess their own

political institutions in a way that

is temporally and cross-nationally

comparable.

_{By contrast, the Varieties}

of Democracy project relies on

multiple country experts and uses a

sophisticated strategy to correct for

potential sources of error and bias.

We found that all four democracy

indices are positively associated with

implementation; although only three

of the four are significant (figure).

Third, we compared countries’

adoption of WHO’s best buy

non-communicable disease policies in 2017,

finding autocracies only outperform

Figure: Association between democracy and implementation of non-communicable disease policy

(A) Regression results for non-communicable disease policy implementation and four democracy indices for the years 2015 and 2017. We did separate random-effects regressions for each democracy index. The dependent variable is implementation of non-communicable disease policy, measured as an aggregate score ranging from 0 (no policies implemented) to 18 (all policies fully implemented). Squares are point estimates, with whiskers showing 95% CIs. The following time-varying independent variables were included in the regressions, but are not included in the figure (available on request from corresponding author): GDP per capita, female educational attainment at age 15 years, risk of premature mortality from non-communicable diseases, tax share in GDP. The following time-invariant independent variables were included in the regressions, but are not included in the figure (available on request from corresponding author): continent, legal origin, tropical climate, average distance to nearest ice-free coast, and oil endowment. (B) Proportion of countries not implementing each non-communicable disease policy by regime type for 2017. No

implementation means neither partial nor full policy implementation. The implementation data is drawn from WHO Noncommunicable Disease Progress Monitor for 2017. We classified regimes using V-Dem’s regimes of the world index. There are 64 autocracies and 87 democracies covered by the WHOProgress Monitor. EIU= Economist Intelligence Unit. FH=Freedom House. GDP=gross domestic product. V-Dem=Varieties of Democracy. WB=the World Bank

Autocracies Democracies Multiplicative Polyarchy Index

(V-Dem) Political and Civil Liberties Index (FH) Voice and Accountability Index (WB) Democracy Index (EIU)

Tobacco tax Tobacco mass media Tobacco advertising bans Smoke-free places Salt policies Risk factor surveys Physical activity mass media National action plan National non-communicable disease targets Mortality data Graphic warnings on cigarette labels Fat policies Clinical guidelines Child food marketing Cardiovascular therapies Breastmilk code Alcohol tax Alcohol sale restrictions Alcohol advertising ban

0

A

B

Proportion of countries that did not implement policies (%) p=0·0039

p=0·014 p=0·0031

p=0·066

For WHO Noncommunicable

Disease Progress Monitor 2017

see https://www.who.int/nmh/ publications/ncd-progress-monitor-2017/en/

Correspondence

e483 www.thelancet.com/lancetgh Vol 8 April 2020

3 Coppedge M, Gerring J, Lindberg SI, Skaaning S-E, Teorell J. V-Dem comparisons and contrasts with other measurement projects. Working Paper 45. Gothenburg: University of Gothenburg Department of Political Science, April, 2017: 9. 4 Coppedge M, Gerring J, Knutsen CH, et al.

V-Dem dataset - version 9. Varieties of Democracy (V-Dem) Project, 2019. https://www.v-dem.net/en/data/data-version-9/ (accessed Feb 3, 2020). 5 Sen A. Development as freedom. New York,

NY: Anchor Books, 1999: 180–81.

democracies for four of the 19 policy

indicators (figure). Allen and colleagues

hypothesised that autocracies are more

likely to implement health policies that

restrict personal freedoms or reduce

commercial profits than democracies

are. This hypothesis proves true

for bans on alcohol and tobacco

advertising, which some governments

consider a form of speech. Democracies

slightly outperform autocracies

on smoke-free public places and

are more likely to tax tobacco and

alcohol, require graphic warnings on

cigarette labels, restrict the marketing

of unhealthy foods to children, and

have pro-health policies on breastmilk

substitutes, promoting physical

activity, and reformulating food to

reduce trans fatty acids and sodium.

Our results are in accordance with

the literature showing autocratic

leaders have less incentive than their

democratic counterparts to invest in

the policies needed to reduce

non-communicable diseases.

_Democracy

is often messy, but remains better

than the alternatives at addressing the

health challenges that are confronting

most nations.

We declare no competing interests. SW, JLD, TT, and TJB coauthored the manuscript. SW did the quantitative analysis. SK provided editing support. Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

*Simon Wigley, Joseph L Dieleman,

Tara Templin, Samantha Kiernan,

Thomas J Bollyky

wigley@bilkent.edu.tr

Bilkent University, Ankara, Turkey (SW); Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA (JLD); Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA (TT); and Council on Foreign Relations, Washington, DC, USA (SK, TJB)

1 Allen LN, Nicholson BD, Yeung BYT, Goiana-da-Silva F. Implementation of non-communicable disease policies: a geopolitical analysis of 151 countries. Lancet Glob Health 2020; 8: e50–58.

2 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. Lancet 2019; 393: 1628–40.