Democratic reform and health: interpreting causal estimates
Authors: Samuel I Watson
Journal: The Lancet Global Health (2016)

In The Lancet Global Health, Hannah Pieters and colleagues (September, 2016)1Pieters H Curzi D Olper A Swinnen J Effect of democratic reforms on child mortality: a synthetic control analysis.Lancet Glob Health. 2016; 4: e627-e632Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar analyse the effect of democratic reforms on child mortality across the world. We wish to highlight, however, that even with sophisticated causal inference techniques, such results cannot necessarily be interpreted as causal effects. First, the results are compatible with a number of different theories including that democratic reforms have no effect on health ceteris paribus (ie, holding everything else fixed). Consider the cases of South Africa, Zambia, Mozambique, and Zimbabwe, all notably missing from the analyses but experiencing substantial democratic changes, analysed here using a similar synthetic control analysis (figure).1Pieters H Curzi D Olper A Swinnen J Effect of democratic reforms on child mortality: a synthetic control analysis.Lancet Glob Health. 2016; 4: e627-e632Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 2Brodersen KH Gallusser F Koehler J Remy N Scott SL Inferring causal impact using bayesian structural time-series models.Ann Appl Stat. 2015; 9: 247-274Crossref Scopus (345) Google Scholar No change is observed in South Africa after the end of apartheid in 1994. In Zambia, after reform in 1991, a reduction is observed but not until the price of copper tripled and GDP per capita doubled. In Mozambique, the large fall is likely attributable to the cessation of the civil war in 1993. And in Zimbabwe, democratic restrictions in 1987 did not precipitate an increase in child mortality. Second, political regime does very little to explain differences between countries. Rwanda, Congo (Brazzaville), and Tanzania have very similar child mortality rates (between 40 and 60 deaths per 1000 livebirths in 2014)4United Nations Inter-agency Group for Child Mortality EstimationChild Mortality Estimates. C. Info.http://www.childmortality.org/Date: 2016Google Scholar to South Africa, Botswana, and Namibia despite the former countries being considered autocratic and the latter democratic. It is difficult to articulate a theory of political economy within the confines of the word limits of a journal. However, in none of the above cases, is democratic reform either a necessary or sufficient condition for improvements in child mortality. A theory first, rather than data first, approach to political economic analysis is needed. I declare no competing interests. I am part-funded/supported by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands. This paper presents independent research and the views expressed are those of the author and not necessarily those of the HS&DR, NHS, NIHR, or the Department of Health. Democratic reforms and health: interpreting causal estimates – Authors' replyIn his Correspondence, Samuel Watson refers to two sets of African countries to support his argument that one cannot necessarily interpret the synthetic control method (SCM) results of our study1 as causal effects. Full-Text PDF Open Access