Democracy and implementation of non-communicable disease policies
Authors: Simon Wigley, Joseph L Dieleman, Tara Templin, Samantha Kiernan, Thomas J Bollyky
Journal: The Lancet Global Health (2020)

In their Article in The Lancet Global Health, Luke Allen and colleagues1Allen 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-e58Summary Full Text Full Text PDF PubMed Scopus (51) Google Scholar 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.1Allen 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-e58Summary Full Text Full Text PDF PubMed Scopus (51) Google Scholar 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.2Bollyky 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: 1628-1640Summary Full Text Full Text PDF PubMed Scopus (81) Google Scholar 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.3Coppedge M Gerring J Lindberg SI Skaaning S-E Teorell J V-Dem comparisons and contrasts with other measurement projects. Working Paper 45. University of Gothenburg Department of Political Science, April, Gothenburg2017: 9Google Scholar 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.4Coppedge 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/Date accessed: February 3, 2020Google Scholar 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 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.4Coppedge 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/Date accessed: February 3, 2020Google Scholar 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.5Sen A Development as freedom. Anchor Books, New York, NY1999: 180-181Google Scholar 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. Implementation of non-communicable disease policies: a geopolitical analysis of 151 countriesImplementation of WHO-recommended NCD policies is increasing over time. On average, countries implemented just under half of the NCD policies recommended by WHO in 2017. Nutrition-related policies saw gains, while those related to alcohol and physical activity were the most likely to have been dropped. Aggregate implementation scores tended to be highest in high-income countries that invest in health care and education. Full-Text PDF Open AccessDemocracy and implementation of non-communicable disease policies – Authors' replyWe heartily welcome Simon Wigley and colleagues' comments on our Article1 and further analysis on the association between democracy and implementation of non-communicable disease policy. Their use of four different democracy indicators helps to triangulate the Economist Intelligence Unit data that we used in our study, and provides further evidence that democracy is associated with a range of positive health outcomes.2–4 We note that the three additional measures (from the Varieties of Democracy project, Freedom House, and the World Bank) ascribe lower point values than the Economist Intelligence Unit data, but all were significant with p values of less than 0·05. Full-Text PDF Open Access