Democracy and implementation of non-communicable disease policies – Authors' reply
Authors: Luke N Allen, Francisco Goiana-da-Silva, Brian D Nicholson
Journal: The Lancet Global Health (2020)

We heartily welcome Simon Wigley and colleagues' comments on our Article1Allen 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 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.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, 3Feigl AB Ding EL Evidenced Formal Coverage Index and universal healthcare enactment: a prospective longitudinal study of economic, social, and political predictors of 194 countries.Health Policy. 2013; 113: 50-60Crossref PubMed Scopus (15) Google Scholar, 4McGuire JW Political regime and social performance.Contemp Polit. 2013; 19: 55-75Crossref Scopus (31) Google Scholar 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. Their finding that democracies outperformed alternative forms of government in the full implementation of specific non-communicable disease policies is another interesting observation. It raises questions around the temporal association between policy implementation and government type that we intend to explore once WHO has released 5 years' worth of Non-Communicable Disease Progress Monitor data. While citizens of many developed nations report increasing democratic dissatisfaction,5Foa RS Klassen A Slade M Rand A Williams R The global satisfaction with democracy report 2020. Centre for the Future of Democracy, Cambridge2020Google Scholar Wigley and colleagues argue that “democracy is often messy, but remains better than the alternatives at addressing health challenges confronting most nations.” The current evidence supports this position. 4-to-5-year election cycles and differential voter turnout can skew the priorities of elected leaders towards short-term so-called quick wins and polices that primarily benefit the socioeconomic groups with the highest turnouts. Nevertheless, democratic leaders have an undeniable personal stake in ensuring that the health of their population is protected because they can be defenestrated for failing to act in the public interest. Governments that are not as beholden to the whims of the public might more easily implement long-term national health plans. For instance, China, Cuba, and Rwanda have seen impressive improvements in health outcomes under successive decades of one-party rule. However, when it comes to implementing non-communicable disease policies, the aphorism ascribed to Winston Churchill still resonates, democracy seems to be “the worst form of government, except for all the others”. LNA and FG-d-S work as non-communicable disease consultants for WHO. BDN declare no competing interests. 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 policiesIn their Article in The Lancet Global Health, Luke Allen and colleagues1 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.1 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.2 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. Full-Text PDF Open Access