Linking measures of governance to general health indicators

Both governance and health can be measured in many different ways, and one factor complicating efforts to measure the association between the two is the difficulty finding accurate, sensitive, and specific enough indicators for either variable. Broad measures of population health - such as life expectancy, and infant and maternal mortality - have been chosen by a number of authors, in part because these indicators capture (and average the effects of) multiple specific diseases and are broadly distributed across the population. To measure governance, two approaches have been used. Some authors have chosen the rankings of the organization Freedom House, which scores countries based upon political rights and civil liberties, electoral process, political pluralism and participation, functioning of government (including transparency and corruption), freedom of expression and belief; association; organizational rights, rule of law and personal autonomy; and individual rights (Freedom House, 2006). Other authors have used a set of governance indicators collected by the World Bank that includes measures of voice and accountability, political stability, government effectiveness, regulatory quality, rule of law, and corruption (Kaufmann et al, 2003).

In a 2004 article in the British Medical Journal, Alvaro Franco and his colleagues plotted life expectancy and maternal and infant mortality in 170 countries against the "freedom index" produced by Freedom House (Figure 15.1). Controlling for determinants of health that include socio-economic and political measures such as wealth, equality, and the size of the public sector, the authors found a statistically significant relationship (r = .XX, P < .0X) between freedom ratings and health indicators at all income levels. In their conclusion, they speculate that democracies produce better health outcomes because they "allow more space for social capital," like social networks and pressure groups, opportunities for empowerment, better access to information, and better recognition by government of people's needs (Franco et al., 2004).

In a similar study, again using life expectancy, infant and maternal mortality as health indicators, Alvarez-Dardet and Franco-Giraldo (2006) analyzed data from 23 post-Communist countries during the last decade of the twentieth century. Again there was a significant correlation between the level of democratization

Jonathan Cohen and Joseph J. Amon Life expectancy

Infant mortality

Material mortality

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Figure 15.1 Health indicators in 170 countries by classification of economies (World Bank) and democracy (Freedom House), 1998. Source: Franco etal. (2004).

Material mortality

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Figure 15.1 Health indicators in 170 countries by classification of economies (World Bank) and democracy (Freedom House), 1998. Source: Franco etal. (2004).

and health (r = 0.XX, P < 0.0X), taking into account both wealth and the level of inequality.

In a third study, using governance indicators collated by the World Bank, Reidpath and Allotey (2006) plotted a composite governance indicator against infant mortality and healthy life expectancy (disability adjusted life expectancy) in 176 countries, and found significant correlation (r = -0.68 and r = 0.72, respectively, P < 0.001 for both). To control for per capita wealth the authors performed regression analyses, which identified both governance and wealth (measured as per capita gross domestic product (GDP)) as independently, and significantly, associated with life expectancy and with each other. The authors noted that these multiple correlations, as well as the correlation with another variable studied, the adequate supply of water, made it difficult to fully describe causality.

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