Elsevier

Social Science & Medicine

Volume 190, October 2017, Pages 237-246
Social Science & Medicine

The impact of democracy and media freedom on under-5 mortality, 1961–2011

https://doi.org/10.1016/j.socscimed.2017.08.023Get rights and content

Highlights

  • A theory linking child health and democracy via economic incentives is proposed.

  • A theory linking child health and media freedom via information flows is proposed.

  • Level of democracy is associated with decreases in under-5 mortality.

  • Media freedom amplifies the reductive effect of democracy on under-5 mortality.

Abstract

Do democracies produce better health outcomes for children than autocracies? We argue that (1) democratic governments have an incentive to reduce child mortality among low-income families and (2) that media freedom enhances their ability to deliver mortality-reducing resources to the poorest. A panel of 167 countries for the years 1961–2011 is used to test those two theoretical claims. We find that level of democracy is negatively associated with under-5 mortality, and that that negative association is greater in the presence of media freedom. These results are robust to the inclusion of country and year fixed effects, time-varying control variables, and the multiple imputation of missing values.

Introduction

Child mortality primarily occurs among the poorest members of society in developed countries and especially developing countries (de Looper and Lafortune, 2009, Yazbeck, 2009). Moreover, it is often due to illnesses that are easy to prevent or treat (via, for example, vaccination, peri- and neonatal care, access to clean water, antibiotics, oral rehydration solutions, etc.). Infectious diseases accounted for 51.8% of global deaths in children younger than five years in 2013. The largest share of those deaths were due to pneumonia (14.9%), diarrhea (9.2%) and malaria (7.2%) (Liu et al., 2015). Effective interventions exist for all three diseases (Jones et al., 2003). In addition, approximately 45% of all child deaths were linked to undernutrition in 2011 (Black et al., 2013). This suggests that child mortality rates among the poor could be responsive to public policy-making.

A key determinant of public policy is regime type. Democratic leaders must win the support of a larger share of the population than their autocratic counterparts in order to stay in power. Thus, they have an incentive to provide welfare-promoting resources to a larger proportion of the population. In support of that theoretical claim there are a growing number of cross-national studies that find that that democracies produce healthier, more educated and better nourished populations than autocracies (see, for example, Besley and Kudamatsu, 2006, Blaydes and Kayser, 2011; Brown, 1999, Gerring et al., 2012, Mackenbach et al., 2013, Patterson and Veenstra, 2016, Wigley and Akkoyunlu, 2011). It is not immediately obvious, however, that democracies are better at promoting the well-being of the poorest members of society. It remains possible that democratic governments will not target welfare transfers and public goods to low-income citizens because their votes are not required in order to secure a winning majority. Thus, democratic leaders may be no better at reducing child mortality among the poor than autocratic leaders (Ross, 2006).

In response to that challenge we argue, in what follows, that democratic leaders have a greater incentive to reduce child mortality, even in those cases when they do not require the electoral support of low-income voters (section 2.1). This is because of the economic benefits – economies of scale, positive externalities and enhanced productivity - associated with improved child health. In addition, we argue that democracies are better equipped to reduce child mortality because the greater protection they afford to free speech, and especially media freedom, enhances government responsiveness (section 2.2).

In order to test those two theoretical claims we employ a panel of 167 countries (all countries with populations greater than 250,000) for the years 1961–2011 (sections 3 Model, variables and data, 4 Results, 5 Robustness checks). We include country fixed effects in order to control for those unchanging factors, such as climate and colonial history, which might be simultaneously determining regime type and child health. We also employ a measure of democracy that takes into account the two central ingredients of democratic rule, political competition and political participation. Previous studies on the link between democracy and well-being outcomes, have tended to focus on the extent to which there are regular and genuinely competitive elections. As a consequence, they have not taken into account the degree to which citizens actually participate in those elections, or even whether there is universal suffrage. Our measure of democracy, therefore, provides a more complete picture of each country's democratic status.

Section snippets

Theoretical framework

In this section we develop our two theoretical claims. Namely, that democratic leaders have a greater incentive and capability to reduce child mortality than autocratic leaders. Subsequent sections present empirical evidence in support of those two claims.

Model, variables and data

In order to assess the two hypothesis noted above we employ a panel of 167 countries for each year from 1961 to 2011, to analyze the relationship between democracy and under-5 mortality. In order to assess whether level of democracy (as measured by competitive participation) influences the level of under-5 mortality (Hypothesis 1) we employ an additive model of the following form.lnUnder5mortalityit+1=β0+β1CompetitiveParticipationit+β2lnΧit+uit+1

In order to assess whether media freedom

Results

The results of our analysis are presented in Table 1. The first three columns present the results of the additive model and the next two columns present the results of the multiplicative model. The remaining columns provide robustness checks for our baseline results.

Robustness checks

Fixed effects specifications are crucial as they provide a way to control for unchanging or slow changing factors (physical geography, culture, colonial history, etc.) that may be simultaneously determining the main independent variables of interest and the dependent variable, thereby producing spurious correlations. However, that type of specification has a tendency to underestimate the significance of variables that do not change or are slow changing over time. We therefore ran the additive

Discussion and conclusion

In this study we have argued that democratic governments have a greater incentive and capability to reduce child mortality among the poor than their autocratic counterparts. In the first place, they have more of an incentive to pursue the economic benefits associated with improved child health. That is, they have reason to improve child health among the poorest even if they do not require their votes in order to secure a winning majority. In the second place, they are better at redirecting

Acknowledgements

The authors are grateful for the financial support that they received from the Scientific and Research Council of Turkey (TÜBİTAK) (Project number: 114K765). An earlier version of this article was presented to the ECPR workshop ‘Was Plato Right: Should Experts Rule?’ at the Scuola Normale Superiore, Pisa, 24–25 April, 2016. The authors are grateful to the participants in that workshop for their comments.

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