(iPoster) Institutional, Political, and Social Dimensions of Health in a Global Context

• In Event: Poster Session: Democracy and Autocracy II & Health Politics and Health Policy
  In Poster Session: Poster Session: Health Politics and Health Policy

Abstract

Health system performance is essential for promoting well-being and societal resilience. While previous studies have primarily focused on healthcare budgets to explain variations in health system performance, recent research suggests that factors like power dynamics, governance, and institutional context also play a significant role.
This study investigates how the institutional context and its administrative, political, and social dimensions affect health system performance.
As for healthcare system structure, we expect systems with a high share of public health expenditures to achieve better universal health results than market-oriented systems focused on private expenditure. Administrative traditions may affect health system performance because they consist of norms about the role of the state vis-à-vis society and about the degree to which public servants should focus on implementing rules or rather on achieving results. In terms of political context, we distinguish political system and institutions from political preferences and ideology. The main distinction is between democracies, non-democratic systems, and those in between. While it has been long assumed that democracies have an advantage in providing prosperity and essential goods such as health because of their inbuilt feedback and accountability mechanisms (Halperin et al. 2010), studies about health system resilience in the COVID-19 pandemic have emphasized the ability of non-democratic systems to intervene and suspend social and economic life more rigorously for public health purposes (Sebhatu et al. 2020). Once we move beyond OECD countries state capacity becomes relevant as well. State capacity is widely used in political science to refer to the extent to which a state controls and penetrates all territories under its jurisdiction. Previous studies have linked state capacity to the achievement of development goals (Cingolani et al. 2015). Finally, the societal context may matter for how much health systems are able to achieve their goals in practice. Higher social trust may facilitate the interaction between healthcare professionals and ordinary citizens and thereby foster the effectiveness of the healthcare system.
To assess health system performance, we use indicators from the United Nations Sustainable Development Goals Global Database. Key independent variables include public health expenditure, social health insurance coverage, and health workers per 10,000 residents (from WHO and World Bank) to represent healthcare system size; legal origin and administrative tradition (following classifications by LaPorta et al., 1999, and Bianculli et al., 2013); degree of democracy, political system, share of women in parliament (from V-Dem dataset), state capacity (Hanson and Sigman, 2021), left-right ideology, populist orientation (Kavakli 2020), and social trust (World Values Survey). Income levels are controlled with logged GDP per capita. Observations are at the country level, covering all countries and territories from 2000 to 2020, with panel data analysis using random effects. An exploratory analysis on how central state reach moderates the impact of female political representation on maternal and child mortality was additionally carried out employing two-way fixed effects models and staggered difference-in-differences.
The most significant effects on health system performance are associated with administrative tradition, health workers per population, and GDP per capita. Countries with interventionist administrative traditions that support a strong, proactive state tend to show better health outcomes. In models including legal origin, countries with Socialist, French, Germanic, and Scandinavian traditions exhibit better health outcomes than those with a British administrative tradition. By contrast, social health insurance and public health expenditure are only significantly related to specific indicators, such as vaccination coverage and births attended by medical personnel. Among political variables, political system, government ideology, and state capacity show significant relationships with about half of the health performance indicators, while democracy and government populism are rarely significant. Social trust is associated with many health indicators, particularly the incidence of preventable diseases. Female political representation has a weaker impact on maternal and infant mortality in countries with Anglo-Saxon administrative traditions / British legal origin or that are more decentralized.
Identifying the drivers of health system performance is crucial for both theory and policy. The result that administrative traditions matter more often or more systematically than state capacity and more than public health expenditures suggests that it is less important how much a state does for health and more important how a state runs its healthcare system and how it delivers healthcare services.

Authors

• Giulia Fornaro, Bocconi University

• Kerim Can Kavakli, Bocconi University