The Health Cost of Autocratization

Abstract

Are democratic crises also human crises? While the determinants of the erosion of democracy have been extensively scrutinised in the literature, their public policy consequences remain relatively unexplored. In a novel attempt to navigate this uncharted terrain, we analyse the effect of autocratization on health outcomes. We conceptualise autocratization as the relative decline of ‘vertical’ and ‘horizontal’ accountability. ‘Vertical accountability’ is threatened in the absence of regular free and fair elections as well as restricted political participation. A decline in vertical accountability lowers citizens’ capacity to ensure governmental responsiveness to public demands. ‘Horizontal accountability’ is reduced when the executive branch undermines the other branches of government. Limited electoral competition further strengthens the executive branch relative to other branches. We argue that such a movement away from democracy – autocratization – has a detrimental effect on public health outcomes. We present empirical evidence supporting this argument in within- and cross-country contexts using regression discontinuity designs as well as panel data analysis.

Keywords:

• Autocratization
• public health
• executive competition
• political participation
• health spending

Acknowledgements

Previous versions of this paper were presented at Midwest Political Science Association Annual Meeting (Chicago, IL, 2019) and Invited Speaker Series of Institute of Korean Studies (University Missouri-Columbia, 2020). The authors thank the participants of both seminars, as well as the two anonymous reviewers, for constructive comments. The replication materials are made available in the author website https://ben-son.netlify.app (ABBREVIATED FOR ANONIMITY).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary Materials

Supplementary Materials are available for this article which can be accessed via the online version of this journal available at https://doi.org/10.1080/00220388.2021.2017891.

Notes

1. Because in terms of checks and representation, the role of an authoritarian legislature would be similar (though much limited) to a democratic one, we do not expect the effect of substantive reduction in horizontal accountability to be limited only to democracies.

2. This primarily relates to vertical accountability but has implications for horizontal accountability as well in so far as it reduces the ability of challengers to hold incumbents accountable.

3. In about 70 per cent of cases horizontal and vertical autocratizations overlap. In fact, as shown in Supplementary Materials Appendix Table A5, all measures used in this paper are highly correlated. This should not be surprising given the empirical inseparability of vertical and horizontal accountability – where one is compromised, the other is also very likely to be limited.

4. We note one caveat in applying the result of our case studies to more recent autocratization cases. As Boese, Edgell, Hellmeier, Maerz, and Lindberg (2021, p. 6) demonstrate, the post-Cold War autocratization cases involve significantly more gradual declines in EDI than others did. This aspect of autocratization is not directly accounted for in any of our three cases although we believe that our panel data analysis, where the autocratization measure reflects cumulative decline in democracy over time, does shed light on it.