Democracy, Income and Health: Evidence from Sub-national Comparative Method

Dina Balalaeva (NRU Higher School of Economics)
Vladimir Kozlov (NRU Higher School of Economics)
Alexander Libman (Stiftung Wissenschaft und Politik)

Abstract: The conventional wisdom holds that, ceteris paribus, democracies are better at promoting population health than autocracies. Under democracies politicians are more accountable to voters and therefore redistribute more public goods and of higher quality. However, the empirical evidence is mixed and results are not robust to different country-level confounders. In this light Russia presents a unique opportunity to put this theory to a new test given its tremendous sub-national variation in both democracy level and health outcomes (e.g., life expectancy ranges from 61.8 to 78.8). Our findings are twofold. First, sub-national democracies significantly impact health outcomes. Second, the effect of democracy is more subtle than previosuly thought and acts through income level: in poor regions, high level of democracy is associated with worse health outcomes, while in rich regions democracy has a positive impact on health. Due to infancy and institutional imperfections, subnational democracies fail to redistribute healthcare goods in an optimal way, which is compensated either by rising incomes or high mobilizational efforts under non-democratic sub-national regimes.