Health and Historical Levels of Freedom

Background:The link between political freedom and health is unclear. We aimed to determine the association byexploring the relationship of historical and cumulative freedom levels with important health outcomes.Methods:We obtained countrywide health indicators for life expectancy, infant mortality, maternal mortality ratio, %low birth weight babies, Gini coefficient (a measure of wealth inequality) and various markers of freedom based onpolitical rights and civil liberties. We applied multivariable logistic regression to examine the association betweenhealth indicators and within-country years of freedom as determined by Freedom House rankings.Results:The total proportion of free years from 1972-2005, the duration of current freedom level, and the Ginicoefficient show independent positive associations with health indicators, which remain after the adjustment fornational wealth, total government expenditure, and spending on health. Countries identified as having high totalproportion of free years demonstrated significantly better health outcomes than countries with low levels of freedom(life expectancy, Odds Ratio [OR] 7.2, 95% Confidence Interval [CI], 2.3-22.6, infant mortality OR 19.6, 95% CI, 5.6-67.7,maternal mortality ratio, OR 24.3, 95% CI, 6.2-94.9, and % low birth weight babies OR 3.8, 95% CI, 1.4-10.8). This was alsothe case for infant mortality (OR 3.4, 95% CI, 1.0-8.4), maternal mortality ratio (OR 4.0, 95% CI, 1.2-12.8), and % low birthweight babies (OR 2.6, 95% CI, 1.0-6.6) among countries considered as having medium levels of freedom.Interpretation:We found strong associations between country-level freedom and important health outcomes. Thecumulative level of freedom over time shows stronger associations with all health indicators than the duration ofcurrent freedom level.