Making sense of dictatorships and health outcomes

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Cuba is an authoritarian state and is poor even by the standards of Latin America. Yet it has managed to achieve levels of life expectancy and infant mortality that (even after adjusting for possible data manipulation) surpass those observed in advanced economies. Cuba is not the sole non-democratic regime to have achieved similar outcomes. The former Union of Soviet Socialist Republics (USSR) also stands as a clear example of such a case where there was a rapid increase in health outcomes post-1945, which made the USSR compare favourably with Western Europe  in spite of the fact that it was relatively poorer.

While it is true that, on average, dictatorships do not seem to improve health outcomes, Cuba, the USSR, and past or current autocratic regimes in China (especially in the recent outbreak of covid-19) or Ethiopia are well-known exceptions that are often praised. This is in part due to their impressive accomplishments in spite of low levels of economic development, as argued, in the case of Cuba, by Wenham and Kittelsen (pp11–12, 14–15) in this edition of BMJ Global Health. Numerous policy experts and policy-makers have recommended attempting to import the ‘good’ from such regimes (ie, high-quality, cheap healthcare) and leaving behind the ‘bad’ (ie, the non-democratic institutions, repressed private sector economy, the limited respect for human rights and other restrictions imposed by the regime).

In this editorial, we point out that such a sorting of the wheat from the chaff is impossible. First, we point out that it is unsurprising to see some dictatorships performing well with regard to health indicators due to their ability to forcibly mandate the allocation of resources towards achieving the regime’s objectives. Second, we point out that there are trade-offs associated with this ability that actually lead to poor economic outcomes and also to inferior outcomes on other (prosperity-related) health indicators. Third, we point out that some dictators have an incentive to invest in healthcare if it serves to bolster their regime. While the explanations provided in this editorial do not individually apply to all past and present dictatorships and autocratic regimes with impressive health policies and outcomes, they provide a useful way to make sense of their progress.