Article Text

Association of rule of law and health outcomes: an ecological study
  1. Angela Maria Pinzon-Rondon1,
  2. Amir Attaran2,
  3. Juan Carlos Botero3,
  4. Angela Maria Ruiz-Sternberg1
  1. 1Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
  2. 2Faculties of Law and Medicine, Canada Research Chair in Law, Population Health and Global Development Policy, University of Ottawa, Ottawa, Ontario, Canada
  3. 3The World Justice Project, Washington, DC, USA
  1. Correspondence to Dr Angela Maria Pinzon-Rondon; angela_pinzon{at}hotmail.com

Abstract

Objectives To explore whether the rule of law is a foundational determinant of health that underlies other socioeconomic, political and cultural factors that have been associated with health outcomes.

Setting Global project.

Participants Data set of 96 countries, comprising 91% of the global population.

Primary and secondary outcome measures The following health indicators, infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, were included to explore their association with the rule of law. We used a novel Rule of Law Index, gathered from survey sources, in a cross-sectional and ecological design. The Index is based on eight subindices: (1) Constraints on Government Powers; (2) Absence of Corruption; (3) Order and Security; (4) Fundamental Rights; (5) Open Government; (6) Regulatory Enforcement, (7) Civil Justice; and (8) Criminal Justice.

Results The rule of law showed an independent association with infant mortality rate, maternal mortality rate, life expectancy, and cardiovascular disease and diabetes mortality rate, after adjusting for the countries’ level of per capita income, their expenditures in health, their level of political and civil freedom, their Gini measure of inequality and women's status (p<0.05). Rule of law remained significant in all the multivariate models, and the following adjustment for potential confounders remained robust for at least one or more of the health outcomes across all eight subindices of the rule of law. Findings show that the higher the country's level of adherence to the rule of law, the better the health of the population.

Conclusions It is necessary to start considering the country's adherence to the rule of law as a foundational determinant of health. Health advocates should consider the improvement of rule of law as a tool to improve population health. Conversely, lack of progress in rule of law may constitute a structural barrier to health improvement.

  • PUBLIC HEALTH
  • LAW (see Medical Law)
  • HEALTH ECONOMICS

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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