The Political Architecture of Health: How Regimes Shape Public Health Outcomes

This study investigates the relationship between political regime types and public health outcomes, an underexamined yet foundational question at the intersection of political science and population health. Health and health care are not merely technical policy domains; they have deep political roots. After all, decisions about life, protection, and distributive priorities are made in political arenas, reflecting the impact political accountability, representation, and institutional capacity have on population health. Persistent cross-national disparities in infant mortality, life expectancy, and access to basic services such as clean water cannot be accounted for by socioeconomic conditions alone. Even so, public health has remained marginal within mainstream political science, often relegated to policy analysis rather than treated as a core dimension of governance. Drawing on a comprehensive systematic scoping review (CSSR), this study aims to establish a coherent lens in Political Science, examining how political regimes shape public health outcomes. The paper proposes a conceptual framework to guide future empirical research in the area, in which existing approaches to regime conceptualization were synthesized and the causal mechanisms linking regime characteristics to health outcomes were evaluated. Democracy is conceptualized not as a binary condition but as a multidimensional system of governance, allowing for greater analytical precision. In doing so, the framework contributes to ongoing debates on the conceptualization and measurement of the Quality of Democracy (QoD). Recent episodes of democratic backsliding in some countries, including the United States, Austria, and Poland, bring even more relevance on how the erosion of democratic norms has had negative impacts on public health. Their restrictive reproductive policies, discriminatory measures targeting LGBTQ+ populations, and denial of scientific expertise has produced a tangible toll on population health among these nations. These developments, alongside the increasing frequency and scale of global and/or regional health crises, underscore the urgency of systematically reassessing how regime characteristics condition health outcomes. The conceptual framework developed in this paper organizes the democracy–health relationship across multiple analytical layers: foundational regime inputs, institutional mechanisms, policy pathways, and public health outcomes, while incorporating key societal moderators. It identifies how democratic institutions—through mechanisms of accountability, representation, transparency, and constitutional protections of health—tend to incentivize higher public health spending, broader access to universal health coverage, and sustained investment in infrastructure and professionalized health workforces. By contrast, autocratic regimes often approach health instrumentally, prioritizing labor productivity or regime stability, while hybrid regimes frequently generate poorer outcomes due to political instability and weak channels for grievance redress. These regime effects are further conditioned by income levels, social fragmentation, and resource dependence. Overall, the framework demonstrates that political institutions matter for health, specifically through identifiable mechanisms of accountability and policy choice. Democratic governance is associated with lower infant, child, and maternal mortality and higher life expectancy, particularly where democratic quality is robust. By integrating concepts, mechanisms, and outcomes into a coherent analytical structure, this study re-centers public health within the study of politics and governance and lays the groundwork for future empirical testing.