Yes, democracy is good for our health-but which democracy?

Richard Horton wrote a compelling inquiry on the complex scenario surrounding the challenges emerging from liberal democracies in the face of the COVID-19 pandemic. We take his timely discussion one step further. To discuss the benefits and shortcomings of democracies, especially in a global context, we need to look in detail at the actors and politics that govern the design and implementation of health policies. As Horton argued, choosing between liberal democracies and autocracies is an overly simplistic decision. After all, the tertium non datur must be considered. Thus, we should not fall into the trap of polarising the health debate within the current geopolitical dispute. Are democracies generally better for our health? We are convinced so, even in the face of a health crisis such as the COVID-19 pandemic. A holistic analysis of effective public health policies undoubtedly encompasses aspects of civil liberties. Nevertheless, discussing health and its systems from a category as broad as democracy does not seem to be the best strategy, given the complexity of today's world. Instead, it is useful to look at other indicators such as accessibility and universality of health services, equity, and social participation in policy decisions. Furthermore, it is not only nations that should be assessed on whether they are democratic and inclusive, but particularly their governments and decision making processes, which vary in intensity depending on periodic constraints and contingencies.

Brazil is a clear example of this discussion. As the country reaches the 34th anniversary of its democratic constitution, its Unified Health System (Sistema Único de Saude, SUS), faces unprecedented challenges. SUS is one of the most ambitious health initiatives globally, built on a grassroots organisation based around multistakeholder decision making councils and conferences. Its history is emblematic of how hard it is to build a universal health system in a democracy and, especially, to sustain it in the face of political and institutional challenges. Currently, the influence of lobbies and the pharmaceutical industry—through commercial determinants of health—has infiltrated the public health agenda, co-opting politicians and completely distorting public demand in favour of the market's imperatives. Therefore, the question of whether democracy is good for health is important but not enough. It is urgent to discuss how to effectively promote the inclusion of the greatest number of actors in health policy debates through transparent procedures that strengthen our bonds of solidarity and cooperation. Democracy is a tough terrain; still, it is perhaps less disturbing correcting its route than imagining ourselves in an authoritarian political system.