Can political regimes be singled out as a factor affecting health? Rating countries by the extent of their freedom is a useful proxy for measuring the effects of democracy on health related variables Although the influence of democracy in preventing famines has been reported, 1 there have been no empirical studies on the relation between the extent of freedom allowed by political regimes and the effect on a nation's health. We explored the effect of democracy on life expectancy and maternal and infant mortality in most countries, taking into account a country's wealth, its level of inequality, and the size of its public sector. Politics and healthSince Virchow's seminal work, in which medicine was first proposed as a political science, 2 politics has often been referred to in the medical literature, although mostly at a rhetorical level. 3Studies of political epidemiology are therefore needed, with research focusing on the effects on health of the institutions derived from political power.Some authors have tried to determine empirically whether governments can have an effect on the incidence of specific health problems. Studies in the United Kingdom and elsewhere have measured the effect of Labour and Conservative governments on suicide rates. 4 More recently, welfare state policies have been associated with health benefits in people from countries belonging to the Organisation for Economic Cooperation and Development. Data are now available to enable the measurement of the global impact on health of a wide range of political and economic variables. As a result the World Health Organization commission on macroeconomics and health has produced valuable information on associations between health and wealth.6 Yet information is still lacking on the relation between the extent of freedom of a particular country and the health of its people. Each year, Freedom House, a non-profit making, independent organisation promoting democracy, publishes a freedom rating for most countries, classifying them as free, partially free, or not free. 7These ratings could be used as a proxy to explore the effects of democracy on health, as has been done recently with democracy and the provision of public services.

Law 100 introduced the Health Sector Reform in Colombia, a model of managed competition. This article addresses the effects of this model in terms of output and outcomes of TB control. Trends in main TB control indicators were analysed using secondary data sources, and 25 interviews were done with key informants from public and private insurers and provider institutions, and from the health directorate level. We found a deterioration in the performance of TB control: a decreasing number of BCG vaccine doses applied, a reduction in case finding and contacts identification, low cure rates and an increasing loss of follow up, which mainly affects poor people. Fragmentation occurred as the atomization and discontinuity of the technical processes took place, there was a lack of coordination, as well as a breakdown between individual and collective interventions, and the health information system began to disintegrate. The introduction of the Managed Competition (MC) in Colombia appeared to have adverse effects on TB control due to the dominance of the economic rationality in the health system and the weak state stewardship. Our recommendations are to restructure the reform's public health component, strengthen the technical capacity in public health of the state, mainly at the local and departmental levels, and to improve the health information system by reorienting its objectives to public health goals.

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