Association between the rule of law and health-related sustainable development goals: an ecological study

In the context of ongoing global challenges, such as pandemics, climate change, and armed conflicts, the achievement of Sustainable Development Goal 3 (SDG 3) is confronted with multiple risks. Effectively addressing these challenges has become a pivotal issue in global health governance. This study seeks to analyze the association between the rule of law (ROL) and health-related Sustainable Development Goals (SDGs). A cross-sectional ecological design was employed to investigate the association between the ROL Index and health-related indicators, including life expectancy, healthy life expectancy, and 13 indicators under SDG 3. Multiple linear regression analyses were conducted, adjusting for gross national income (GNI) per capita, current health expenditure (CHE), total population, urbanization, and the Gender Gap Index (GGI). Subgroup analyses were further performed to assess the potential influence of national income levels on these associations. The Pearson correlation analysis showed that the ROL Index was markedly correlated with 15 health-related indicators. After adjusting for confounders, the ROL Index was positively associated with life expectancy, healthy life expectancy, DTP3 immunization coverage, and the density of medical doctors, nursing and midwifery personnel, and pharmacists. It was also negatively associated with adolescent birth rate. Subgroup analyses further revealed that the associations of the ROL Index with DTP3 immunization coverage, adolescent birth rate, and the density of nursing and midwifery personnel varied across national income levels. This study is the first to identify the significant associations between the ROL and critical health outcomes, the health workforce, and immunization service indicators under the SDG 3 framework. It suggests that the ROL is an effective yet underestimated and underutilized tool for advancing global health. Policymakers should prioritize strengthening national legal frameworks and integrating ROL principles into health systems. These integrated efforts should focus on tackling corruption, executing public legal education, protecting the rights of health workers, eradicating workplace discrimination, and improving sexuality education and reproductive healthcare in low- and lower-middle-income countries.