Democratic governance, public service satisfaction, and health equity in Africa: a multivariate statistical analysis

Abstract This study examines the political determinants of health access in Africa by analyzing how democratic demand, democratic supply, and perceptions of government health performance shape reported difficulty in accessing health care. We conducted a cross-sectional, multi-country analysis using pooled individual-level data from Afrobarometer Round 8 (2019–2021), comprising 45,589 adult respondents across 34 African countries. Given the hierarchical data structure, we employed generalized estimating equations (GEE) with a logit link to estimate population-averaged associations while accounting for within-country clustering. Health access difficulty was measured as self-reported experiences of going without needed medicines or medical treatment. Democratic demand was operationalized at the individual level, while democratic supply captured country-level perceptions of how democracy functions. We further assessed perceived government handling of basic health services as a mediating mechanism and tested whether democracy moderates socioeconomic inequities in health access. Results indicate that lower democratic supply is strongly associated with higher odds of health access difficulty, independent of individual and community-level factors. Democratic demand exhibits a more complex relationship: individuals with stronger democratic expectations report greater difficulty accessing care, partly mediated by more critical evaluations of government health performance. Mediation analysis confirms that perceptions of government handling of health care explain approximately one-quarter of the total effect of democratic demand on access difficulty. Moderation analyses show that democratic contexts significantly attenuate socioeconomic gradients in health access. Overall, the findings highlight democracy’s dual role as both a structural determinant of health access and an equity-enhancing force in African health systems.