(Un?)Healthy Politics: The Political Determinants of Subnational Health Systems in Brazil

Abstract

AbstractHow does political competition shape institutions that govern the expansion of social policy subnationally? Brazilian states have shown a surprising variation in the design of their public health institutions, which regulate the distribution of health resources and citizen access to public health care. While many states have experienced fragmentation, some have remained highly centralized and discretionary, and only a select few have established a coordinated system based on power sharing and rules-based distribution. Accounts that link public health care expansion to federal government imposition, the presence of the public health care movement, and leftist parties cannot fully explain this variation. Instead, in the three Brazilian states examined here, the nature of subnational political competition triggered different institution-building strategies. The findings indicate that plural political competition yielded incentives for limiting state-level discretion and for sharing power with municipal governments, while political concentration reinforced the attraction to centralized and discretionary policymaking.