Working Papers
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When Capacity Is Not Enough: Political Incentives and the Selective Activation of Preventive Health in Brazil. Job Market Paper.
Abstract: Despite universal coverage and substantial state capacity, Brazil has experienced a decline in vaccination since 2015, including the resurgence of previously controlled diseases. This decline predates COVID-19 and Bolsonaro’s anti-vaccine rhetoric, posing a puzzle: explanations rooted in individual hesitancy or supply shortages are insufficient. I argue that this territorially uneven decline reflects not the absence of capacity but how local governments deploy it over time. In decentralized settings, political incentives shape whether preventive workforce capacity is sustained or redirected toward more visible curative services. Using original panel data from 1,119 Brazilian municipalities from 2000 to 2022, I show that community health worker (CHW) density significantly predicts vaccine uptake. Municipal fixed-effects models demonstrate that within-municipality changes in CHW coverage are associated with corresponding shifts in influenza vaccination rates. I employ a mixed-methods research design combining OLS regression at the municipal level over time with nested case studies. Qualitative evidence from original interviews, government social media accounts, and municipal campaign plans illustrates that, even in high-capacity contexts, state resources are systematically redirected when political incentives undermine preventive policy legacies in favor of short-term visibility. This article contributes to scholarship on state capacity, implementation politics, and decentralized governance by showing how selective activation during routine implementation reshapes preventive policy trajectories.
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Misinformation and Trust: Survey experiments on vaccine attitudes.
Abstract: Vaccines have been widely recognized as one of the most effective biomedical interventions to eradicate diseases, control pandemics, and prevent premature deaths. However, hesitancy to receive vaccines has increased rapidly in recent years, with detrimental implications for disease prevention and for healthcare systems worldwide. This paper examines vaccine hesitancy in Brazil, which has experienced declining immunization rates since 2015 despite maintaining high coverage throughout the 2000s. Drawing on a survey (n = 340) and 72 interviews with community health workers, policy experts, and health professionals across municipalities in Santa Catarina, as well as federal and state bureaucrats, this study investigates the determinants of vaccine hesitancy related to misinformation, COVID-19 vaccine attitudes, institutional trust, and socio-political influences. The survey’s experimental section assessed how the sender of misinformation affects hesitancy. Results indicate that health professionals exert the strongest influence—both in preventing and in amplifying hesitancy. When misinformation originates from health professionals, people are more likely to believe it than when it comes from religious leaders, politicians, or relatives. Additionally, voting for the far-right candidate Jair Bolsonaro in 2022 correlates with higher vaccine hesitancy than voting for the left-wing candidate Luiz Inácio Lula da Silva. Finally, trust in different levels of government (municipal, state, and federal) has distinct implications for hesitancy behavior. The findings highlight that discussions about vaccine hesitancy in fragile institutional contexts should center on strengthening trust in the vaccine-delivering institution.
