Commitment, Capacity, and Community: The Politics of Multilevel Health Reform in Spain and Brazil

Chapman Osterkatz, Sandra

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March 22, 2019

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Chapman Osterkatz, Sandra
- Affiliation: College of Arts and Sciences, Department of Political Science

Abstract

Inequality is a primary concern for many social and political actors, yet often the distributive profile of society seems over-determined by structure and institutions. Federalism, ethnic heterogeneity, and greater numbers of veto actors are near universally associated with higher levels of inequality and less generous public support for the most vulnerable members of society. A key challenge for scholars has been unpacking multilevel governance and empirically assessing the way the territorial distribution of authority interacts with other forces that determine policies, inhibiting clear theorizing about why and how particular territorial arrangements matter for distributive outcomes. In this dissertation I choose two "hard" cases in which we would not expect equity-enhancing social policy reforms and assess a similar attempt at universal health reform in both cases. Spain and Brazil share long histories of authoritarian rule, ethno-linguistic or racial heterogeneity, lack of fiscal capacity, and asymmetry in the territorial distribution of authority. Spain has been more successful than Brazil at establishing a universal health system that is efficient, sustainable, and broadly supported in society. In both cases the role of structural factors has been significant, yet I argue that particular constellations of ideological commitment at multiple levels of government and at key moments in the reform process, combined with fiscal and administrative capacity, explain much of the difference in outcomes. I take a mixed-method approach, using statistical and comparative historical analysis and assessing variation both between and within the countries.

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