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In Brazil, a look at why health care declines around elections

Guillermo Toral PhD '20 finds health care quality drops in months leading up to mayoral elections, and if the incumbent loses, the quality continues to fall.
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Photo of the doors to a health clinic
Health clinic in Bento Fernandes, a small municipality in the state of Rio Grande do Norte in Brazil
Photo courtesy of Guillermo Toral.

In October 2016, shortly after Brazil’s mayoral elections, significant numbers of public servants were dismissed from their positions in several municipalities across the country. Porto Nacional’s schools abruptly closed because there were simply not enough teachers staffed to keep the schools open. In Miracema do Tocantins, classes ended six weeks early after 30 percent of city employees were laid off. And dozens of health care providers lost their jobs in Itacoatiara. What did the elections in these three municipalities have in common? In all cases, the incumbent mayor lost their bid for re-election. 

Guillermo Toral PhD '20, an assistant professor of political science at Vanderbilt University and an MIT Governance Lab (MIT GOV/LAB) research affiliate, studies how the behavior of politicians, their relationships with civil servants, and the laws constraining these behaviors and relationships impact the quality of public services citizens receive in Brazil, and in one project, studied how this quality varies around elections. Brazilian municipalities are in charge of providing health care, education, and social assistance to their constituents, and mayors play a big role in hiring employees, including local teachers, doctors, and social workers. 

Toral says that political scientists have studied the ways in which elections benefit public service delivery for decades. But Toral’s research finds that the quality of health care drops in the months leading up to mayoral elections, and if the incumbent loses, that the quality of health care continues to fall. “The fact that, ahead of elections, these places are providing less services in an area as critical as primary health care, to me, that’s super disturbing,” Toral says. 

When the incumbent loses, health care suffers

In interviews with local politicians and bureaucrats, as well as auditors and prosecutors, Toral says “people kept telling me, oh yes, if the mayor loses, everything stops.” And these slowdowns can have consequences for people’s health. A secretary of health care in Ceará told him that cases of dengue fever rose by over 500 percent after the mayor lost a re-election bid. Toral then dug into data on health care service around elections, looking at changes in the quality of service after the incumbent mayor lost a close race. He found that visits by nurses and doctors dropped significantly in the three months between the election and the new administration taking office. The number of prenatal checkups dropped as well, as did medical consultations with infants and children. And these numbers did not immediately rebound once the new administration was sworn in.

Toral focused on these categories of health care because he had access to monthly data and because the services are mandatory, so the changes were likely due to fewer services being available, rather than demand decreasing. But he hypothesizes that the delivery of other services, such as education, could be similarly suffering, since polls suggest that health care is the most important issue to Brazilian voters. Natália S. Bueno, assistant professor of political science at Emory University, says this is certainly possible, and thinks services that require a lot of frequent work from bureaucrats, such as services for the poor and for people with disabilities, could also be affected. Toral thinks the consequences of these health-care service declines could continue to manifest well after the election. “These effects are serious enough that they could be harming childhood development,” he says.

Hiring and firing bureaucrats and campaigning can disrupt services

So why is health care worse around elections? Toral found that in general, health care service delivery declines not only right after, but also right before the election, and does so regardless of the outcome of the election. Bureaucrats have suggested to Toral that “cycles” in the hiring, dismissing, resigning, and transferring of bureaucrats around the elections are to blame. Toral’s data also show that bureaucratic turnover increases around elections. Bueno, who has received MIT GOV/LAB funding for her research, says that this turnover hasn’t been studied before. “There’s a lot more instability around elections than we have thought,” she says. “And that hurts voters in the short term.” 

But the data suggest that the cycles themselves might be less important than what Toral calls “distraction effects.” Before the elections, political energy may be focused on campaign events in an attempt to “mobilize votes more easily,” says Toral. And after the election, the bureaucracy might feel less accountable to the lame duck. In an interview with Toral, another secretary of health care in the state of Ceará said that after an incumbent loses, tenured bureaucrats “cross their arms because there’s no manager to hold them accountable. They don’t accept orders from those who lost.”

Politicians are neither angels nor devils

What can be done to improve health-care delivery around elections? Toral cautions against restricting politicians’ ability to hire and fire civil servants, because such restrictions often have unintended consequences. Brazil has a “freeze period” in place that limits municipal governments’ spending and their ability to hire and fire civil servants for the three months before and after the election. But Toral’s research shows that politicians just anticipate the freeze, beginning the cycle of hiring and firing before the freeze kicks in. “When we design policies that try to contain these cycles, we’ve got to be very careful, and think about how politicians are going to respond to those constraints,” he says. 

Bueno agrees, saying that while such legal constraints were designed to prevent politicians from “trad[ing] jobs for support,” they actually make it harder to provide services. “If politicians want to do things not by the book, they’ll find ways around it, and it’s really hard to constrain that behavior unless there are good incentives in place for them to do well,” she says. Toral acknowledges that corruption of course exists, and that politicians don’t always have pure motives. “But they are also not devils,” he says. “We need to exploit their good halves.”  

Toral suggests several specific strategies to improve public services without further restraining politicians. One is expanding the management training of bureaucrats and adopting better management strategies. Another is sharing statistics on health care services before elections to encourage politicians to make health-care delivery a bigger part of their campaigns. Bueno says that Toral’s work “diagnoses a problem” and that techniques like management training and data sharing should be studied further to determine how they can be utilized best to improve service delivery around elections. Toral would like to continue to study which variables have the strongest impact on the service decline. “There might be some management solutions that minimize this effect,” Bueno says. “It might not solve it completely, but it’s something we can do.”

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