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Federalism and decision making in health care: the influence of subnational governments in Brazil

ABSTRACT Existing scholarship on federalism seeks to gauge the extent of centralization and decentralization by examining the role of federal and subnational governments in policymaking in a range of federal countries. Most of these studies are focused on debates about self-rule and subnational representation in the legislative branch. This paper explores the role of subnational governments in health care decisions made at the national level in Brazil. Some researchers argue that health care policymaking in Brazil is heavily centralized. This article aims to deepen our understanding of how subnational governments influence decisions in the health care equalization system. The existing scholarship shows that the effective power of states and municipalities in national decision making remains limited, yet this paper argues that other players, who support changes towards increased centralization, influence health policy decisions.