Subnational Unevenness in Healthcare Provision: the Role of Fiscal Dependence and Local Governance in Brazilian Municipalities.

Does distributive politics align with the regionalisation of healthcare at subnational level? Regionalisation emerges as an institutional response to correct inequalities in access and equalise the provision of services within countries. Yet, in a context of great fiscal disparity, funding is key to the success of this strategy. In this paper we focus on the role of distributive politics, which by decentralising federal funding based on the preferences of congresspeople might not align with the coordination of policy goals regarding regionalisation. We argue that distributive politics can either reinforce or undermine regionalisation: legislators may strengthen coordination by directing amendments to hub cities with spillover benefits, or they may fragment provision by targeting municipalities in an uncoordinated manner. We use Brazil’s Unified Health System as a case, which organises over 5,570 municipalities into roughly 450 health regions. Using an original dataset of 165,576 pork barrel funds allocated for health (2015–2025), we combine amendment records with municipal health indicators to assess how distributive resources intersect with regional planning. Employing spatial analysis to test three allocation mechanisms: strategic, neighbouring, and political. By analysing the intersection between the allocation of distributive policies and the regionalisation of health policy, we contribute to understanding the mechanisms that promote (or restrict) equal access to public policies at sub-national level.