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Contextualizing Obesity and Diabetes Policy: Exploring a Nested Statistical and Constructivist Approach at the Cross-national and Sub-national Government Level in the United States and Brazil

Journal article
Eduardo J. Gómez
International Journal of Health Policy and Management (forthcoming)

Abstract: Background: This article conducts a comparative national and sub-national government analysis of the political, economic, and ideational constructivist contextual factors facilitating the adoption of obesity and diabetes policy. Methods: We adopt a nested analytical approach to policy analysis, which combines cross-national statistical analysis with sub-national case study comparisons to examine theoretical prepositions and discover alternative contextual factors; this was combined with an ideational constructivist approach to policy-making. Results: Contrary to the existing literature, we found that with the exception of cross-national statistical differences in access to healthcare infrastructural resources, the growing burden of obesity and diabetes, rising healthcare costs and increased citizens’ knowledge had no predictive affect on the adoption of obesity and diabetes policy. We then turned to a subnational comparative analysis of the states of Mississippi in the US and Rio Grande do Norte in Brazil to further assess the importance of infrastructural resources, at two units of analysis: the state governments versus rural municipal governments. Qualitative evidence suggests that differences in subnational healthcare infrastructural resources were insufficient for explaining policy reform processes, highlighting instead other potentially important factors, such as state-civil societal relationships and policy diffusion in Mississippi, federal policy intervention in Rio Grande do Norte, and politicians’ social construction of obesity and the resulting differences in policy roles assigned to the central government. Conclusion: We conclude by underscoring the complexity of subnational policy responses to obesity and diabetes, the importance of combining resource and constructivist analysis for better understanding the context of policy reform, while underscoring the potential lessons that the US can learn from Brazil.

The State of Political Science Research in Global Health Policy

Journal article
Eduardo J. Gómez
Global Health Governance 2016, 10(3): 3-9.

In this article, I review the current state of political science research in the field of global health policy. I also introduce the themes and arguments made about this topic in our special series of Global Health Governance titled “Political Science in Global Health.”

Democratic Transitions, Health Institutions, and Financial Protection in Emerging Economies

Journal article
Eduardo J. Gómez
Health Economics, Policy and Law 2016, DOI: 10.1017/S1744133116000293:1-15.

Abstract: In recent years, several emerging economies have introduced national health insurance programs ensuring access to healthcare while offering financial protection from out-of-pocket (OOP) and catastrophic expenses. Nevertheless, in several nations these expenses continue to increase. While recent research has emphasized the lack of funding, poor policy design and corruption as the main culprits, little is known about the politics of establishing federal regulatory agencies ensuring that state governments adhere to national insurance reimbursement and coverage procedures. This article fills in this lacuna by providing an alternative perspective, one that accounts for differences between nations in the creation of regulatory institutions, with an emphasis instead on governing elite strategies to campaign on access to healthcare during transitions to democracy, civil societal mobilization, constitutional constraints, and the national electoral incentives to overcome ineffective decentralization processes. The cases of Indonesia and China are introduced as examples of how and why their differences in this political process accounted for Indonesia’s success and China’s failure to ensure financial protection.

Brazilian Foreign Policy in Health: Transitions and Challenges under the Dilma Rousseff Administration (2011-2014)

Journal article
Eduardo J. Gómez and Fernanda Perez
Lua Nova 2016, 98:171-197.

Abstract: In this article, we analyze the evolution of Brazil’s foreign policy in health. We argue that the Dilma Rouseff administration has not been committed to sustaining prior governments’ efforts to increase foreign aid in health, nor has the government increased the federal budget for those institutions governing this process. A decrease in economic growth, recession, and the Dilma administration’s focus on domestic policy are seen as the main reasons why this transformation has occurred. We consider the long-term impact that this may have on global health diplomacy and Brazil’s position in the world.

Confronting Health Inequalities in the BRICS: Institutions, Foreign Policy Goals, and State-Civil Societal Relationships

Eduardo J. Gómez
Global Policy 2016, Doi:10.111/17585899.12340

Abstract: The BRICS (Brazil, Russia, India, China, and South Africa) have emerged as robust economies with considerable international influence. Nevertheless, essentially all of these nations have fallen short of simultaneously developing strong economies and healthcare systems, in turn contributing to the emergence of healthcare inequalities, such as inadequate access to medicine, out-of-pocket spending, and geographic differences in access to quality healthcare infrastructure and human resources. This is puzzling considering that most of these nations’ economies burgeoned during the 1990s and early-2000s, thus potentially providing additional revenue for healthcare spending, while constitutional guarantees of universal access to healthcare and the presence of democratic electoral institutions in most of these nations should have incentivized governments to successfully address these inequality issues. Nevertheless, with the exception of South Africa, this study finds that waning political commitment to healthcare spending, increased foreign aid assistance and tenuous state-civil societal relationships accounted for these ongoing inequality challenges.

Crafting AIDS Policy in Brazil and Russia: State-Civil Societal Ties, Institutionalized Morals, and Foreign Policy Aspirations

Journal article
Eduardo J. Gómez
Global Public Health 2016, 11(9): 1148-1168.

Abstract: During the 1990s, Brazil and Russia diverged in their policy response to AIDS. This is puzzling considering that both nations were globally-integrated emerging economies transitioning to democracy. This article examines to what extent international pressures and partnerships with multilateral donors motivated these governments to increase and sustain federal spending and policy reforms. Contrary to this literature, the cases of Brazil and Russia suggest that these external factors were not important in achieving these outcomes. Furthermore, it is argued that Brazil’s policy response was eventually stronger than Russia’s and that it had more to do with domestic political and social factors: specifically, AIDS officials’ efforts to cultivate a strong partnership with NGOs, the absence of officials’ moral discriminatory outlook towards the AIDS community, and the government’s interest in using policy reform as a means to bolster its international reputation in health.

Understanding the United States and Brazil's Response to Obesity: Institutional Conversion, Policy Reform, and the Lessons Learned

Journal article
Eduardo J. Gómez
Globalization & Health 2015, 11(24): 1-14.

Abstract: In the United States (US) and Brazil, obesity has emerged as a health epidemic. This article is driven by the following research questions: how did the US and Brazil’s federal institutions respond to obesity? And how did these responses affect policy implementation? The aim of this article is therefore to conduct a comparative case study analysis of how these nations’ institutions responded in order to determine the key lessons learned. Methods: This study uses primary and secondary qualitative data to substantiate causal arguments and factual claims. Results: Brazil shows that converting preexisting federal agencies working in primary healthcare to emphasize the provision of obesity prevention services can facilitate policy implementation, especially in rural areas. Brazil also reveals the importance of targeting federal grant support to the highest obesity prevalence areas and imposing grant conditionalities, while illustrating how the incorporation of social health movements into the bureaucracy facilitates the early adoption of nutrition and obesity policies. None of these reforms were pursued in the US. Conclusions: Brazil’s government has engaged in innovative institutional conversion processes aiding its ability to sustain its centralized influence when implementing obesity policy. The US government’s adoption of Brazil’s institutional innovations may help to strengthen its policy response.

Understanding the BRICs Response to AIDS: Political Institutions, Civil Society, and Historical Policy Backlash in Comparative Perspective

Journal article
Eduardo J. Gómez
Commonwealth & Comparative Politics 2015, 53(3): 315-340.

Abstract: The BRICs nations (Brazil, Russia, India, and China) have differed in their government response to health epidemics. It is argued that Brazil eventually outpaced her emerging counterparts in response to AIDS (Acquired Immune Deficiency Syndrome) due to the presence of political institutional, civil societal, and foreign policy strategies that both sustained and encouraged the introduction of innovative policies. The concept of historical policy backlash is introduced in order to explain how the BRICs’ differences in their historic roles as foreign aid donors in health shaped their incentive to either focus on domestic AIDS policy or foreign aid strategies at the expense of domestic policy. This article therefore submits the first attempt to combine comparative political historical, social, and international processes to account for differences in the BRICs willingness and capacity to respond to AIDS.

Constitutions, Civil Society, and the Politics of Pro-Poor Health Insurance Programs in the Emerging Economies

Journal article
Eduardo J. Gómez
Global Health Governance (forthcoming)

Abstract: In recent years, several emerging economies, such as India, China, Russia, and Indonesia, have introduced national health insurance programs targeting the poor, safeguarding them from increased out-of-pocket and catastrophic expenses. With the exception of Indonesia, increased government spending for these programs has not helped to safeguard the poor from these expenses. This article introduces an analytical framework combining the importance of constitutional design, federalism and decentralization, and social health movements to account for these differences in policy outcomes. The author’s proposed analytical approach differs from those studies emphasizing financial constraints, the effective targeting of funds, and administrative capacity, suggesting instead that the design of political institutions and the incentives that they create for policy implementation and regulation may provide greater insight into why these targeted health insurance programs are not achieving their goals.

Health Spending and Inequalities in the Emerging Economies: India, China, Russia, and Indonesia in Comparative Perspective

Policy Report
Eduardo J. Gómez
Oxfam GB 2015

Abstract: New research from the Empowering CSO Networks in an Unequal Multi-polar World programme compares the cases of India, China, Russia and Indonesia in terms of levels and structures of health spending, and the impact on inequality in each of these countries. The report finds that in order to reduce inequality and improve the overall quality of healthcare there is a need to increase public healthcare spending. The research finds clear evidence to show a relationship between increased public provision of healthcare and publically-funded national health insurance programmes, and an overall reduction in inequality. Nevertheless, not all of these four countries are adopting the same path to increase healthcare coverage, and as such the impact on inequality has been mixed. Furthermore, the research highlights a number of ongoing challenges, and suggests that even with political willpower and support to increase public health spending, the detail of how this spending is channelled and monitored is vital in terms of having a positive effect on inequality.

Assessing the Importance of Tripartite Global Health Partnerships: Conducting a Nested Empirical Approach

Journal article
Eduardo J. Gómez
Global Health Governance (forthcoming)

Abstract: In recent years, tripartite partnerships between multilateral health agencies, ministries of health, and civil society have been viewed as important for building and sustaining the creation of national AIDS programs. This article critically examines this argument. In so doing, it uses a new database the author created measuring the presence of these tripartite partnerships and their affects on AIDS program spending. Statistical evidence suggests that these partnerships do not affect AIDS spending. The case of Brazil is then used to further examine various theoretical schools of thought as well as these statistical results at the domestic level, with the usage of qualitative case study evidence. Findings from Brazil further confirms this negative cross-national statistical finding, while highlighting other factors that may account for why governments decide to engage in ongoing AIDS spending, such as the state’s efforts to proactively seek out and strengthen preexisting partnerships with NGOs, while strategically using increased domestic AIDS spending as a means to bolster the government’s foreign policy aspirations.

Political Repression, Civil Society, and the Politics of Responding to AIDS in the BRICS Nations

Journal article
Eduardo J. Gómez and Joseph Harris
Health Policy & Planning 2016, 31(1): 56-66.

Abstract: The policy responses to AIDS in the BRICS nations have played out amid radically different political environments that have shaped state-civil society relations in critical ways. In contrasting these different environments, this article offers the first comparison of the policy response to AIDS in the BRICS nations and seeks to understand the way in which political context matters for conditioning the response to a major epidemic. Using a comparative historical approach, we find that while collaborative state-civil society relations have produced an aggressive response and successful outcomes in Brazil, democratic openness and state-civil society engagement has not necessarily correlated with an aggressive response or better outcomes in the other cases. Response to the epidemic has been worst by far in democratic South Africa, followed by Russia, where in the former, denialism and antagonistic state-civil society relations fueled a delayed response and proved extremely costly in terms of human lives. In Russia, a lack of civil societal opportunity for mobilization and NGO growth, political centralization, and the state’s unwillingness to work with NGOs led to an ineffective government response. Top-down bureaucratic rule and a reluctance to fully engage civil society in democratic India substantially delayed the state’s efforts to engage in a successful partnership with NGOs. Nevertheless, China has done surprisingly well, in spite of its repressive approach and narrow engagement with civil society. And in all cases, we find the relationship between state and civil society to be evolving over time in important ways. These findings suggest the need for more research on the links between democratic openness, political repression, and policy responses to epidemics.

Responding to Obesity in Brazil: Understanding the Intersect of International and Domestic Politics and Policy through a Nested Analytical Approach to Comparative Research

Journal article
Eduardo J. Gómez
Journal of Health Politics, Policy & Law 2015, 40(1): 73-99.

Abstract: Why do governments pursue obesity legislation? And is the case of Brazil unique compared

to other nations when considering the politics of policy reform? Using a nested analytic

approach to comparative research, I found that theoretical frameworks accounting for why

nations implement obesity legislation were not supported with cross-national statistical

evidence. I then turned to the case of Brazil’s response to obesity at three levels of

government, the national, urban, and rural levels, to propose alternative hypotheses for why

nations pursue obesity policy. The case of Brazil suggests that the reasons why governments

respond are different at these three levels of government. International forces, historical

institutions, and social health movements were factors that prompted national government

responses. Alternatively, at the urban and rural government levels, receiving federal financial

assistance and human resource support appeared to be more important. The case of Brazil

therefore suggests that the international and domestic politics of responding to obesity are

highly complex, that national and subnational political actors have different perceptions and

interests when pursuing obesity legislation.

The Global and Domestic Politics of Health Policy in Emerging Nations

Journal article
Eduardo J. Gómez and Jennifer Prah Ruger
Journal of HealthPolitics, Policy & Law 2015, 40(1): 1-11.

Abstract: In recent years, several emerging nations with burgeoning economies and in transition to

democracy have pursued health policy innovations. As these nations have integrated into the

world economy through bilateral trade and diplomacy, they have also become increasingly

exposed to international pressures and norms and focused on more effective, equitable

health care systems. There are several lessons learned from the case studies of Brazil, Ghana,

India, China, Vietnam, and Thailand in this special issue on the global and domestic politics

of health policy in emerging nations. For the countries examined, although sensitive to

international preferences, domestic governments preferred to implement policy on their own

and at their own pace. During the policy-making and implementation process, international

and domestic actors played different roles in health policy making vis-à-vis other reform

actors — at times the state played an intermediary role. In several countries, civil society also

played a central role in designing and implementing policy at all levels of government.

International institutions also have a number of mechanisms and strategies in their toolbox

to influence a country’s domestic health governance, and they use them, particularly in the

context of an uncertain state or internal discordance within the state.

Understanding Brazil, China, and India's Response to Obesity and Diabetes: Proposing an Interdisciplinary Approach to Unifying International Relations Theory, Historical Institutionalism, and Policy-making

Journal article
Eduardo J. Gómez
Global Health Governance / Spring-Autumn 2014

Abstract: The emerging nations of Brazil, China, and India are currently facing the costly epidemics of

obesity and type 2 diabetes. While similar in their pursuit of world prominence, these nations

nevertheless varied in the timing and depth of their policy response. Brazil seemingly

outpaced China and India in the area of prevention and especially with respect to the

universal provision of diabetic medication. Through the introduction of an interdisciplinary

theoretical approach combining different strands of international relations theory, it is

argued that the Brazilian government’s historic interest in simultaneously strengthening its

international reputation in health, as well as the institutionalization of access to medicine as a

human right, facilitated this more aggressive policy response. While China joined Brazil in

having similar geopolitical aspirations, it never institutionalized universal access to medicine

as a human right, thus failing to ensure type 2 diabetics with access to medicine. India, on

the other hand, has never had these geopolitical aspirations or government commitments to

the universal distribution of medication.

Smart Development: How Colombia, Mexico, and Singapore Beat the BRICS

Journal article
Eduardo J. Gómez
Foreign Affairs 2014, February

This article explains how and why a small group of emerging nations, i.e., Colombia, Mexico,

and Singapore, beat the BRICS (Brazil, Russia, India, China, and South Africa) in

simultaneously reforming their economic and social welfare system

Proposing a Sequential Comparative Analytical Method for Assessing Multilateral Health Agency Transformation and Sustainability: Exploring the Advantages of Institutional Theory

Journal article
Eduardo J. Gómez
Globalization & Health 2014, 10(38): 2-14

Abstract: This article proposes an approach to comparing and assessing the adaptive capacity of

multilateral health agencies in meeting country and individual healthcare needs. Most studies

comparing multilateral health agencies have failed to clearly propose a method for

conducting agency comparisons. Methods: This study conducted a qualitative case study

methodological approach, such that secondary and primary case study literature was used to

conduct case study comparisons of multilateral health agencies. Results: Through the

proposed Sequential Comparative Analysis (SCA), the author found a more effective way to

justify the selection of cases, compare and assess organizational transformative capacity, and

to learn from agency success in policy sustainability processes. Conclusions: To more

affectively understand and explain why some multilateral health agencies are more capable of

adapting to country and individual healthcare needs, SCA provides a methodological

approach that may help to better understand why these agencies are so different and what

we can learn from successful reform processes. As funding challenges continue to hamper

these agencies’ adaptive capacity, learning from each other will become increasingly


Global Health in Foreign Policy - and Foreign Policy in Health? Evidence from the BRICS

Journal article
Nicola Watt, Eduardo J. Gómez, and Martin McKee
Health Policy & Planning 2014, 29(6): 763-773

Abstract: Amidst the growing literature on global health, much has been written recently about the

Brazil, Russia, India, China, South Africa (BRICS) countries and their involvement and

potential impact in global health, particularly in relation to development assistance. Rather

less has been said about countries’ motivations for involvement in global health negotiations,

and there is a notable absence of evidence when their motivations are speculated on. This

article uses an existing framework linking engagement in global health to foreign policy to

explore differing levels of engagement by BRICS countries in the global health arena, with a

particular focus on access to medicines. It concludes that countries’ differing and complex

motivations reinforce the need for realistic, pragmatic approaches to global health debates

and their analysis. It also underlines that these analyses should be informed by analysis from

other areas of foreign policy.

Geopolitics, Obesity, and Diabetes: How Brazil, China, and India Responded

Journal article
Eduardo J. Gómez
Harvard International Review 2013, 35(1): 1-8

Abstract: In this article I explain the international and domestic factors that led to the emergence of

the obesity and diabetes epidemics in Brazil, China, and India. I argue that Brazil outpaced

India and China in the provision of proactive prevention and medical treatment services.

Emergence of Multilateral Protoinstitutions and New Approaches to Governance: Analysis using Path Dependency and Institutional Change Theory

Journal article
Eduardo J. Gómez and Rifat Atun
Globalization & Health 2014, 9(18): 1-29

Abstract: The role of multilateral donor agencies in global health is a new area of research, with limited

research on how these agencies differ in terms of their governance arrangements, especially

in relation to transparency, inclusiveness, accountability, and responsiveness to civil society.

We argue that historical analysis of the origins of these agencies and their coalition formation

processes can help to explain these differences. We propose an analytical approach that links

the theoretical literature discussing institutional origins to path dependency and institutional

theory relating to proto institutions in order to illustrate the differences in coalition

formation processes that shape governance within four multilateral agencies involved in

global health. We find that two new multilateral donor agencies that were created by a

diverse coalition of state and non-state actors, such as the Global Fund to Fight AIDS,

Tuberculosis and Malaria and GAVI, what we call proto-institutions, were more adaptive in

strengthening their governance processes. This contrasts with two well-established

multilateral donor agencies, such as the World Bank and the Asian Development Bank, what

we call Bretton Woods (BW) institutions, which were created by nation states alone; and

hence, have different origins and consequently different path dependent processes.

The Politics of Global Health Diplomacy: Conceptual, Empirical, and Theoretical Lessons from the United States, Southeast Asia, and Latin America

Book Chapter
Eduardo J. Gómez
Global HIV/AIDS, Politics, Policy, and Activism (Praeger, 2013, edited by Ray Smith), 73- 90

Understanding Brazil’s Strategic Response to HIV/AIDS: History, Politics, and International Relations

Book Chapter
Eduardo J. Gómez
Global HIV/AIDS, Politics, Policy, and Activism (Praeger, 2013, edited by Ray Smith), 73- 90

What Reverses Decentralization? Failed Policy Implementation, Civic Supporters, Policy Ideas, or Central Bureaucrats' Expertise? The Case of Brazil's AIDS Program

Journal article
Eduardo J. Gómez
Administration and Society 2013, 20(2): 1-31

Abstract: This article argues that Brazil’s success in responding to the AIDS epidemic rested in the

government’s pursuit of a reversal of decentralization, which entailed the government’s

delegation of policy-making autonomy, funding, and discretionary fiscal transfers to the

national AIDS program. AIDS bureaucrats achieved this by establishing close partnerships

with social health movements and AIDS nongovernmental organizations advocating policy

ideas with a historically proven track record of success while resembling similar social health

movements in the past. This partnership, in turn, provided AIDS bureaucrats with the

legitimacy and influenced needed for policy reform.

An Inter-dependent Analytical Approach to Explaining the Evolution of NGOs, Social Movements, and Government Response to HIV/AIDS and Tuberculosis in Brazil

Journal article
Eduardo J. Gómez
Journal of Health Politics, Policy & Law 2013, 38(1) 123-159

Abstract: The politics of government response to health epidemics is a new area of scholarly research.

Nevertheless, to date scholars have not considered how social science theory can be used

and interdependently linked to provide a more thorough discussion of civil societal and

national government response to different types of health epidemics. Introducing what I call

an interdependent analytic framework of government response to epidemics, this article

illustrates how social science theories can be interdependently linked and applied to help

explain the evolutionary role of interest groups and social movements in response to AIDS

and tuberculosis in Brazil, and when and why the government eventually responded more

aggressively to AIDS but not tuberculosis. Evidence from Brazil suggests that the policy

influence of interest groups and social movements evolves over time and is more influential

after the national government implements new policies; moreover, this response is triggered

by the rise of international pressures and government reputation building, not civil society. I

highlight new areas of research that the framework provides and provide examples of how

this approach can help explain civil societal and biased government responses to different

types of epidemics in other nations.

Climate Change, Drought, and Primary Healthcare in Northeaster Brazil: Building Sub- national State Capacity and Community Participation in a Context of Weakened Decentralization Processes

Book Chapter
Eduardo J. Gómez
The Impact of Climate Change on Water and Health (Science Publishers, 2013, edited by Velma Rogers), 308-322

Exploring the Utility of Institutional Theory in Analyzing International Health Agency Stasis and Change

Journal article
Eduardo J. Gómez
Health Policy & Planning 2013, 28(7): 1-9

Abstract: Of recent interest is the capacity of international health agencies to adapt to changes in the

global health environment and country needs. Yet, little is known about the potential

benefits of using social science institutional theory, such as path dependency and

institutional change theory, to explain why some international agencies, such as the WHO

and the Global Fund to Fight AIDS, Tuberculosis and Malaria, fail to adapt, whereas others,

such as the World Bank and UNAIDS, have. This article suggests that these institutional

theories can help to better understand these differences in international agency adaptive

capacity, while highlighting new areas of policy research and analysis.

Understanding Brazilian Global Health Diplomacy: Social Health Movements, Institutional Infiltration, and the Geopolitics of Accessing AIDS Medication

Journal article
Eduardo J. Gómez
Global Health Governance 2012, 6(1): 1-29

Abstract: Global Health Diplomacy (GHD) is a new area of scholarly research. While much has been

written on this topic, to date few have analyzed the social and political origins of GHD

processes and their outcomes. Using the case of Brazil as illustration, in this article I carefully

analyze the historical social and institutional conditions motivating nations to engage in

intensive international negotiations for access to essential medicines. Moreover, this article

maintains that scholars have failed to address how praises from the international community

can create incentives for nations to sustain their commitment to not only international

negotiations but also bi- lateral assistance to other nations.

The Effects of Global Fund Financing on Health Governance in Brazil

Journal article
Eduardo J. Gómez and Rifat Atun
Globalization & Health 2012, 8(25): 1-14

Abstract: The impact of donors, such as national government (bi-lateral), private sector, and individual

financial (philanthropic) contributions, on domestic health policies of developing nations has

been the subject of scholarly discourse. Little is known, however, about the impact of global

financial initiatives, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, on

policies and health governance of countries receiving funding from such initiatives. Methods:

This study employs a qualitative methodological design based on a single case study: Brazil.

Analysis at national, inter-governmental and community levels is based on in-depth

interviews with the Global Fund and the Brazilian Ministry of Health and civil societal

activists. Primary research is complemented with information from printed media, reports,

journal articles, and books, which were used to deepen our analysis while providing

supporting evidence. Results: Our analysis suggests that in Brazil, Global Fund financing has

helped to positively transform health governance at three tiers of analysis: the national-level,

inter-governmental-level, and community-level. At the national-level, Global Fund financing

has helped to increased political attention and commitment to relatively neglected diseases,

such as tuberculosis, while harmonizing intra-bureaucratic relationships; at the inter-

governmental-level, Global Fund financing has motivated the National Tuberculosis

Programme to strengthen its ties with state and municipal health departments, and non-

governmental organisations (NGOs); while at the community-level, the Global Fund’s

financing of civil societal institutions has encouraged the emergence of new civic

movements, participation, and the creation of new municipal participatory institutions

designed to monitor the disbursement of funds for Global Fund grants. Conclusions: Global

Fund financing can help deepen health governance at multiple levels. Future work will need

to explore how the financing of civil society by the Global Fund and other donors influence

policy agenda-setting and institutional innovations for increased civic participation in health

governance and accountability to citizens.

Centralizing Decentralized Governance in Brazil

Journal article
Jessica Rich and Eduardo J. Gómez
Publius: Journal of Federalism 2012, 42(4): 636-661

Abstract: Contrary to the once-popular notion of the central bureaucracy withering away as an

outcome of decentralization, scholars have shown that in cases of local policy success,

national bureaucrats have instead redefined their roles, strengthening their focus on

monitoring and accountability. Yet building national capacity for effective oversight presents

a challenge within a context of strong subnational autonomy such as Brazil. Comparing the

dynamics of decentralization across two areas of health policy, AIDS and tuberculosis, this

article presents one strategy utilized by federal bureaucrats to increase their regulatory

capacity: seeking resources located outside the formal political arena. Specifically, national

bureaucrats utilize international resources to mobilize local civic groups as policy watchdogs,

thus increasing the accountability of subnational politicians both to the center and to the


Pursuing Centralization in a Context of Decentralization: The Politics of Brazil's Innovative Response to HIV/AIDS

Journal article
Eduardo J. Gómez
Journal of Politics in Latin America 2011, 3(3): 95-126

Abstract: In recent years, Brazil has been highly revered for its response to HIV/AIDS. Despite the

government’s delayed response, why and how did the national AIDS program eventually

become so successful? This is even further puzzling when one considers the challenges

associated with Brazil’s decentralized response to healthcare needs, lack of subnational

resources and political will to effectively implement AIDS policy. This article maintains that

Brazil’s successful response eventually required the strategic centralization of national AIDS

bureaucratic and policy authority, entailing policies designed to aid local governments while

creating fiscal policies incentivizing sub-national compliance with the national bureaucracy

and more effective policy implementation. Taking advantage of renewed political sup- port,

kindled by international pressures and the president’s reputation- building pursuits, the

sources of AIDS officials’ success, however, resided not in their technical and financial

prowess, but in their ability to forge historically-based partnerships with civic AIDS NGOs

and social movements sharing like-minded ideational beliefs in policy centralization. This

article also discusses how these findings contribute new insights into theories ad- dressing

the reasons for centralization, as well as the ideational sources of gradual institutional


Dilma’s Education Dilemma: Oil, Education, and State-Building in a Context of Neo- liberalism

Journal article
Eduardo J. Gómez
The Americas Quarterly 2011, Fall

An Alternative Approach to Evaluating, Measuring, and Comparing Domestic and International Health Institutions: Insights from Social Science Theories

Journal article
Eduardo J. Gómez
Heath Policy 2011, 101(3): 1-11

Abstract: This article introduces the benefits of applying social science theories discussing institutional

stasis and change to better measure, explain, and compare elite behavior within health

administration and decentralization processes. A new comparative method based on these

theories is introduced, as well as methods for collecting and analyzing data. Methods: A

literature review of health governance, health system governance, and path dependency and

institutional change theory was conducted to reveal the limitations of health governance

approaches explaining elite behavior. Next, path dependency and institutional change theory

was applied to case studies in order to demonstrate their utility in explaining institutional

stasis and change. Results: Current approaches to analyzing and comparing elite behavior in

the health governance frameworks are limited in their ability to accurately explain the

willingness of elites to pursue more efficient institutional and policy designs. Current

indicators measuring elite behavior are also too static, failing to account for periodic

resistance to change and the conditions for it. Conclusions: By applying path dependency

and institutional change theory, the policy com- munity can obtain greater insight into the

willingness and thus capacity of institutions to pursue innovations while developing

alternative analytic frameworks and databases that better measure and predict this process.

The Politics of Brazil’s Successful Response to HIV/AIDS: Civic Movements, Infiltration, and Strategic Internationalization

Journal article
Eduardo J. Gómez
Brown Journal of World Affairs 2011, 17(2): 51-64

Overcoming Decentralization’s Defects: Discovering Alternative Routes to Centralization in a Context of Path Dependent Health Policy Devolution: Lessons from Brazil's Response to HIV/AIDS

Journal article
Eduardo J. Gómez
Global Health Governance 2011, 5(1): 1-35

Abstract: In a context of poorly designed health policy decentralization processes and constitutional

commitments to decentralization, what can national governments do to overcome sub-

national policy inefficiencies and respond more effectively to health epidemics, such as

HIV/AIDS? Examining the case of Brazil, this article argues that within these constraining

political contexts, national AIDS programs can devise approaches to what the author calls

“indirect centralization”. That is, by creating new conditional fiscal transfer programs based

on sub-national government adherence to national policy mandates while at the same time

working with local AIDS NGOs to monitor sub-national AIDS policy performance, thus

increasing local government accountability to the center, the national AIDS program can

sustain its centralized influence within a decentralized context. The case of Brazil provides

an example of what other nations can achieve in order to ensure that decentralization

continues to work effectively in response to AIDS and other diseases.

Brazil’s Ascendance: The Soft Power Role of Global Health Diplomacy

Journal article
Kelley Lee and Eduardo J. Gómez
European Business Review 2011, January-February, 61-64.

How Brazil outpaced the United States when it came to HIV/AIDS: The Politics of Civic Infiltration, Reputation, and Strategic Internationalization

Journal article
Eduardo J. Gómez
Journal of Health Politics, Policy and Law 2011, 36(2): 317-352

Abstract: Using a temporal approach dividing the reform process into two periods, this article explains

how both Brazil and the United States were slow to respond to AIDS. However, Brazil

eventually outpaced the United States in its response due to international rather than

democratic pressures. Since the early 1990s, Brazil’s success has been attributed to “strategic

internationalization”: the concomitant acceptance and rejection of global pressure for

institutional change and antiretroviral treatment, respectively. The formation of tripartite

partnerships between donors, AIDS officials, and NGOs has allowed Brazil to avoid foreign

aid dependency, while generating ongoing incentives for influential AIDS officials to

incessantly pressure Congress for additional funding. Given the heightened international

media attention, concern about Brazil’s reputation has contributed to a high level of political

commitment. By contrast, the United States’ more isolationist relationship with the

international com- munity, its focus on leading the global financing of AIDS efforts, and the

absence of tripartite partnerships have prevented political leaders from adequately

responding to the ongoing urban AIDS crisis. Thus, Brazil shows that strategically working

with the international health community for domestic rather than international influence is

vital for a sustained and effective response to AIDS.

Education Woes could Delay Brazil’s Rise

Eduardo J. Gómez
World Politics Review, 2011 January

Health Financing in Brazil, Russia, and India: What Role does the International Community Play?

Journal article
Devi Sridhar and Eduardo J. Gómez
Health Policy & Planning 2010, 26(1): 12-24

Abstract: In this paper we examine whether Brazil, Russia and India have similar financing patterns to

those observed globally. We assess how national health allocations compare with

epidemiological estimates for burden of disease. We identify the major causes of burden of

disease in each country, as well as the contribution HIV/AIDS, tuberculosis and malaria

make to the total burden of disease estimates. We then use budgetary allocation information

to assess the alignment of funding with burden of disease data. We focus on central

government allocations through the Ministry of Health or its equivalent. We found that of

the three cases examined, Brazil and India showed the most bias when it came to financing

HIV/AIDS over other diseases. And this occurred despite evidence indicating that

HIV/AIDS (among all three countries) was not the highest burden of disease when

measured in terms of age-standardized DALY rates. We put forth several factors building on

Reich’s (2002) framework on ‘reshaping the state from above, from within and from below’

to help explain this bias in favour of HIV/AIDS in Brazil and India, but not in Russia:

‘above’ influences include the availability of external funding, the impact of the media

coupled with recognition and attention from philanthropic institutions, the government’s

close relationship with UNAIDS (UN Joint Programme on HIV/AIDS), WHO (World

Health Organization) and other UN bodies; ‘within’ influences include political and

bureaucratic incentives to devote resources to certain issues and relationships between

ministries; and ‘below’ influences include civil society activism and relationships with

government. Two additional factors explaining our findings cross-cutting all three levels are

the strength of the private sector in health, specifically the pharmaceutical industry, and the

influence of transnational advocacy movements emanating from the USA and Western

Europe for particular diseases.

Brazil’s Passion for Health Equality: What the United States can Learn

Journal article
Eduardo J. Gómez
Harvard Health Policy Review 2010, 11(2): 8-11

Abstract: In this article I discuss Brazil’s commitment to health equality as well as its passion for health

policy innovations and how the United States can learn from Brazil’s success.

What the United States can learn from Brazil in Response to HIV/AIDS: International Reputation and Strategic Centralization in a Context of Health Policy Devolution

Journal article
Eduardo J. Gómez
Health Policy & Planning 2010, 25(6): 529-41

Abstract: Contrary to what many may expect, this article argues that Brazil did a better job than the

USA when it came to responding to HIV/AIDS. Because of the Brazilian government’s

concern about its international reputation and the partnerships it has forged with

international donors and civil society, the government has been committed to strengthening

decentralization processes by introducing both formal and informal re-centralization

measures that strengthen health policy devolution, while effectively targeting the biggest at-

risk groups. The US, in contrast, has not achieved these objectives, due to its lack of interest

in increasing its international reputation and its focus on bi-lateral aid rather than investing in

domestic policy. The paper closes by explaining the lessons that Brazil can teach the US and

other large federations seeking to ensure that decentralization and prevention policy work

more effectively.

Going Beyond Brazil: How History, Morals, and International Reputation Inspired President Lula to Help Africa Combat HIV/AIDS

Journal article
Eduardo J. Gómez
Georgetown Public Policy Review 2010, 15(1): 37-50

Abstract: In this article, I explain how Brazil’s unique history and current geopolitical strategy

generates incentives for the government to achieve this, while providing an alternative model

of bilateral aid assistance—one that is premised on knowledge transfer and long-term

partnerships. I close by explaining the lessons that other nations can learn from Brazil and

the model it provides for what other emerging nations— such as India and China—can

achieve in their regions.

Friendly Government, Cruel Society: AIDS and the Politics of the Gay Community’s Response in Brazil

Book Chapter
Eduardo J. Gómez
The Politics of Sexuality in Latin America (University of Pittsburgh Press, 2010; edited by Javier Corrales and Mario Pechney)

The Politics of Receptivity and Resistance: How Brazil, Russia, India, and China Strategically use the International Health Community for Domestic Responses to AIDS: A Theory

Journal article
Eduardo J. Gómez
Global Health Governance 2009, 3(1): 1-29

Abstract: Little is known about how emerging nations, such as Brazil, Russia, India and China (aka,

B.R.I.C.), strategically use the international health community in order to strengthen their

domestic HIV/AIDS programs. In this article, I introduce a new theoretical framework,

strategic “receptivity” and “resistance,” in order to explain how and why this process occurs.

Brazil emerges as the most successful case of how this process leads to the formation of

international partnerships and domestic policies strengthening its AIDS program, with India

gradually building such a response, followed by China and Russia. This article closes with an

explanation of how this strategic interaction reflects the growing independence and influence

of BRIC while highlighting how this framework applies to other cases.

The Politics of Brazil’s Commitment to Combating HIV/AIDS in Africa: Technological Assistance, Capacity Building, and the Emergence of a New Donor Aid Paradigm

Journal article
Eduardo J. Gómez
Harvard Health Policy Review 2009, 10(2): 16-18

A Temporal Analytical Approach to Decentralization Processes: Lessons from Brazil’s Health Sector Reforms

Journal article
Eduardo J. Gómez
Journal of Health Politics, Policy, and Law 2008, 33(1): 53-91

Abstract: This article introduces a new concept to the study of decentralization processes: policy

dynamism. At its core is the notion that the sequential and temporal process of health

decentralization affect the nature of intergovernmental relationships and municipal

bureaucratic capacity. Examining the case of Brazil, I argue that the rush to decentralize

health services to municipalities has, in the absence of sufficient financial and technical

assistance from the federal and state governments, increased state-municipal conflict over

the management of health policy, limiting municipalities’ ability to increase bureaucratic

capacity. Consequently, some states have attempted to recentralize reforms, generating

further conflict between both subnational levels of government. While some municipalities

have tried to overcome these problems by creating associations and working with

international organizations, several bureaucratic obstacles remain. This article attributes these

outcomes not to federal institutions and economic constraints (the traditional approach in

the literature) but rather to the noninstitutional, temporal policy dynamics of


Brazil’s Response to AIDS and Tuberculosis: Lessons from a Transitioning Government

Book Chapter
Eduardo J. Gómez
Health Systems and Communicable Diseases: Challenges to Transitional Societies (Open University Press, 2008; edited by Richard Coker, Rifat Atun, and Martin McKee), 217-230

Bureaucratizing Epidemics: The Challenge of Institutional Bias in the United States and Brazil

Journal article
Eduardo J. Gómez
Global Health Governance 2007 1(1): 1-24

Abstract: This paper examines the politics of government response to health epidemics in the United

States and Brazil. Using a global structural approach, it explains why, despite their various

similarities, Brazil has been a bit better at responding to both sexually transmitted (STDs),

while the U.S. has been better at responding to non-STDs, such as the specter of avian flu

and bioterrorism. The paper closes with a discussion of why democracies are biased in the

types of epidemics they respond to and what this means for democratic equality and

commitment to its citizenry.

Why Brazil Responded to HIV/AIDS and not Tuberculosis: International Organizations and Domestic Institutions

Journal article
Eduardo J. Gómez
ReVista: Harvard Review of Latin America 2007, Spring

Learning from the Past: State-Building and the Politics of AIDS Policy Reform in Brazil

Journal article
Eduardo J. Gómez
The Whitehead Journal of Diplomacy and International Relations 2006, Winter/Spring, 143- 164

Understanding Decentralization: The Need for a Broader Approach

Book Chapter
Paul Smoke, Eduardo J. Gómez, and George Peterson
Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2006; edited by Paul Smoke, Eduardo J. Gómez and George Peterson)

The Institutional Genesis of Fiscal Decentralization Management: Lessons from Brazil

Book Chapter
Eduard J. Gómez
Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2006; edited by Paul Smoke, Eduardo J. Gómez and George Peterson)

Decentralization’s Horizontal, Vertical, and Policy-Fluctuation Mechanisms: Method for Cross-Regional Comparative Analysis

Book Chapter
Eduardo J. Gómez
Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2006; edited by Paul Smoke, Eduardo J. Gómez and George Peterson)

Decentralization in Asia and Latin America: Processes, Outcomes, and Underlying Dynamics

Book Chapter
Paul Smoke, Eduardo J. Gómez, and George Peterson
Decentralization in Asia and Latin America: Towards a Comparative Inter-Disciplinary Perspective (Edward Elgar Press, 2006; edited by Paul Smoke, Eduardo J. Gómez and George Peterson)

Decentralization and Municipal Governance: Suggested Methodological Approaches for Cross-Regional Analysis

Journal article
Eduardo J. Gómez
Studies in Comparative International Development 2003, 38(3): 57-80

Abstract: The study of decentralization and municipal governance has captured much scholarly

attention. This article highlights the importance of factors that have been generally ignored,

and, in the process, suggests dimensions that facilitate comparison, including at the cross-

regional level. First, regarding the creation and reform of decentralization policy, scholars

may compare cases based on the horizontal and ex-post vertical political processes of reform.

Second, cases can be compared based on the degree of center-state policy fluctuation, i.e., the

institutions and incentives generating continual policy change and delayed outcomes, over

time. Finally, I encourage scholars to scale down to the municipal level, comparing cases

based on the following variables: historical state-municipal fiscal relations, institutional

innovations, and the policy-making process. I close by explaining the various benefits

associated with these approaches and the new research questions and challenges that they

pose for comparative scholars.

Colombia in Crisis: Game Strategies for an International Military Response

Policy Report
Angel Rabasa, Eduardo J. Gómez, and Kim Cragin
Rand Corporation 2000, PM-1110-A