Erosion by Demand: Bolsonarismo and the Collapse of Child Immunization Coverage in Brazil

Abstract

Brazilian child immunization coverage collapsed at the turn of the 2010s, in parallel with the rise of Bolsonarismo. This article stems from a chronological fact — the decline spans three politically distinct phases: the pre-government period (until 2018), the Bolsonaro government without a pandemic (2019), and the government during the pandemic (2020–2022) — to examine, in each phase, the channel through which Bolsonarismo operates: through demand (families' willingness to take children to vaccination centers) or through supply (the installed capacity of primary health care responsible for vaccine administration). Three hypotheses are formulated, one for each phase: (a) in the pre-government period, Bolsonarismo — an anti-institutional disposition predating Bolsonaro — eroded vaccination through demand, without affecting supply; (b) in 2019, the first year of the administration disordered the Unified Health System (SUS) and impacted vaccination through supply (primary care, Family Health Strategy - ESF); (c) during the pandemic, the leader's signal affected both demand and supply simultaneously. Combining a municipal panel of immunization coverage (SI-PNI/DATASUS, 2012–2022) with the 2018 vote for Bolsonaro (TSE), socioeconomic covariates, and six independent primary care supply indicators (e-Gestor, CNES, IEPS, FINBRA), difference-in-differences models are estimated using Hepatitis B at birth as a negative control for demand. The results confirm (a), refute (b) in its strong form, and qualify (c) — "strong form" because, although federal funding indeed contracted differentially in 2019, the tier delivering the vaccine did not recue and the decline was not mediated by supply. The pre-government demand hypothesis holds: the gradient opens as early as 2018, concentrates on follow-up vaccines, and spares the birth dose. The 2019 dismantling hypothesis is not supported across the measured dimensions: ESF and primary care coverage, primary health care nursing, and health expenditure did not decrease — in several cases they increased — where Bolsonarismo was strongest, and the 2019 vaccine decline survives direct control for supply, not being mediated by it; the only honest exceptions are community health agents and basic health units (UBS) per capita, which declined, though without the timing of 2019 and without mediating the vaccine. Finally, during the pandemic, the surge primarily affected the birth dose — a signature of supply and registration, rather than hesitancy. All three findings are reported, including the refuted hypothesis: a non-confirmation is also a result.