Introduction Understanding the international and domestic political factors influencing the evolution of type 2 diabetes policies and primary care institutions is a new area of scholarly research. This article contributes to this area of inquiry by illustrating how a government’s shifting foreign policy aspirations, that is, to establish the government’s reputation as an internationally recognised leader in type 2 diabetes policy, and presidential electoral incentives provide alternative insights into the evolution of type 2 diabetes treatment policies and primary care institutional reforms.

Methods I conduct a single-case study analysis with the usage of qualitative data; quantitative statistical data on epidemiological trends and government policy spending is also provided as supportive evidence.

Results The case of Brazil illustrates how a reduction in foreign policy commitment to international reputation building in health as well as presidential electoral incentives to use diabetes policy as an electoral strategy account for a decline in sustaining policy and primary care institutional innovations in response to type 2 diabetes.

Conclusion Future scholars interested in understanding the lack of sustainability and effectiveness in type 2 diabetes programmes should consider investigating the complex international and domestic political factors influencing political interests, incentives and commitment to reform.