Article Text

A partisan pandemic: state government public health policies to combat COVID-19 in Brazil
  1. Michael Touchton1,
  2. Felicia Marie Knaul1,2,
  3. Héctor Arreola-Ornelas1,3,
  4. Thalia Porteny1,4,
  5. Mariano Sánchez5,
  6. Oscar Méndez1,3,
  7. Marco Faganello6,
  8. Vaugh Edelson2,
  9. Benjamin Gygi7,
  10. Calla Hummel7,
  11. Silvia Otero8,
  12. Jorge Insua8,
  13. Eduardo Undurraga9,
  14. Julio Antonio Rosado10
  15. Group from the Observatory for the Containment of COVID-19 in Latin America
    1. 1Department of Political Science, Institute for Advanced Study of the Americas, University of Miami, Coral Gables, Florida, USA
    2. 2Dept of Public Health, University of Miami Miller School of Medicine, Miami, Florida, USA
    3. 3Consejo Promotor de Universalidad y Competitividad en Salud, Fundacion Mexicana para la Salud AC, Mexico City, Mexico
    4. 4Department of Community Health, Tufts University, Medford, Massachusetts, USA
    5. 5Department of Politics, Colegio de Mexico, Mexico City, Mexico
    6. 6MAF dataScience, Universidade Estadual de Campinas, Campinas, Brazil
    7. 7Department of Political Science, University of Miami College of Arts and Sciences, Coral Gables, Florida, USA
    8. 8Universidad del Rosario, Bogota, Cundinamarca, Colombia
    9. 9Department of Government, Pontificia Universidad Catolica de Chile, Santiago, Chile
    10. 10Department of Social Sciences and Politics (currently listed in Spanish), Universidad Iberoamericana, Mexico City, Mexico
    1. Correspondence to Dr Michael Touchton; miketouchton{at}


    Introduction To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs).

    Materials and methods We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil’s 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic.

    Results Brazil’s national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation.

    Conclusions The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States’ NPIs and their scores on the composite policy index both align with the governors’ political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil.

    • COVID-19
    • health policy
    • qualitative study
    • descriptive study

    Data availability statement

    Data are available on request. For data request, please contact the corresponding author. All data and replication code will be made publicly available on our site ( as well as a dedicated repository (Harvard Dataverse) on publication.

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    Data availability statement

    Data are available on request. For data request, please contact the corresponding author. All data and replication code will be made publicly available on our site ( as well as a dedicated repository (Harvard Dataverse) on publication.

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    • Handling editor Seye Abimbola

    • Twitter @harreolao, @marcofaganello

    • Collaborators Salvador Acevedo Gómez, Raymond Balise, Miguel Betancourt Cravioto, Layla Bouzoubaa, Karen Jane Burke, Alberto Cairo, Carmen Elena Castañeda Farill, Fernanda Da Silva, Daniel Alberto Díaz Martínez, Javier Dorantes Aguilar, Ariel García Terrón, L. Lizette González Gómez, Kim Grinfeder, Héctor Hernández Llamas, Sallie Hughes, Karen L. Luján López, Lenny Martínez, Víctor Arturo Matamoros Gómez, Cesar Arturo Méndez Lizárraga and Gerardo Pérez Castillo.

    • Contributors Dr MT developed the manuscript. The rest of the coauthors made equal contributions regarding the analysis and writing.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.