Scholars of Brazil’s public health system commonly note the intertwined roles that federal, state, and municipal governments play in delivering care, yet few studies systematically examine varying service performance in areas with overlapping mandates, such as state capitals. This study addresses that gap by developing and analyzing a novel measure of municipal primary care provision that accounts for the proportion of the population without access to private services in 11 large capital cities, then comparing them to the noncapital municipalities in their states. The study finds that capitals generally underperform the noncapital municipalities in primary service delivery. It then draws on a comparative case study in two major capitals, Salvador and Belo Horizonte, and their encompassing states to explore how a history of cooperative or adversarial relations between state and local governments conditions the impact of partisanship, participatory institutions, and public health activists on primary care delivery.

中文翻译：

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国家和卫生首都：巴西的多层次卫生治理

巴西公共卫生系统的学者们普遍注意到联邦、州和市政府在提供医疗服务方面发挥的相互交织的作用，但很少有研究系统地研究在州首府等职责重叠的地区的不同服务绩效。本研究通过开发和分析一种新的市政初级保健提供衡量标准来解决这一差距，该衡量标准占 11 个大型首府城市中无法获得私人服务的人口比例，然后将它们与所在州的非首府城市进行比较。研究发现，在提供初级服务方面，首府城市的表现通常不如非首府城市。然后，它借鉴了两个主要首都萨尔瓦多和贝洛奥里藏特的比较案例研究，