In Brazil, public access to vaccines is one of the cornerstones of the Universal Health System, since vaccination rights are a constitutional right of all citizens and residents and a legal duty of the government. Special circumstances surrounding the COVID-19 pandemic and the urgent need for vaccines to fight the disease required a rapid response by government authorities. Despite the fact that vaccines are generally successfully provided through the National Immunization Program (PNI), the COVID-19 vaccination campaign was marked by shortages and delays due to President Jair Bolsonaro’s continuous undermining of public health guidance. This failure by the federal government meant that other agents had to act in favor of public health.

During the pandemic, the Brazilian Health Surveillance Agency (“ANVISA”), which is the agency linked to the Ministry of Health responsible for the control and regulation of health-related products, urgently issued a variety of regulations enabling the emergency use of new vaccines. In contrast, the Ministry of Health lagged behind in creating a national COVID-19 vaccination plan, as well as in negotiating access to vaccines with manufacturers. This standstill was clearly related to Bolsonaro continuously deriding the seriousness of the pandemic, which undermined public health mandates endorsed by global health organizations.

Although part of the executive federal government, the Ministry of Health is an independent ministry and should not directly respond to the president of the republic. However, during Bolsonaro’s term, it became common for officials in the Ministry of Health to get fired for not supporting the president’s opinion, as happened to three ministers of health. These terminations resulted from disagreements around Bolsonaro’s fierce endorsement of hydroxychloroquine and his regular assertions that the virus poses little threat and vaccines are ineffective. Due to fear of retaliation, ministers followed the desires of the president instead of elaborating public policies that were scientifically based. This compliance led to the dissemination of inconsistent health recommendations resulting in public mistrust of the Ministry of Health’s actions, which was worsened by the highly criticized appointment of several military officers and inexperienced professionals to key positions in the ministry.

Despite the failure of the federal government to adopt effective public health measures and speedily formulate a plan to vaccinate its population, 80% of Brazil’s population is fully vaccinated, a rate above the world’s average. This success can mainly be attributed to two factors: ANVISA’s performance and the actions of local governments.

ANVISA is characterized by administrative independence, financial autonomy, and stability of its leaders and technical personnel, which leads to scientifically supported and unbiased technical decisions. In addition to issuing emergency regulations and analyzing requests for emergency use of vaccines, ANVISA has sought to clearly demonstrate to Brazilians the basis for all of its decisions through public meetings. Every decision was thoroughly presented and explained to the lay community, which resulted in public trust in the approved vaccines.

Along with ANVISA’s performance, state and municipal governments stepped in to fill the void left by the federal government and were fundamental to the success of the vaccination campaign. Normally, local governments do not have the ability to negotiate with drug companies or purchase vaccines, and they are obligated to use only the products distributed by the Ministry of Health. However, because of the federal government’s delayed response to the pandemic, the Brazilian Supreme Court authorized states, cities, and the Federal District to directly purchase vaccines approved by ANVISA if those provided by the federal government were insufficient or offered overdue. One month later, legislators enacted Law No 14,124/2021 and codified this option in Brazilian legislation. With this authorization, several local governments tried to negotiate with manufacturers to acquire vaccines, but the majority failed, as most manufacturers restricted their worldwide sales to federal governments only.

Local governments were able to predominately negotiate the purchase of Sputnik V or Covaxin, which were not approved by ANVISA and, thus, could not be imported and used in Brazil. The only successful case of vaccine procurement came from the government of the State of São Paulo, which was already manufacturing the Coronavac in Brazil in partnership with Sinovac Biotech Ltd. and the public laboratory Instituto Butantan. Instead of keeping all the doses for the southeastern state, as authorized, the State of São Paulo government made an agreement with the federal government to transfer more than 100 million doses of the vaccine to be used across Brazil.

In addition to direct negotiations for vaccines, local governments were extremely important in spearheading and advancing other non-pharmacological initiatives to control the COVID-19 pandemic, including the dissemination of trusted and consistent public health information, partial lockdowns, and social distancing in public places. Their consistent performance during the pandemic resulted in trust from the community, which facilitated the vaccination campaign.

The COVID-19 pandemic revealed that the Brazilian federal government is not prepared to deal with an international public health emergency. Denial, lack of governance, and pervasive political influence over science were the main reasons why the Ministry of Health failed in its duty to vaccinate the country. Fortunately, Brazilians relied on ANVISA’s excellent technical performance and the consistent action of local governments to quickly import safe and effective vaccines and improve community trust in such products. This situation demonstrates the vital importance of administrative autonomy in public positions, especially those related to public health policies. Although having a federal body that centralizes management of the health policies is important for promoting equitable access in a country as big as Brazil, the Ministry of Health’s actions should always be guided by the best scientific evidence and international standards. Until this reform is achieved, local governments should have more independence and resources to implement policies and actions that would actually be followed by the community.