Policy formulation, trust and the need for public service

Policy formulation, trust and public service needs: evidence from a nationwide family planning program

Concerns are growing that citizens around the world are losing confidence in organizations such as public health organizations, private corporations, scientists or vaccine manufacturers. This column focuses on a family planning campaign in Peru so that government initiatives in implementing government programs can build trust in the organization and thus influence demand for public service and welfare outcomes. Following the public disclosure of the alleged forced sterilization, the most affected municipalities have shown a massive decline in public health services and low levels of confidence in government institutions. The results show how failure to implement policies can break the social contract between citizens and their government.

Confidence in the government is a key driver of the effectiveness of public policy, as it affects public demand for goods and services. However, there are recent and growing concerns that citizens around the world are losing confidence in organizations such as public health organizations, private corporations, scientists or vaccine manufacturers.

If faith is essential to prosperity, what are the reasons behind this tendency to disbelief? This is an important question because most of us need coordination and trust between economic agents, social actors and political organizations for global challenges. Bargain and Aminjonov (2021) show that confidence in the government was a strong predictor of compliance with the lockdown system in Europe in 2020. Blanchard-Rohner et al. (2021) Investigate whether early failure to provide adequate emergency care may explain the dilemma of vaccines in the UK. The authors show that the quality and effectiveness of emergency care predict the likelihood of subsequent vaccination against COVID-19.

In a new study (Leon-Ciliotta et al. 2022), we examine how government initiatives in implementing government programs can build trust in related institutions and, as a result, affect the demand for public service and relevant welfare outcomes. By studying the short-term and long-term effects of large-scale family planning campaigns held in Peru, we have shed light on this question where some have claimed that human rights violations have occurred.

Nationwide family planning campaigns

Alberto Fujimori’s second presidency lasted from 1995 to 2000. In 1996, his authoritarian government launched a large-scale family planning program to reduce fertility and poverty rates. At the time, the program was portrayed as an anti-poverty initiative aimed at improving reproductive rights through better access to modern contraceptives, including male and female infertility. The program was naturally targeted in areas where fertility was highest, which matched the position of the most at-risk populations (poor municipalities, low education levels, rural and non-Spanish speaking). There were serious (and some claim, systematic) failures in its implementation, as many sterilizations were performed without proper consent, with insufficient information on the unchanging nature of sterilization, or under threat or bribery.

The program, published by official correspondence between the health minister and Fujimori, was a top priority for the administration. Each month, the minister had to report directly to the President whether the disinfection target had been met and, if not, he had to explain any delays (see Figure 1).1 In addition to these ambitious goals, the government has introduced legal reforms to waive the right of doctors to object to treatment or certain procedures. The regime also had control over the media and other institutions; Therefore, initial reports of alleged abuse were quickly dismissed.

Figure 1 Letter from the Minister of Health to President Alberto Fujimori

Failure to implement the program (i.e. violation of medical and ethical guidelines) was revealed in the late 2000s (Figure 2) after the fall of the authoritarian regime. In particular, the so-called forced sterilization manifested itself when the newly elected government and Congress began to look into the matter, leading to a constitutional complaint in 2001 that sparked public discussion of widespread media coverage and violations. It also set a legal precedent in December 2015 for the creation of a national registry of victims of forced sterilization by the Ministry of Justice. We use this newly collected data to see if there is a low demand for public services in the affected municipalities which can be explained by the low level of trust.

Figure 2 Number of news articles, including “Forced sterilization + Peru”, by year

Note:: The figure shows the total number of news articles in the Factiva database containing the words “Forced Sterilization + Peru”.

Low confidence reduces public demand for services, leading to poor health outcomes

Using a variety of empirical methods, we show that after the public disclosure of so-called forced sterilization, more vulnerable municipalities are less in need of contraceptive methods and less likely to use antenatal care and birth delivery services. These reductions in healthcare use make child health worse. Furthermore, we show that in these municipalities, the demand for public health services has declined significantly. Interestingly, all of these effects are still present 17 years after the data was released.

In addition, the revelation of alleged human rights violations has eroded the confidence of citizens in the affected districts. We also show that citizens in high-risk districts show low levels of confidence in government institutions. Using the election data, we see that, after the publication, there are fewer votes in the district that suffered the most for Fujimori party in the municipal elections.

These results show that the expression of alleged forced sterilization has created distrust and mistrust towards the organizations involved in this program or has failed to take action against the authorities at the command of the program. Furthermore, the durability of the impact indicates that errors made by a particular public administration have long-term consequences because citizens stop trusting government institutions altogether. In other words, failure to implement the policy can break the social contract between the citizens and their government.

Political frustration, public service and the need for confidence

What are the reasons for the decline in health care use (contraceptive methods, antenatal care and delivery services)? Using additional data, we show that municipalities, with strong support for Fujimori’s party in the baseline, are leading to a decline in demand for health services. This result indicates that the decline in demand for public services is not driven by social education based on identification as in other settings (Alsan and Wanameker 2018, Martinez-Bravo and Stegman 2021, Loyes and Montero 2021). Instead, distrust emanates from frustrated voters who initially supported a government that tackled a number of economic and social problems but misled its citizens through a public health program where thousands of women lost the ability to conceive. The long-term consequences of learning about these violations are not only for the party and government organizations, but also for the women and children of the affected municipalities.

We think of policy failures as programs that do not achieve their specific goals. Here, we highlight the importance of failure to implement public programs and how they can cause long-term erosion of citizens ’confidence, even after the responsible administration leaves government office.


Alsan, M and M Wanamakar (2018), “Taskegi and the health of black men”, Quarterly Journal of Economics 133 (1): 407–455.

Bargain, O and U Aminjonov (2020), “Confidence and Consent to Public Health Policy in COVID-19”, VoxEU.org, 23 October.

Blanchard-Rohner, G, B Caprettini, D Rohner and HJ Voth (2021), “Hesitation from Tragedy: How Public Health Failure Raises Doubts About COVID-19 Vaccine”, VoxEU.org, 1 June.

Leon-Ciliotta, C, D Zejcirovic and F. Fernandez (2022), “Policy Making, Trust and the Demand for Public Service: Evidence from a Nationwide Family Planning Program”, CEPR Paper 17361.

Lowes, S and E Montero (2021), “The legacy of colonial medicine in Central Africa.” American Economic Review 111 (4): 1284-1314.

Martinez-Bravo, M. and A. Stegman (2022), “Do We Believe in Vaccines? The Impact of CIA Vaccines on Vaccination in Pakistan”, Journal of the European Economic Association 20 (1): 150-186.


1 All these documents were made public because of the open trial against this authority accused of human rights violations.

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