Policy-making, trust and demand for public services

Policymaking, Trust, and Demand for Public Services: Evidence from a National Family Planning Program

There are growing concerns that citizens around the world have declining trust in institutions such as public health agencies, private companies, scientists or vaccine manufacturers. This column focuses on a family planning campaign in Peru to examine how government actions in implementing public programs can shape trust in institutions and thereby affect demand for public services and well-being outcomes. be. After public disclosure of alleged forced sterilizations, municipalities with more victims showed a sharp decline in public health services and lower levels of trust in public institutions. The results show how policy implementation failures can break the social contract between citizens and their government.

Trust in government is a key factor in the effectiveness of public policies, as it affects the demand for public goods and services. However, there are growing concerns that citizens around the world trust institutions such as public health agencies, private companies, scientists or vaccine manufacturers.

If trust is essential to prosperity, what are the causes of this growing trend of mistrust? This is an urgent question because most of our global challenges require coordination and trust between economic agents, social actors and political institutions. Bargain and Aminjonov (2021) show that trust in government was a good predictor of compliance with lockdown measures in Europe in 2020. Blanchard-Rohner et al. (2021) examine whether early failures in providing adequate emergency care can explain vaccine hesitancy in the UK. The authors show that the quality and effectiveness of emergency care predicts subsequent willingness to be vaccinated against COVID-19.

In a new article (León-Ciliotta et al. 2022), we examine how government actions in implementing public programs can shape trust in the institutions involved and, in turn, affect demand for public services and outcomes. relevant social outcomes. We have shed some light on this issue by studying the short- and long-term effects of a large-scale family planning campaign that took place in Peru in which some claim human rights abuses took place. .

The National Family Planning Campaign

Alberto Fujimori’s second presidential term was from 1995 to 2000. In 1996, his authoritarian government launched a large-scale family planning program to reduce fertility and poverty rates. At that time, the program was described as an anti-poverty initiative aimed at improving reproductive rights through greater access to modern contraceptives, including male and female sterilizations. The program was naturally targeted to areas with the highest fertility, which coincided with where the most vulnerable population was located (poor municipalities, low levels of education, rural and non-Spanish speaking areas). Its implementation has experienced serious (and some claim, systematic) failures, as many sterilizations were reportedly carried out without proper consent, with insufficient information about the irreversible nature of the sterilization, or under threat or bribes. wine.

The program was a top priority for the administration, as official correspondence between the health minister and Fujimori revealed. Each month, the minister had to report directly to the president whether sterilization targets had been met and, if not, he had to justify any delays (see Figure 1).1 In addition to these ambitious goals, the government had enacted 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, early reports of alleged mistreatment were quickly dismissed.

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

Program implementation failures (ie violations of medical and ethical guidelines) became public knowledge after the fall of the authoritarian regime in late 2000 (Figure 2). In particular, the disclosure of alleged forced sterilizations occurred when the newly elected government and Congress began to address the issue, leading to a constitutional impeachment in 2001 that sparked widespread media coverage and a public debate on the violations. It also set a legal precedent for the creation of the National Register of Victims of Forced Sterilizations in December 2015 by the Ministry of Justice. We use this newly collected data to determine whether the affected municipalities have lower demand for public services, which may be explained by lower levels of trust.

Figure 2 Number of press articles including “forced sterilizations + Peru”, by year

To note: The figure shows the total number of press articles containing the words “forced sterilization + peru” in the Factiva database.

Lower trust reduces demand for public services, leading to poorer health outcomes

Using a variety of empirical methods, we show that after public disclosure of alleged forced sterilizations, municipalities with more victims have lower demand for contraceptive methods and are less likely to use antenatal care services and childbirth. These reductions in health care utilization translate into poorer child health. In addition, we show that in these municipalities there is a sharp drop in demand for public health services. Interestingly, all of these effects are present even 17 years after the disclosure of the information.

Furthermore, the exposure of alleged human rights violations has eroded the trust of citizens in the affected districts. We also show that citizens in neighborhoods with the most victims display lower levels of trust in public institutions. Using election data, we find that after disclosure, districts with more casualties have lower vote shares for Fujimori’s party in municipal elections.

These results show that the disclosure of alleged forced sterilizations generated distrust and disbelief in the institutions involved in the program or who did not take action against the authorities in charge of the program. Moreover, the persistence of impacts indicates that mistakes made by a particular public administration have long-term consequences, as citizens completely cease to trust government institutions. In other words, policy implementation failures can break the social contract between citizens and their government.

Political disappointment, demand for public services and trust

What are the mechanisms behind the decline in health care utilization (contraceptive methods, antenatal care and delivery services)? Using additional data, we show that municipalities strongly supported by Fujimori’s party at the outset drive reductions in demand for health services. This result indicates that reductions in demand for public services are not driven by identification-based social learning, as in other contexts (Alsan and Wanamaker 2018, Martinez-Bravo and Stegmann 2021, Lowes and Montero 2021) . Instead, distrust emerges from disappointed voters who initially supported a government that tackled several economic and social issues but also cheated their citizens with a public health agenda where thousands of women lost the ability to have children. Knowledge of these violations had lasting consequences not only for the party and public institutions, but also for the children of the women in the municipalities concerned.

We tend to think of policy failures as programs that fail to achieve their stated goals. Here, we highlight the importance of failures in the implementation of public programs and how they can lead to a long-term erosion of citizen trust, even after the responsible administration leaves the public service.


Alsan, M and M Wanamaker (2018), “Tuskegee and Black Men’s Health”, The Quarterly Journal of Economics 133(1): 407–455.

Bargain, O and U Aminjonov (2020), “Trust and compliance with public health policies in the time of COVID-19”, VoxEU.org, 23 October.

Blanchard-Rohner, G, B Caprettini, D Rohner and HJ Voth (2021), “From tragedy to hesitation: how public health failures have fueled COVID-19 vaccine skepticism”, VoxEU.org, 1 June .

León-Ciliotta, C, D Zejcirovic and F Fernandez (2022), “Policy-Making, Trust and the Demand for Public Services: Evidence from a Nationwide Family Planning Program”, CEPR Discussion 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 Stegmann (2022), “In vaccines we trust? The effects of the CIA’s vaccine ruse on vaccination in Pakistan”, Journal of the European Economic Association 20(1): 150-186.


1 All these documents have been made public because of the public trial against these authorities, accused of human rights violations.