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This study analyzed the first experience with vertical health consortia in Ceará State, Brazil, in order to shed light on their implementation. In the theoretical field, the article establishes a dialogue with studies on the state government's role in federalism and intergovernmental cooperation in health. A qualitative study was based on interviews with administrators associated with the consortia at the municipal, regional, and state levels, in addition to document analysis and a literature review. The results indicate that the implementation of consortia was designed by the state government and conducted initially in centralized fashion. A relationship of coordination was established with the definition of the arrangement's institutional design. We identified four factors that favor vertical cooperation in the state: (i) the history of health policy in Ceará; (ii) action by the state government as the coordinating body in the regionalization process; (iii) the existence of policy leaders and cohesion in the bureaucracy; and (iv) juxtaposition between the consortia's institutional design and the decision-making structure of the Brazilian Unified National Health System (SUS). Vertical consortia represent a step forward in overcoming the negative effects of decentralization.