Health decentralisation

The decentralisation of health competences in Portugal was launched with the aim of bringing decision-making closer to local realities and strengthening municipalities’ role in promoting population well-being. A regulatory framework introduced between 2018-2019 enabled the transfer of specific responsibilities from central government to local governments. However, by 2022, only around a quarter of eligible municipalities had accepted these competences, highlighting the existence of structural, political, and financial barriers to reform. While the effects of decentralisation on health system have been widely studied, there remains limited empirical evidence on the factors that influence local jurisdictions’ willingness to assume new responsibilities. Addressing this gap, the present study analyses 201 eligible Portuguese mainland municipalities over the 2020-2022 period, modelling acceptance decisions based on demographic, political, financial, and health-related variables through binary logistic regression. Findings reveal that acceptance was more likely in municipalities politically aligned with the central government, with greater per capita financial resources, and with younger population profiles. In addition, regional dynamics emerged as an important contextual factor. These results highlight the need for decentralisation processes to account for territorial diversity, funding adequacy, and local capacity-building in order to ensure equitable and effective implementation.