Health decentralisation in Portugal: local government profiles, territorial dynamics and policy implications

Health decentralisation has been promoted worldwide as a means of improving responsiveness, efficiency, and citizen participation in health governance. In Portugal, this reform represents a major shift in local policy responsibilities, particularly in health promotion, disease prevention, and well-being, following the transfer of competences established by Decree-Law No. 23/2019. Despite its relevance, empirical evidence on how local governments perceive and approach this process remains limited. This study addresses this gap by examining municipal perspectives on health decentralisation in mainland Portugal. A questionnaire survey was administered to all 278 mainland Portuguese municipalities formally involved in the decentralisation process, yielding valid responses from 163 municipalities (approximately 60% of the total). Data were analysed using Multiple Correspondence Analysis combined with cluster analysis. Five distinct municipal profiles were identified, ranging from proactive and consensual engagement to constrained acceptance or resistance shaped by financial, operational, and political factors. The results indicate that institutional capacity, transparency of financing mechanisms, and the quality of intergovernmental coordination are closely associated with how municipalities interpret and implement decentralised health responsibilities. Municipalities with stronger technical and organisational capacity and more collaborative governance arrangements tend to view decentralisation as an opportunity to enhance proximity, efficiency, and responsiveness in health service delivery, whereas limited capacity, financial uncertainty, and weak coordination are associated with more hesitant or resistant positions. This study contributes empirical evidence to international debates on decentralised health governance and offers policy-relevant insights for strengthening collaborative arrangements and maximising the public health benefits of decentralisation.