Health decentralization in portuguese municipalities: the perceptions of municipal assembly
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Over the past two decades, decentralization to local governments has been a vital reform strategy in European public
administration to improve decision-making, optimize costs, increase efficiency, and enhance accountability and
transparency (Maia et al., 2023; Teles, 2021). Portugal has adopted this approach and started a decentralization process
in 2018, transferring competencies, including healthcare, to 201 out of 308 municipalities. This process requires
cooperation between the executive and deliberative bodies. Still, the potential problem of information asymmetry,
particularly the control role of deliberative bodies over executive bodies, must be examined. This study uses the
principal-agent theory to analyze municipal deliberative bodies' perceptions of executive agencies' implementation of
health decentralization. Surveys were conducted to collect data from the presidents of the municipal assemblies (APM)
of all 201 municipalities. The survey was distributed by email and was open for completion from December 12, 2022, to
February 3, 2023, with the support of the National Association of Municipal Assemblies. One hundred eleven validated
responses were collected during this period, resulting in a 55% response rate. The survey aimed to assess Municipal
Assemblies' theoretical and practical perceptions of decentralization. Specifically, it examined whether PMAs supported
decentralization in theory and contrasted this perception with the actual transfer process within the municipality. The
survey also explored the flow of information between the executive body, the central government, and the PMAs. The
results show that although the PMA respondents support decentralization in theory, the practical aspects must be
improved. In particular, the prevailing view is that the financial resources allocated to the process are insufficient and
that decentralization is perceived as a means by which the central government passes on costs to municipalities. These
findings highlight the importance of addressing these concerns to ensure a more effective decentralization process. The
national government should prioritize better communication and prior coordination with local authorities, especially in
defining the financial resources associated with the process. The results also highlight the need for more active
involvement of municipal councils and improved communication and coordination with these representative bodies. In
addition, the results underline the importance of municipal councils using existing tools, such as municipal health
councils or municipal health strategies, to engage in discussions and control the decentralization process.
