Municipal health strategies in Portugal: opportunities for local health governance

Problem

In Portugal, decentralized health planning was mostly confined to Regional Health Administrations and public health units, with limited autonomy. In 2019, a decentralisation reform transferred health competencies to municipalities, enabling tailored prevention programmes and investment in health-promoting environments. As most European countries retain centralised health governance, Portugal’s experience offers a relevant reference for those considering similar reforms.

Description of the problem

The 2019 law mandated the development of Municipal Health Strategies (MHS), medium to long-term local priority frameworks. This analysis examines MHS implementation across Portugal’s municipalities, asking: How many developed an MHS? Were strategies built on relevant population health data? Were community stakeholders and the local population meaningfully involved? Are strategies being monitored and evaluated effectively?

Results

As of March 2026, 26 of 308 municipalities (8.4%) had developed an MHS or equivalent document. Collaboration with local health services enabled access to relevant data, including morbidity patterns, barriers to access, and service availability. Community stakeholders and the local population were involved primarily through online surveys. None of the published MHS included a publicly accessible monitoring platform for citizens to follow implementation progress.

Lessons

Legislative mandate alone seems insufficient for widespread implementation, research on barriers for the development of MHS is needed. Portugal’s experience also reveals a transparency gap: without accessible monitoring tools, accountability to the population remains limited. Meaningful involvement of communities throughout the planning process is essential to build ownership and ensure local relevance. For European countries considering decentralisation, these findings highlight both opportunities and dificulties found on the translation from policy into practice.

Key messages

• Portugal’s 2019 decentralisation reform created a legal framework for the transfer of competencies in health planning to municipalities, with a focus on disease prevention and health promotion.

• Six years after decentralisation, fewer than 9% of municipalities developed a health strategy, highlighting that legislative reform alone is insufficient forwidespread implementation