Asymmetry in inter-municipal cooperation in health services - How does it affect service quality and autonomy?

Throughout Europe, local health services are increasingly being provided through various forms of inter-municipal cooperation (IMC). One of the most common forms of IMC is when small municipalities delegate the operational responsibility for providing health services to a larger host municipality. However, despite the size asymmetry usually inherent in this type of IMC, this aspect has largely been neglected in the existing literature, which mainly focuses on the size of individual municipalities. Based on data from 97 partner municipalities and 25 host municipalities in Norway, this study examines how varying degrees of size asymmetry between them affect the perceived service quality and loss of autonomy resulting from IMC in health services. From the perspective of the relatively smaller partner municipalities, the results suggest that these are likely to benefit greatly from size asymmetry in terms of improved service quality, although this would appear to be at the expense of losing decision-making autonomy to their host. However, from the perspective of the relatively larger hosts municipalities, this type of asymmetry is likely to affect service quality negatively while having no effect on decision-making autonomy.