The relationship between the Swedish government and the Swedish Association of Local Authorities and Regions (SALAR) has sparked debates, particularly regarding the agreements established in the healthcare sector. These agreements strive to ensure national equivalence while allowing municipal influence in governance. However, the agreements entail closed negotiations and bestow decision-making authority upon SALAR – a non-public employers’ and interest organization funded by tax money – representing the municipalities. Despite their significance, limited research has explored the utilization and repercussions of these agreements, especially concerning their democratic implications. This knowledge gap is striking given the regional authorities’ substantial management of tax revenues and primary responsibility for healthcare, as regional democracy has received scant attention in political science research and society.

Therefore, this thesis aims to bridge this gap by mapping and evaluating the democratic legitimacy of the agreement development process between the government and SALAR. The focus of analysis is on the 2023 agreement relating to maternity care and women’s health. The empirical material includes accessible documents, as well as interviews with individuals knowledgeable about the decision-making process and those anticipated to have gained insights.

Through reconstructing the decision-making process and employing two contrasting democratic ideals – the traditional representative model and the network-based multi-actor model – this study uncovers the challenges encountered in upholding these ideals during the agreement development. Notably, the democratic values of accountability, openness, and transparency were significantly compromised. Therefore, the decision-making process can be assessed as lacking full democratic legitimacy.