Governance in the Nordic countries has a highly local character. Most public services are provided by locally elected bodies that enjoy a high degree of autonomy in relation to political institutions at the national level. In recent years, questions about the appropriate size of local government have re-surfaced, prompted, at least in part, by the current trend towards regionalisation within the EU. In this paper we investigate empirically the question of whether regionalisation in the Nordic setting can be said to reduce the democratic quality of governance in the area of health care. We do so by comparing conditions for democracy in a provincial governing unit (a so-called county council) in Sweden, with an average size of about 260,000 inhabitants, with those in a newly created region, populated by 1.5 million. We ask, thus, if it is true that governance in the smaller unit, i.e. the county council, is more democratic than in the region, and, if so, in what way? Our results point to that there is in fact little difference in democratic conditions between the region and the county council; a result that can be attributed to the fact that local institutions for decision-making and citizen participation were carefully re-constructed when Swedish county councils were amalgamated into regions. Hence, we conclude that institutions that facilitate direct democratic participation, such as the right of citizens to attend assembly meetings or submit proposals to the assembly are probably more important for the democratic quality of governance than size. 'Small' is not always more beautiful, at least not in democratic terms