These often poorly structured
and somewhat ad hoc relations between the state and civil society
signal a deeper problem of how participation is viewed and structured
within health systems.
Participation as a concept
implies control as much as action. Assuming that power is distributed
differently between communities and health sector personnel,
control is exercised by the group which holds greater power,
which generally relates to who has greater say in decision-making,
particularly over money. This balance of power is shown in Figure
As control shifts, so too does
authority. Power balances alter between health workers, managers
and communities, and between different spheres of authority:
medical, political, traditional, civil, bureaucratic and financial.
Different types of knowledge and experience are brought to bear
on decision-making and different norms and values applied.