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 1.

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.