Public health planning has historically tended to be a top-down process, based on expert identification of priorities and the strategies to address them. This is intensified by curative medical systems that are hierarchical, mystified and paternalistic to clients, that have been built on traditions of clinical autonomy in decision-making and that are poorly prepared for taking on other interests in decision-making.

Communities for their part often lack the capacity to engage in these competing spheres of authority. They lack the 'language', information, cohesion and organizational structures to do so. They can become disempowered and distrustful in the process.