'Participation' of civic groups
and communities has at worst been included to give programmes
respectability. Such programmes have continued to use top-down
approaches to decision-making, have continued to set up bureaucratic
blocks, have failed to invest in the material and institutional
conditions to support participation and have continued to marginalize
the most vulnerable.
Participation has been weakest
in areas of decision-making, such as in resource allocation,
which is what people feel most strongly about. As noted later,
this is a potential constraint in ensuring that resources reach
the intended communities and in mobilizing resources from communities.
For both health sector programmes and communities, poor forms
of participation lead to poor returns for time and resources
spent, and to poor health outcomes.