These problems signal that policy designers have paid inadequate attention to making public participation part of decentralization. They have failed to maximize the potential contribution that community based organizations or civic groups can make to health systems.

Civil society can act as a critical missing link between grassroots groups and the state, particularly where they have a good working relationship with local government. Civil society can offer a vehicle for reaching strata bypassed by the state, but more importantly for reintegrating such strata into wider health systems that involve both the state and the private sector.