How do the poorest groups, who are often least organized, obtain a voice and representation in the decision-making process in health systems?

Their primary preoccupations generally lie outside health. They relate more to issues of employment, incomes and access to infrastructure. While these issues have a direct bearing on health, they are weakly integrated into health sector approaches and thus poorly accommodated by health services.

Obtaining a sustained representation from the poorest groups is difficult. Many of their organizations have limited resources. Special interest groups with a greater focus on health may have more resources for participation, but may also be far less representative of the real voices of the poor - or of constituents generally.

One option is to use or facilitate links between service or special interest groups and membership-based groups. In this way, the human and technical resources of the former can be applied to the interests and concerns of the latter. The networking of civic groups in Zimbabwe is an example of another option: linking stronger with weaker civic groups.