The structures and processes for interactions between services and civil groups also need attention. The literature documents problems when there is inadequate structural support, weak information access, limited authority and vague roles. Community-service interactions are weaker when there are too many poorly coordinated, poorly resourced, issue-specific forums, with weak abilities and procedures for resolving conflict, poorly supported by information, and with weak legitimacy. They are undermined when managers and service providers have weak incentives to respond to directions given by participatory structures and are resistant to or poorly prepared for changes in authority or for using non-medical inputs. Equally, weakened citizen interest, paternalistic cultures, illteracy and weak civil capacities also undermine these interactions (Kahassy & Baum, 1996; Bennett et al., 1995; Gilson et al., 1994).

Hospital boards, for example, are a particular form of participation in the management of services that have suffered from ambiguity between their powers and responsibilities. Bennett et al. (1995) noted that the power and roles allotted to the board, and the degree of autonomy they were given by the ministry of health, were important factors in their success. Where boards have had little influence over capital investment and financial and personnel policy, they have had limited impact on efficiency or service provision. Given that referral hospitals provide public services, central governments clearly need to continue to exercise some control over their performance. It would, however, appear that the best balance - between arm's length measures providing legal and performance standards and incentives and the more direct forms of control - has generally not yet been found (Bennett et al., 1995).