The gain of a wider, more sustained involvement in health systems carries with it the tensions and risks in bringing state and civil society together. These need to be managed.

For the state, and the interest groups that have been protected through state patronage or support, there can be distrust of autonomous initiative. There may also be attempts to limit it to predefined programmes or areas that are marginal to or too costly for state activity. The state may be equally suspicious of NGO inputs that are parochial or regional when framing national health standards and programmes. For officials within the state, putting policies through public scrutiny may lengthen the process of implementation in circumstances where there is pressure to deliver. It may also be seen to duplicate the decision-making roles of officials. There may be distrust of elite groups, who are more articulate, more likely to participate and who risk distorting priorities (Siegel et al., 1996).

Equally for civil society, heightened energy is in part a consequence of the feeling that the state has abandoned them, is neither all powerful nor greatly concerned, and that people must take charge of their lives or become even more marginalized and oppressed (Friedmann, 1992; Agbaje, 1990). Civic groups may have experiences of the state as patron, employer and engineer of social consent, and thus be suspicious of relationships that may lead to cooption or submergence without tangible benefits to members (Miller, 1994).

Confronting these concerns is important, but it is also more difficult in an environment where relations between the state and civil society are adversarial or hostile.