Community participation in formal decision-making mechanisms

Abstract

This article deals with the formal mechanisms of population participation: with any sort of institutional form of participation aimed at decision-making concerning health in the community. A case study concerning Community Health Councils (England and Wales) and the fluoridation of the water supply illustrates the following points: (i) the defensive or protester role of the population in decision-making: the population may want to share power without changing the rules of the game or may wish to change the norms and values put forward by the authorities; (ii) the lay versus the expert approaches of those professionals mandated to represent the population; (iii) the democratic representation of a heterogeneous population within a health service. Results show that a health committee may participate effectively, even in an advisory capacity, and that conflicts may be seen as an indicator of the reality of participation. Implications for the development of population participation include the distinction between expertise and decision-making, the need for the community to develop networking of sub-groups and organizations, and the shift from a democratic representation of the population to a polyarchy system (the rule of minorities).