Citizen participation and health care: problems of government induced participation

In this paper we trace the implications of some common contradictions in government-inspired efforts to increase citizen participation in health care delivery. We cover general problems of generating citizen participation, specific difficulties in community organization resulting when issues of health are the organizing focus, and the benefits that were thought to result from efforts to increase citizen participation in social programs in the 1960's. When programs focused on increased citizen participation were initiated program administrators attempted to maximize citizen involvement quickly by: projecting an image of maximal social impact; minimizing or ignoring questions of long-term fiscal uncertainty; projecting an image of maximal control by citizens; and projecting images of institutional solidarity and of experimentation and innovation. They tended to recruit to the staff social activists taken to be representative of the community (although they might not be), promising opportunities for upward mobility. They also tended to adopt conciliatory administrative styles in keeping with their experimental non-elitist orientations. These tendencies characteristic of the initiation phase of projects conflicted with the demands placed upon programs in later phases of program implementation. These demands resulted from later perceived needs to: evaluate programs; limit spending; counter internal organizational opposition; and respond to sponsors' shifting interests. Paraprofessionals recruited to the staff tended to lose their "community" orientation, and administrative style tended to focus considerably more on program accountability. These shifting program demands substantially account for what otherwise appears to be the failure of efforts to increase citizens' participation in health delivery programs, and, by extension, in other areas where the impetus for increased citizen participation comes from government initiatives.