Community participation in health: perpetual allure, persistent challenge.

The concept of community participation continues to capture the attention of international health policymakers and analysts nearly a quarter of a century after it was formally introduced at the Alma Ata Conference. This paper reviews trends in the participation literature of the 1990s, drawing examples primarily from Latin America. The following topics are discussed: sustainability, new methods for operationalizing and evaluating participation, the significance of local and cultural variability in determining outcomes, participatory self-determination as raised in the social movements literature, the increasing importance of intersectoral linkages, and continuing impediments posed by biomedical ideologies and systems. While the rhetoric and practice of participation have become fully integrated into mainstream health and development discourses, the paper concludes that ideological and political disagreements continue to divide pragmatists, who favour utilitarian models of participation, from activists, who prefer empowerment models.