Community participation is one of the underlying principles of democratic societies and the potential benefits of the participation process are well documented. Although a number of participatory mechanisms have been established by government departments and community agencies to facilitate community participation in health, few Australians regularly or actively participate. This paper examines the context for participation in health action in Australia including a political culture which serves to discourage participation in health, and many other areas, and barriers to participation associated with the complex structure and financing of the health care system.
Community participation in decision-making has traditionally been considered one of the pillars of democratic societies with benefits to be gained at the national, community, interpersonal and individual levels (Florin and Wandersman, 1990; MacDonald, 1992). In the health care system community participation is regarded as a mechanism for ensuring services are accessible and appropriate to community needs, for involving disadvantaged groups in health service planning, implementation and evaluation and for increasing awareness of health issues (Palmer and Short, 1989). In recognition of these factors, community participation is a fundamental principle of a number of strategic health policy documents including the Declaration of Alma-Ata (World Health Organisation/United Nations International Children's Emergency Fund, 1978) and the Ottawa Charter For Health Promotion (World Health Organisation, 1986).
Despite the proposed benefits of participation, and the establishment of structures to facilitate the participatory process, in practice, few people participate when given the opportunity (Bracht and Tsouros, 1990; Carr, Dixon and Ogles, 1976; Wandersman, Florin, Freidmann and Meier, 1987). Some of the problems experienced by health workers attempting to facilitate meaningful participation in decision-making are related to a lack of clarity in defining the concepts of community and participation and the range of processes participation encompasses (Heller, 1989; Kroutil and Eng, 1989; Mullins, 1987; Rifkin, 1986). As Rifkin (1986) concludes, difficulties in defining the relevant concepts have contributed to many community health programs having `the cloak of a new community-based approach under which the traditional health care system remains' (Rifkin, 1986 p. 240).
In order to facilitate effective community participation in health action an understanding of the unique context for participation in Australia is required. This paper reviews the concept of community participation and discusses the impact of some of the cultural, historical, political, economic and social factors influencing community participation in health action. These factors include a political culture characterised by a highly instrumental view of government, a traditional acceptance of the need for `big government', a relatively poor understanding of political institutions and issues and an apathy towards politics in general. The paper concludes by examining barriers to participation associated with the complicated structure of the health care system, including the mix of public and private services and the role of both the federal and state governments in financing health care expenditure.
Defining Community Participation in Health
The concept of community has traditionally referred to a specific geographical area or locality. This definition, however, is now considered to be obsolete in many Western societies where the communities within which people live and work are not necessarily those which contain the associations that are most significant to them.
Community is also used in the literature to describe a relational community, referring to the social cohesion that can develop as a result of close interpersonal ties, and as an entity with collective political power (Heller 1989; Rissel, 1996a). …