Summary This article outlines some of the challenges faced in moving away from a health system largely planned and governed by technical personnel to one that involves wider public participation and accountability in planning, implementing and monitoring health services. It considers factors that contribute to motivation for changes in approach, and towards a greater degree of community participation in mechanisms for and the governance of health service delivery. Set within the current environment of real declines in access to health care in Zimbabwe, the liberalisation of health providers and consequent demand for informed consumers, the article explores consumer demand for improved quality services and ways to tackle the need to ensure greater impact in resource use. It explores changing roles within health policy reforms and in relation to processes of decentralisation. It considers health service motivations to widen resource mobilisation strategies, and particularly community contributions to health. The article outlines the perceptions of civic groups, elected and traditional leaders and health service providers in how participation should be restructured in Zimbabwe, noting the general call for greater participation in the planning of resource mobilisation and allocation approaches and of monitoring quality of care. It discusses mechanisms for making such a shift, and the issues to be faced in doing so.