In recent years there has been a major shift in attitudes to community involvement in health care. Approaches that saw communities primarily as passive recipients of health care have given way to those which seek to make more of the potential that more active community participation might offer for enhanced accountability and improved responsiveness of services. With this shift has come a greater emphasis on issues of governance and on institutional dimensions of participation, whilst the introduction of partnership models in the health sector has further increased debates about participation in health care. In 1999 the IDS Participation and Health and Social Change groups convened a workshop to share experiences of the use of participatory approaches in enhancing accountability in the health sector and to explore some of these challenges. The fifteen articles in this Bulletin reflect some of the richness of experience on the ground in building effective participation as well as some of the many issues that arise in moving towards more active citizen engagement with service provision. They draw experience from current work in countries such as Zimbabwe, Cambodia, China, Nepal, Zambia and Pakistan to reflect on links between participation, accountability and improvements in health.