Background: Social participation has been recognized as an important public health policy since the declaration of Alma-Ata presented it as one of the pillars of primary health care in 1978. Since then, there have been many adaptations to the original policy recommendations, but participation in health is still seen as a means to make the health system more responsive to local health needs, and as a way to bring the health sector and the community closer together. Aim: To explore the role that social participation has in a municipal-level health system in Guatemala in order to inform future policies and programs. Methods: The fieldwork for this study was carried out over eight months and three field visits between early January of 2009 and late March of 2010. During this time, 38 indepth interviews with provincial and district-level health authorities, municipal authorities, community representatives and community health workers were conducted. Using an overall applied ethnographic approach, the main means of data collection were participant observation, in-depth interviews, group discussions and informal conversations. The data was analyzed in two different rounds. In the first one we used documentary analysis, role-ordered matrices and thematic analsis (see papers I-IV) and in the second round, thematic analysis was utilized. Results: We found four themes that frame what the role of social participation in the municipality of Palencia is. The first theme presents the historical, political and social context that has contributed to shaping the participation policies and practices in Guatemala as a whole. The second theme takes a deeper look at these policies and how they have been received in the municipality of Palencia. The third theme presents data regarding the three situated practices of participation, each occurring at a different level: municipal, community and the individual level. Finally, the last theme presents reflections on what it means to participate to the people that were involved in this study. Conclusion: In the process of social participation there are two different and complementary kinds of power that depend on the amount and the kind of resources available at each level of the participation structure. Stakeholders that have higher levels of power to formulate policies will have better access to financial, human and material resources while stakeholders that have higher levels of power to implement policies will have resources like community legitimacy, knowledge of local culture, values and mores, as well as a deep understanding of local social processes. The coordination of financial, human and material resources is just as important as the legitimacy that comes from having community leaders involved in more steps of the process. True collaboration can only be obtained through the promotion and creation of meaningful partnerships between institutional stakeholders and community leaders and other stakeholders that are working at the community level. For this to happen, more structured support for the participation process in the form of clear policies, funding and capacity building is needed.