Citizen engagement with institutions and policy processes gives shape and content to the meaning of citizenship by placing obligation on both citizens and state, and helps to ground the abstract relationship between state and citizen within the consciousness of people. Participation meets the concern not only for citizen 'voice' but also for citizen agency. This article explores people's perceptions and reality about participation in newly opened spaces within the Bangladesh public health care delivery system. The empirical findings suggest that the effectiveness and ability of community groups to function as spaces for participation and provide the means for developing capabilities to participate is limited, being constrained by poverty, social inequality and dependency relationships, invisibility, low self-esteem and absence of political clout. Neither have these groups been able to foster a sense of community, since perceptions of rich-poor differences in capabilities and responsibility remain strong.