Citizen participation has been included as part of health reform, often in the form of lay health authorities. In Canada, these authorities are variously known as regional health boards or councils. A set of challenges is associated with citizen participation in regional health authorities. These challenges relate to: differences in opinion about whether there should be citizen participation at all; differences in perception of the levels and processes of participation; differences in opinion with respect to the roles and responsibilities of health authority members; differences in opinion about the appropriate composition of the authorities; differences in opinion about the requisite skills and attributes of health authority members; having a good support base (staff, good information, board development); understanding and operationalizing various roles of the board (governance and policy setting) versus the board staff (management and administration); difficulties in ensuring the accountability of the health authorities; and measuring the results of the work and decisions of the health authorities. Despite these challenges, regional health authorities are gaining support as both theoretically sound and pragmatically based approaches to health-system reform. This review of the above challenges suggests that each of the concerns remains a significant threat to meaningful public participation.