This thesis uses conflicts over the role of rural hospitals in the Southern region as a means to explore how the health system created by the 1991 'Green and White Paper' works in practice. A combination of 'new institutionalist' and Alford's 'structural interests' approaches provide the conceptual tools. The thesis argues that the goals of the 1991 health reforms included an intention to redesign the institutional structure of the health system to reduce what was seen as the disproportionate power of local communities and providers, and privilege the fiscal interests of central government. But, as the thesis demonstrates, rural communities in alliance with providers, were sometimes able to overcome their lack of formal power and, however briefly, become significant actors in the health system. The case also points to the larger forces that made the Regional Health Authorities vulnerable to abolition in the Coalition Agreement of December 1996. The thesis also, shows that the power of actors to influence the context and course of debates in the health system is not solely dependent on their, formal institutional position, but is affected by informal relations and political pressures.