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The Venezuelan health reform Barrio Adentro (BA), initiated in 2003, aims to improve population health and promote popular participation. Access to healthcare has improved but the distinguishing feature of BA is participation by communities. Popular participation has been institutionalized through the formation of health committees and communal councils. We explored the challenges/barriers faced by these community groups in BA. A mixed-methods participatory methodology was used involving 31 participants selected through non-random purposive sampling from five Venezuelan states. Results indicate that implementation issues challenge participation. There is political will at the highest level but the opposition political parties, Venezuelan Medical Federation, and the private media oppose the reform. Public participation in state affairs is facilitated if there are popular arenas of participation that promote engagement of organized citizenry with the state and an ongoing interaction between state and civil society in order to radically transform the state. [ABSTRACT FROM AUTHOR]