This paper will address issues of user participation in a large centralistic organization. It is based on one year experience of developing a computerized health information system within the Cuban health services. Relevant literature suggests that participative methods may be less feasible in centralistic environments. This paper confirms this by describing how participation in Cuba is restricted by political and organizational constraints. There is however documented that participatory approaches may be very rewording where such constraints are overcome. Experiences from a broad range of health units and organizational levels in the Cuban project show a trend of weakening centralistic control with regard to hierarchical level and geographic distance, and thus more autonomous organizational units and participating individuals at lower level farther from Havana. The research reported is carried out within a framework of a larger network of similar health information projects being carried out in Africa and Asia, and the case of Cuba is being compared with experience from these countries.