This paper explores the local political setting in which primary health care and community participation have been implemented in Pelotas, Brazil over the past two decades. We argue that in a medically plural setting with a mixture of private and public health care schemes, capitalist-based principles and ideals (such as the predominant role given to technology) shape generalized concepts of good clinical skills and quality of care, thereby regulating the medical system as a whole. The analysis shows that some women living in shantytowns reject the negative class-based associations made with their communities in a variety of ways, including the non-use of their local primary health care (PHC) centre which they considered to be a poor substitute for what the wealthy take for granted. Recent studies show that primary level antenatal care is of low quality when compared with other sectors. Nevertheless, local politicians and physicians often blamed various aspects of local 'culture' (folk health beliefs, low valuing of biomedicine, lack of modern concepts of community-building and altruism) for failed PHC programmes, contributing a prejudicial feedback cycle between frustrated professionals often engaging in prejudicial clinical practices and offended users. Rather than discuss community participation through vague concepts such as empowerment and citizenship, those involved in PHC reform would do well to take explicit (publicly stated) responsibility for the socio-political, financial and bureaucratic constraints to PHC.