<p>This paper argues for a re-balancing of decision-making power in health systems away from metrocentric and technocratic norms and a fundamental re-shaping towards democratic and participatory models of governance. These changes are understood as critical to the objective of improving healthcare access and delivery in regional, rural, and remote communities. In articulating this argument, we highlight the highly political nature of how we structure and govern healthcare delivery, which is imbued with value judgments. We critique currently dominant neo-liberal approaches to healthcare governance that frame the “voices” of local communities as optional inputs into the system, rather than active agents in decision-making processes. From health justice and spatial justice perspectives, public participation in governance may be an important factor to enable improved access to regional, rural, and remote health services and to promote community self-determination.</p>