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Introduction: The growing burden of non-communicable diseases challenges health systems of low-and middle-income countries and requires health care reform by the introduction of models focused on patient participation. Objective: This article puts into perspective the management of two chronic diseases, diabetes and HIV/AIDS, in Mali. It explores the way in which the patient’s role is conceived and implemented at three levels: policy-makers, healthcare professionals and patients, in order to more clearly understand the dynamics and rationales underlying promotion of the patient’s role in the context of a low-income country. Methods: Results were derived from qualitative interviews conducted between 2010 and 2012 with key stakeholders involved in policy, healthcare professionals and patients, and from observations of healthcare relationships in two specialized healthcare structures in Bamako. Results: The chronic nature of the disease is not sufficient to define the patient’s role in healthcare. Other factors also influence the emergence and practice of an active patient care model: the political, clinical and social history of the disease; the institutional work contexts of healthcare professionals; patients’ representations and practices. Patients are well aware of the role they need to play in the management of a chronic disease and they develop resources to remain active. Conclusions: These various dynamics should be better taken into account to make effective changes in the health care system and to strengthen patients’ autonomy.