What justifies public engagement in health financing decisions?

The World Bank's report, Open and inclusive: fair processes for financing universal health coverage, represents an important effort to specify the benefits and criteria of fair processes in health financing decisions. Here we argue that the report's justification for increasing public engagement in health financing decisions, one of its most novel contributions, rests on a widely shared but flawed assumption that public engagement will produce more equitable outcomes. Examining evidence from national-level public engagement initiatives cited in the report, we argue that there is no reason to assume that engaged publics will prioritize equity over other relevant values such as the maximization of population health. We conclude that instead of seeing public engagement as a tool for advancing particular values, policy-makers should view it as a neutral way of assessing what the public values and gathering insights that can inform the design of health benefits packages. If policy-makers wish to prioritize equity, they should do so directly through substantive policy choices regarding the design and financing of coverage schemes.