Objective Public engagement in priority setting for health is recognised as a means to ensure more inclusive, fair and legitimate decision making processes, especially in the context of Universal Health Coverage where demands outweigh available resources. Deliberative engagement approaches are often viewed as particularly useful in considering social values and balancing trade-offs, however, implementation of these approaches for priority setting is scant, especially in low and middle income settings. In order to address this gap we implemented a context specific public deliberation tool in a rural community in South Africa to determine priorities for a health services package.

Methods Qualitative data were analysed from seven group deliberations using the engagement tool. Content analysis was conducted and inductive and deductive coding was used. The analysis focused on understanding the deliberative process, what the participants prioritised, the reasons for these selections and how negotiations took place within the groups.

Results The deliberations demonstrated that the groups often prioritised curative services over primary prevention which related to perceived lack of efficacy of existing health education and prevention programmes in leading to behaviour change. The groups engaged deeply with trade-offs between costly treatment options for HIV/AIDS and those for non-communicable disease. Barriers to healthcare access were considered especially important by all groups and some priorities included investing in more mobile clinics.

Discussion South Africa is committed to public engagement in priority-setting for health, yet the views of communities are not considered in policy and programme development which largely involves top down decision making. This study demonstrates that deliberative engagement methods can be successful in helping communities balance trade-offs and in eliciting social values around health priorities. The findings from such deliberations, alongside other evidence and broader ethical considerations, have the potential to inform decision-making with regard to health policy design and implementation.