Notwithstanding these efforts and despite the expected benefits of public engagement in HPS, there is currently little evidence on how to undertake it effectively. Mitton and colleagues identified 15 different techniques through which the public in high-income countries was engaged in HPS (either at the national or local level) 
. Some even involved deliberative methods, in which the public was engaged face-to-face over a period of time. However, only one third of over 170 studies assessed included some form of evaluation, and this mostly comprised process evaluation. (The World Bank review of its own Project Assessment Documents noted that only 40% of those with a focus on local participation included a monitoring system 
.) Only one study systematically compared the outcome of the approaches used, and concluded that deliberative engagement can affect the outcome, provided that the decision relates to a manageable issue affecting a specific population 
. Ultimately, the study recommended a balanced approach of broad consultation with in-depth, deliberative engagement, but noted that evidence in support of any approach was weak.
In addition, the perceptions of the public on their roles in this process, and on methods for their engagement, have not been well assessed. Moreover, while the public may seek participation in HPS 
and indeed demand various roles according to the level and objectives of the process 
, this may differ from what health practitioners and bureaucrats expect or want 
. Not surprisingly then, it is difficult to form practical guidelines on whom to engage, when and in what role(s), and how to combine different stakeholders' inputs in HPS, especially given how context-specific these might be 
If the appropriateness and effectiveness of public engagement is unclear in high-income countries 
, the situation is even less certain in LMICs. Not only does the context differ greatly from that in high-income countries, but engaging the LMIC public in HPS in a meaningful, equitable way is also affected by various structural barriers including physical access, poverty, social exclusion, and the low social status of women in many settings. These barriers have the potential to result in “civil society failure.” As noted in the World Bank report 
, “organizing groups of people to solve market and government failures is itself subject to problems of coordination, asymmetric information and pervasive inequality” (p. 4).
For example, in a study in Uganda poverty was a practical determinant of whether people could participate at meetings; the patriarchal culture was intimidating for young people; and community members felt the local councils were not interested in their perspective, and that only those with something to offer (the rich) were actively mobilized for planning meetings 
. In Kenya 
and Tanzania 
, although national policy mandates community engagement in local health planning, community representatives were disenfranchised by a lack of information, facilitation and time constraints, and an overarching disconnect between local and national priorities. In decentralized Pakistan, the frequent transfer of staff, capture of HPS by local elites, and corruption were among many factors that contributed to the failure of mandated, bottom-up resource allocation and budgeting 
. In settings where women are disempowered and the poor marginalized, mandating public participation in any public process does not change the effective exclusion of these groups, and does not reliably improve the outcomes of the decision-making process 
It seems that in many LMICs, even if the public has a constitutional right to participate and expresses interest in being involved, the processes for public participation do not function as intended. Moreover, although public engagement can be costly and time consuming, little public input is actually incorporated into plans and budgets. For political, practical, or cultural reasons and in the absence of effective oversight, most HPS in LMICs remains dominated by the “executive” and appointed authorities 
. To summarize, although public participation in that context is perceived as the right thing to do, based on current evidence it seems unfeasible and unlikely to result in helpful outcomes.