The prioritisation approach at the heart of the health reform movement not only failed to improve access to services for the very poor but was based on poor methods. Its notion of efficiency ignored local contexts, the interaction of interventions and local specification of needs. The authors argue that a more efficient strategy for prioritisation involves resuscitating the primary healthcare approach and its emphasis on procedural, as well as distributive, equity. A growing body of evidence supports the link between enhancing the voice of local communities and improving the allocation and impact of resources in health service provision.