There is growing recognition in the academic literature that critical decisions concerning resource allocation and resource management in health and care are influenced by a range of contextual factors. In their paper in this journal, Williams et al define these ‘decisions of value’ as being characterized by a significant and demonstrable impact on quality and resources in health and care. ‘Decisions of value’ are key functions of health and care organizations, yet relatively little is known about how contextual factors (such as different sources and types of evidence used, organizational context and decision-making structures, and the wider interests of patients, the public and politicians) influence those decisions. In this commentary we offer some reflections on our international experiences in capacity building, developing and implementing priority setting and resource allocation (PSRA) mechanisms in the health and care sectors in a range of low-, middle-, and high-income countries. We focus on the role of organizational culture, the relationship to government including political and regulatory environments, and the potential for patient and public engagement in PSRA mechanisms.