Watkins, DavidAhmed, Sali2025-08-012025-08-012025-08-012025Ahmed_washington_0250E_28322.pdfhttps://hdl.handle.net/1773/53234Thesis (Ph.D.)--University of Washington, 2025Essential Health Benefit Packages (EHBPs) are a key implementation strategy for achieving Universal Health Coverage (UHC). EHBP determines entitlement, reallocates resources, guides budgeting, influences service delivery, generates demand, and reduces service fees. Despite countries' interest in EHBP, the development of its implementation has been suboptimal. EHBPs are often criticized as aspirational rather than pragmatic. This has been attributed to 1) ad hoc and unsystematic prioritization, 2) High uncertainty in cost estimates, and 3) Lack of agreed-upon performance indicators. Through my dissertation, I aim to strengthen the effective implementation of EHBPs by utilizing innovative methods, tools, and data that bridge the gap between EHBPs development and implementation. For the first aim of the dissertation, I address the question of how policymakers choose which health interventions to implement when they face resource constraints. Second, I developed a model to assess the amount of funding governments would need to implement a comprehensive EHBP. Lastly, I address the question of how implementers in resource-limited settings monitor the implementation of EHBPs at a national scale.For aim 1, I conducted a discrete choice experiment among 49 policymakers involved in developing Ethiopia's EHBP. The experiment used a four-attribute, forced-choice design. Vignettes presented two hypothetical alternative interventions, totaling 18 vignettes. The attributes specified for the two alternatives were (1) absolute reduction in mortality, (2) severity of disease targeted, (3) age group targeted, and (4) absolute reduction in medical impoverishment. Based on 864 total observations, I estimated the average preference weights for each attribute using a random-parameter mixed logit model. I found that all four criteria were statistically significant and varied monotonically across different attribute levels, as expected. The conditional relative importance of each of the four attributes was 38.8% for the targeted age group, 27.8% for the absolute reduction in mortality, 19.1% for the reduction in medical impoverishment, and 14.2% for the severity of the disease targeted. These findings provide empirical preference weights that can be incorporated into multicriteria decision analysis, thereby enhancing the systematic and transparent development of EHBP in Ethiopia and similar resource-limited settings. For aim 2, based on the Disease Control Priority Project (DCP 3) costing methodology, I developed a cost support model for EHBPs using Malawi as a case study. The model leveraged cost data and health system performance parameters to systematically estimate the total and incremental costs of EHBP implementation, mapping these costs by cost centers (delivery platforms and disease areas). The model utilizes the unit cost and Population in Need estimates collected through the structured review process. It uses estimates on health financing sources from the National Health Account and the Malawi health finance mapping exercise to map the cost distribution across cost centers. To demonstrate the model's utility, I estimated the projected cost of implementing Malawi's current Emergency Health Budget Plan (EHBP). The cost increases from $300 million in 2026 to $620 million under an adjusted coverage scenario (80% by 2050). The model presents a timely and non-resource-intensive starting point for countries to cost EHBPs. It provides a transparent and systematic approach to EHBP costing, enabling policymakers to align service packages with available fiscal space. For aim 3, I developed a framework for utilizing health facility surveys and geospatial data to measure population coverage of a broader range of services and to demonstrate its application in Malawi. Using the data from the 2019 Harmonized Health Facility Assessment conducted in Malawi, I identified a list of 129 interventions recommended by the DCP 3 for inclusion in health benefits packages in low-resource countries. I conducted a structured literature search to develop an input-based composite indicator for each intervention and then assessed the readiness of each intervention in Malawi's 564 public healthcare facilities. I used high-resolution population estimates for Malawi from WorldPop 2020 Raster to conduct a service area analysis to translate these readiness statistics into informative input-adjusted coverage estimates for Malawi. This framework can be adapted for other types of facility surveys, interventions, and countries, facilitating the monitoring of EHBP implementation progress. Most countries recognize UHC as a goal but have not taken concrete implementation steps to achieve it. Through providing a proof of concept for the quantification of decision makers' preferences, a cost support model that estimates the cost of EHBPs, and a flexible framework to assess health service coverage, the dissertation addresses three critical gaps and provides implementation research-oriented solutions to facilitate the support of the development and implementation of EHBPs. I hope that this work will provide starting points for researchers and public health policymakers interested in implementing EHBP and advancing UHC in resource-constrained settings.application/pdfen-USnonePublic healthGlobal HealthThesis