Date of Award

5-11-2025

Date Published

June 2025

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Administration

Advisor(s)

John McPeak

Keywords

Arba Minch Health Science College;Discrete Choice Experiment;Ethiopia;Mid-upper arm circumference (MUAC);Normalized Difference Vegetation Index (NDVI);South Omo Zone

Subject Categories

Public Administration | Public Affairs, Public Policy and Public Administration | Social and Behavioral Sciences

Abstract

Abstract Achieving universal health coverage necessitates equitable access to healthcare services. The World Health Organization estimates that nearly half of the global population lacks full coverage of essential health services, with Low and Middle-Income Countries (LMICs) being disproportionately affected. The situation is further exacerbated by the increasing frequency and severity of climate change-induced extremes, which are deepening health equity challenges in these regions. In response, governments and various international and national organizations have implemented numerous policy initiatives to improve healthcare access for marginalized populations in LMICs. Given the growing emphasis on achieving universal health coverage in developing countries, there is a pressing need for more research to inform evidence-based policies aimed at enhancing healthcare accessibility. This dissertation addresses this critical issue by examining the extent to which insufficient health services worsens health outcomes in remote regions and exploring policy measures that can effectively enhance healthcare access in rural and remote areas. This dissertation is divided into three chapters. The first chapter focuses on the impact of drought on child health, utilizing panel data from the Index-Based Livestock Insurance (IBLI) collected in the Borana Zone of Ethiopia's Oromia region between 2012 and 2015. This data is combined with remote sensed satellite data, specifically the Normalized Difference Vegetation Index (NDVI), which serves as a drought indicator by capturing photosynthetic activity and assessing the greenness of a location. Child nutrition outcomes are measured using Mid-Upper Arm Circumference (MUAC). The study estimates the prevalence of undernutrition and the effect of drought on these outcomes using multivariate regression models. The findings reveal that 11.2% of the sampled children in the Borana Zone experience moderate undernutrition, and a one standard deviation decrease in NDVI z-score is associated with a more than 7% increase in the probability of undernutrition among children under five. Chapter two presents’ findings from a discrete choice experiment to examine the preferences of health workers in South Omo Zone of Southern Nations Nationalities and Peoples Region (SNNPR) of Ethiopia regarding rural job attributes. This zone was selected because it is where I served as a head of health department from 2010 to 2016, enabling me to leverage my professional network and apply my in-depth knowledge of the Ethiopian public health system to interpret the results. Four focus group discussions and eighteen in-depth interviews were conducted to identify job attributes and their levels. A fractional factorial experimental design was used to minimize the number of job options presented to health workers to allow elicitations of preferences in a discrete choice experiment with a feasible number of alternative choices. The discrete choice experiment produced sixteen choice sets with two alternatives per set. Survey data was collected from 314 health workers in eight districts in southwestern Ethiopia between mid-September and mid-November 2022. Using a mixed logit model with full correlation between utility coefficients, I estimated the relative importance of job attributes, willingness to pay, probability of job uptake, and cost of policy options. The results show that educational opportunities, improved salary, and housing are the most significant factors influencing the attraction and retention of health workers in remote and rural regions. Job uptake rate estimation indicates that offering educational opportunities after one and three years of service at base salary makes remote and rural jobs attractive to 80% and 67.5% of health workers, respectively. In the third chapter, I further investigate the most important attributes of rural and remote jobs to attract graduating health science college students to these areas. Additional focus group discussions were conducted with students at Arbaminch College of Health Sciences, which is also located in the southwestern corner of Ethiopia near where I served as a head of health department and where I attended graduate studies in public health. A total of 332 final-year students participated in the discrete choice experiment survey. Separate analysis was required because combining student and practicing health workers could potentially overestimate the willingness of qualified health workers to accept specific job conditions. Using a mixed logit model with full correlation of utility coefficients, I estimated the relative importance of job attributes, willingness to pay, and probability of job uptake. The findings indicate that educational opportunities, improved salary, and housing are the most important attributes influencing graduating students’ job location decisions. The simulated probability of job uptake shows that at base salary, providing educational opportunities after one year of service makes the job attractive to 76.4% of respondents. Both health workers and students prioritize future educational opportunities, but key differences exist. While salary is valued similarly, it is structured differently in the choice experiment. Health workers values housing and workplace management greatly, whereas students' decisions are more heavily influenced by education opportunities. Additionally, health workers value all job attributes, while students do not place much importance on infrastructure and facility location. Conducting research with both groups is crucial to capturing these differences, ensuring that policy interventions effectively address the motivations of both current health workers and future workforce entrants. This dissertation contributes to the development of evidence-based policies aimed at improving healthcare accessibility in low-resource settings, with a focus on mitigating the impacts of drought and enhancing rural health workforce retention.

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