Sergio Torres-Rueda - Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
Anna Vassall - Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
Raza Zaidi - Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
Nichola Kitson - Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
Muhammad Khalid - Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
Wahaj Zulfiqar - Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
Maarten Jansen - Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
Wajeeha Raza - Centre for Health Economics, University of York, York, UK
Maryam Huda - Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
Frank Sandmann - Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
Rob Baltussen - Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
Sameen Siddiqi - Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
Ala Alwan - DCP۳ Country Translation Project, London School of Hygiene and Tropical Medicine, London, UK

Background  Pakistan embarked on a process of designing an essential package of health services (EPHS) as a pathway towards universal health coverage (UHC). The EPHS design followed an evidence-informed deliberative process; evidence on ۱۷۰ interventions was introduced along multiple stages of appraisal engaging different stakeholders tasked with prioritising interventions for inclusion. We report on the composition of the package at different stages, analyse trends of prioritised and deprioritised interventions and reflect on the trade-offs made. Methods  Quantitative evidence on cost-effectiveness, budget impact, and avoidable burden of disease was presented to stakeholders in stages. We recorded which interventions were prioritised and deprioritised at each stage and carried out three analyses: (۱) a review of total number of interventions prioritised at each stage, along with associated costs per capita and disability-adjusted life years (DALYs) averted, to understand changes in affordability and efficiency in the package, (۲) an analysis of interventions broken down by decision criteria and intervention characteristics to analyse prioritisation trends across different stages, and (۳) a description of the trajectory of interventions broken down by current coverage and cost-effectiveness. Results  Value for money generally increased throughout the process, although not uniformly. Stakeholders largely prioritised interventions with low budget impact and those preventing a high burden of disease. Highly cost-effective interventions were also prioritised, but less consistently throughout the stages of the process. Interventions with high current coverage were overwhelmingly prioritised for inclusion. Conclusion  Evidence-informed deliberative processes can produce actionable and affordable health benefit packages. While cost-effective interventions are generally preferred, other factors play a role and limit efficiency.

Health Benefit Packages, Essential Packages of Health Services, Pakistan, Priority Setting, Cost-Effectiveness, Decision Criteria