PCLM-D-24-00229

Improving an Integrative Framework of Health System Resilience and Climate Change: Lessons from Bangladesh and Haiti

PLOS Climate

Dear Dr. Ridde,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Two external reviewers have evaluated your submission and have identified several opportunities to improve the manuscript. Please respond carefully to all of their recommendations when preparing your revisions.

Please submit your revised manuscript by Feb 20 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at climate@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pclm/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Jamie Males

Executive Editor

PLOS Climate

Journal Requirements:

1. In the ethics statement in the Methods, you have specified that verbal consent was obtained. Please provide additional details regarding how this consent was documented and witnessed, and state whether this was approved by the IRB

2. Please include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. The questionnaire can also be requested at the journal’s discretion for any other submissions, even if these conditions are not met.  Please find more information on the policy and a link to download a blank copy of the questionnaire here: https://journals.plos.org/climate/s/best-practices-in-research-reporting. Please upload a completed version of your questionnaire as Supporting Information when you resubmit your manuscript.

3. Please provide an Author Summary. This should appear in your manuscript between the Abstract (if applicable) and the Introduction, and should be 150–200 words long. The aim should be to make your findings accessible to a wide audience that includes both scientists and non-scientists. Sample summaries can be found on our website under Submission Guidelines:

https://journals.plos.org/globalpublichealth/s/submission-guidelines#loc-parts-of-a-submission.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: General Comments:

This manuscript makes an important contribution to the development of a conceptual framework for health system resilience related to climate change. The integration of both demand-side (population) and supply-side (healthcare providers) perspectives is innovative and relevant. The use of the World Café method and reflective analysis enriches the ClimHB framework development.

Strengths of the Manuscript:

Theoretical Contribution: Integrating the Levesque model and DFID framework offers new insights into health system resilience.

Contextual Relevance: The focus on Haiti and Bangladesh provides valuable case studies for regions facing similar challenges.

Participatory Methodology: The workshop with stakeholders strengthens the framework’s validity.

Suggestions for Improvement:

Simplified Framework for Policymakers: Consider providing a simplified version of the framework for policymakers to facilitate practical implementation.

Clearer Visuals: Improve diagrams to better illustrate the relationships between the framework’s components, especially “exposure,” “sensitivity,” and “adaptive capacity.”

Additional Data: If possible, include supplementary qualitative data or workshop transcripts to support the framework’s revisions.

Terminology Clarity: Simplify definitions for technical terms to ensure broader audience comprehension.

Reviewer #2: PCLM-D-24-00229

Peer Review: Major Revision

Thank you for the opportunity to review this manuscript, which falls within my area of expertise. I appreciate the authors’ efforts in addressing the important topic of health system resilience in the context of climate change and poly-crisis, as well as their attempt to refine the ClimHB framework by integrating empirical evidence and theoretical insights. Below, I provide feedback to guide revisions. While the manuscript covers and important topic and the authors are obviously content experts, changes are needed to enhance its accessibility, conciseness, clarity, and impact.

General Comments

• Accessibility: The paper is heavily theoretical and appears to target a narrow academic audience. To make it more broadly applicable (especially to policymakers and practitioners), I recommend using more accessible language and explaining technical terms upon their first use. I am not sure it is reasonable to assume readers are familiar with your first article on this topic, nor the origin frameworks from Levesque and DFID. Simplifying sentences and reducing cognitive load would enhance readability. Introducing ‘topic sentences’ and subheadings within sections would better orient readers to the argument's flow.

• Rationale: The manuscript introduces the problem of an overabundance of resilience frameworks but fails to clearly articulate how the revised ClimHB framework addresses this issue, which seems to add to the problem. A stronger rationale is needed for developing yet another framework, including adapting an existing one framework. How does this framework advance the field or address the gaps identified in previous models? How does applying the framework to case studies add value? Perhaps clarify the research question here that the study sought to answer?

• Integration of Key Concepts: The introduction of the concept of (im)mobility feels abrupt and disconnected from the core discussion of health systems. It should be more clearly introduced earlier in the manuscript and integrated throughout the text, with explicit links to health system resilience.

Methodological Concerns

• Use of Quotations: Several long quotations are presented without sufficient framing or analysis. Employing the “sandwich method” — introducing the theme, presenting the quote, and interpreting its significance — would provide better structure and ensure the quotes contribute meaningfully to the discussion. The reader is struck with the task to see how this quote aligns with the theme and this is rather the job of the authors. A table with the themes and an illustrative quote that best demonstrates each theme would be helpful and would also reduce text load.

• Transparency and Reproducibility: The methods section lacks clarity, making it difficult to evaluate or reproduce the research. It is unclear how data was gathered and analysed, and the relationship between qualitative and quantitative methods, framework analysis, and thematic analysis is ambiguous. A clear, step-by-step explanation of the methodology is needed.

- Were subheadings in the manuscript derived from themes identified during the thematic analysis? This is unclear.

- How were workshop and World Café methods operationalized?

- Consider include an image/visual summary of the identified themes to enhance clarity.

Other

• Logical Flow and Concept Building: Concepts should be introduced logically, building upon one another to guide the reader through the framework’s development and application. This would also reduce the cognitive burden on readers unfamiliar with the topic.

• Conclusion Revision: The conclusion introduces “neoliberal policies” without prior discussion, which seems politically motivated. Many readers will not be able to distinguish neoliberalism from philosophical liberalism. Mention of “hope” in the conclusion feels out of place in an academic paper. I suggest rewriting the conclusion, which come across as an afterthought rather than a meaningful interpretation of the study and findings as a whole.

• Incorporating Updated Frameworks: The manuscript would benefit from referencing the latest version of the WHO Operational Framework, which incorporates low-carbon considerations (WHO, 2023), to ensure alignment with current standards and practices.

• Clarify the distinction between what the researchers have discovered previously (in 2019) versus what is novel in this manuscript. Readers may not have read the authors previous work.

Conceptual Model Improved – ClimHb framework 2.0

• It is helpful that the authors have broken the conceptual model into parts and applied case studies to the model to demonstrate how it works. The conceptual model needs a succinct legend to explain it. Note: in the original version of this framework, the legend was 1 page long – which seems excessive and I doubt most people would read – it could be more precise. A more detailed description can appear in the main text.

• How are contexts and chronic tensions events? Define and differentiate. Define routine and ‘pertubations’.

• The IPCC Propellar diagram conceptualises risk as a product of hazard + vulnerability + exposure. This is somewhat different from the resilience process conceptualised here as exposure (empty part of the bag) and sensitivity (full part) leading through adaptive capacity to health systems resilience. It is unclear what Exposure + Sensitivity (bi-directional arrow to) Adaptive Capacity means in the demand side of healthcare access and how it relates to the IPPC conceptualisation. Please clarify in your response and in the paper.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Peer Review_PLOS Climate_18.12.24.docx

PCLM-D-24-00229R1

Improving an Integrative Framework of Health System Resilience and Climate Change: Lessons from Bangladesh and Haiti

PLOS Climate

Dear Dr. Ridde,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 15 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at climate@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pclm/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Masahiro Hashizume, MD, PhD

Section Editor

PLOS Climate

Journal Requirements:

1. In the ethics statement in the Methods, you have specified that verbal consent was obtained. Please provide additional details regarding how this consent was documented and witnessed, and state whether this was approved by the IRB".

2. Please include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. The questionnaire can also be requested at the journal’s discretion for any other submissions, even if these conditions are not met.  Please find more information on the policy and a link to download a blank copy of the questionnaire here: https://journals.plos.org/climate/s/best-practices-in-research-reporting. Please upload a completed version of your questionnaire as Supporting Information when you resubmit your manuscript.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Reviewer 2: Thank you for the thoughtful revisions, which have strengthened the manuscript. My view is that the manuscript should be accepted with minor revisions. Clarity, accessibility, and methodological transparency have been improved that enhanced the contribution of the revised ClimHB framework. The manuscript now reads more clearly for interdisciplinary audiences (albeit a highly academic audience). However, the conclusion still includes a critique of neoliberal policies that feels unnecessary and overly simplistic. The consequences cited could stem from multiple causes, no alternative is offered, and given this is not a policy analysis, this critique should be removed and replaced with the central finding, interpretation of the actual research.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Does this manuscript meet PLOS Climate’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you for the thoughtful revisions, which have strengthened the manuscript. My view is that the manuscript should be accepted with minor revisions. Clarity, accessibility, and methodological transparency have been improved that enhanced the contribution of the revised ClimHB framework. The manuscript now reads more clearly for interdisciplinary audiences (albeit a highly academic audience). However, the conclusion still includes a critique of neoliberal policies that feels unnecessary and overly simplistic. The consequences cited could stem from multiple causes, no alternative is offered, and given this is not a policy analysis, this critique should be removed and replaced with the central finding, interpretation of the actual research.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Improving an Integrative Framework of Health System Resilience and Climate Change: Lessons from Bangladesh and Haiti

PCLM-D-24-00229R2

Dear Dr. Ridde,

We are pleased to inform you that your manuscript 'Improving an Integrative Framework of Health System Resilience and Climate Change: Lessons from Bangladesh and Haiti' has been provisionally accepted for publication in PLOS Climate.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact climate@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Climate.

Best regards,

Masahiro Hashizume, MD, PhD

Section Editor

PLOS Climate

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Additional Editor Comments (if provided):

Reviewer Comments (if any, and for reference):