Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

Isabelle Feldhaus; Somil Nagpal; Stéphane Verguet

doi:10.1371/journal.pone.0259628

Peer Review History

Original SubmissionJanuary 5, 2021
23 Jul 2021 Decision Letter - M. Mahmud Khan, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-21-00305 Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia PLOS ONE Dear Dr. Feldhaus, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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 Sep 06 2021 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 plosone@plos.org. 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Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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 ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE 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 ****** 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: This is a highly sophisticated study which is not very easy to understand. However: 1. Prevention in high-risk individuals is totally ignored whereas it is critical in order to halt the progression of the diabetes "epidemic" and not overwhelm health services in LMICs. Considering also that there are several studies demonstrating the effectiveness of intensive lifestyle intervention studies in terms of curbing the incidence of diabetes, as well as their cost-effectiveness (see for instance Alouki K et al 2016). Was it not possible to integrate this in the model? If not, at least discuss this major limitation. Even if strengthening the Cambodia health system is on-going, it is doubtful that it could absorb the rising number of diabetes cases and provide quality management. 2. Would the strategies of covering diagnostics only or of covering medication only not also allow for earlier diagnosis and treatment thereby contributing to curbing or delaying complications (Table 1)? 3. That covergae if diagnostics only would increase the negative health impact would have to be better substantiated. 4. The impact of user-fee removal on healthcare seeking has been assessed for conditions other than diabetes. References should be provided on this issue in the discussion, including for instance the study by Beaugé Y et al (2020). 5. Please insert 'diabetes' in the title. ****** 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. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: 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. 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Revision 1
6 Sep 2021 Author Response Responses to editor comments: 1. We have reviewed the PLOS ONE style requirements and revised the manuscript according to the PLOS ONE style template provided in the comments. 2. One of the authors of the manuscript, SN, is employed by the World Bank Group, whose parent organization is the United Nations. 2.1. We have provided an amended Funding Statement declaring this affiliation and that the organization did not play a role in the study. Authors' contributions remain the same. SN contributed to the review and final revision of the study. 2.2. We have provided an updated Competing Interests Statement declaring this affiliation and confirm that it does not alter our adherence to PLOS ONE policies. All authors confirm that we have no competing interests to declare. Responses to reviewers' comments: Reviewer #1: This is a highly sophisticated study which is not very easy to understand. However: 1. Prevention in high-risk individuals is totally ignored whereas it is critical in order to halt the progression of the diabetes "epidemic" and not overwhelm health services in LMICs. Considering also that there are several studies demonstrating the effectiveness of intensive lifestyle intervention studies in terms of curbing the incidence of diabetes, as well as their cost-effectiveness (see for instance Alouki K et al 2016). Was it not possible to integrate this in the model? If not, at least discuss this major limitation. Even if strengthening the Cambodia health system is on-going, it is doubtful that it could absorb the rising number of diabetes cases and provide quality management. Thank you for this comment and highlighting the importance of prevention measures as some of the most cost-effective efforts to curb the incidence of diabetes. Indeed, we agree. This study focuses on what coverage can be provided by the Health Equity Funds in Cambodia to address the prevalence of diabetes. Unfortunately, prevention measures in the form of lifestyle or other daily activity interventions were determined to be outside of the scope of current HEF coverage policies, which largely focus on services that can be sought at health centers. Discussion of the importance of strategies aimed at preventing diabetes is included in the main text as the last paragraph of the section, “Financial risk protection and health systems strengthening for diabetes”. 2. Would the strategies of covering diagnostics only or of covering medication only not also allow for earlier diagnosis and treatment thereby contributing to curbing or delaying complications (Table 1)? Thank you for this insightful comment. Yes, we agree that this is a possibility and a hoped-for impact of such a coverage strategy. Other models on diabetes have stratified cases by early diagnosis and late diagnosis of diabetes. We considered this approach as well. Unfortunately, for Cambodia, there is no information available describing how many diabetes cases are diagnosed early or later in disease progression, and there is limited data on the extent to which early vs. late diagnosis has an impact on treatment outcomes. As a result, we conservatively did not make this distinction in classification of diagnosis. Such an impact may drive more favorable results. Similarly, the typical timing of treatment in the diabetes trajectory remains unknown in Cambodia data sources. We have made revisions in the text to outline these limitations. 3. That coverage if diagnostics only would increase the negative health impact would have to be better substantiated. The manuscript describes the negative health impact of the diagnostics only strategy due to disability weights attributed to daily psychological stress due to the knowledge of diagnosis result in negative health impact. These disability weights were used because they are standard as reported in the data source (IHME, 2017). In the scenario in which these disability weights are not acceptable for whatever reason, the diagnostics only strategy would have no impact. Following discussion of this point in the discussion section, the primary point made is that treatment subsequent to diagnosis would have truly positive health impacts. 4. The impact of user-fee removal on healthcare seeking has been assessed for conditions other than diabetes. References should be provided on this issue in the discussion, including for instance the study by Beaugé Y et al (2020). Thank you for your comment and pointing us to this literature. Relevant discussion has been added to the introduction and discussion sections. 5. Please insert 'diabetes' in the title. The title of the manuscript already includes the term ‘diabetes’ as follows: “Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia”. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0259628.r002
25 Oct 2021 Decision Letter - M. Mahmud Khan, Editor Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia PONE-D-21-00305R1 Dear Dr. Feldhaus, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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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 #1: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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 ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE 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 ****** 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 #1: Our comments were modestly addressed but in the last paragraph before 'Limitations...', references are needed on the cost-effectiveness of prevention through lifestyle interventions. Additionally, the authors will want to consult and eventually cite the studies by Alouki K et al (2015, 2016, 2017) on the medical costs of diabetes treatment in the presence of absence of complications, based on a standardized treatment protocol, in West Africa (and the software for the process). ****** 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. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0259628.r003
Formally Accepted
28 Oct 2021 Acceptance Letter - M. Mahmud Khan, Editor PONE-D-21-00305R1 Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia Dear Dr. Feldhaus: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. M. Mahmud Khan Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0259628.r004

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