PONE-D-21-18147Uneven economic burden of non-communicable diseases among Indian households: A comparative analysisPLOS ONE

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Reviewers' comments:

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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

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Thanks for providing me the opportunity to review this manuscript. The authors analyze the Indian national survey NSSO 75th round. The analysis has value in terms understanding the economic burden of NCDs in India. This research could provide reflections on how the recent healthcare reforms in lines with India’s UHC aspirations has succeeded/failed to produce coveted effects. Presently the analysis and overall manuscript stand week. There are several lacks related to methodological description, presentation of descriptive results, theoretical basis of choice of variables in regression, focused discussion, policy implications etc. This manuscript can benefit from major revision. The specific comments for each section are given below.

Abstract

1. The term ‘lower and middle income countries’ is incorrect, it is not clear whether the authors are referring to ‘low and middle income countries’ or lower-middle income countries’ please revise accordingly.

2. Please provide the acronym-NCDs at its first use.

3. Please elaborate the methods used.

4. Results: please mention if you are reporting mean expenditures

5. Results: please replace ‘2 times more’ with ‘more than twice’

6. Results: The text ‘Particularly, expenditures on medication and diagnosis are troublesome for households with NCDs.’ seems generic. It would be good if authors can provide proportion of total OOP expenditure incurred on medicines and diagnostics.

7. For results of generalised linear regression model please provide odds ratio and p-values.

8. Presently, the conclusion statement is crude. It needs to be specific with expansion.

Introduction

1. General comments: There are multiple grammatical errors in the text. I have attempted to point out many of these mistakes, but a thorough copy-edit is required to catch all of these errors.

Additionally, the introduction is unnecessarily lengthy owing to repetition of concepts. The structure of the introduction needs to be reworked to ensure that distinct ideas are grouped together into paragraphs and that concepts flow to build a context across paragraphs.

Specific comments:

1. Page 2 line 3, as explained above please replace the term ‘lower and middle income countries’

2. Page 2 line 3 please replace the word ‘kills’ with ‘kill’

3. Page 2 line 4 please pluralize the word ‘death’

4. Please be consistent in the use of the acronym for non-communicable diseases. There is an inconsistency in the use of the full form and the acronym. Additionally at some places ‘NCD’ is used and at others it is ‘NCDs’.

5. Page 2 line 9 please pluralize the verb ‘trap’

6. Page 2 line 10 please replace the word like with ‘such as’

7. Page 2 line 11 again the authors have used the full form instead of the abbreviation for non-communicable diseases. It is advised to give the full form at first-in-text reference along with the acronym in parenthesis and then use the acronym in the subsequent references.

8. Page 2 line 13 please revise the sentence ‘the economic cost of NCDs..’ for it to be grammatically correct. Additionally please specify ‘…macroeconomic effect’ for whom?

9. Page 2 line 14 please replace the word ‘force’ with ‘workforce’

10. Page 3 lines 1-2, there is incorrect use of prepositions, please revise accordingly.

11. Page 3 lines 4-5, please do not capitalize the words succeeding colon and semi colon.

12. Page 3 line 15 please pluralize the word ‘death’

13. Page 3 line 15 please add ‘the’ before the word ‘..death are’

14. Page 3 Please do not provide the full form for DALYs again. Also look out for similar errors for other acronyms (UHC, SDG) used in the manuscript.

15. Page 3, the authors provide DALYs from 1990-2016, it is advised to provide more recent figures using GBD study 2019.

16. Page 3 please provide a reference for the sentence ‘OOPE constitutes 58.7% of total health expenditure in India’

17. Page 3 the figures cited by the authors ‘23 to 32 million people below the poverty line’ does not refer to impoverishment due to NCDs. Furthermore, the reference cited uses data from 1999-2000 which is more than two decades old. The authors are advised to accordingly revise these facts.

18. Page 3 please pluralize the word ‘policymaker’

19. Page 3 it is not clear how understanding of OOP expenditure would provide information on prevention and control of NCDs. Additionally, how would this reduce financial hardship. These lines need additional clarifications.

20. Page 4 contrary to the authors’ claim there are multiple studies assessing the OOP expenditure for NCDs apart from the two cited. Please provide a strong justification of the novelty of your study and how would it contribute to existing literature.

METHODOLOGY

General comments: The authors have analysed nationally representative NSSO data and provide useful descriptive results. The findings are important but empirically obvious. Furthermore, the depth of analysis is thin, the authors do not justify the methodology for computation of catastrophic health expenditures and the theoretical basis of selection of independent variables for their regression model.

Specific comments:

1. The authors do not provide a clear justification on how have they grouped the 15 broad disease categories into NCDs and non-NCDs. For instance respiratory ailments can be either NCDs or infectious diseases.

2. Page 5: under variables section it is not clear why the authors choose these particular variables in this analysis. For instance, why do the authors think religion is an important variable impacting your outcome variables-OOP expenditure due to NCDs.

Similarly, when you have already included wealth quintile as an independent variable why do you include type of ‘latrine’ which is a component of estimating proxy of economic status of household.

3. Page 6, the authors state that they use world bank criteria to measure OOPE. It is not clear what is meant by this since OOPE is already reported in NSSO data.

4. The authors do not provide a justification of calculating CHE based on 10% of total income. Previous literature reports that using consumption expenditure is a better indicator for calculating CHE in comparison to income. Further a range of thresholds is used 10%, 25%, 30% and 40%, please justify the selection of 10% cut-off.

5. Page 6 para 2 there is repetition of what is given in the preceding text.

6. Page 6 para 3, the authors provide theoretical description of a generalized linear model which may not be needed. Instead as mentioned previously please consider adding details on the reason for selection of variables in your model. Further, there is no mention about how multicollinearity issue was assessed and addressed?

Results

1. For results ‘Households hospitalised due to NCDs have more elderly members as compared to the non-NCD’ please mention corresponding figures-what proportion

2. ‘Nearly 80% of households, both NCDs and non-NCDs’ this is obvious depending on overall NSSO sample and India’ demographic statistics where majority of the population is Hindu.

3. Page 7, lines 4-5 please the authors report results for social class for NCDs households, please report corresponding results for Non-NCDs households as well.

4. Page 7 lines 6 the authors report combined results for NCD and non-NCDs households, please report the findings separately.

5. Also reporting results for all categories is redundant for example the authors state 96% drink safe water so it is not necessary to state that 4% are drinking unsafe water. It is suggested to report major findings only.

6. Please provide corresponding numbers ‘More number of hospitalisation cases

are found in the case of households having 1-5 members as compared to 6-7 and 8+ members’ and also how does it differ in NCDs versus non-NCDs households.

7. Page 7 in the sentence ‘As expected, analysis of hospitalisation.’, the authors should refrain from making speculations.

8. Overall, please use a standardized pattern for reporting descriptive results. For some variables the authors provide compare results for both NCDs and non-NCDs households and for others overall results for the complete sample are provided.

9. Page 9 lines 1-5, please provide results as proportion of total expenditure rather than absolute numbers.

10. The authors report Hindus are spending more than Muslims for NCDs is this difference statistically significant?

11. There is an inconsistency in reporting results for OOP expenditure, for some variables the authors make an intra-variable comparison (Hindus versus Muslims) for others the authors compare differences for NCDs vs non-NCDs households.

12. Table 2 and 3 please reconsider the title of the table ‘Difference in mean out-of-pocket expenditure’, the authors do not report the difference in these tables.

13. The authors report CHE is less for others categories for public hospitals and more for private hospitals with Hindus as reference category. Have the authors controlled for confounders for this analysis. Also in your discussion section please provide plausible reasons why this difference is observed.

14. Why is the role of gender not explored for OOPE and CHE. Previous literature has identified gender as one of the major independent variables affecting OOP and CHE

Discussion

General comments: The discussion section largely repeats the results of analysis and the authors do not comprehensively discuss the reasons for observing specific findings.

Specific comments

1. Page 18 line 1, the findings differ from what has been reported in results section and Table 1

2. Page 18 sentence ‘poor people are not going for seeking care due to cost constraints’, please reference this appropriately.

3. Page 18 sentence ‘highest number of hospitalisation cases reported from the southern region and lowest from the northeast’. Please discuss the basis of this finding.

4. ‘In public health centres, the rural-urban difference in mean OOPE is found to be very less among NCD households, however, this difference is more while considering non-NCD households. Why? Please discuss.

5. ‘households that belong to the Hindu religion are spending more on hospitalisation as compared to Muslim households’ Is this difference significant? Explore possible reasons for the difference. Does this finding has any policy implications in Indian context.

6. The authors state that ‘In public facilities, households using unsafe drinking water are reporting a higher burden of OOPE expenditure compared to the households using safe drinking water. This is because the chances of infection are more in the case of former than in the latter.’ NCDs do not occur as a result of infection. Please clarify the statement how it relates in the context of current research.

7. Please include a section on limitations of your study

Conclusion: Please discuss appropriate policy implications of your findings

Reviewer #2: 1. Introduction:

• There are some spelling mistakes.

• Some abbreviations are written without the whole word at first such as GDP in page 3

• On the other hand, some phrases are repeated and abbreviations should be used such as DALY use the abbreviation not the Disability Adjusted Life Years and United Nations Sustainable Development Goals in page 3.

• The estimated figure in page 3.. what figure?

2. Study design:

• An NCD should be a NCD.

• Use the abbreviation for non-communicable disease

3. Results:

• Table 1: I think a column for the total % should be added

• INR: I understood it is for Indian Rupee but the whole word was not written anywhere in the manuscript

• Table 3: I think you can test the significant difference between different variables and put the p value

• Comment for table 3 should be before the table.

• Table 4: how is the percentage calculated? It is not equal 100%

• Table 5: why there is mention for 10% significant? Mostly we use 1% or 5% only. 10% consider not-significant

4. Discussion:

• Why there is a table 6 in the discussion? It should be in the result section and it is not present in the manuscript at all.

5. Conclusion:

• Use abbreviations for non-communicable disease, out-of-pocket expenditure and catastrophic health expenditure

6. Ethical consideration:

• I don't understand why there is no ethical approval or statement?

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Reviewer #1: No

Reviewer #2: No

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Uneven economic burden of non-communicable diseases among Indian households: A comparative analysis

PONE-D-21-18147R1

Dear Dr. BEHERA,

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.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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. 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 #2: Yes

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

Reviewer #2: Yes

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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 #2: Yes

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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 #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: (No Response)

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Reviewer #2: No