Leaving no one behind in health: Financial hardship to access health care in Ethiopia

Yawkal Tsega; Gebeyehu Tsega; Getasew Taddesse; Gebremariam Getaneh

doi:10.1371/journal.pone.0282561

Peer Review History

Original SubmissionAugust 14, 2022
1 Nov 2022 Decision Letter - Khurshid Alam, Editor PONE-D-22-22796Leaving no one behind in health: financial hardship to access health care in EthiopiaPLOS ONE Dear Dr. Tsega, 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. ============================== ACADEMIC EDITOR:Please address my following comments along with reviewers' comments:1. It is multiple logistic regression, not multivariate logistic regression. So, please change it throughout the manuscript.2. Before modelling factors using multiple logistic regression you need to develop a conceptual framework of your own or use an established framework from the literature. This conceptual model will serve as hypotheses that will guide your modelling process. For example, you may find some factors not statistically significant but they could be theoretically important for the Ethiopian contexts and you need to retain those factors in your final parsimonious model although they are not statistically significant.3. Your interpretation of OR is wrong. You interpreted OR like RR. OR 2.5 means 2.5 times higher odds, not 2.5 times more likely! ============================== Please submit your revised manuscript by Dec 16 2022 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. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ 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 academic editor and reviewer(s). 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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 Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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 Reviewer #2: 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 Reviewer #2: 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: Comments The paper is about “Leaving no one behind in health: financial hardship to access health care in Ethiopia” which is very important and interesting research area for Ethiopia and beyond, as it is clearly shown in the introduction part of the manuscript that financial hardship (risk) protection is the international and national agenda, such as SDGs and Health Sector Transformational Plan two(HSTPII), which is a five year(2021-2025) plan (part of the long Ethiopia’s health sector’s fifteen years strategic plan (2015-2035)).As per the findings of this study, due to financial hardship, the poor people(found in low income countries including Ethiopia) either forgone and/or delayed for accessing health care they need or they are obligated to access the needy health care on the expense of other basic needs like food which is against the zero hunger goal of the agenda 2030. In the era of Covid-19 pandemic and other disasters (e.g. conflict and climate change), the poor left behind in health (care).The findings of this study indicated that financial hardship becomes a significant barrier to achieve the notion of leave no behind. For example, impoverished health care makes, about 10.4%, households became poor and catastrophic health expenditure was found in 37.1% of the households. Hence, it is very relevant and suitable to publish this evidence that showed the extent of financial hardship (and the associated factors) on households in Ethiopia in general and in Debre Tabor town (one of conflict affected areas of Ethiopia) in particular. This evidence will inform policy options in the country in order to attain the universal health coverage (leave no one behind in health).Despite, there are few comments that need to be either clear or addressed before this paper could be published. 1. The threshold that the authors used for catastrophic health expenditure is 10%. However, they put the results in three thresholds (10%, 25% and 40% non-food). Why this is so? 2. In the introduction and discussion sections of the manuscript, there are long sentences that can be reconstructed to simple, short and concise sentences as per the plos one journal recommendation. 3. The authors should convert the Ethiopia Birr to US Dollar in bracket to make it clear for international community. 4. in the methods section your dependent variable says Financial hardship of healthcare(CHE ) : here the abbreviation CHE is not represent financial hard ships of health care so use either of the two / catastrophic health expenditure or financial hard ship 5. In the measurement of catastrophic health expenditure as you clearly present the threshold ranges from 10%- 40 %. So why you select the lower value (10%)? Because of this decision you may under estimate the level of catastrophic health expenditure in the study area? Say something about this issue in your manuscript. Reviewer #2: Really the result was technically sound and It is so in my professional experience. As I am the CEO of the private Hospital in Bahir Dar, nearby city and the regional capital, I repeatedly saw many customers unable to cover the out of pocket expenditures. I recommend to study how the user fee setting is set both in public and private health institutions. Thank you very much. ****** 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 Reviewer #2: Yes: Habitamu Ayehualem Bayu ******** [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: comments on leave no one behind.docx https://doi.org/10.1371/journal.pone.0282561.r001
Revision 1
25 Nov 2022 Author Response Response to editor: We really thank you, editor, for your insightful comments that are vital to improve the manuscript. We accept all of your comments and we corrected accordingly. Here, below, are the responses for the comments: 1. “It is multiple logistic regression, not multivariate logistic regression. So, please change it throughout the manuscript”. • Yes, you are quite right, we changed to multiple logistic regression throughout the manuscript. 2. “Before modelling factors using multiple logistic regression you need to develop a conceptual framework of your own or use an established framework from the literature. This conceptual model will serve as hypotheses that will guide your modelling process. For example, you may find some factors not statistically significant but they could be theoretically important for the Ethiopian contexts and you need to retain those factors in your final parsimonious model although they are not statistically significant”. • We have developed the conceptual framework, but not reported in the 1st version of the manuscript. Now, we have reported in the manuscript. 3. “Your interpretation of OR is wrong. You interpreted OR like RR. OR 2.5 means 2.5 times higher odds, not 2.5 times more likely!” • Yes, you are correct, in the current version, we have corrected accordingly. Response to reviewers Thank you, reviewers, for your constructive comments that are vital to improve the manuscript. We accept all of your comments and we corrected accordingly. Here, below, are the responses for the comments and questions raised: 1. “The threshold that the authors used for catastrophic health expenditure is 10%. However, they put the results in three thresholds (10%, 25% and 40% non-food). Why this is so?” • Most authors, including in World health organization and World Bank joint report on UHC, used 10% and 25% thresholds. The 40% non-food also used by authors as well, as stated in the methods part of the manuscript. Therefore, we used the 10% threshold for statistical modeling which is the WHO threshold. However, we stated (in the manuscript) that the incidence CHE with the three thresholds (10%, 25% and 40% non-food) to allow the readers and/or reviewers to compare the incidence with these three thresholds. This will give more information than using only 10% threshold. 2. “In the introduction and discussion sections of the manuscript, there are long sentences that can be reconstructed to simple, short and concise sentences as per the plos one journal recommendation”. • We have reconstructed accordingly. 3. “The authors should convert the Ethiopia Birr to US Dollar in bracket to make it clear for international community” • We have converted in to $ in bracket as per the comment. 4. “In the methods section your dependent variable says Financial hardship of healthcare (CHE): here the abbreviation CHE is not represent financial hardships of health care so use either of the two / catastrophic health expenditure or financial hard ship”. • We corrected as per the comment 5. “In the measurement of catastrophic health expenditure as you clearly present the threshold ranges from 10%- 40 %. So why you select the lower value (10%)? Because of this decision you may under estimate the level of catastrophic health expenditure in the study area?” • This is because 10% the usual threshold that used in global reports, including WHO and WB. Hence, the audience can compare the findings with that of such reports (e.g WHO reports on UHC). However, we have reported the incidence/headcount at 25% and 40% non-food as well to give additional information at these thresholds. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0282561.r002
21 Feb 2023 Decision Letter - Khurshid Alam, Editor Leaving no one behind in health: financial hardship to access health care in Ethiopia PONE-D-22-22796R1 Dear Dr. Tsega, 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. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. 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 onepress@plos.org. Kind regards, Khurshid Alam, Ph. D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0282561.r003
Formally Accepted
2 Mar 2023 Acceptance Letter - Khurshid Alam, Editor PONE-D-22-22796R1 Leaving no one behind in health: financial hardship to access health care in Ethiopia Dear Dr. Tsega: 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. Khurshid Alam Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0282561.r004

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