PONE-D-23-12526Performance Evaluation of National Healthcare Systems in the Prevention and Treatment of Non-Communicable Diseases: Data Envelopment AnalysisPLOS ONE

Dear Dr. Arhin,

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.

A comprehensive and useful analysis by the authors are commendable with the use of multiple datasets covering a topic of high importance today. I hope the authors will be able to address to the comments by the reviewers to make this manuscript even stronger.

Please submit your revised manuscript by Aug 05 2023 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Krishna Kumar Aryal

Academic Editor

PLOS ONE

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Additional Editor Comments:

In addition to the comments from reviewers, please address the following.

Title: kindly include/mention that this analysis is for SSA in the title.

Please shift the strengths and limitations from the conclusion to the discussion. It is a struggle to find the key message from your analysis in the conclusion. Please try to have the most important message from the results of your analysis with possible recommendations.

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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: Yes

Reviewer #2: Partly

Reviewer #3: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: No

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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: No

Reviewer #2: Yes

Reviewer #3: No

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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

Reviewer #3: 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: • The last part of introduction section that details the contents in different sections can be removed.

• Sections are not numbered as per PLOS format and thus can be removed.

• Currently, methodology section spreads over 9.5 pages which could be shortened for the convenience of reader.

• Conclusion section of the study does not need to focus on does not need to summarize the methodology part. First paragraph of the conclusion is not needed.

• Together with description, provide the exact link from which data were extracted.

Reviewer #2: This is an interesting study measuring system performance across the relatively large number of countries using global database.

However, there are some limitations that I would suggest addressing:

1. Since two of the output variables selected in this study are high level impact indicators (mortality and DALY). Considering this, there will be reasonable time lag between the inputs and output variables. That means impact of increased budget and human resources will be reflected on mortality and DALY after certain time period and could sustain for multiple years. Therefore, due attention should be given on this, otherwise need to be mentioned as a major limitation.

2. Moreover, input variables selected in the study mainly cover recurrent costs (per capita expenditure and HR) and do not take into account the existing infrastructure which will have direct implication on efficiency. This is partially taken care by the variable returns to scale but inclusion of infrastructure such as number of hospital beds and/no number of primary health care centers could be considered. For enhancing the efficiency, right mix of the fixed (capital) and variable (recurrent) becomes an important aspect. Therefore, please consider dealing with capital aspects as well otherwise clarify on this.

3. In the discussion section, there is "financial burden households face when accessing NCDs healthcare services [67], which could lead to inefficiencies in the healthcare system." This does not seem to be a plausible statement or at least causal path is not straight forward.

Domestic private financing can be either in the form of prepaid fund e.g., in the form of health insurance premium or out of pocket payments. If private financing is mainly in the form of OOP, it can pose barrier on health service utilization and hence adversely affects the outputs variables such as service coverage and mortality. Otherwise, system efficiency may not be impacted just because who is paying for it.

Reviewer #3: The manuscript addresses an interesting issue. The analysed data collect a wide range of information and several features deserve to be properly modelled. The use of frontier methods is generally sound, though rather basic. Results are promising, but some checks are still required. Some comments follow.

1. The data are not fully available. This does not allow netiher for the reproduciblity of the results. Please, provide the data and the code used to obtain the results as a supplementary material. More details about the used software are required.

2. The statistical methods employed are rather basic. The same characteristics that make DEA a powerful tool can also create problems. The authors should keep these limitations in mind when choosing whether or not to use DEA. Just to mention a few: since DEA is an extreme point technique, noise (even symmetrical noise with zero mean) such as measurement error can cause significant problems; DEA is good at estimating "relative" efficiency of a DMU but it converges very slowly to "absolute" efficiency, it can tell you how well you are doing compared to your peers but not compared to a "theoretical maximum."; since DEA is a nonparametric technique, statistical hypothesis tests are difficult and are the focus of ongoing research; since a standard formulation of DEA creates a separate linear program for each DMU, large problems can be computationally intensive. Overall, the approache should be better motivated, as stochastic frontiers are often preferred to DEA.

3. I am not fully sure that such a basic approach is able to adequately capture all the data features. Please, refer to Panwar, A., Olfati, M., Pant, M. et al. A Review on the 40 Years of Existence of Data Envelopment Analysis Models: Historic Development and Current Trends. Arch Computat Methods Eng 29, 5397–5426 (2022). https://doi.org/10.1007/s11831-022-09770-3 and Omrani, H., Valipour, M., & Emrouznejad, A. (2021). A novel best worst method robust data envelopment analysis: incorporating decision makers’ preferences in an uncertain environment. Operations Research Perspectives, 8, 100184 for general overviews of extended approaches. I feel that it is rather important to investigate and properly account for atypical observations, noise, outliers, etc

4. I do not really get how the longitudinal and spatial structure of the data is modelled. Observations are not independent over time and space. These features are completely overlooked and may strongly affect the inferential results.

5. I am wondering why the analysis is commented assuming an a-priori endogenous clustering. My feeiling is that a clustering structure is present in the data, but it has to be estimated along with other model's parameters. The assumption that countries are homogeneous given the income is rather questionable.

6. Regression results should be further investigated. The assumptions underlying the regression modelling must be checked. Moreover, the p-value should be treaten with caution (please, describe how it is obtained from the bootstrapped estimates).

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Reviewer #1: No

Reviewer #2: Yes: Ghanshyam Gautam

Reviewer #3: No

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PONE-D-23-12526R1Performance evaluation of national healthcare systems in the prevention and treatment of non-communicable diseases in sub-Saharan Africa: Data envelopment analysisPLOS ONE

Dear Dr. Arhin,

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.

Kindly find some remaining comments from Reviewer 3

Please submit your revised manuscript by Sep 21 2023 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). 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'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Krishna Kumar Aryal

Academic Editor

PLOS ONE

Additional Editor Comments:

Dear Authors, majority of the responses have been found satisfactory by the reviewers. However, you are kindly requested to address the remaining comments from Reviewer 3.

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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

Reviewer #3: (No Response)

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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

Reviewer #3: Partly

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

Reviewer #2: Yes

Reviewer #3: No

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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

Reviewer #3: 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

Reviewer #3: Yes

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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)

Reviewer #3: Thank you very much for all your replies to my former comments.

Nevertheless, there is still a general lack of statistical knoweldge.

1. Although pros and cons of the proposed approach are discussed properly, no solutions to the discussed drawbacks are proposed, applied, investigated. Mainly, statistical inference is a crucial aspect of any empirical analyses. A comparison with other approaches, SFA for example, is required.

2. Longitudinal and spatial dimensions do not refer to noise. Both must be included, as a main assumption of the modelling (i.e. independence across observations) is not tenable. You can easily include both even in the DEA modelling, there are several papers discussiong both in the literature.

3. Please, provide evidence that results are robust against endogenous clustering and/or other a-priori exogenous clustering.

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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 #2: No

Reviewer #3: 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.

Performance evaluation of national healthcare systems in the prevention and treatment of non-communicable diseases in sub-Saharan Africa

PONE-D-23-12526R2

Dear Dr. Arhin,

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,

Krishna Kumar Aryal, MPH, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for addressing all the comments raised by the reviewers and the editor.

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 #3: 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 #3: (No Response)

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

Reviewer #3: (No Response)

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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 #3: (No Response)

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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 #3: (No Response)

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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 #3: (No Response)

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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 #3: No

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