PONE-D-23-38248"Sickness has no time": Awareness and perceptions of health care workers on universal health coverage in UgandaPLOS ONE

Dear Dr. Ifeagwu,

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 insert comments here and delete this placeholder text when finished. Be sure to:Editor commentsPlease address the reviewers’ comments, including adding further consideration on methods and discussion. You will see that one of the reviewers has suggested improvements on methods and the other one ways of discussing the results. To ensure the Editor and Reviewers will be able to recommend that your revised manuscript is accepted, please pay careful attention to each of the comments that have been shared with you. Please also consider improving the concluding remarks and policy implication of your work. This way we can avoid future rounds of clarifications and revisions, moving swiftly to a decision.Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

For Lab, Study and Registered Report Protocols: These article types are not expected to include results but may include pilot data. 

==============================

Please submit your revised manuscript by Apr 24 2024 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,

Dr Patrick Christian Ilboudo

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF.

Additional Editor Comments:

As per one of the reviewers comments, please ensure that the manuscript has been proofread.

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: No

**********

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

Reviewer #1: No

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: No

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: Overall Comment

This is an interesting article examining the perceptions towards the priorities and importance of UHC among healthcare workers in Uganda. I think this is an important topic for policymakers, researchers and practitioners working on health systems strengthening. However, there are some major shortcomings in several sections of the paper, in particular, how the information is presented as well as discussed. Below are the detailed comments where I point specifically to the limitations, as well as suggestions to improve them.

Specific Comments

1) In the second paragraph of ‘study design’ sub-section, there is description about the online survey but one key information is lacking: how was the survey designed? Was it based on a prior instrument that has been deployed somewhere else or any published study? Or was it designed from scratch by the researchers? Were the questions validated and adapted to the Ugandan cultural context? I think it would be important to incorporate these information in the study design sub-section as well.

2) Table 1 currently appears to be rather messy and overloaded with information. I think the figures can be presented more succinctly and clearly. I think there is no need to spell out categories for ‘other’ and details for ‘other’ in the table. Rather, these information can be placed as notes under the table.

3) The authors should explain how the radar chart (Figure 3) is interpreted better. I am somewhat confused by the information presented here. How is goal 3 (health and well-being) perceived as very likely to be impacted by UHC by more than half of the respondents? Where does the 57% come from? It is not very intuitive if I look at the radar chart. How about the percentages for Goal 6 and Goal 1? Again, I cannot see these information from the radar chart. Perhaps it is better to present the information in a table format with clear figures instead of a vague radar chart, unless the authors describe clearly how should this radar chart be interpreted by the readers.

4) Table 2 seems to appear from nowhere. I am not sure if there is any value presenting the findings in this manner. Perhaps there is no need to present these information. Even if the authors would like to, I would suggest making them as narratives/texts.

5) I think Table 3 can be presented in a different manner. First, I do not think there the description column is redundant as each of the six building blocks is already quite clear and intuitive to the readers. What can go to the table, instead, would be a summary of the facilitators for and barriers to each of the six building blocks. What the authors can do here is to summarize the narratives in the main text as bullet points here.

6) In addition to all the findings presented in the article, I find that there might be another interesting analysis which the authors could explore. What are the predictors or factors influencing (i) knowledge of UHC, and (ii) awareness towards UHC? Can regression analyses be performed to tease out what might be some of the demographic, social and institutional factors influencing the above two dependent variables (knowledge and awareness towards UHC)?

7) Discussion section (P23 L470-472), the authors wrote “Financing and political will were considered the most important factors in achieving UHC, and conversely, financing and the political economy were reported as the main barriers.” This sentence is unclear and vague, I do not quite understand what the authors mean here. Please revise.

8) The discussion section is too thin. I think there needs to be deeper reflection on the following points:

a. implications of findings to the UHC agenda and UHC implementation in Uganda.

b. What do the findings from this study mean for other low- and middle-income countries (LMIC)? In other words, what can other LMICs learn from your findings?

c. Generalisability (external validity) of your findings needs to be discussed as well.

d. What would be some of the policy recommendations in lieu of the findings.

9) This article needs to be edited more carefully. I spotted some grammatical mistakes throughout the paper, just to highlight a few more obvious one:-

a. P.4 L97 ‘focussed’ should be ‘focused’.

b. P.5L140 ‘The final online survey was comprised of an introductory section…’ should be ‘The final online survey comprised an introductory section…”

c. P.9 L239-240, the authors wrote ‘Most respondents were based in an urban setting, as opposed to a rural one, which was derived from the health facility location’. This sentence is very convoluted, can be simplified as ‘most respondents were based in an urban setting’. What do you mean by ‘derived from the health facility location’? Please clarify and revise.

d. P.24 L499: Shouldn’t ‘considering these limitations’ be ‘despite these limitations’?

Reviewer #2: The topic is interesting because UHC is a concept that need to be understood by the implementers. The way the implementers will understand UHC will affect its implementation.

However there are several clarifications that authors need to provide mainly in the method and discussion sections.

Title

the title needs to be reformulate to reflect the content. I suggest a title : Awareness and perceptions of health care workers on universal health coverage in Uganda

Introduction

From Line 102 to 106. The authors presented the results of a study in Asia. I suggest to present results from study in Africa related to UHC perceptions such as Koon AD, et al 2017.

Method

Study design

The use of mix method is not clear. What is the sequence of utlization and how each of these studies are linked ?

The online survey was sent to the entire sub-Saharan African region (line 151) but the scope of the study was uganda, why did you select these sample from sub saharan african region. How did the author estimate the sample size for the online survey ?

They sent too many email to many individual, how did they insure that there was not double entry.

About the sampling of the in-depth semi-structured key informant interviews, from line 164 to 165 authors stated that « the in-depth semi-structured key informant interviews were selected through purposive ». That is in contracdiction with what they stated on line 173 « Further interviewees were identified through the snowballing technique to attempt to expand the breadth of informants included. » Please explain how the interviewees were selected.

How did the authors check the saturation ? Please explain.

Why did you use semi structured key informant interviews and focus group discussion. What was the add value of each technique ? Especially because the questions for the FGD were drew from the online survey like the individual semi structured interviews. In adition there was only 1 FGD. Please explain why did you conduct only one FGD ?

The population study was not clearly defined for each survey . Also the selection was not clear

Results

-How many individual interviews were conducted ? how many parcipants did you have in FGD ? What were their background ? Even if youd id not collect their name , information related to their professionnal category, organization, level of facility could be collected.

-On line 323, the authors stated that « None of the FGD participants had heard of UHC prior to the discussion, ». That is surprising because the praticipants for the FGD were drawn from the online survey. How could you explain this situation ?

The categorization of the six building blocks into the main themes is not clear because some themes such as trust or communication are backbone of challenges in the health system. Why did you choose to categorise like this ? I suggest to revise the presentation by looking at the main theme for each block.

Discussion

The discussion is confusing and not reflect the results. I suggest a deep revision of this section taking into account the results and interpretations. To reinforce the discussion, a literature review will be helpful on the different themes and results.

**********

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: 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.

Attachments

Attachment

Submitted filename: review PLOs One.docx

"Sickness has no time": Awareness and perceptions of health care workers on universal health coverage in Uganda

PONE-D-23-38248R1

Dear Dr. Ifeagwu,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Patrick Christian Ilboudo

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors have adequately addressed all the comments raised in a previous round of review by reviewer, therefore qualifying the paper for publication.

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

**********

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

**********

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?

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

**********

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: We are satisfied with the responses and revised version. We recommend that the manuscript will be accepted

**********

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

**********