Dear Dr. Chimatiro, 

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.

Overall, this is an important and interesting study! Please see the revision notes below.

Please submit your revised manuscript by Aug 02 2025 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.

• 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'.

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We look forward to receiving your revised manuscript.

Kind regards,

Jobst Augustin, Associate Professor/Senior lecturer

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. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

- https://doi.org/10.3390/ijerph15030538

-https://kmco.co.ke/wp-content/uploads/2023/01/VOLUME-2-ENVIRONMENTAL-BOOK-FINAL.pdf

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

3. In the online submission form, you indicated that: 

“The data will be available upon reasonable request from the corresponding author”

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This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 

4. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process.

5. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. 

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7. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments :

The planned study is a relevant piece of work. The scoping review protocol is well written and only requires minor revisions:

- For clarity, the term 'Sub-Saharan Africa' should be defined at the beginning. The fact that the focus is on Malawi is only mentioned later.

- The consequences of climate change on the health system are mentioned, but not the associated costs. Are these not relevant here?

- The implementation schedule should be specified in more detail under Methods.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

Reviewer #1: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses??>

Reviewer #1: Partly

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable??>

Reviewer #1: Yes

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4. Have the authors described where all data underlying the findings will be made available when the study is complete??>

The PLOS Data policy

Reviewer #1: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

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Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

Reviewer #1: Thank you for sharing this interesting scoping review protocol. The topic you have chosen is both important and highly relevant. As you move forward with writing the full review, here are a few aspects that you might consider:

- Include specific numbers and relative risks regarding the prevalence/ incidence of relevant negative health outcomes in your research area Sub-Saharan Africa (to highlith the importance).

- "heat stress" as environmental stressor is not the only cause for premature deaths (due to CC). Air pollution, hurricanes, and floods could also play an important role? (You can clarify your sentence: "CC will cause an additional 250,000 deaths per year from malnutrition, malaria, diarrhea, and heat stress")

- In your research environment, are there differences between the consequences of CC in rural and urban areas? (Perhaps this is also a relevant topic for your discussion.)

- Does climate change only affect the infrastructure of health systems? It may also have an impact on human resources (which are particularly lacking in Malawi) and, in the worst case, even lead to cumulative effects of climate change.

- You could describe the role of infectious disease more detalied (Malaria and the Cholera outbreak in 2022).

- Briefly describe the health care system in Sub-Saharan Africa/ Malawi and it’s challenges (less human resource, less training opportunities, limited treatment options ...) as well as the economic situation in a global context (dependency of other countries etc.) in order to understand why research is important for Sub-Saharan Africa/ Malawi. CC seems to be a major problem that adds to the structural and already existing fundamental problems.

- Since scoping reviews do not formally assess the methodological quality of the included studies, their results are not directly applicable for evidence-based recommendations or policy-making. However, they provide a valuable basis for structuring the research field and identifying existing gaps in the evidence.This should be mentioned in the limitations. (Your sentence: "The findings will also be shared with the Ministry of Health in Malawi for possible policy considerations and University of the Western Cape Library for future reference" should be worded more carefully.)

- Check consistency in terminology (e.g., climate change vs. CC).

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Reviewer #1: No

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Strategies and responses to the effects of Climate Change on health systems in Sub-Saharan Africa: A scoping review protocol

PONE-D-24-57662R1

Dear Dr. Chancy Skenard Chimatiro, 

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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Kind regards,

Jobst Augustin, Associate Professor/Senior lecturer

Academic Editor

PLOS ONE