PONE-D-24-09524Technical Efficiency of Primary Health Facilities in Providing Adolescent Mental, Sexual and Reproductive Health Services in Ghana: a case study of selected districts in the Greater Accra RegionPLOS ONE

Dear Dr.  Fenny,

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Yitagesu Habtu Aweke, Ph.D

Academic Editor

PLOS ONE

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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: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

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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: Yes

Reviewer #2: No

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: No

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: Title need to be coincide more and easily understandable. In title it is mentioned Primary Health Facilities, rather it is better to mention Primary Health Care Facilities. Title might be "Efficiency of Primary Health Care Facilities in Providing Adolescent Health Services in Greater Accra, Ghana: a case study"

Abstract section can be more shorter. In abstract the background portion is large enough. It is better to prepare one sentence like " There are gaps in access to and use of AMSRH services, as well as in the quality and efficiency of care provided in many low- and middle-income countries like Ghana." The objective need to be rephrase. To assess is better to mention rather to estimate.

Introduction: This section is also very large. Please avoid to provide similar information in several sentences. Rather provide more references with one sentence. In objective there is mentioned the environmental factor, which can be inserted in title also.

Methodology: How many private facilities and public facilities are selected. How many facilities are selected from urban areas and rural areas need to be mentioned. The process of data collection need to be mentioned more elaborately. Who collect data from whom, and how the consent was taken, who provide permission to assess data need to be added in methodology.

Result: p value need to be added in Table 2. There in huge differences in services providing in different health facilities. So how many facilities providing - the best services, good services, Average services, poor services, and very poor services (Likert scale) can be incorporated. There are some abbreviation used without mentioning their elaboration like OPD, SRH, STIs etc.

Conclusion: This section will more to be reflected from the findings. The conclusion is more generic rather specific. So it could be improved based on the specific findings of the paper.

Reviewer #2: This article has the potential to contribute both strategy and knowledge to future efforts to evaluate and improve health system technical efficiency, especially in low-resource settings. However, as it stands, the work fails to frame the study methods and findings with this potential impact in mind. While I am interested in the “possibility of producing more outputs within the existing resource envelope”, I do not feel that this paper provides a path towards this goal.

In revising this manuscript, I urge the authors to consider the following:

1) Refocus the Introduction to center around resource limitations and the need to maximize AMSRH resources given the demand/burden of disease (draw data from GBD).

2) Define inputs and outputs earlier in the methods and use them to define the analysis in layman’s terms. I am not familiar with SFA so I will defer to the other reviewers on this analysis.

3) Do not discuss the paucity of mental health care in Methods; that is Results.

4) Start the discussion with one paragraph summary of results then describe i) how the methods may be used to evaluate technical efficiency in other low-resource settings and/or other specializations and ii) how the results may be used to improve technical efficiency, in other words, advise where efforts to improve resource efficiency should be focused. Be specific.

5) De-emphasize privacy from the Discussion unless you have additional data on privacy to contribute to the Results.

I thank the authors for their efforts and wish them the best of luck in future submissions.

Reviewer #3: Please see additional file for comments.

This study estimates the technical efficiency of adolescent sexual and reproductive health services among healthcare facilities in Greater Accra Region, Ghana and their environmental determinants. The authors use stochastic frontier analysis to estimate the technical efficiency of each healthcare facility, then multivariable regression analysis to assess the statistical relationships between environmental characteristics and technical efficiency. The authors find that healthcare facilities provide adolescent sexual and reproductive health services at approximately 60% efficiency, but with significant heterogeneity across the sample. Services covered by clinical staff, insurance coverage, the Gini Index, and the literacy rate were all statistically significant. This research provides an assessment of technical efficiency of specific services that are vital for the growing youth population in Ghana, as well as evidence for future policies that could improve the efficiency of those services if implemented.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: PONE-D-24-09524_Review.pdf

PONE-D-24-09524R1Technical Efficiency of Primary Health Facilities in Providing Adolescent Mental, Sexual and Reproductive Health Services in Ghana: a case study of selected districts in the Greater Accra RegionPLOS ONE

Dear Dr. Fenny,

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 invited you to submit the revised version. Please submit your revised manuscript by Mar 03 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.

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,

Yitagesu Habtu Aweke, Ph.D

Academic Editor

PLOS ONE

Journal Requirements:

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:

 In addition to the reviewer's minor issues, you may consider the following comments: 

• In your abstract section, "Primary healthcare (PHC) facilities have become essential in promoting adolescent healthcare, yet they face resource limitations that hinder their effectiveness. Ensuring the efficient use of available resources has therefore become pertinent.” Yes, it is important, but what was your research questions?  Describing the research question (gaps) that led you to assess the technical efficiency of primary health care facilities benefits the clarity before you state your objective (i.e., This study assessed.....)
• Numbering headings, and sub-heading adds minimal benefits to the clarity of your content in some sections. So, it’s important to think over removing numbering of headings and subheadings  or  collapsing some third-level headings into second level, and succinctly describing them benefit the clarity and organization of the manuscript. e.g. collapse "2.3.1 "  in your method section into  2.3, and do the same thing in your result section, eg. 3.2.1.... Finally, avoid the sub-sectioning, and continue as “Introduction”, “methods”, “results”, Discussion”, “conclusion”...
• Break your  "3.0 Results and discussion" into separate levels  as " Results", " Discussion"
• Your discussion seems to lack depth. Please first, summarize what you learned from the results, and discuss and compare your findings with other studies in Ghana. There are studies within Ghana, and other countries with nearly similar contexts,  possible bias, limitations, policy implications etc

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: (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 #3: Yes

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

Reviewer #3: 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 #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 #3: No

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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: Dear authors,

Thank you for the opportunity to review this new submission, and for your detailed responses to my comments and those of the other reviewers. As I wrote earlier, I enjoyed reading this article for your study on the technical efficiency of adolescent health services in Ghana.

In the introduction, please carefully review the formatting for citations, since several are outside of the sentences to which they belong.

In the materials and methods section, please define DEA (line 126) and add some context to what "flexibility" means for the translog function (line 151).

For the results, in Table 2, please clarify what "Insurance" as a characteristic means. Also, I want to reiterate that, for lines 262-273, for many of the facility characteristics, the differences in mean efficiency scores is very small and the confidence intervals overlap. For example, the mean score for rural facilities is 0.630, but that score is fits in the confidence interval for urban facilities. Therefore, I am unsure if you can say that they differences are statistically significant, as you do in lines 272-273. This is even more pronounced--that the mean scores are very narrowly different--for characteristics like facility laboratory or gender of facility head.

Finally, for the discussion, I saw that you revised the writing around fieldwork observations. I suggest adding some language to couch the statements as from your or the data collection team's perspectives. For example, "We heard from adolescent patients that they would prefer to self-medicate..." While I saw that you addressed my comment about sample size, I recommend that you discuss this as a limitation to the study. I am not familiar with the SFA, but I wonder whether ~50 firms in the analytic sample is sufficient, especially with the 20 covariates in the final models. I looked around and found some studies that simulate SFA models under different sample sizes, like Cheng et al. (2024): https://www.sciencedirect.com/science/article/pii/S0304407622000677.

Throughout the paper, there are still grammatical errors and formatting issues that need to be addressed, including extra spaces, missing periods, incomplete sentences, etc.

Thank you!

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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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[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.

Technical Efficiency of Primary Health Facilities in Providing Adolescent Mental, Sexual and Reproductive Health Services in Ghana: a case study of selected districts in the Greater Accra Region

PONE-D-24-09524R2

Dear Dr. Ama Pokuaa Fenny,

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,

Yitagesu Habtu Aweke, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Although they don't have much impact on the scientific content, and readability effect, it is good if you are able to:

  avoid numbering of  "headings" and "subheading"  because you have a maximum of two headings

avoid "Materials" from the "Materials and Methods"

remove "Acknowledgements"  if you don't have anybody to acknowledge,  instead of writing "Not applicable".