Health service utilization and associated factors among fee waiver beneficiaries in Ethiopia: Systematic review and meta-analysis

Bizunesh Fantahun Kase; Hiwot Altaye Asebe; Etsay Woldu Anbesu; Dejen Kahsay Asgedom; Abubeker Alebachew Seid; Abdulkerim Hassen Moloro; Aragaw Asfaw Hasen; Nuru Mohammed Hussen; Molla Getie Mehari; Kassaye Getaneh Arge; Abdu Hailu Shibeshi

doi:10.1371/journal.pone.0326131

Peer Review History

Original SubmissionJanuary 29, 2025
29 Jan 2025 Author Response https://doi.org/10.1371/journal.pone.0326131.r001
Decision Letter - Daniel Ogbuabor, Editor Dear Dr. Kase, 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: The finding on residence is missing from the abstract results. The introduction can be improved by consolidating the first two paragraphs into one and highlighting fee waiver as a pathway to universal health coverage and equitable access to health care. Lines 50-51 focus on rural and remote areas. The authors should also highlight urban inequities in access to healthcare. In line 67-71, the authors describe the fee waiver policy in Ethiopia, but this case description needs expansion. In line 72-75, the authors analyse the knowledge gap, but this gap analysis is not comprehensive. The authors should review the pertinent literature on how fee waiver policies influence health service utilization elsewhere to enrich the gap analysis. The authors should also be more systematic in the Discussion section. Discuss the pooled prevalence, regional and sub-group variations first, and then the factors affacting health service utilisation. Notably, the findings about place of residence was not discussed. So, the authors should include a discussion of the urban-rural disparity in health service utilisation. Please submit your revised manuscript by May 19 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'. 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, Daniel Chukwuemeka Ogbuabor, Ph.D., M.D. 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. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following: A numbered table of all studies identified in the literature search, including those that were excluded from the analyses. For every excluded study, the table should list the reason(s) for exclusion. If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed. A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study: Name of data extractors and date of data extraction Confirmation that the study was eligible to be included in the review. All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses. If data or supporting information were obtained from another source (e.g. correspondence with the author of the original research article), please provide the source of data and dates on which the data/information were obtained by your research group. If applicable for your analysis, a table showing the completed risk of bias and quality/certainty assessments for each study or outcome. Please ensure this is provided for each domain or parameter assessed. For example, if you used the Cochrane risk-of-bias tool for randomized trials, provide answers to each of the signalling questions for each study. If you used GRADE to assess certainty of evidence, provide judgements about each of the quality of evidence factor. This should be provided for each outcome. An explanation of how missing data were handled. This information can be included in the main text, supplementary information, or relevant data repository. Please note that providing these underlying data is a requirement for publication in this journal, and if these data are not provided your manuscript might be rejected. 3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 5. 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 finding on residence is missing from the abstract results. The introduction can be improved by consolidating the first two paragraphs into one and highlighting fee waiver as a pathway to universal health coverage and equitable access to health care. Lines 50-51 focus on rural and remote areas. The authors should also highlight urban inequities in access to healthcare. In line 67-71, the authors describe the fee waiver policy in Ethiopia, but this case description needs expansion. In line 72-75, the authors analyse the knowledge gap, but this gap analysis is not comprehensive. The authors should review the pertinent literature on how fee waiver policies influence health service utilization elsewhere to enrich the gap analysis. The authors should also be more systematic in the Discussion section. Discuss the pooled prevalence, regional and sub-group variations first, and then the factors affacting health service utilisation. Notably, the findings about place of residence was not discussed. So, the authors should include a discussion of the urban-rural disparity in health service utilisation. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? 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 Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The manuscript is well-structured, and the data presented robustly supports the conclusions drawn. All data is fully accessible, and the statistical analysis has been conducted with appropriate rigor. While the manuscript is generally clear and written in standard English, several grammatical errors are present throughout. These should be carefully reviewed and revised to ensure the precise and accurate communication of the research findings, thereby enhancing clarity and reinforcing the author's expertise. Reviewer #2: Abstract: no need to put again the percentage at the conclusion. Re-paraphrase the conclusion as the findings. Line 41-42 can leave there as for the recommendation of the study. Introduction: perfect and clear Methods: okey Results: Line 208 (OR = 0.69; 95% CI: 0.51, 0.95), please check for the notation at the CI. I think it supposes to be minus (-) to replace coma (,). Discussion: Okey Conclusion: Line 285-286 can be deleted for this sentence “Based on seven primary studies with a total of 11,488 participants, the pooled prevalence of health service utilization was 60.57%, indicating moderate utilization levels” as it has already mentioned at the results and discussion. ****** 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: Yes: Dr. Nicole Bell-Rogers FNP-C, PMHNP-BC, RN Reviewer #2: Yes: Ni Ketut Aryastami ******** [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 Attachments Attachment Submitted filename: T_comments_PONE D-25-04792.docx https://doi.org/10.1371/journal.pone.0326131.r002
Revision 1
12 May 2025 Author Response Point by Point Response to the Editor, and Reviewers Comments Title: Health service utilization and associated factors among fee waiver beneficiaries in Ethiopia: Systematic review and meta-analysis Manuscript ID: PONE-D-25-04792 Date: May, 2025 Subject: Revision of the manuscript Dear Editor and Reviewers, we sincerely appreciate the time and effort you have dedicated to reviewing our manuscript and providing insightful comments. We found your feedback to be constructive and vital in improving the quality of our work. In response, we have carefully revised the manuscript and addressed all the questions and comments raised by the editors and reviewers. As requested, we have included a point-by-point response to your feedback below. Thank you once again for your valuable input. Sincerely, On behalf of Co-authors. Bizunesh Fantahun Kase (Corresponding Author) Journal 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 Response: Thank you for the reminder. We have reviewed and updated the manuscript and all associated files to ensure they meet PLOS ONE's style requirements. 2. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following: A numbered table of all studies identified in the literature search, including those that were excluded from the analyses. For every excluded study, the table should list the reason(s) for exclusion. If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed. A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study: Name of data extractors and date of data extraction Confirmation that the study was eligible to be included in the review. All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses. If data or supporting information were obtained from another source (e.g. correspondence with the author of the original research article), please provide the source of data and dates on which the data/information were obtained by your research group. If applicable for your analysis, a table showing the completed risk of bias and quality/certainty assessments for each study or outcome. Please ensure this is provided for each domain or parameter assessed. For example, if you used the Cochrane risk-of-bias tool for randomized trials, provide answers to each of the signalling questions for each study. If you used GRADE to assess certainty of evidence, provide judgements about each of the quality of evidence factor. This should be provided for each outcome. An explanation of how missing data were handled. This information can be included in the main text, supplementary information, or relevant data repository. Please note that providing these underlying data is a requirement for publication in this journal, and if these data are not provided your manuscript might be rejected. Response: Thank you for your detailed and helpful instructions regarding data availability. We have ensured that all required information is included in the revised manuscript and supplementary materials. 3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table. Response: Thank you for your helpful comment. We have now referenced Table 2 in the text of the manuscript. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: Thank you for your helpful suggestion. We have included captions for all Supporting Information files at the end of the revised manuscript. 5. 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. Response: Thank you for your careful review. We have thoroughly reviewed the reference list and can confirm that no retracted references are included in the manuscript. All references cited are current and appropriate for the study. Editor's Comments and Authors’ Response 1. The finding on residence is missing from the abstract results. Response: We appreciate your careful review of our manuscript. In response to your comment, we have now included the finding on residence in the abstract results section. 2. The introduction can be improved by consolidating the first two paragraphs into one and highlighting fee waiver as a pathway to universal health coverage and equitable access to health care. Response: Thank you for your valuable comment. We have addressed this point in the revised manuscript as requested. 3. Lines 50-51 focus on rural and remote areas. The authors should also highlight urban inequities in access to healthcare. Response: We appreciate the suggestion to address urban inequities in access to healthcare. In response, we have revised the manuscript to highlight urban inequalities alongside those in rural areas. 4. In line 67-71, the authors describe the fee waiver policy in Ethiopia, but this case description needs expansion. Response: Thank you for your valuable comment. We have now expanded the description to provide greater clarity and context. 5. In line 72-75, the authors analyse the knowledge gap, but this gap analysis is not comprehensive. The authors should review the pertinent literature on how fee waiver policies influence health service utilization elsewhere to enrich the gap analysis. Response: Thank you for your insightful suggestion. We have addressed this comment by expanding the gap analysis in the revised manuscript. We have reviewed and incorporated relevant literature on the influence of fee waiver policies on health service utilization in other settings. 6. The authors should also be more systematic in the Discussion section. Discuss the pooled prevalence, regional and sub-group variations first, and then the factors affecting health service utilisation. Response: Thank you for your constructive feedback. We have considered your suggestion and revised the Discussion section accordingly. 7. Notably, the findings about place of residence was not discussed. So, the authors should include a discussion of the urba--n-rural disparity in health service utilisation. Response: Thank you for highlighting this important point. We have addressed your comment by including a discussion of the urban-rural disparity in health service utilization in the revised manuscript. Reviewer #1 1. The manuscript is well-structured, and the data presented robustly supports the conclusions drawn. All data is fully accessible, and the statistical analysis has been conducted with appropriate rigor. While the manuscript is generally clear and written in standard English, several grammatical errors are present throughout. These should be carefully reviewed and revised to ensure the precise and accurate communication of the research findings, thereby enhancing clarity and reinforcing the author's expertise. Response: Thank you for your positive feedback. We have carefully reviewed the manuscript and revised the grammatical errors to ensure accurate communication of our findings. Reviewer #2 1. Abstract: no need to put again the percentage at the conclusion. Re-paraphrase the conclusion as the findings. Response: We appreciate your suggestion. We have revised the conclusion section of the abstract by removing the repeated percentage and rephrasing it. 2. Line 41-42 can leave there as for the recommendation of the study. Response: Thank you for your valuable comment. We included the statement in the abstract in accordance with the PLOS ONE submission guidelines, which recommend summarizing the most important results and their significance. Additionally, previously published research articles in the journal also report recommendations under the conclusion section of the abstract. However, if our explanation does not fully address your concern, we are willing to revise the manuscript based on your recommendation. 3. Introduction: perfect and clear Response: Thank you for the positive feedback on the introduction. 4. Methods: okey Response: We appreciate your positive assessment. 5. Results: Line 208 (OR = 0.69; 95% CI: 0.51, 0.95), please check for the notation at the CI. I think it supposes to be minus (-) to replace coma (,). Response: Thank you for your comment. We have reviewed and corrected the notation in the confidence interval. 6. Discussion: Okey Response: Thank you for the positive feedback 7. Conclusion: Line 285-286 can be deleted for this sentence “Based on seven primary studies with a total of 11,488 participants, the pooled prevalence of health service utilization was 60.57%, indicating moderate utilization levels” as it has already mentioned at the results and discussion. Response: Thank you for your insightful comment. We agree with your suggestion and have deleted the sentence to avoid redundancy. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0326131.r003
Decision Letter - Daniel Ogbuabor, Editor Dear Dr. Kase, In the Background, line 57-61 of the revised manuscript focused on the pertinent literature. However, four papers are few, and do not represent the existing scholarship in this area. Equally, the ommitted the review of the factors associated with utilization of free care services. In the Discussion section, the authors should expunge the last sentence of the first paragraph of the Discussion section. In its place, they should summarize the key findings that were subsequently discussed. In the Discussion, the authors completely ommitted comparing the study's findings with existing literature. It is the practice to compare study findings to existing literature and explain any variations. Doing this will enrich the discussion. Please submit your revised manuscript by Jun 29 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'. 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, Daniel Chukwuemeka Ogbuabor, Ph.D., M.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: I commend the authors for addressing most the comments. Nevertheless, there are a few important concerns that must be addressed to bring the manuscript to a publishable level. In the Background, line 57-61 of the revised manuscript focused on the pertinent literature. However, four papers are few, and do not represent the existing scholarship in this area. Equally, the ommitted the review of the factors associated with utilization of free care services. In the Discussion section, the authors should expunge the last sentence of the first paragraph of the Discussion section. In its place, they should summarize the key findings that were subsequently discussed. The authors completely ommitted comparing the study's findings with existing literature. It is the practice to compare study findings to existing literature and explain any variations. Doing this will enrich the discussion. [Note: HTML markup is below. Please do not edit.] [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. https://doi.org/10.1371/journal.pone.0326131.r004
Revision 2
17 May 2025 Author Response Point by Point Response to the Editor, and Reviewers Comments Title: Health service utilization and associated factors among fee waiver beneficiaries in Ethiopia: Systematic review and meta-analysis Manuscript ID: PONE-D-25-04792 Date: May, 2025 Subject: Revision of the manuscript Dear Editor and Reviewers, we sincerely appreciate the time and effort you have dedicated to reviewing our manuscript and providing insightful comments. We found your feedback to be constructive and vital in improving the quality of our work. In response, we have carefully revised the manuscript and addressed all the questions and comments raised by the editors and reviewers. As requested, we have included a point-by-point response to your feedback below. Thank you once again for your valuable input. Sincerely, On behalf of Co-authors. Bizunesh Fantahun Kase (Corresponding Author) Journal 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 Response: Thank you for the reminder. We have reviewed and updated the manuscript and all associated files to ensure they meet PLOS ONE's style requirements. 2. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following: A numbered table of all studies identified in the literature search, including those that were excluded from the analyses. For every excluded study, the table should list the reason(s) for exclusion. If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed. A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study: Name of data extractors and date of data extraction Confirmation that the study was eligible to be included in the review. All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses. If data or supporting information were obtained from another source (e.g. correspondence with the author of the original research article), please provide the source of data and dates on which the data/information were obtained by your research group. If applicable for your analysis, a table showing the completed risk of bias and quality/certainty assessments for each study or outcome. Please ensure this is provided for each domain or parameter assessed. For example, if you used the Cochrane risk-of-bias tool for randomized trials, provide answers to each of the signalling questions for each study. If you used GRADE to assess certainty of evidence, provide judgements about each of the quality of evidence factor. This should be provided for each outcome. An explanation of how missing data were handled. This information can be included in the main text, supplementary information, or relevant data repository. Please note that providing these underlying data is a requirement for publication in this journal, and if these data are not provided your manuscript might be rejected. Response: Thank you for your detailed and helpful instructions regarding data availability. We have ensured that all required information is included in the revised manuscript and supplementary materials. 3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table. Response: Thank you for your helpful comment. We have now referenced Table 2 in the text of the manuscript. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: Thank you for your helpful suggestion. We have included captions for all Supporting Information files at the end of the revised manuscript. 5. 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. Response: Thank you for your careful review. We have thoroughly reviewed the reference list and can confirm that no retracted references are included in the manuscript. All references cited are current and appropriate for the study. Editor's Comments and Authors’ Response 1. The finding on residence is missing from the abstract results. Response: We appreciate your careful review of our manuscript. In response to your comment, we have now included the finding on residence in the abstract results section. 2. The introduction can be improved by consolidating the first two paragraphs into one and highlighting fee waiver as a pathway to universal health coverage and equitable access to health care. Response: Thank you for your valuable comment. We have addressed this point in the revised manuscript as requested. 3. Lines 50-51 focus on rural and remote areas. The authors should also highlight urban inequities in access to healthcare. Response: We appreciate the suggestion to address urban inequities in access to healthcare. In response, we have revised the manuscript to highlight urban inequalities alongside those in rural areas. 4. In line 67-71, the authors describe the fee waiver policy in Ethiopia, but this case description needs expansion. Response: Thank you for your valuable comment. We have now expanded the description to provide greater clarity and context. 5. In line 72-75, the authors analyse the knowledge gap, but this gap analysis is not comprehensive. The authors should review the pertinent literature on how fee waiver policies influence health service utilization elsewhere to enrich the gap analysis. Response: Thank you for your insightful suggestion. We have addressed this comment by expanding the gap analysis in the revised manuscript. We have reviewed and incorporated relevant literature on the influence of fee waiver policies on health service utilization in other settings. 6. The authors should also be more systematic in the Discussion section. Discuss the pooled prevalence, regional and sub-group variations first, and then the factors affecting health service utilisation. Response: Thank you for your constructive feedback. We have considered your suggestion and revised the Discussion section accordingly. 7. Notably, the findings about place of residence was not discussed. So, the authors should include a discussion of the urba--n-rural disparity in health service utilisation. Response: Thank you for highlighting this important point. We have addressed your comment by including a discussion of the urban-rural disparity in health service utilization in the revised manuscript. 8. In the Background, line 57-61 of the revised manuscript focused on the pertinent literature. However, four papers are few, and do not represent the existing scholarship in this area. Equally, the ommitted the review of the factors associated with utilization of free care services. Response: Thank you for the comment. We have expanded the Background section to include additional relevant literature and add information on key factors associated with the utilization of health services among fee waiver beneficiaries as suggested. 9. In the Discussion section, the authors should expunge the last sentence of the first paragraph of the Discussion section. In its place, they should summarize the key findings that were subsequently discussed. Response: Thank you. We have removed the sentence and replaced it with a summary of the key findings as advised. 10. In the Discussion, the authors completely ommitted comparing the study's findings with existing literature. It is the practice to compare study findings to existing literature and explain any variations. Doing this will enrich the discussion. Response: Thank you for the insightful comment. We have now expanded the Discussion section to compare our findings with existing literature. Reviewer #1 1. The manuscript is well-structured, and the data presented robustly supports the conclusions drawn. All data is fully accessible, and the statistical analysis has been conducted with appropriate rigor. While the manuscript is generally clear and written in standard English, several grammatical errors are present throughout. These should be carefully reviewed and revised to ensure the precise and accurate communication of the research findings, thereby enhancing clarity and reinforcing the author's expertise. Response: Thank you for your positive feedback. We have carefully reviewed the manuscript and revised the grammatical errors to ensure accurate communication of our findings. Reviewer #2 1. Abstract: no need to put again the percentage at the conclusion. Re-paraphrase the conclusion as the findings. Response: We appreciate your suggestion. We have revised the conclusion section of the abstract by removing the repeated percentage and rephrasing it. 2. Line 41-42 can leave there as for the recommendation of the study. Response: Thank you for your valuable comment. We included the statement in the abstract in accordance with the PLOS ONE submission guidelines, which recommend summarizing the most important results and their significance. Additionally, previously published research articles in the journal also report recommendations under the conclusion section of the abstract. However, if our explanation does not fully address your concern, we are willing to revise the manuscript based on your recommendation. 3. Introduction: perfect and clear Response: Thank you for the positive feedback on the introduction. 4. Methods: okey Response: We appreciate your positive assessment. 5. Results: Line 208 (OR = 0.69; 95% CI: 0.51, 0.95), please check for the notation at the CI. I think it supposes to be minus (-) to replace coma (,). Response: Thank you for your comment. We have reviewed and corrected the notation in the confidence interval. 6. Discussion: Okey Response: Thank you for the positive feedback 7. Conclusion: Line 285-286 can be deleted for this sentence “Based on seven primary studies with a total of 11,488 participants, the pooled prevalence of health service utilization was 60.57%, indicating moderate utilization levels” as it has already mentioned at the results and discussion. Response: Thank you for your insightful comment. We agree with your suggestion and have deleted the sentence to avoid redundancy. Attachments Attachment Submitted filename: Response_to_reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0326131.r005
Decision Letter - Daniel Ogbuabor, Editor Dear Dr. Bizunesh Fantahun Kase, 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. The study set significance level at p-value less than 0.05. On page 20, Table 2 indicates that family size with p-value = 0.47 is not significant, while urban residence and having chronic disease significantly influenced health service utilisation (p-value <0.001). However, the abstract, results, and discussion sections indicate that residence do not significantly influence health service utilization, while family size significantly influenced health utilization. The discrepancies between Table 2 and the narratives need clarification from the authors, as these could affect the abstract, results and discussion. ============================== Please submit your revised manuscript by 4 June 2025. 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'. 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, Daniel Chukwuemeka Ogbuabor, Ph.D., M.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 (if provided): The study set significance level at p-value less than 0.05. On page 20, Table 2 indicates that family size with p-value = 0.47 is not significant, while urban residence and having chronic disease significantly influenced health service utilisation (p-value <0.001). However, the abstract, results, and discussion sections indicate that residence do not significantly influence health service utilization, while family size significantly influenced health utilization. The discrepancies between Table 2 and the narratives need clarification from the authors, as these could affect the abstract, results and discussion. [Note: HTML markup is below. Please do not edit.] [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 https://doi.org/10.1371/journal.pone.0326131.r006
Revision 3
22 May 2025 Author Response Point by Point Response to the Editor, and Reviewers Comments Title: Health service utilization and associated factors among fee waiver beneficiaries in Ethiopia: Systematic review and meta-analysis Manuscript ID: PONE-D-25-04792 Date: May, 2025 Subject: Revision of the manuscript Dear Editor and Reviewers, we sincerely appreciate the time and effort you have dedicated to reviewing our manuscript and providing insightful comments. We found your feedback to be constructive and vital in improving the quality of our work. In response, we have carefully revised the manuscript and addressed all the questions and comments raised by the editors and reviewers. As requested, we have included a point-by-point response to your feedback below. Thank you once again for your valuable input. Sincerely, On behalf of Co-authors. Bizunesh Fantahun Kase (Corresponding Author) Journal 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 Response: Thank you for the reminder. We have reviewed and updated the manuscript and all associated files to ensure they meet PLOS ONE's style requirements. 2. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following: A numbered table of all studies identified in the literature search, including those that were excluded from the analyses. For every excluded study, the table should list the reason(s) for exclusion. If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed. A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study: Name of data extractors and date of data extraction Confirmation that the study was eligible to be included in the review. All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses. If data or supporting information were obtained from another source (e.g. correspondence with the author of the original research article), please provide the source of data and dates on which the data/information were obtained by your research group. If applicable for your analysis, a table showing the completed risk of bias and quality/certainty assessments for each study or outcome. Please ensure this is provided for each domain or parameter assessed. For example, if you used the Cochrane risk-of-bias tool for randomized trials, provide answers to each of the signalling questions for each study. If you used GRADE to assess certainty of evidence, provide judgements about each of the quality of evidence factor. This should be provided for each outcome. An explanation of how missing data were handled. This information can be included in the main text, supplementary information, or relevant data repository. Please note that providing these underlying data is a requirement for publication in this journal, and if these data are not provided your manuscript might be rejected. Response: Thank you for your detailed and helpful instructions regarding data availability. We have ensured that all required information is included in the revised manuscript and supplementary materials. 3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table. Response: Thank you for your helpful comment. We have now referenced Table 2 in the text of the manuscript. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: Thank you for your helpful suggestion. We have included captions for all Supporting Information files at the end of the revised manuscript. 5. 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. Response: Thank you for your careful review. We have thoroughly reviewed the reference list and can confirm that no retracted references are included in the manuscript. All references cited are current and appropriate for the study. Editor's Comments and Authors’ Response 1. The finding on residence is missing from the abstract results. Response: We appreciate your careful review of our manuscript. In response to your comment, we have now included the finding on residence in the abstract results section. 2. The introduction can be improved by consolidating the first two paragraphs into one and highlighting fee waiver as a pathway to universal health coverage and equitable access to health care. Response: Thank you for your valuable comment. We have addressed this point in the revised manuscript as requested. 3. Lines 50-51 focus on rural and remote areas. The authors should also highlight urban inequities in access to healthcare. Response: We appreciate the suggestion to address urban inequities in access to healthcare. In response, we have revised the manuscript to highlight urban inequalities alongside those in rural areas. 4. In line 67-71, the authors describe the fee waiver policy in Ethiopia, but this case description needs expansion. Response: Thank you for your valuable comment. We have now expanded the description to provide greater clarity and context. 5. In line 72-75, the authors analyse the knowledge gap, but this gap analysis is not comprehensive. The authors should review the pertinent literature on how fee waiver policies influence health service utilization elsewhere to enrich the gap analysis. Response: Thank you for your insightful suggestion. We have addressed this comment by expanding the gap analysis in the revised manuscript. We have reviewed and incorporated relevant literature on the influence of fee waiver policies on health service utilization in other settings. 6. The authors should also be more systematic in the Discussion section. Discuss the pooled prevalence, regional and sub-group variations first, and then the factors affecting health service utilisation. Response: Thank you for your constructive feedback. We have considered your suggestion and revised the Discussion section accordingly. 7. Notably, the findings about place of residence was not discussed. So, the authors should include a discussion of the urba--n-rural disparity in health service utilisation. Response: Thank you for highlighting this important point. We have addressed your comment by including a discussion of the urban-rural disparity in health service utilization in the revised manuscript. 8. In the Background, line 57-61 of the revised manuscript focused on the pertinent literature. However, four papers are few, and do not represent the existing scholarship in this area. Equally, the ommitted the review of the factors associated with utilization of free care services. Response: Thank you for the comment. We have expanded the Background section to include additional relevant literature and add information on key factors associated with the utilization of health services among fee waiver beneficiaries as suggested. 9. In the Discussion section, the authors should expunge the last sentence of the first paragraph of the Discussion section. In its place, they should summarize the key findings that were subsequently discussed. Response: Thank you. We have removed the sentence and replaced it with a summary of the key findings as advised. 10. In the Discussion, the authors completely ommitted comparing the study's findings with existing literature. It is the practice to compare study findings to existing literature and explain any variations. Doing this will enrich the discussion. Response: Thank you for the insightful comment. We have now expanded the Discussion section to compare our findings with existing literature. 11. The study set significance level at p-value less than 0.05. On page 20, Table 2 indicates that family size with p-value = 0.47 is not significant, while urban residence and having chronic disease significantly influenced health service utilisation (p-value <0.001). However, the abstract, results, and discussion sections indicate that residence do not significantly influence health service utilization, while family size significantly influenced health utilization. The discrepancies between Table 2 and the narratives need clarification from the authors, as these could affect the abstract, results and discussion. Response: Thank you for your valuable observation, and we sincerely apologize for the confusion caused. Regarding the p value reported in table two, we would like to clarify that I² indicates the percentage of heterogeneity, and the accompanying p-value is from Cochran’s Q test, which assesses the statistical significance of this heterogeneity. A p-value < 0.05 suggests significant heterogeneity. This explanation has now been clearly stated in the footnote of Table 2 in the revised manuscript. Reviewer #1 1. The manuscript is well-structured, and the data presented robustly supports the conclusions drawn. All data is fully accessible, and the statistical analysis has been conducted with appropriate rigor. While the manuscript is generally clear and written in standard English, several grammatical errors are present throughout. These should be carefully reviewed and revised to ensure the precise and accurate communication of the research findings, thereby enhancing clarity and reinforcing the author's expertise. Response: Thank you for your positive feedback. We have carefully reviewed the manuscript and revised the grammatical errors to ensure accurate communication of our findings. Reviewer #2 1. Abstract: no need to put again the percentage at the conclusion. Re-paraphrase the conclusion as the findings. Response: We appreciate your suggestion. We have revised the conclusion section of the abstract by removing the repeated percentage and rephrasing it. 2. Line 41-42 can leave there as for the recommendation of the study. Response: Thank you for your valuable comment. We included the statement in the abstract in accordance with the PLOS ONE submission guidelines, which recommend summarizing the most important results and their significance. Additionally, previously published research articles in the journal also report recommendations under the conclusion section of the abstract. However, if our explanation does not fully address your concern, we are willing to revise the manuscript based on your recommendation. 3. Introduction: perfect and clear Response: Thank you for the positive feedback on the introduction. 4. Methods: okey Response: We appreciate your positive assessment. 5. Results: Line 208 (OR = 0.69; 95% CI: 0.51, 0.95), please check for the notation at the CI. I think it supposes to be minus (-) to replace coma (,). Response: Thank you for your comment. We have reviewed and corrected the notation in the confidence interval. 6. Discussion: Okey Response: Thank you for the positive feedback 7. Conclusion: Line 285-286 can be deleted for this sentence “Based on seven primary studies with a total of 11,488 participants, the pooled prevalence of health service utilization was 60.57%, indicating moderate utilization levels” as it has already mentioned at the results and discussion. Response: Thank you for your insightful comment. We agree with your suggestion and have deleted the sentence to avoid redundancy. Attachments Attachment Submitted filename: Response to comments.docx https://doi.org/10.1371/journal.pone.0326131.r007
Decision Letter - Daniel Ogbuabor, Editor <p>Health service utilization and associated factors among fee waiver beneficiaries in Ethiopia: Systematic review and meta-analysis PONE-D-25-04792R3 Dear Dr. Bizunesh Fantahun Kase, 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, Daniel Chukwuemeka Ogbuabor, Ph.D., M.D. Academic Editor PLOS ONE Additional Editor Comments (optional): The paper is accepted but the authors should insert the p-values for the odd ratios in Table 2. The p-values for the index of heterogeneity of the papers does not replace those of the odd ratios. Reviewers' comments: https://doi.org/10.1371/journal.pone.0326131.r008
Formally Accepted
Acceptance Letter - Daniel Ogbuabor, Editor PONE-D-25-04792R3 PLOS ONE Dear Dr. Kase, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Daniel Chukwuemeka Ogbuabor Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0326131.r009

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