Transforming multi-stakeholder engagement towards coproduction of optimized maternal, newborn, and child health and a resilient community health system in rural Ethiopia: A qualitative study

PLOS ONE

Dear Dr. Gebremeskel,

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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?

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Thank you for the study that highlights a growing interest and need to incorporate community voices and ideas in what affects their own health in an attempt to get communities to own and become responsible for their health. the article is generally well written, with a few suggestions to consider.

Please check that the numbers are correct on Introduction, page 4, paragraph 4 on the proportion of health finance.

In the results section, I suggest that the authors reduce text on the much longer themes and have a balance in the number of quotes presented across all themes.

Under Barriers, "the challenges of alignment", "lack of systemic coordination and patforms" and inadequate

coordination and implementation capacity" seem to refer to the same thing in their current presentation.

THe Abbreviation list is not complete, e.g. SSA not included

There a few typing errors. e.g. finding vs findings

Reference: there is not consistency in the reference list, stick to one style and and be consistent to what you choose. Some years missing, use of short or full names for journal names, use of month and date for some and not for others.

Reviewer #2: Abstract

In the abstract section-Methods: We conducted a qualitative case study – not recommended in research writing to use We/I – instead better - A qualitative case study was conducted …

Check and correct all – in the case of using abbreviation in the first place write the full word (abbreviation).

In the abstract the conclusion is not supported by the result stated?

Methods

In research setting – The authors wrote more detail about Ethiopia but focus on the study setting.

In this research, the nested nature of the case study encompasses two distinct populations including HEWs/CHWs (16 FGD participant), and subnational and national public health policy actors (12 KII participant).

The authors not include the community or service users – so lack triangulation in this aspect. If you can better inclued.

KII participants Key

Informants were recruited based on their known involvement in the policy process leading to the planning and the implementation of CHWs/ MNCH program.

The authors need specify the number from working at regional and ministry separately – because these are responsible for policy issues.

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Reviewer #1: No

Reviewer #2: Yes:  Esubalew Tesfahun

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Dear Dr. Gebremeskel,

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.

The reviewers have provided the following suggestions. Please make your best effort in addressing them.

Reviewer #3:

1. Addressing PLOS ONE’s open data policy by specifying whether anonymized transcripts or coding frameworks can be shared.

2. Expand the conclusion by providing more actionable recommendations on how policymakers and practitioners can implement the findings.

Reviewer #4:

Introduction (Pages 1-5)

o Page 5- I would like to see the figure of the final theoretical framework.

o The section could clarify how multi-stakeholder engagement differs from traditional public-private partnerships.

o Consider briefly discussing power dynamics (government vs. NGOs, local vs. international stakeholders).

Methods (Pages 5-8)

o It would be helpful to clarify why West Shewa Zone was selected.

o You said it was translated from Amharic and Oromia languages, how did you the translation consistency and inter-rater reliability? Consider discussing inter-coder reliability or alternative interpretations.

o Page 8 - Explain why data was manually coded instead of using qualitative software like NVivo. Provide more details on how data saturation was determined and why manual coding was preferred over software.

o Please add more detail on how themes were developed inductively/deductively would strengthen credibility. If it is both inductive and deductive, specify how themes emerged and how prior frameworks influenced coding.

o In the recent publications by Braun & Clarke (2021), emphasized the importance of clarifying the theoretical and philosophical assumptions underlying the chosen thematic analysis procedure. Clearly state epistemological and ontological assumptions. Is the study critical realist, constructivist, or positivist? Does it assume an objective reality (realism) or multiple realities (relativism)?

Results (Pages 9-15)

o Some quotes are long, consider summarizing or paraphrasing for clarity.

o The concept of "donor dependency" is discussed but could be linked to alternative funding solutions.

Discussion (Pages 16-19)

o More discussion on CHW mental health/workload challenges would strengthen practical implications.

o Provide examples of successful coproduction models from other LMICs for comparison.

Please submit your revised manuscript by May 24 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,

Tatchalerm Sudhipongpracha

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.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: N/A

Reviewer #4: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #2: I see this revised manuscript and confirmed that all my comments have been addressed, no addtional comments.

Reviewer #3: The manuscript presents a timely study and addresses critical gaps in the literature regarding the intersection of multi-stakeholder collaboration and community health resilience. The authors provide a thorough background, theoretical framework, and methodology to support their research.

Regarding response to previous comments, the authors have adequately responded to prior concerns and incorporated relevant revisions.

The manuscript describes a technically sound qualitative study using appropriate data collection and analysis methods, with a well detailed thematic analysis. The findings are in line with the data presented, which further supports the study’s conclusions.

A statistical analysis is not applicable in this study as this is a qualitative study. However, the thematic coding and methodological rigor ensure validity.

Regarding data availability, although the data availability statement indicates restrictions on sharing interview transcripts due to ethical considerations. However, PLOS ONE has an open data policy that encourages data transparency. I would recommend that the authors specify if anonymized versions of transcripts or coding frameworks could be shared upon reasonable request.

Overall, the manuscript is well-organized, and the language is clear and intelligible. The study fills an important gap in understanding multi-stakeholder engagement for MNCH services in Ethiopia, and its findings have practical implications for improving stakeholder collaboration in community health systems. However, there are a few areas for improvement such as;

1. Addressing PLOS ONE’s open data policy by specifying whether anonymized transcripts or coding frameworks can be shared.

2. Expand the conclusion by providing more actionable recommendations on how policymakers and practitioners can implement the findings.

Reviewer #4: It is very important topic and the study addresses a critical public health issue, high maternal and child mortality in Ethiopia. The title clearly reflects the study's focus on multi-stakeholder engagement and coproduction in MNCH services.

Introduction (Pages 1-5)

o Page 5- I would like to see the figure of the final theoretical framework.

o The section could clarify how multi-stakeholder engagement differs from traditional public-private partnerships.

o Consider briefly discussing power dynamics (government vs. NGOs, local vs. international stakeholders).

Methods (Pages 5-8)

o It would be helpful to clarify why West Shewa Zone was selected.

o You said it was translated from Amharic and Oromia languages, how did you the translation consistency and inter-rater reliability? Consider discussing inter-coder reliability or alternative interpretations.

o Page 8 - Explain why data was manually coded instead of using qualitative software like NVivo. Provide more details on how data saturation was determined and why manual coding was preferred over software.

o Please add more detail on how themes were developed inductively/deductively would strengthen credibility. If it is both inductive and deductive, specify how themes emerged and how prior frameworks influenced coding.

o In the recent publications by Braun & Clarke (2021), emphasized the importance of clarifying the theoretical and philosophical assumptions underlying the chosen thematic analysis procedure. Clearly state epistemological and ontological assumptions. Is the study critical realist, constructivist, or positivist? Does it assume an objective reality (realism) or multiple realities (relativism)?

Results (Pages 9-15)

o Some quotes are long, consider summarizing or paraphrasing for clarity.

o The concept of "donor dependency" is discussed but could be linked to alternative funding solutions.

Discussion (Pages 16-19)

o More discussion on CHW mental health/workload challenges would strengthen practical implications.

o Provide examples of successful coproduction models from other LMICs for comparison.

**********

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: Yes:  Esubalew Tesfahun

Reviewer #3: Yes:  Chibuzor Stella Amadi

Reviewer #4: Yes:  Muluken Basa

**********

[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

Transforming multi-stakeholder engagement towards coproduction of optimized maternal, newborn, and child health and a resilient community health system in rural Ethiopia: A qualitative study

PONE-D-23-23186R2

Dear Dr. Gebremeskel,

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.

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Kind regards,

Tatchalerm Sudhipongpracha

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #4: Yes

**********

Reviewer #2: All comments have been addresses in this version, no addtional comments and concern in this revised version.

Reviewer #4: To the Editors of PLOS ONE,

Thank you for the opportunity to review the revised version of this important and timely manuscript. I appreciate the authors’ thoughtful and thorough responses to the previous round of feedback. After reviewing the revised manuscript and the detailed point-by-point responses, I am pleased to confirm that the authors have fully addressed all prior comments and recommendations.

Given the substantial improvements and the robust nature of the research, I am satisfied with the current version of the manuscript and recommend it for publication in PLOS ONE without further revision.

Thank you again for the opportunity to contribute to the review process.

Warm regards,

**********

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: Yes:  Esubalew Tesfahun

Reviewer #4: Yes:  Muluken Basa

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