Dear Dr. Kekeli Kodjo Adanu,

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.

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Kind regards,

Xiuping Yu

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: This study presents a cross-sectional cost-of-illness analysis of Benign Prostatic Hyperplasia (BPH) among 105 men attending the Urology Unit of Ho Teaching Hospital, Ghana. Using a bottom-up, patient-level costing approach, the authors estimate direct medical, direct non-medical, and productivity loss components from the patient perspective. The findings highlight that direct medical costs account for approximately 86% of total expenses, with non-medical and productivity losses contributing around 9% and 4%, respectively. The authors emphasize the growing economic burden of BPH and the need for policy attention in Ghana. This is a valuable and timely contribution to the limited literature on the economic burden of BPH in low- and middle-income countries. The study demonstrates methodological transparency and fills an important data gap for Ghana. The following comments could be addressed to improve the manuscript.

Comments:

The study addresses an important evidence gap—the economic burden of BPH in Ghana. However, data from a single tertiary hospital may not represent the broader population. Patients at referral centers often have more advanced disease or greater financial means to access specialist care. The discussion could better acknowledge how these selection factors may bias cost estimates and limit national generalizability.

The discussion references some studies from Europe and Asia but does not include countries of similar economic status to Ghana. Even brief inclusion of such studies would contextualize Ghana's results within a comparable economic and healthcare framework.

The manuscript’s main message is that BPH imposes a “significant economic burden,” but it lacks a clear linkage to policy or health system strategies (e.g., screening, early intervention, insurance coverage). Expanding this section to describe how the results could inform local reimbursement or urological service planning would strengthen its relevance.

Reviewer #2: Major Comments

1. BPH disease severity was not measured or adjusted, despite being a key driver of treatment choice and cost. This is a major limitation that should be emphasized.

2. Productivity loss estimation using minimum wage for all participants likely underestimates indirect costs and ignores income heterogeneity.

3. Catastrophic health expenditure (CHE) appears to be calculated using mean costs, rather than individual patient-level cost–income ratios, which may misclassify CHE. If feasible, re-estimate CHE using individual patient-level cost–income ratios.

4. Regression analysis is under-specified, excluding key clinical and treatment-related variables. Regression findings should be reframed as exploratory, and the limitations imposed by omitted variables should be explicitly discussed.

Minor Comments

1. Costs are reported in both GHS and USD using a single exchange rate. The authors should clarify whether any inflation adjustment was applied and state explicitly that USD conversions are for international comparison.

2. Standardize terminology for indirect costs and productivity losses throughout the manuscript.

3. Large standard deviations suggest skewed cost data; A brief justification for reporting means alongside medians would improve statistical clarity.

4. Strengthen policy implications: More concrete policy recommendations (e.g., NHIS medication coverage expansion, decentralization of urology services, transport subsidies) would strengthen the public health relevance.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes:  Manisha Tripathi

Reviewer #2: No

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Productivity losses and treatment cost of Benign Prostatic Hyperplasia in Ghana

PONE-D-25-56374R1

Dear Dr. Adanu,

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,

Xiuping Yu

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. 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: (No Response)

Reviewer #2: (No Response)

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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:  Manisha Tripathi

Reviewer #2: No

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