-->PONE-D-25-44483-->-->The health systems strategies and responses to the effects of Climate Change in Sub-Saharan Africa: A scoping review-->-->PLOS One

Dear Dr. Chimatiro,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

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Olushayo Oluseun Olu

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?

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Partly

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

Reviewer #1: N/A

Reviewer #2: I Don't Know

Reviewer #3: N/A

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: No

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: The paper is technically sound and the data support the conclusions. The authors employed appropriate methods for conducting a scoping review as clearly shown in table 1. However one of the statements in the conclusion - Prompt efforts should be made to ensure that the effects of CC on health systems are reduced if the region is to achieve the Sustainable Development Goals and the desired African Agenda 2063 - is not derived from the data. This study did not look at the effects of CC on health systems and the achievement of SDG in Africa, so this extrapolation of conclusions is not valid. All the data is presented in the manuscript. This was a simple descriptive qualitative study so did not require statistical analysis. The paper is written in clear, easy-to-understand language.

Reviewer #2: The topic, “The health system strategies and responses to climate change in Sub-Saharan Africa: a scoping review” is important and timely. However, the manuscript in its current form has substantial conceptual, methodological, structural, and language-related problems that limit its scientific contribution.

ABSTRACT

1. The abbreviation Sub-Saharan Africa (SSA) should be introduced once and used consistently throughout the abstract and manuscript. Variations such as “Sub-Saharan Region” and “Sub-Saharan African Region” could be avoided.

2. The abbreviation climate change (CC) is inconsistently used. For example, “Climate Change” appears later without abbreviation. This should be standardized throughout.

3. The title may not require “The” at the beginning.

4. The Methods subsection is incomplete. The abstract does not describe the inclusion and exclusion criteria, an essential component for transparency, especially for a scoping review.

5. In the Results subsection, the reference to “all building blocks of the health system” needs clarification. If this refers to the six WHO health system building blocks, this should be stated.

INTRODUCTION

6. The introduction requires substantial language editing for clarity, coherence, and flow. Several sentences are long, repetitive, or conceptually unclear.

7. There is confusion about what the manuscript identifies as the primary stressor in SSA, climate change, poverty, or overlapping systemic vulnerabilities. The narrative shifts without clear positioning.

8. The claim that climate change “exposes humans to pandemics and epidemics” is made without a supporting reference. This type of statement needs scientific grounding.

9. Paragraphs that attempt to explain the relationship between climate change and health systems (particularly paragraph 3) are difficult to follow and require restructuring for conceptual and language clarity.

10. Subsequent paragraphs also lack coherence and do not clearly articulate the problem, the evidence gap, or the rationale for conducting this review.

11. Major section headers such as introduction, methods, results, discussion, and conclusion should be uppercase to distinguish them from subheadings.

12. The document contains unnecessary subheadings (e.g., a separate “Protocol Registration Status”), which are more appropriate within the Methods narrative. The manuscript should reflect scientific writing conventions rather than technical report formatting.

METHODS

This section has major methodological shortcomings that affect the credibility and reproducibility of the review.

13. The database selection is limited. A scoping review on SSA health system responses should include a broader range of databases relevant to the region (e.g., EMBASE, Web of Science, Africa Index Medicus, regional and policy databases).

14. The grey literature search is insufficient. Limiting grey literature to WHO websites does not capture national policies, NGO reports, or locally generated evidence that are central to understanding SSA health system strategies.

15. The manuscript does not provide full, reproducible search strings.

16. Search dates are incompletely reported. It only says “the search was completed on January 31, 2025”.

17. Overlap between PubMed and MEDLINE is not acknowledged or justified. PubMed search yielded 9430 studies whilst MEDLINE yielded only 1 study.

18. The decision to include commentaries, editorials, and reviews without clear justification weakens the evidence base.

19. Excluding non-English articles due to “lack of funds” introduces significant bias and needs proper acknowledgment or alternative mitigation.

20. The process for resolving screening disagreements is missing.

21. The data extraction process is inadequately described. There is no mention of piloting extraction tools.

22. The rationale for mapping findings to the WHO building blocks is not explained, and alternative frameworks are not considered.

RESULTS

23. There are inconsistencies in the PRISMA numbers, textual descriptions, and tables. These discrepancies undermine confidence in the accuracy of the review process.

24. Table numbers do not match their in-text citations.

25. Some included studies appear to be from countries outside SSA (e.g., Egypt) with no explanation.

26. The results section largely lists strategies rather than synthesizing or analyzing them.

27. The mapping of findings to the WHO building blocks feels forced in some cases, and some listed strategies do not reflect true “health system strategies.”

28. The "characteristics of included articles" table lacks essential details.

DISCUSSION

29. The discussion section tends to repeat results rather than interpreting them.

30. The conceptual framing is unfocused. The narrative jumps between climate adaptation, health system resilience, environmental disasters, and emergency preparedness without a clear thread.

31. There is no assessment of the quality, strength, or limitations of the included evidence.

32. Key limitations, including the narrow search strategy, English-only restriction, and limited grey literature, are not sufficiently acknowledged.

33. Policy implications remain broad and disconnected from the actual evidence extracted.

CONCLUSION

34. The conclusion partially repeats earlier sections and introduces new general statements rather than summarizing grounded findings. The conclusion should be more concise and aligned with what the study actually demonstrates.

PRESENTATION AND LANGUAGE QUALITY

35. The manuscript requires significant editing for grammar, clarity, structure, and readability, particularly the results and discussion sections.

36. Line numbers are missing from the submitted manuscript, which complicates the review process.

Reviewer #3: FORM AND PRESENTATION

The manuscript is generally well structured and adheres to the journal’s formatting requirements. However, there are some weaknesses in the reference section:

1. The use of et al. is inconsistent across citations with more than six authors. According to the Uniform Requirements for Manuscripts, this should be standardized.

2. Reference 56 is missing its publication year.

3. Several in-text citations (e.g., references 39, 40, and 41 in Table 2) do not correspond to the numbering in the reference list. This inconsistency may also affect other citations throughout the manuscript and should be carefully corrected.

CONTENT AND SOURCES

The paper addresses the question: “What are the health system strategies and responses to the effects of climate change in Sub-Saharan Africa?”

While health system responses, understood as concrete adaptation or resilience-building activities, can be documented through scientific publications, identifying health system strategies, defined as strategic and planning documents, is more challenging. Relying solely on peer-reviewed papers is not the most appropriate approach.

Grey literature, particularly WHO country support documents, national health system plans, and climate-health reports, provides more reliable evidence for strategic planning.

Databases such as PubMed, CINAHL, Scopus, and MEDLINE are not suitable sources for grey literature. Instead, repositories such as:

1. ATACH Community Country Documents Repository (https://www.atachcommunity.com/resources/country-documents-repository/)

2. ClimHealth Africa Resources (https://climhealthafrica.org/resources/)

should be consulted to capture relevant planning documents and reports.

References 1 to 4 can be updated by recent releases from Lancet Countdown, IPCC AR6 and many other papers focusing on health impact of CC

LANGUAGE CONSIDERATION

The manuscript focuses only on English-language sources.

In the current era of AI-assisted translation, language barriers are no longer a strong justification for restricting the review to English. Including documents at least in French and Portuguese would strengthen the comprehensiveness of the study.

SUMMARY OF KEY REVISIONS IF the SCOPING REVIEW IS ACCEPTED IN PLOS ONE

1. Update and standardize reference formatting and correct inconsistencies.

2. Incorporate grey literature sources for health system strategies and planning.

3. Expand beyond English-only sources by leveraging translation tools.

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Reviewer #1: Yes:  Jayne Byakika Tusiime

Reviewer #2: Yes:  Robert Lubajo

Reviewer #3: No

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-->PONE-D-25-44483R1-->-->Health system strategies and responses to the effects of climate change in Sub-Saharan Africa: A scoping review-->-->PLOS One

Dear Dr. Chimatiro,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.-->-->

Please submit your revised manuscript by May 03 2026 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 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,

Olushayo Oluseun Olu

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

Please see below for additional comments from the academic editor for your careful consideration and appropriate response.

Thank you for your comprehensive responses to the comments provided by the three reviewers. Your revisions have strengthened both the quality and substance of the manuscript. Nevertheless, additional refinements are needed to further enhance its clarity, accuracy, and overall readiness for publication. Please find specific suggestions below.

Introduction

Although the introduction includes many of the essential components, its readability is affected by repetitions, structural gaps, and a few factual inaccuracies. For instance, the impacts of climate change are reiterated several times in the first two paragraphs, and the emergence and re emergence of diseases as climate related outcomes are mentioned in multiple places. Additionally, the statement in lines 86–87 that “health systems have a responsibility to maintain social determinants of health using a holistic approach” does not appear to be conceptually accurate.

To improve coherence and flow, I recommend fully restructuring the introduction section as follows:

• Paragraph 1: Define the health system, explaining its dimensions at both facility and community levels; describe its building blocks; introduce the concept of health system resilience in relation to climate change; and outline factors that support resilience.

• Paragraph 2: Define climate change and describe its potential impact and implications for health systems and their resilience.

• Paragraph 3: Review existing evidence on health system resilience to climate change, highlighting what is known and the evidence gaps this scoping review intends to address.

• Paragraph 4: State the research objectives and guiding questions.

Results

• The current PRISMA ScR diagram requires redrawing for better clarity and completeness, ensuring that all elements raised by Reviewer 2 are fully incorporated.

• Table 1 appears to be missing; you may consider relabeling the current Table 2 accordingly.

• Content in lines 275–279 should be moved to the Methods section, as the Results should focus exclusively on reporting outcomes of the quality assessment and findings.

Discussion

The discussion covers most of the expected components but would benefit from a more concise and structured presentation, as also previously recommended by Reviewer 2. I suggest reorganizing this section as follows:

• Paragraph 1: Summarize the study objectives and key findings, including the breadth of available literature, evidence related to the health system building blocks (governance and leadership, human resources, health information management, and service delivery), the limited evidence on health financing and essential medicines/health technologies, and the challenges identified.

• Paragraphs 2–4: Provide a detailed discussion of findings, exploring the factors that may explain observed trends and comparing them with results from other studies.

• Paragraph 5: Present the identified evidence gaps and discuss their implications for future research.

• Paragraph 6: Outline the study’s limitations.

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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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->PONE-D-25-44483R2-->-->Health system strategies and responses to the effects of climate change in Sub-Saharan Africa: A scoping review-->-->PLOS One

Dear Dr. Chimatiro,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jun 08 2026 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Olushayo Oluseun Olu

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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:

Many thanks for addressing the editorial comments provided during the last round of peer review. This has further improved the quality of your paper. Nevertheless, more work is required to improve the manuscript as follow:

1. Why are all tables and figures included as supplementary? At the least, the current supplementary figure 1 and supplementary table 3 should be included in the manuscript text.

2. No mention is made of supplementary tables 1-2 in the manuscript text? Where are they?

3. Lines 244-249 fits more in the methods section. You should then present the result of the MMAT in the result section.

4. In line 245, please correct the referencing style to be consistent with the rest of the document.

5. Please introduce a sub-heading in line 270 (just before service delivery) to read "Health system building blocks strategies for mitigating the impact of climate change"

6. Line 436-443 is unclear. Is this conclusion from the finding of your review or the finding of other studies? Please make this clearer

7. Further copy-editing and proof reading of the manuscript is required to correct some errors that may have been included in the use of track change mode.

Thank you

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To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

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Health system strategies and responses to the effects of climate change in Sub-Saharan Africa: A scoping review

PONE-D-25-44483R3

Dear Dr. Chimatiro,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Olushayo Oluseun Olu

Academic Editor

PLOS One

Additional Editor Comments (optional):

Please ensure careful attention is given to the nomenclature of figures and tables prior to final publication. Supplementary tables and figures should be appropriately cited within the main manuscript but will be presented as annexes in the final published article. Accordingly, the labeling of supplementary and main tables should be clearly distinguished. For example, “Supplementary Tables 1, 2, 3,” versus “Tables 1, 2, 3.” What is the difference between supplementary table 3 and table 4? You may wish to retain only table 4 which should be included in the main article as table 1 as previously advised. Thus, your final manuscript will have supplementary tables and 1 and table 1. Thank you.

Reviewers' comments: