-->PONE-D-26-08248-->-->Economic barriers to diagnostic equity: a multi-country analysis of patient costs for rapid SARS-CoV-2 testing in sub-Saharan Africa-->-->PLOS One

Dear Dr. Ekwunife,

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 study addresses a critical and understudied dimension of diagnostic equity by trying to quantify patient-level cost of SARS-CoV-2 testing across some African counties. The study is relevant for policy decisions and may be applicable to several African settings beyond the countries represented in the study.-->--> -->-->The methodology is well presented with some observations that require revisions to strengthen analytical rigor, clarify study design, and refine interpretation of findings. Please carefully review comments provided by Reviewer 2 and address them accordingly. Additionally, please add the following details:-->-->- Financial disclosure (funding details) – please add grant number-->-->- Ethical approval – add approvals number-->--> -->-->Please submit your revised manuscript by May 24 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Ibrahim Jahun, MD, MSC, PhD

Academic Editor

PLOS One

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: 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 requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: 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 manuscript was well written with data and results well presented. The authors explained well why the study is important in planning for future outbreaks and were able to show what was obtained in three African countries. There may be need for a much broader study involving more countries so as to have a good picture of what was obtained in sub-Saharan Africa and solutions proffered.

Reviewer #2: This manuscript addresses an important and underexplored aspect of diagnostic access in sub-Saharan Africa, namely the patient-side economic burden of SARS-CoV-2 rapid diagnostic testing. The multi-country design and focus on affordability provide valuable insights for health policy and future pandemic preparedness. Overall, the study is timely, relevant, and contributes meaningfully to the literature.

The manuscript is generally well-structured, and the conclusions are broadly supported by the data. However, several areas require clarification and minor strengthening to improve transparency, rigor, and interpretability.

Review comments

1. Clarity of costing methodology

While the study outlines the components of patient costs (transport, medical, non-medical, productivity loss), further clarification is needed on:

• How productivity loss was calculated in practice, particularly the substitution of missing self-reported income with minimum wage estimates

• Whether sensitivity analyses were conducted to assess the robustness of these assumptions

• How extreme values (e.g., very high SD in Nigeria costs) were handled

Given that productivity loss is a major cost driver, more transparency here is essential.

2. Statistical reporting and rigor

The analysis is largely descriptive, which is acceptable given the study objectives. However:

• No confidence intervals or uncertainty measures are presented for key estimates

• There is no indication of statistical comparison across countries or modalities

• The rationale for not performing comparative statistical tests should be stated

Including basic inferential comparisons or explicitly justifying their absence would strengthen the analytical rigor.

3. Interpretation of catastrophic health expenditure

The use of a 10% threshold is standard, but:

• The manuscript should acknowledge that this threshold may not fully capture financial hardship across heterogeneous income settings

• There should be a brief discussion of how income measurement (self-reported) may introduce bias

4. Generalizability

The limitations section correctly notes selection bias (only those who sought testing were included), but this point should be strengthened:

• The study likely underestimates true costs, especially for those unable to access care

• This limitation has important implications for interpreting affordability estimates

Other Comments

1. Typographical and formatting issues

• Minor inconsistencies (spacing, punctuation, duplicated percentage symbols in Table 2)

• Ensure uniform reporting of currency (US$ vs $)

2. Terminology consistency

• “Drug stores” vs “community pharmacies” should be clearly defined early and used consistently

3. Results clarity

• The very high standard deviation in Nigeria (SD = 16.0) should be briefly explained in the text

4. Figure and tables

• Figure 1 (supplementary files)could benefit from clearer labeling (x-axis titles and formatting)

• Some tables are dense and may need slight simplification for readability especially table 2

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-->6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: Yes: Vincent Pam Gyang

Reviewer #2: Yes: Ayoola Bosede

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Economic barriers to diagnostic equity: a multi-country analysis of patient costs for rapid SARS-CoV-2 testing in sub-Saharan Africa

PONE-D-26-08248R1

Dear Dr. Ekwunife,

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,

Ibrahim Jahun, MD, MSC, PhD

Academic Editor

PLOS One

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Yes

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

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: Thank you to the authors for the time and effort invested in revising the manuscript and responding carefully to all the concerns raised during the review process. The responses were clear, satisfactory, and adequately addressed the major and minor issues highlighted. The revisions have improved the clarity, methodological transparency, and overall quality of the manuscript. In my opinion, the paper is now substantially strengthened and is suitable for publication in PLOS ONE.

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #2: Yes: Dr. Ayoola O. Bosede

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