PONE-D-20-02052

Accessing Medicines for Non-Communicable Diseases: Patients and Health Care Workers’ Experiences at Public and Private Health Facilities in Uganda

PLOS ONE

Dear Mr Tusubira,

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Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

This is an important study addressing the issue related with access to essential medicines for NCDs covering both public and private sectors. To strengthen scientific integrity and applicability of research evidence for Universal Health Coverage, authors have to revise extensively. Moreover, English language correction is deemed necessary.

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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: No

Reviewer #2: No

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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: Thank you for giving me the opportunity to review this manuscript.

The manuscript is well written and addresses an important public health problem. However, the manuscript requires major revision in terms of methods and results section.

General comments: Entire manuscript requires proofreading for typographical and grammatical errors.

Introduction: Background and rationale are well written. However, further points on the necessity and application of current study findings is required.

Methods: Study setting: Details on distribution of NCD patients receiving care at public sector and private sector can be provided. Public and private sector distribution can be provided.

Study design: Can be mentioned as qualitative descriptive instead of cross-sectional qualitative

Sampling strategy: total number of facilities in this region can be provided to see how much the sample is representative. Case load of this hospitals can also be provided. Maximum variation sampling can be mentioned here as it comes up only in overcoming the limitation part

Table 1: Why there is over-representation of public health facilities and only 2 FGD done in private health facilities.

Data collection and management: Details on why these many number of FGD, IDI and KII was done can be mentioned. Was it done till data saturation or pre-fixed numbers?

Table 3: Framework can be split into two: As patient perspective and health provider prespective as it will help in exploring both their perspectives. Barriers and facilitators is also not differentiated and mixed up in the same framework. Hence, under each theme, barriers and facilitators can be stated in bracket.

Discussion: Discussion is very well written by summarizing the main study findings and comparing and contrasting with previous studies with relevant recommendation for public health action and future studies. Limitations in the study is also provided.

However, a small suggestion is that the author can consider removing the second paragraph in discussion can be removed as it anyways gets repeated throughout the discussion part.

Reviewer #2: This is an important study in the under-examined field of medication access in Uganda. As chronic diseases take over the disease burden in this country and the surrounding region - concurrent with a rise in private-sector care - examination of barriers and facilitators to obtaining medications for non-communicable disease in private and public facilities becomes ever more urgent. I feel the study is robust and its conclusions rigorous and easy to follow. My only comments - for a suggested minor revision - relate to clarity of writing and some remaining questions regarding the methods and implications of the work. Details by manuscript line are as below:

Abstract: would remove "interestingly" from the results section (line 55) and expound a bit more on actionable next steps in the conclusion section (lines 59-60) - for instance why these three proposed solutions are most likely to succeed across both public and private sectors. Would add commas to line 51.

Methods: would change to "works on a referral basis" in line 87. Also kindly clarify the "apparently influence of diabetes patient groups" in lines 109 - 111: who are these groups; how do they influence medication access in Uganda; and what did you feel that their chairpersons would add to the study if interviewed? Lines 129-130 allude to this issue but the specifics remain unclear. How did you select the hospitals and clinics (line 114) apart from geographic diversity? Also, how did you decide (lines 126-127) which patients were assigned to an FGD or IDI? Did patients get to select one of these options, or did you do so? Lastly, please clarify the Framework Method further in lines 156-159 - how does it differ from other analytic strategies in which themes should be analyzed concurrent with contextual review?

Results: generally clear and straightforward, in my view. I would change some passive-voice sentences (lines 246, 339) to active for readability.

Discussion: the first few summary lines (400-404) are somewhat redundant and could be shortened or omitted. Similarly, the paragraph from 405-412 - which largely states results rather than analyzing them - could be deleted or moved to the results section. More generally, I'd be excited to see the discussion focus more on potential solutions than the underlying cause of the problems with access. What, for instance, is the PATH Coalition doing now, and what might it do better going forward, in promoting NCD medication access in Uganda? The final paragraph from lines 517 to 532 discusses such steps, but would benefit from more detail if possible - for instance around the nature of innovative patient-centered delivery platforms as mentioned in lines 496-499. Lastly, please note typos in lines 430 and 439.

Thank you for the opportunity to review this important work. I'd be happy to review a revised draft if helpful.

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Reviewer #1: No

Reviewer #2: No

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Accessing Medicines for Non-Communicable Diseases: Patients and Health Care Workers’ Experiences at Public and Private Health Facilities in Uganda

PONE-D-20-02052R1

Dear Dr. Tusubira,

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,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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: I Don't Know

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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

**********

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: I appreciate the authors' dutiful response to my critique - which concerned chiefly readability rather than content. However, the authors have also carefully addressed important questions from reviewer 1 regarding the pertinent background and context, as well as the distribution of facilities studied. I have no further comments to add and recommend the paper is accepted and published as written.

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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: No