Using allocative efficiency analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking decision support

Nicole Fraser-Hurt; Xiaohui Hou; Thomas Wilkinson; Denizhan Duran; Gerard J. Abou Jaoude; Jolene Skordis; Adanna Chukwuma; Christine Lao Pena; Opope O. Tshivuila Matala; Marelize Gorgens; David P. Wilson

doi:10.1371/journal.pone.0260247

Peer Review History

Original SubmissionMay 11, 2021
4 Sep 2021 Decision Letter - M. Mahmud Khan, Editor PONE-D-21-15273 Using allocative efficiency analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking decision support PLOS ONE Dear Dr. Hou, 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 Oct 19 2021 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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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please ensure that you include a title page within your main document. We do appreciate that you have a title page document uploaded as a separate file, however, as per our author guidelines (http://journals.plos.org/plosone/s/submission-guidelines#loc-title-page) we do require this to be part of the manuscript file itself and not uploaded separately. Could you therefore please include the title page into the beginning of your manuscript file itself, listing all authors and affiliations. 3. We note that you have referenced (Duran et al. Cote d’Ivoire, Internal government documents, unpublished, Ministry of Health and Child Care Zimbabwe, Expenditure and appropriation account 2016 (unpublished, Results from the Health Interventions Prioritization Tool (unpublished]) which has currently not yet been accepted for publication. Please remove this from your References and amend this to state in the body of your manuscript: (Duran et al. Cote d’Ivoire, Internal government documents, unpublished, Ministry of Health and Child Care Zimbabwe, Expenditure and appropriation account 2016 (unpublished), Results from the Health Interventions Prioritization Tool (unpublished])as detailed online in our guide for authors http://journals.plos.org/plosone/s/submission-guidelines#loc-reference-style. 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [Note: HTML markup is below. Please do not edit.] 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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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: No Reviewer #2: Yes ****** 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 ****** 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: This article addresses critical resource allocation issues within developing countries health sector. The authors did a great job in explaining the framework, data, and analytic part. They also did a good job addressing limitations of the study. There are couple of items that, if addressed, can strengthen the article. 1. Authors use governmental statistics to construct their analysis. In developing countries use of this data can be problematic (as authors indicate) due to reliability. For example, population estimates usually are overestimates since a large number immigrates seasonally or permanently without it being reflected in the updated numbers due to several reasons. Armenia is a classical case in this regards as a large number of (male) population usually seasonally works in Russia. 2. it will be helpful to use similar graphics style in displaying results. Also, will be helpful to the reader to have comparative graphs (if possible ) to compare outcomes for three countries. Reviewer #2: The topic of the paper is very important. I find the main problem with presentation of the paper, which may be difficult for the readers to follow. The following comments might be useful for improvement. Comment: Authors wrote (page 12, just before table 2) that the HIPtool optimization algorithm also estimates an optimized resource allocation within defined resource envelopes. Can you detail this somewhere in the paper? Comment: Involving stakeholders is a good process for selecting the variables/data etc. It would be more useful to know who those stakeholders were (researchers, development partners, or any others). Comment: You should give a heading of the first column in table 1. Comment: While it is well-describe what HIPtool does, I miss a clear description of how it does all the steps. For instance, the authors wrote the questions that HIPtool is able to answer. But it is unclear how the tool does so. Comment: Figure 1 is a good presentation. A simple example should be developed in the paper (might be fictitious), relating figure 1 so that the readers can follow the complex calculations (country cases). Comment: The authors should make the concept of optimization clearer in the text and detail the optimization process that they used. They should describe more clearly for the readers how they address allocative efficiency in this very context (in methods and findings as well as in results). Comment: The authors wrote about the limitations. It would be great if they explain how this tool and analysis are useful despite such limitations. They should also guide from their experience (of this paper/work) what data and methodological improvement are needed so that HIPtool or any similar ones can be used more appropriately. Comment: Some of the text is appendices may be summarized (while keeping the appendices as they are) and put in the main manuscript so that they readers can read the article independently. Comment: Conclusions are too general. The authors can additionally connect to the findings of three country cases. ****** 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: No Reviewer #2: No [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. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0260247.r001
Revision 1
16 Oct 2021 Author Response Reviewers’ comments and responses 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 #2: Partly We hope that our revisions to the manuscript respond to the concerns of this reviewers regarding the technical quality of our report. 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: No The default data is available in http://hiptool.org (the weblink to the application is now provided in the introduction), which contains the DCP3 interventions, estimation of unit costs and ICER values. We have also provided a weblink allowing readers to access the publicly available, read-only Excel workbook from Armenia which illustrates the data inputs and calculations/estimations, as well as scenarios in an application. Data for Zimbabwe and Cote D’Ivoire can be available through formal request. Review Comments to the Author and Responses Reviewer #1: This article addresses critical resource allocation issues within developing countries health sector. The authors did a great job in explaining the framework, data, and analytic part. They also did a good job addressing limitations of the study. Thank you very much. There are couple of items that, if addressed, can strengthen the article. 1. Authors use governmental statistics to construct their analysis. In developing countries use of this data can be problematic (as authors indicate) due to reliability. For example, population estimates usually are overestimates since a large number immigrates seasonally or permanently without it being reflected in the updated numbers due to several reasons. Armenia is a classical case in this regard as a large number of (male) population usually seasonally works in Russia. We thank the reviewer for this comment and agree. We have made an addition in the limitations section: “For instance, the demographic data might not reflect true population sizes in a country due to international migration which is significant among men in Armenia.” 2. it will be helpful to use similar graphics style in displaying results. Also, will be helpful to the reader to have comparative graphs (if possible) to compare outcomes for three countries. We have harmonised the colours in Figures 3 and 4 (red/green) and adjusted a label in Figure 3. Regarding the choice of graphs in the main article, we would like to keep the current selection as the intention is to present the types of outputs the HIPtool can provide. This reflects the nature of the report, which is about the local applications rather than comparison of model outputs between the three countries. Reviewer #2: The topic of the paper is very important. Thank you very much. I find the main problem with presentation of the paper, which may be difficult for the readers to follow. The following comments might be useful for improvement. Comment: Authors wrote (page 12, just before table 2) that the HIPtool optimization algorithm also estimates an optimized resource allocation within defined resource envelopes. Can you detail this somewhere in the paper? We agree with the reviewer that the reader should be referred to more explanation about the optimization steps, and have made an insert in the methodology section to the section ‘optimization module’ in Appendix 1 of the supplementary material. Comment: Involving stakeholders is a good process for selecting the variables/data etc. It would be more useful to know who those stakeholders were (researchers, development partners, or any others). We thank the reviewer for this important point, as this type of analysis entirely relies on effective stakeholder involvement. Given they are somewhat country-specific, we have mentioned them in the ‘policy context’ sections of the three countries, rather than upfront when describing the general approach. For Armenia, the key stakeholders we had listed were the HIPtool Focal Points from various Ministry of Health units, the State Health Agency, National Institute of Health, and World Bank Project Implementation Unit. For Cote d’Ivoire, the key stakeholders listed are a Ministry of Health Core Team including representatives from the Cabinet (chief health financing advisor to the Minister of Health), Finance, Planning, Monitoring and Evaluation, the newly launched health insurance agency, the Directorate of Health Services Directorate of Budget. In Zimbabwe, the main stakeholders have equally been mentioned in this section as the Ministry of Health and Child Care (MHCC), the Ministry of Finance and Economic Development, the Clinton Health Access Initiative and the World Health Organization. Comment: You should give a heading of the first column in table 1. Thank you, we have completed the table with an insert labelling this column. Comment: While it is well-describe what HIPtool does, I miss a clear description of how it does all the steps. For instance, the authors wrote the questions that HIPtool is able to answer. But it is unclear how the tool does so. We thank the reviewer for this comment on how the model works. All main aspects are described in Appendix 1, including how the impact model operates to link interventions to disease burden and effect, how the concept of effective and maximal effective coverage is applied, the optimization module itself, as well as the equity and financial risk protection modules. We have included the main equations and trust that this information can help the reader follow how the tool works. The focus of this article is on tool implementation in different country contexts. Comment: Figure 1 is a good presentation. A simple example should be developed in the paper (might be fictitious), relating figure 1 so that the readers can follow the complex calculations (country cases). We thank the reviewer for the positive comment on figure 1. In order to illustrate the calculations carried out in a country application, we have inserted a link which enables the reader to access the Armenia HIPtool data book (Results section, first paragraph). Comment: The authors should make the concept of optimization clearer in the text and detail the optimization process that they used. They should describe more clearly for the readers how they address allocative efficiency in this very context (in methods and findings as well as in results). We appreciate this suggestion and have made several explanatory additions in the text. Comment: The authors wrote about the limitations. It would be great if they explain how this tool and analysis are useful despite such limitations. They should also guide from their experience (of this paper/work) what data and methodological improvement are needed so that HIPtool or any similar ones can be used more appropriately. We agree with the reviewer that readers may be interested to hear how the tool’s limitations inform its methodological improvements. We have therefore added several sentences under the limitations heading. The addition highlights key improvements such as the use of a more consistent intervention taxonomy, the automation of certain calculations while maintaining functionality to manually adjust estimates, and better data import functionalities. We also reflect on what countries can do to strengthen the process and generate data that usefully inform priority setting. Comment: Some of the text is appendices may be summarized (while keeping the appendices as they are) and put in the main manuscript so that they readers can read the article independently. We thank the reviewer for this suggestion. With the additions made especially on the optimization step (see above), we believe that some of the technical detail about the tool is now better summarized in the main text. We are open to further additions but want to be sensitive to the journal guidelines on concise presentation and discussion of findings. The main article has now a length of approximately 7,000 words. Comment: Conclusions are too general. The authors can additionally connect to the findings of three country cases. We thank the reviewer for the suggestion. We have only made small changes in the conclusions, which we would like to keep at a high level. The discussion already covers the countries’ individual and shared insights from the assessment. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0260247.r002
8 Nov 2021 Decision Letter - M. Mahmud Khan, Editor Using allocative efficiency analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking decision support PONE-D-21-15273R1 Dear Dr. Hou, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, M. Mahmud Khan Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0260247.r003
Formally Accepted
16 Nov 2021 Acceptance Letter - M. Mahmud Khan, Editor PONE-D-21-15273R1 Using allocative efficiency analysis to inform health benefits package design for progressing towards Universal Health Coverage: Proof-of-concept studies in countries seeking decision support Dear Dr. Hou: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. M. Mahmud Khan Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0260247.r004

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