The Editor

HARPS

Dear Sir / Madam,

Cover Letter for Manuscript Re-submission (Version-3)

On behalf of my co-authors, I am resubmitting the attached manuscript(MS: 5106701224984409) titled“Understanding client satisfaction with a health insurance scheme in Nigeria: factors andenrolees experiences”for consideration for publication in your prestigious journal.

We would like to thank the reviewers for their additional comments and reassessments of our manuscript. We have made the recommended minor essential changes to the manuscript as requested by the second reviewer (Chima Onoka). Changes to the manuscript have been highlighted (green)and deletions (red) in the manuscript. The changes have been detailed in the attached letter.

Thank you for considering our manuscript

Looking forward to hearing from you soon.

Yours sincerely,

Hengjin Dong (PhD)

Authors response to the reviewers comments.

The authors would like to thank both of the reviewers for their reassessments of our manuscript. Please find our responses to the additional comments below.

  • Reviewer-1 (Hong Wang)

Reviewer’s Summary Report:

No additional comments.Authors' responses already answered my questions/comments appropriately.

Level of interest: An article of importance in its field

Quality of written English: Acceptable

Statistical review: Yes, and I have assessed the statistics in my report.

Declaration of competing interests: 'I declare that I have no competing interests'

  • Reviewer-2 (Chima Onoka)

Reviewer’s Summary Report:

Level of interest: An article of importance in its field

Quality of written English: Needs some language corrections before being published

Statistical review: No, the manuscript does not need to be seen by a statistician.

Declaration of competing interests: I declare that I have no competing interests

Revisions:

  1. Research question.

Reviewer’s concern:

Response is satisfactory.

Authors’ response:

No additional comments requested by the reviewer.

  1. Methods

Reviewer’s concern:

  1. The sampling section has not been corrected yet. The authors have tried to explain multistage sampling in their response but that was not the question asked. There is nothing like ‘two stage sample selection was made at random’. My guess is that what the authors have in mind is that they used a two stage sampling method and each stage involved a simple random sample selection. At random does not mean simple random sampling in the first place.
  2. If the authors are very persuaded about the use of a detectable difference of 10%, they should explain the reason for this departure from the norm in the manuscript and not just as a response. The methods should be repeatable.
  3. Authors cannot talk about ‘loss to follow up’ in a study as this and should stick to ‘non-response’. Secondly, the authors could not have increased to 280 and then send out 300 questionnaires. The possible non responses have been covered by the increase to 280 based on the formula for calculating this. Response rate will then be based on 280 and not 300. However the authors increased from 280 to 300 and have obtained 280 questionnaires and presented a response rate based on 300. They may just state that to allow for non-response and other possible incidentals, they chose to increase to 300 (NOT 280) and then obtained 280 giving the stated response rate.

Authors’ response:

  1. We thank the Reviewer for his useful comments. We have addressed the issue raised by the reviewer in the 1st and 2nd sentences of the first paragraph in the Sampling sub-section of the main texts.
  2. We have added a sentence in the second paragraph of the Sampling sub-section in the main texts. The sentence explained the reason about the use of a detectable difference of 10% which was taken into consideration based on the assumed underlying level of knowledge of the population. As we earlier mentioned (to the Reviewer-1) we conducted a qualitative study (FGDs) during the initial phase of the study design which guided us to havetaken necessary measures to tackle some intricacies that might evolved in the quantitative aspect of the study. Again, we had provided a reference for the sample size determination which gave further theoretical explanation. The method we used is well grounded in the field of statistics.
  3. We appreciated the reviewer’s concern. Now, we changed to “non-response” and the sentence has been rephrased and corrected in line with the Reviewer’s suggestion. Please see the last sentence of the second paragraph of the Samplingsub-section.
  1. Data.

Reviewer’s concern:

Response is acceptable.

Authors’ response:

No additional comments requested by the reviewer.

  1. Standards for reporting.

Reviewer’s concern:

No comments.

Authors’ response:

No additional comments requested by the reviewer.

  1. Discussion and Conclusions.

Overall I think the authors should patiently look through these sections so that they will come out with a manuscript they would be happy with and proud about. The content and appeal of a manuscript to readers is very important and one should afford it the time needed to produce such quality work and not be in a hurry.

Reviewer’s concern:

  1. The authors respond that ‘the reviewer should understand that, we are only

monitoring the progress of implementation in terms of health service provision..’ Please the authors should provide this good information somewhere in the manuscript to guide the potential readers. This is the reviewers concern.

  1. The inserted sentence in the second paragraph ‘Since the NHIS specified that contributions....’ is incomplete and hanging and needs to be sorted out. There seems be a problem here with use of capital letters when starting a sentence and use of full-spot. Again, I do not understand the grammar of the earlier sentence ‘This was a contrast with our hypothesis that, the polygamous family would be less satisfied due to the entitlement of principal beneficiary.’ (see especially the italicized part). Finally, my earlier comment about discussion of the result on polygamy has not been made. Why is the finding as such warranting it to become an important issue in policy implementation change?
  2. 4th paragraph: The sentence ‘Here we concentrated on the assumption that enrolees knowledge of health insurance AS a good way to help people solve their health expenditure problems and also their knowledge of the basic benefits package of the health insurance scheme AS A COMPOSITE.’ The highlighted areas seem problematic and should be made clearer. My guess is that ‘is’ should replace ‘as’. But what does ‘as a composite’ mean to a reader? In fact, this sentence could be deleted. Generally my comments on this paragraph have not be addressed.
  3. The 7th paragraph starting with ‘General knowledge...’ needs to be looked at once again. Authors have repeated the statements about polygamy and marital status here which was earlier presented in the second paragraph. I do not understand why.
  4. The authors have still not provided a conclusion for the study in the body (please compare with than in the abstract). What they have presented sound more like implications and some generic statements. The conclusion in the body should be similar and more elaborate than the conclusions in the abstract which have already been appropriately adjusted based on my previous comments. The authors state that Our most important conclusion is that, the findings from this study assisted both the policy and decision makers of the insurance scheme with guidance in the amendment and re-prioritization of the medium term strategic plan of operations. My opinion is that this is not a conclusion of the study. It is rather about what the real conclusions of the study helped them achieve in terms of amendment of a policy. The real conclusions are the ones that should have been supported by the data. Moreover, the impact on the amendment can only be minimal since this study was carried out between May and September 2008 and the published plan itself is dated 2008 (as referenced) and its the use of the findings with very limited generalization for overall programme amendment is in itself another disturbing issue. I would rather advice that you pay attention to the real conclusions of the study and bring this out clearly for your potential readers.

Authors’ response:

We thank the reviewer for the consideration. The Discussion section has been improved in response to the reviewer’s concern.

  1. As suggested by the Reviewer, we have provided the statement “we are only monitoring the progress of implementation in terms of health service provision…” Please see the last sentence in the 4th paragraph of the Background section in the main texts.
  2. The sentence “Since the NHIS specified that contributions…..” has been rephrased in line with the Reviewers suggestion. The earlier sentence “This was contrast with our hypothesis that, the polygamous family……….” has been rephrased to clarify the statement. We went further to explain the reason why polygamy became an issue worthy of consideration in our study design.A qualitative study which we conducted during the initial phase of the study design guided us to make the inclusion in our study which warranted it (polygamy) to become an important issue in policy implementation change.
  3. We would like the Reviewer to understand that, the 4th paragraph is explicit to follow. We have rephrased few sentences to clarify the statements made in the paragraph. Also, our results have been discussed within the paragraph which was the major concern in the previous review.
  4. The repetition of polygamy and marital status in the 7th paragraph arose because the first Reviewer (Reviewer-1) raised an earlier concern that, we should provide the theoretical background of the contrary of our hypothesis. But to avoid certain repetition as highlighted by you, we have eliminated some repetitive statements.
  5. We have made effort to address the Reviewers concern in the Conclusion part. We have restructured the Conclusion in the main texts which has been supported by the data as requested by the Reviewer. Please the Reviewer could consider that, we are dealing with two Reviewers (Reviewer 1 & 2). The first Reviewer (Reviewer-1) emphasized on “What are the impacts of this issue to policy recommendations proposed in this study?”. We tried as possible to satisfy both Reviewers and also to address the various concerns.
  1. Abstract and title.

Reviewer’s concern:

  1. Methods: As I mentioned in the earlier review, the authors still do not give the reader of the abstract a faint idea of how satisfaction was measured. They have mentioned ‘composite measure’ but this does not help a reader where the abstract is standing alone. The authors can be guided on an appropriate sentence to include here from the first 2 sentences of the subsection on ‘definitions of client satisfaction...’ in page 8.

Authors’ response:

  1. The authors greatly appreciate this important comment.As suggested by the reviewer, we have made additions (3rd sentence) andadjusted the 4thsentence in the Method section of the Abstract. Giving the limited number of words that an Abstract should have, we believed that such specific and precise wordings could be fair enough for the readers understanding. Please we would like the Reviewer to understand that, composite measure is a term that has been established and extensively used to measure client satisfaction. The term has been used in several publications and literatures to express satisfaction measurements. Please see also some of our references: 13 to 16 where it has been stated. The detailed description of such measurement can only be expressed fully in a main text as we have done.
  1. Grammar

Reviewer’s concern:

The author should understand that with regards to the perceptions about the manuscript by readers, it is in their own interest to ensure that the grammar is critically looked at. I have only brought out a few spots here and can only encourage the authors to do another overall grammar review and seek help appropriately for overall and final grammar review of the manuscript.

  1. Study area and population: The sentence ‘The study population was the staff of the university WHO HAS BEEN participating....’ should be corrected.
  2. Sampling: second paragraph, 3rd sentence. Should read ‘The calculated sample size was increased to 280 to make allowance for... AND NOT increased to have allowed for...
  3. Results: The sentence ‘Respondents who had polygamous FAMILY were... should be corrected’
  4. MORE awareness of the enrolees might further PROMOTE PATIENT GOOD INTERACTIONS with health care providers due to MORE SATISFACTION OF SERVICE. Perhaps, better is more appropriate here than more. The highlighted parts need grammar adjustment.
  5. Second to last paragraph of the discussion ‘Health care provider good attitudes...’ needs attention as well

Concerning the background section, typically, extracted sentences should be presented within inverted commas. This is the only way a reader will know that it has not been altered by the authors who did a literature review. In some cases extracted sentences may be incorrect and if now within commas, would give a wrong impression of the author who has done a synthesis. This is quite important.

Thank you.

Authors’ response:

We still thank the reviewer for encouraging us to do another overall grammar review. All the highlighted issues (as above) pointed out by the Reviewer have been taken into consideration.

A third party also assisted us in checking and upgrading the grammar and has proof-read the entire paper carefully.

All extracted sentences in the Background section have been either rephrased or presented with invented commas as requested by the Reviewer. We have carefully taken the advice of the Reviewer into consideration during the entire paper review. We gratefully appreciate all your comments.

Thank you very much for the inputs.