PEER REVIEW HISTORY ARTICLE DETAILS VERSION 1 - REVIEW. Nahyuha Chomi, Eunice United Kingdom 03-Jul-2015

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1 PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form ( and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) AUTHORS Service availability and association between Mutuelles and medical care usage for under-five children in rural Rwanda: a statistical analysis with repeated cross-sectional data Mejía-Guevara, Iván; Hill, Kenneth; Subramanian, S V; Lu, Chunling VERSION 1 - REVIEW Nahyuha Chomi, Eunice United Kingdom 03-Jul-2015 GENERAL COMMENTS General Comment The study has attempted to highlight availability of services as important aspect of the role of health insurance in increasing health services utilisation. Without services of an acceptable quality being available in the first place, even universal coverage with health insurance would be of little use. However, as has been stated as a limitation, the association between Mutuelles enrolment and health service use can only be implied and not empirically stated, given the issue of selection bias and existence of unobserved differences between the insured and non-insured. Hence, the study conclusions should be more focused on the increased services use as a result of increased service provision, rather than insurance status. Introduction Line 41-45, page 3, it is reported that analysis shows funds transferred from the Mutuelles constitutes 22% of funds received by health facilities, and following from this analysis concluding that this provides long term financial support for child health services. Isn t that 22% actually for the provision of all services under the Minimum Service Package (MSP) and Complimentary Service Package (CSP)? Did the analysis show what percentage is used for child health? Methods Line page 4, the main source of data for tracking health services availability between 2005 and 2010 was the DHSST, but there was no information for So when comparing the two years, what was the basis of using 2005 as they year with less health services compared to 2010? There is no mention of ethical considerations. Results Line page 7, the results reported contradict what was reported under data sources line 37-40, page 4. While it appears that a different source was used from the one mentioned under data

2 sources, why wasn t this source mentioned, if indeed it had the information needed? Discussion Line 15-27, page 11. The association of Mutuelles and utilisation cannot be concluded when there could be an issue of selection bias. The study can therefore only conclude regarding the increased utilisation regardless of insurance status possibly due to health system strengthening and increased availability of services between the two years. On the same note, while the limitation has been mentioned, it has not been adequately discussed. The use of repeated cross-sectional data has demonstrated the importance of service availability for health insurance to promote service use, but still does not show that health insurance in itself does increase service use. Desmond, Chris Human Sciences Research Council, Chief research specialist 06-Jul-2015 GENERAL COMMENTS Comments on: Service availability and association between Mutuelles and medical care usage for under-five children in rural Rwanda: a statistical analysis with repeated cross-sectional data This is a well-designed and executed piece of research. It is clear on the questions it asks and is capable of answering and uses appropriate techniques to answer them. The research question is of interest to Rwanda, but also of wider interest in the sub-saharan region, where there is much discussion of how to increase health care coverage (and insurance). My comments relate primarily to the presentation of the paper. There are a number of areas which could benefit from some clarification. In addition, I have two questions relating to the interpretation of results. Presentation: there are a number of grammatical errors and some further proof reading would help with the flow of the paper. Similarly, there are a number of slightly clumsy formulations, which if addressed would help. Further, in terms of presentation, the box which describes what Mutuelles are, needs some work. A clear description of the alternative is required i.e. what is the situation for those who do not belong to the Mutuelles? Furthermore, some introduction to the list of MSP services would be helpful. Interpretation: 1) The authors are rightfully careful to highlight that they cannot determine causality. I think it would also be useful to discuss what other possible explanations there are of the findings other than the explanation that Mutuelles improve access. For example, now that Mutuelle coverage is so high, non-coverage may indicate some social problem. Non-coverage may well simply be a very good indicator of social exclusion identifying those who do not access Mutuelles or health care. I do not think this would in any way detract from the findings, I think only that it would be helpful for the readers to consider. 2) The analysis of the clustering is interesting, and highlighted as a unique aspect of the analysis. Is it possible to comment further on what was found in this regard? Are there enough PSU s to examine if there is something like herd financing? What I am thinking is that as the funds are paid over to the health facility if a high enough proportion of the community are paying, the facility may improve to a point that it becomes a more attractive option, even to the uninsured.

3 I must point out to both the editors and the authors that the model optimization process used is not an approach I am very familiar with. Intuitively it appears correct, by you may want further comment from someone more suited to provide it. Minor comments: P2L7: best to say universal coverage of what exactly P2L10-12: suggest rewording P2L44: much improved or further improved rather than much more improved P3:L14: consider rewording point 2 P3L33: Fully subsidized how? They don t pay for the insurance or they don t have to pay a co-pay? This is clarified elsewhere in the paper, but would be nice here also. P3L37: Consider rewording a few grammatical errors and missed prepositions P4L48: Finances? Financing? P4L57: due to the unavailability of data P5L38-39: consider rewording P5L43-44: consider rewording P6L7: To understand or to isolate? P6L21: National, rural and individual levels? Or National, and individual-rural? P6L40: Adjusted or adjusting? P8L51: Why are these coverage levels so much lower than the 91% mentioned earlier. May be worth a comment. P9: The language sounds like you are taking about the probability Mutuelles coverage rather than the coefficient on the Mutuelles variable. VERSION 1 AUTHOR RESPONSE Reviewer 1 Introduction Line 41-45, page 3, it is reported that analysis shows funds transferred from the Mutuelles constitutes 22% of funds received by health facilities, and following from this analysis concluding that this provides long term financial support for child health services. Isn t that 22% actually for the provision of all services under the Minimum Service Package (MSP) and Complimentary Service Package (CSP)? Did the analysis show what percentage is used for child health? The reviewer is correct in that the 22% corresponds to the provision of all services under the MSP and CSP. We are not able to estimate the percentage of Mutuelles funds used for child health due to the unavailability of data. We have amended our original statement to address this point: Page 3: Our analysis on Rwanda health facility data shows that funds obtained from the Mutuelles program accounted for about 22% of total funds received by rural health centers in 2010, and this provides a long-term financial support to health facilities for the provision of all services under the MSP, which include medical care services for under-five children. Methods Line page 4, the main source of data for tracking health services availability between 2005 and 2010 was the DHSST, but there was no information for So when comparing the two years, what was the basis of using 2005 as they year with less health services compared to 2010?

4 The main data sources using for making comparison on available health facilities, medical staff, and health sector financing between 2005 and 2010 were gathered from various sources. Though we were not able to know the difference in detailed service items in the two years since the DHHST was only available since 2009, the increase in medical staff, health centers, and health care financing from 2005 to 2010 all suggested a stronger service delivery capacity in To improve the clarity, we modified our statements as below to address the reviewers comment. Page 4: To track the change in health service availability in Rwanda between 2005 and 2010, we gathered available data on health sector financing, number of health facilities and medical staff from sources such as the Annual Report of Rwanda Ministry of Health, Rwanda Health Statistics, Rwanda Statistical Yearbook, and National Health Accounts produced by the World Health Organization.8-13 There is no mention of ethical considerations. We truly appreciate the reviewer s reminder and have included a subsection with specific mention to ethical considerations in page 6. Results Line page 7, the results reported contradict what was reported under data sources line 37-40, page 4. While it appears that a different source was used from the one mentioned under data sources, why wasn t this source mentioned, if indeed it had the information needed? Please see our revision in page 4. We have addressed the reviewer s comment by indicating the specific data sources in the revised manuscript, as presented above. Discussion Line 15-27, page 11. The association of Mutuelles and utilisation cannot be concluded when there could be an issue of selection bias. The study can therefore only conclude regarding the increased utilisation regardless of insurance status possibly due to health system strengthening and increased availability of services between the two years. We cannot agree with the reviewer that the association between Mutuelles and utilization cannot be concluded in the present study. As we pointed out in the paper, the causality from the Mutuelles to service utilization could not be supported with the cross-sectional data. However, our results demonstrated a significant association (not causation) between Mutuelles enrollment and medical utilization, which was confirmed by different model specifications and estimation methods. Our results are also consistent with the findings about the association in previous studies, as we discussed in the paper (e.g., in page 4). On the same note, while the limitation has been mentioned, it has not been adequately discussed. The use of repeated cross-sectional data has demonstrated the importance of service availability for health insurance to promote service use, but still does not show that health insurance in itself does increase service use. We agree with the reviewer that understanding the casual relationship between the Mutuelles and service utilization is indeed important. However, this study was not intended to address this issue due to data limitations. Reviewer 2 Presentation: there are a number of grammatical errors and some further proof reading would help

5 with the flow of the paper. Similarly, there are a number of slightly clumsy formulations, which if addressed would help. Further, in terms of presentation, the box which describes what Mutuelles are, needs some work. A clear description of the alternative is required i.e. what is the situation for those who do not belong to the Mutuelles? Furthermore, some introduction to the list of MSP services would be helpful. We truly appreciate the suggestions from the reviewer. We have addressed the reviewer s comments by proof reading the whole manuscript and making necessary changes. We also have revised and made modifications to Panel 1 to improve its presentation. We are not sure about what kind of introductions are needed for the list of the MSP services, as the reviewer suggested. The DHHST data only provided the information as we listed. Interpretation: 1) The authors are rightfully careful to highlight that they cannot determine causality. I think it would also be useful to discuss what other possible explanations there are of the findings other than the explanation that Mutuelles improve access. For example, now that Mutuelle coverage is so high, noncoverage may indicate some social problem. Non-coverage may well simply be a very good indicator of social exclusion identifying those who do not access Mutuelles or health care. I do not think this would in any way detract from the findings, I think only that it would be helpful for the readers to consider. We agree with the reviewer s view and conducted t-tests to examine the difference in sociodemographic factors between children with Mutuelles and those without any insurance. We added a brief discussion for these findings in page 9 as below. We examined differences in socio-demographic factors between children enrolled in Mutuelles and those without any insurance in 2005 and 2010, and found that children living under the poverty line were more likely to be uninsured in both years, in contrast to children with more educated mothers who were more likely to be insured in both years. We also found that children with geographic difficulty to access the nearest health facility were more likely to be uninsured in 2010 (online Supplementary table 3). 2) The analysis of the clustering is interesting, and highlighted as a unique aspect of the analysis. Is it possible to comment further on what was found in this regard? To address the reviewer s comment, we added the following discussions about clustering effects in page 10. Our estimates on clustering effects reveal that most of the between group variation of medical care treatment (84%) was attributable to PSUs rather than to districts, suggesting that the correlation of medical treatment among children living in the same village and same district was substantially higher than the one for children living in different villages within the same district (see the Online supplementary material for details on the estimation method). Are there enough PSU s to examine if there is something like herd financing? What I am thinking is that as the funds are paid over to the health facility if a high enough proportion of the community are paying, the facility may improve to a point that it becomes a more attractive option, even to the uninsured. The reviewer raises an interesting question. We did a quick checking about the correlation of service utilization rates at the PSU level between children with Mutuelles and those uninsured using the RDHS The correlation is about 0.038, not high enough to support herd financing. This is not

6 surprising: Mutuelles contributed about 20% to total received funding of health facilities. Even with a high proportion of Mutuelles enrollment, if funding from other sources were low, service availability and their quality won t improve much. Minor comments: P2L7: best to say universal coverage of what exactly P2L10-12: suggest rewording P2L44: much improved or further improved rather than much more improved P3:L14: consider rewording point 2 P3L33: Fully subsidized how? They don t pay for the insurance or they don t have to pay a co-pay? This is clarified elsewhere in the paper, but would be nice here also. P3L37: Consider rewording a few grammatical errors and missed prepositions P4L48: Finances? Financing? P4L57: due to the unavailability of data P5L38-39: consider rewording P5L43-44: consider rewording P6L7: To understand or to isolate? P6L21: National, rural and individual levels? Or National, and individual-rural? P6L40: Adjusted or adjusting? We thank the reviewer for pointing out these issues and for his valuable suggestions. We have made the necessary changes in the revised version. P8L51: Why are these coverage levels so much lower than the 91% mentioned earlier. May be worth a comment. The 91% estimate was reported in the Rwanda Statistics 2012 Year Book and the Year Book does not provide information on how estimation was done. One explanation could be that the 91% is for coverage of national population, and our estimate is only for coverage of rural population. The difference could also come from time gaps, or differences in the estimation procedures. P9: The language sounds like you are taking about the probability Mutuelles coverage rather than the coefficient on the Mutuelles variable. In the regressions, we generated estimates of odds ratios, not coefficients for the Mutuelles indicator; therefore, our presentation was not about the coefficients of Mutuelles. We also produced the predicted probability of using care for children in different groups, which was discussed in page 9. VERSION 2 REVIEW Nahyuha Chomi, Eunice United Kingdom 14-Aug-2015 GENERAL COMMENTS The reviewer completed the checklist but made no further comments. Desmond, Chris Human Sciences Research Council, Chief research specialist 18-Aug-2015

7 GENERAL COMMENTS The reviewer completed the checklist but made no further comments.