Author's response to reviews. Title:Cost Analysis of Youth Clinic Network in Estonia. Authors: Jari Kempers

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1 Author's response to reviews Title:Cost Analysis of Youth Clinic Network in Estonia Authors: Jari Kempers Version:2Date:1 April 2015 Author's response to reviews: see over

2 Responses to reviewers comments Dear reviewers, Thank you for your comments and the time it took to review this long manuscript. I went through your comments carefully and did many changes to the original manuscript. Please find the below point-bypoint responses to your comments in italics. Best regards, Jari Kempers General comment of Dr José M Belizan One of the reviewers raised serious concern about the length of the manuscript. I am asking you if you can shorten the manuscript as much as you can. Yes, I agree. I have edited and shortened the manuscript from 5,500 to 3,600 words. Also, please you need to work on the references. The majority of them are not from Journals. Please provide a link to every reference. Also, in references with a web link please provide the date that this link was accessed by you. Done. All the references were checked and updated. All the links have been accessed on 9 March We would be grateful if you could address the comments in a revised manuscript and provide a cover letter giving a point-by-point response to the concerns. Reviewer: Helle Karro This is very relevant study and I am absolutely convinced that it will be important to publish it. There is not enough information available about the cost effectiveness of the youth friendly sexual and reproductive health services. Results will be interesting for policy makers and researchers. However, the article needs some revision and restructuring: General comments to author (compulsory revision): 1) Information about the organization, standards, management, changes etc. of youth friendly SRH services in Estonia should be given in the background. There is no need to repeat it in the methodology section. As there are several publications about Estonian youth clinics it would be good to refer to published studies and not necessarily to repeat it.

3 Yes, I agree. I shortened the background part, added references and removed repetition from the methods section. 2) Please describe the aim of the study in the end of introduction. It is repeated in the beginning and in the end of background Ok, I changed the purpose of the study in the beginning to more general and left the detailed objectives at the end of background section. 3) Methodology session should concentrate only on cost analysis. There is no need to describe quality and management of youth clinic network in Estonia. It should be briefly described in the background. Yes, I have changed this. Cost per youth clinic is given in six categories (salaries, medical supplies, operations (?, management? cost), personnel training, ESHA coordination, internet. However, later different categories are described (cost of reaching patient, cost of sexual and reproductive health services, sex education lessons. Please revise categories. These are separate costs analyses, each answering to different question. The leading subresearch questions were somewhat unclear. These have been now clarified. The structure of cost analyses and their breakdowns are correct. 4) Results. Titles of the figures are in text but enclosed figures are without title 5) Discussion. True, but this is on purpose. The figure titles will appear correctly in the final publication. There is no need to repeat all results. Agree. I shortened and kept only the main costing results in the discussion. It would be good to add discussion why Estonia was chosen for study, benefits using information about Estonian youth clinics. Yes, I added this to the background section. There was mentioned similar study in Moldova, but I was missing information about other similar cost studies. Cost analyses of YFSRH services are scarce. I have completed a literature review of economic evaluations of YFSRH services (to be published). As far as I m aware, there is no other comparable studies. There are some studies on African programmes, but it is not meaningful to compare them here. In conclusion will be added value some sentences about cost effectiveness of financing youth clinics.

4 Cost-effectiveness is outside of the scope of this paper. I cannot draw conclusions about costeffectiveness of the YCs at this stage. Young people s SRH outcomes have improved in Estonia, but attributing which portion of the improvement is related to the YCs is difficult and not done. However, there is a new research proposal for investigation of combined impacts of Estonian YCN and school-based sexuality education programmes. Some specific comments Page 5. SRH services. HIV should be included into first point STI/HIV testing Youth clinics do not offer HIV services. Done. Changed HIV services to VCCT. HPV vaccination is not STI consultation, the aim of vaccination is cervical cancer prevention. True. Moved HPV to under SRH services. Page 6 general adolescent medical disorders most probably it is menstrual cycle disorders and other gynaecological problems. I shortened the text here. Left only: and a range of other SRH services. Table 1, medical personnel gynaecologists and medical doctors. Gynaecologists are also medical doctors, perhaps it would be better other medical doctors or specialists. I prefer to keep it simple. Adding other does not provide additional information about the clinics. Reviewer: Osvaldo Ulises Garay 1. Is the question posed by the authors new and well defined? Yes. The question of the study is new and clearly defined. 2. Are the methods appropriate and well described, and are sufficient details provided to replicate the work? Methods are well described but the cost analysis is very limited. The purpose of this paper is to document the costs of Estonian YCN clearly and simply, and present them in a way that is relevant and understandable to readers, i.e. policy makers and programme managers. There is no need to complicate the analyses. 3. Are the data sound and well controlled? Yes. Data appears to be sound and well controlled. 4. Do the figures appear to be genuine, i.e. without evidence of manipulation? Yes they do. 5. Does the manuscript adhere to the relevant standards for reporting and data deposition? The manuscript is unnecessary long and information on tables is limited.

5 Yes, I agree. I have shortened the manuscript. 6. Are the discussion and conclusions well balanced and adequately supported by the data? Yes they are. 7. Do the title and abstract accurately convey what has been found? I would change the tittle to something like Cost Analysis of 3 Youth Clinics in Estonia COMMENTS The paper presents; 1) programme cost of the YCN during the period (= all 18 clinics), and 2) annual clinic level costs of three YCs in Therefore, the current title Cost Analysis of Youth Clinic Network in Estonia is appropriate. Minor Essential Revisions: 1) Page 2: I would include in the abstract what a youth friendly and reproductive health service is. If you don t know what it is, you can only figure that out by reading in deep the manuscript. I assume that the majority readers of the Reproductive Health journal have a general understanding on what the youth friendly SRH services are. There is no need, nor space, to include this in the abstract. Those readers who don t know it, can find it in the text. 2) Page 3: include Sexually transmitted diseases for STD Done. 3) Table 2 needs footnotes with abbreviations. All the abbreviations used in Table 2 are introduced in the text. I leave it up to editors to decide if a footnote is necessary. Discretionary Revisions: 1) I strongly recommend reducing the word count. It would make the document more attractive for readers without conditioning findings explanations. Agree. I have shortened the manuscript. 2) I wouldn t include an introduction of what is going to be discussed in each section. Agree. Removed. 3) Table 1 is unnecessary. That information can be included in the text. I disagree. Table 1 provides readers with a compressed overview of the characteristics of the three YCs. Moreover, it limits the length of the paper.

6 4) A cost analysis should include very detailed tables of costs. Table 2 is too uninvolved. I disagree. One should not complicate presentation of the results by adding unnecessary details. The table summarises the costs of healthcare services in way that is relevant and comprehensible for readers of the journal. 5) I would include a Results table. The cost analyses are conducted on different levels and timeframes, i.e. programme level vs. clinic level Combining these into the same table would confuse the readers and should therefore not be done. Reviewer: Taavi Lai Major compulsory revisions 1. Could you please discuss in a little bit more details, what is the relevance and messages of the findings to international readers e.g. organisational models, possible double counting in claims database etc. Yes, I fine-tuned this. Conclusions are formulated for other programmes. Minor essential revisions 2. The main comment for the paper is that in its current status, it is unclear what are the formal relations between the Estonian Sexual Health Association (ESHA), the Youth Clinic Network (YCN) and individual Youth Clinics (YC). It is described that ESHA holds the coordinating role for YCN but it is not clear how it is financed while 3.6% of the YCN budget goes for ESHA. Does ESHA own one or more YCs? Do all YCs pay a fixed amount to ESHA etc. As the formal set-up of the YCN in regard to ESHA is not described, it is difficult to understand and assess whether the current funding (3.6% of total) is reasonable or not. Moreover, other countries wanting to use the YCN model promoted in the paper could also benefit from a more detailed description of these relations between YCN/YC and ESHA. Response to points 2 and 3. Yes, I added a paragraph on the relationships, and clarified contractual arrangements with the EHIF. More detailed description of the YCN model can found in the two referenced WHO studies; a policy analysis and a case study. 3. It is somewhat unclear from the paper whether all YCs have individual contracts with the Estonian Health Insurance Fund (the main funder of YCN) or is the funding contract with the YCN as a whole or with the ESHA. Moreover, in all these possible contracting arrangements, additional information could be given on how exactly the funding proportions between individual YCs are reached. Please see my response to point In addition to the previous point it is stated that the 3 YCs covered in detail are responsible for 57% of the total YCN budget. It would be good to give also the number of target populations for these three

7 YCs so that reader could get a better understanding about the regional distribution of budget vs target population. Done. I added YCs catchment populations in table A unified youth friendly approach is mentioned in the paper. Please clarify how this is defined in the current paper. This part was removed when shortening the manuscript. 6. While the paper presents the costs per patient. It turns out that the costs are actually per contact of a patient as individuals cannot be distinguished in the available dataset. It would be good to present this more clearly already in the methodological section. Done. Now in the methods: EHIF s reporting system does not capture if the same patient visited an YC several times in a year. Consequently, the cost of reaching a patient must be interpreted as an approximation. 7. The same goes for the services the cost per service seems to be actually not the actual cost but reimbursement price as different services could be provided during one contact but these are all coded as one service due to the set-up of the reimbursement scheme. This should also be presented more clearly already in the methodological section of the paper. First, the cost analysis was carried out from healthcare provider s perspective, i.e. to answer how much the YCN cost to the government. The purpose was not to assesses whether or not the reimbursement fees reflect the cost of producing the services that is a different study. Second, 95% of the budget is covered by the Estonian Health Insurance Fund. Therefore, by definition the cost per service is the same or almost the same as the reimbursement fees per service. Third, objective of this costing study was not to evaluate the reimbursement systems or its coding. 8. In relation to the cost per service/patient these possible limitations and implications of the current aggregation could/should be addressed in more detail in the discussion section of the paper. The cost analysis was carried out from healthcare provider s perspective, i.e. to answer how much the YCN cost to the government. The purpose was not to assesses whether or not the reimbursement fees reflect the cost of producing the services. Hence, in the light of the research questions, it is not necessary include these in the discussion. Moreover, the fact that 95% of the cost are covered by the insurance and that the calculations used their data is not a limitation of the study on contrary it is a strength of the study, i.e. the data covers the large majority of the services, consistent documentation etc. 9. The cost calculations are based on EHIF claims data. At the same time, the paper describes the internal reporting system of the YCN/ESHA. Finally, the paper states that the data does not capture if a patient had several treatments or tests during the same visit and that it is not possible to distinguish whether

8 one person visited the clinic more than one time. Even if the claims data doesn t capture these aspects it begs a more thorough discussion why the YCN/ESHA reporting doesn t capture this and/or how the reporting systems could/should be changed to enable more detailed analysis of the costs. Objective of this costing study was not to evaluate the reimbursement systems or medical reporting of ESHA and YCs. Although some recommendations have been given during the project, these do not belong to this article. 10. Please ensure that all acronyms are defined before their introduction (e.g. NIHD) Done. 11. Table 1. Would be good to add total FTEs for all three YCs. Also adding owners of the two YCs like it has been done for the one in Tallinn, might be good(or present all three without owners). Size of the target population could be added for the YCs. Done. I added total FTEs and excluded owners. 12. The results of the paper state that proportion of the online counselling costs and personnel training covered by the three YCs is 2%. Could you please explain why the share of these costs are so low compared to the overall 57% share of total budgets. The percentages measure different things. Online counselling and personnel training are both 2% of the total expenses of the 3 YCs. On the other hand, the 57% is of the total budget of the YCN (= 18 youth clinics). 13. Table 2 and it s description in the text: would be good to get a breakdown of the service costs by main components e.g. personnel, materials etc. The available data does not provide this level of detail. 14. Regarding the average training costs per one staff could you also provide the volume of the training? Analyses of personnel training costs were left out to shorten the paper. 15. In Discussion, costs of the Estonian YCN is compared to one in Moldova. Please state whether these are total or per capita costs? Latter would be preferable. Moreover, if these are total costs, would it be possible to indicate sizes of GDP (per capita) of these two countries to give the total costs a better perspective. Sizes of target populations might be included as well. Euros were first converted to USD. Then the USD amounts of both programmes were adjusted with World Bank s price level ratios of each country to make the amounts more comparable, i.e. international dollars. The World Bank explains the ratio as follows:

9 Price level ratio of PPP conversion factor (GDP) to market exchange rate: Purchasing power parity conversion factor is the number of units of a country's currency required to buy the same amount of goods and services in the domestic market as a U.S. dollar would buy in the United States. The ratio of PPP conversion factor to market exchange rate is the result obtained by dividing the PPP conversion factor by the market exchange rate. The ratio, also referred to as the national price level, makes it possible to compare the cost of the bundle of goods that make up gross domestic product (GDP) across countries. It tells how many dollars are needed to buy a dollar's worth of goods in the country as compared to the United States. 16. What Youth Clinics Network could do differently? Could you please discuss in a little bit more details, what Estonian to reach better cost estimates and monitoring of it's activities. In general, the YCN has a good medical reporting system. The objective of this costing study was not to evaluate the reimbursement systems or medical reporting of YCs and ESHA. The purpose is to document the programme cost to international audience. Even though some recommendations have been given during the study, these are not relevant for this publication. Discretionary revisions 17. There s a phrase The independent YCs are: This leaves one wondering whether there are also nonindependent YCs and if yes then this needs further clarification in the paper. This has been changed and clarified in the text. 18. There s a sentence saying similar to a youth clinic network in Sweden. Would be good to have a reference for a source, describing the Swedish network. I added a reference to a WHO case study that describes the development of YCN. 19. It is indicated in the paper that the website and other online services are also available in Russian. What about other services? This is clarified in the text. Both in Estonian and Russian. 20. There s a phrase provide trustworthy information. What is meant by that? Evidence-based information or something else? Changed to accurate information in the text. Trustworthy was not a correct word for this. 21. On page 5 there s a description of EHIF funding. What/how has the new legislation made funding sustainable? Does EHIF have an obligation to fund ESHA/YCN and are the contracts long-term, etc? This is clarified in the text. 22. The list of services presented in section Sexual and reproductive health services on pages 5-6 might be more clear to readers if presented as a table/box.

10 I added bullet points in the text. 23. On page 8 there s a mention that each YC receives feedback on how it compares with target and other YCs. It might be a good idea to shortly describe the procedure of setting the targets as part of the description of overall management structure of the YCN and its formal relations with the ESHA. The text about the feedback and evaluation was left out, as it falls outside of the scope of this costing study. 24. Figures 2 and 3: please consider changing the graph format to include time trends. The purpose of these graphs is to illustrate clearly from where the clinics received their funding and on what they spend the funds, which are both relevant for the readers. Adding time trends would dilute the message.