Negotiating Access to Health Care for All through Social and Political Accountability: A Qualitative Study in Rural Nigeria

Round 1

Reviewer 1 Report

I think this is an excellent addition to an important literature on CBHI programs in Africa. It comes closest of many papers in this area to exploring how the intended beneficiaries of these programs were engaged in the design and operations and the influence of such engagement on program sustainability and impact.  I think the paper makes an important contribution and should be selected for publication in this journal.  I do think the paper needs a little editorial attention to ensuring that quotes from participants are clearly separated from commentary and I have a number of suggestions for clarifications and enhancements.

On the methods section, it would be helpful to say a little more about the experience of recruiting the study interview participants-----were people interested in reviewing the CBHI experience? I would also have appreciated more detail on study questions and more about your analytic strategy. I liked the way you used prior studies and other published materials along with participant perspectives in shaping your results narrative and I think you could say more about this.

For section 3.1, I think it would be very valuable to comment on community member and potential beneficiary engagement with the CBHI program during its planning, development and early engagement. It would also be helpful to say more about the program model: does the enrollment fee cover all capitation costs and what roles do local, state, and national governmental and philanthropic funders play? What was the formal role of the state government in CBHI program financial and quality accountability?

For section 3.2, I think you could have provided a little more evidence on how the concerns of committee members were utilized by the provider organizations. You offer some evidence that committees felt their impact was considerable, and it would have been helpful to also hear about variability in responsiveness by place and topic.

In section 3.3., it would be helpful to learn more about the process that lead to closure of the CBHI plan. To what extent was this a state-level decision and to what extent did philanthropic and other funders shape the decision? How were local providers and the committees engaged in the run-up to closure?

I think addressing these factors would only strengthen and extent the already excellent discussion.

Author Response

Reviewer 2 Report

Thank you very much for sending me this manuscript. I have several minor comments to share with the author(s).

1. I agree with the author(s) that the country’s healthcare system/approach is often influenced by the political climate of the country, as suggested in the 3.3. section. While I appreciate this concrete description, I believe it would be beneficial to discuss this mechanism at the theoretical/conceptual level somewhere in the manuscript. What is the theoretical/conceptual link between external politics and healthcare system?
2. I like that the author(s) frames the findings in the context of the Alma Ata Declaration of 1978 in the Discussion section. I think this would be useful to be mentioned earlier in the Introduction.
3. There are typos and other style-related issues throughout the paper. Please carefully check and make relevant changes.

Author Response