Reviewer's report
Title:A comprehensive approach to women's health: lessons from the Mexican
health reform
Version: 1Date:16 July 2012
Reviewer: Deborah Billings
Reviewer's report:
Reviewer's report
Title: A Comprehensive Approach to Women’s Health: Lessons from the Mexican
Health Reform
Version: 1 Date: July 16, 2012
Reviewer: Deborah L. Billings
REVIEWER’S REPORT
- Major Compulsory Revisions
1. This is an important paper in the field of MCH and women’s health as it
introduces a woman AND health approach (moving to ever more comprehensive
ways of addressing gender, inequality and linkages with health and health
systems). It attempts to show the ways in which health systems “offer the
opportunity to address women’s health needs through innovative approaches
focused on promoting gender equality and empowering women as drivers of
change” (last paragraph, introduction) by using the Mexican health reform
process of the 2000s as a case study. The experiences of Mexico have much to
offer toward understanding the paradigm of women AND health, but the authors
do not provide enough evidence to make the case convincing to readers. Below
are suggestions for making the case more compelling. Without these changes,
the article continues to be about women’s health and not W&H (with a constant
focus on structural changes made- new Center, new health insurance, revision of
laws, etc)
• Begin the case study discussing real and important structural reforms, including
the creation of the National Center for Gender Equity and Reproductive Health,
which now is only briefly mentioned toward the end of the article. Establishing
this national center as part of the Ministry of Health was and remains
groundbreaking and significant, especially in terms of “promoting gender equality
and empowering women as drivers of change”.
• Discussion of the creation of the Center (why was it established, what were the
facilitating factors that allowed for resources to be invested in this way?) and the
Seguro Popular should frame the entire discussion of how the women and health
paradigm was implemented in Mexico since these illustrate some of the “broad
changes in health systems” in Mexico (and perhaps the authors want to add
other examples).
2. Make the Women AND Health approach the centerpiece of the manuscript,
since this is the innovation and contribution that this work offers to the field. The
current manuscript lists it as the “third and last section” when really the first and
second sections present the story of and frame how Women and Health came
into existence as an approach. Sections one and two are more “Background”
sections in my view, leading up to the important lessons learned from the
Mexican experience about how the W&H approach was implemented.
3. No mention is made of feminist researchers and feminism as a precursor to
the Women and Health approach. Work such as Geller and Bennett (see for
example https://apha.confex.com/apha/132am/techprogram/paper_75308.htm)
4. More data are needed to fully support the claims made throughout the article.
• In the “Addressing Women’s Concerns in the Context of the Mexican Health
Reform” section, add citations to the first paragraph about health expenditures
and poverty.
• Provide a reference to the full Seguro Popular plan
• Has universal coverage been reached (we are in 2012)?
• The article then discusses maternal mortality and efforts made to decrease it-
provide data on what the MDG goal for Mexico is and where it stands now;
discuss structural changes made to reach the advances made in reducing
maternal mortality but also what still needs to be done, since the MDG 5 will not
be met by 2015; show the differences in maternal mortality ratios between
northern and southern states.
• Include data on obstetric hemorrhage and eclampsia. Perhaps add a pie chart
to show how causes of maternal mortality are distributed. In this way, the
contribution of other important causes, including unsafe abortion, are seen
clearly.
• Discuss the challenges of changing health systems and the structures that
surround them, like state and national laws, for issues like unsafe abortion that
are needed for a W&H approach to be fully implemented.
• Reference is made to public opinion about emergency contraception. Show the
results of such surveys and provide references.
5. Provide deeper insights in terms of lessons learned (“from this debate”- I
question the use of the term “debate” here since I don’t see what’s been
presented as a debate. The lessons learned are from the Mexican experience).
• Lessons include the importance of taking advantage of key political openings
and working collaboratively among key political allies and civil society.
• Democratization is not discussed in the article prior to the “lessons learned”
statement and does not seem to fit here, especially since the “alternatives” (not
sure what this refers to- Seguro Poular?) were not the products of popular
groundswell)
6. The Conclusions section is very general. It should highlight the very strategic
and specific structural changes made through health reform in Mexico that have
allowed for the W&H approach to be implemented and to continue over time. I
agree with the authors that it is a “moral imperative and essential strategy toward
meeting national and international development goals.” More direction should be
given to readers to show how this has been done and can be done in other
contexts.
- Minor Essential Revisions
1. Throughout the manuscript and in the title, “Women’s Health” is emphasized,
yet “girls and women” are highlighted in the last paragraph of the conclusions.
Clarification should be made at the outset of the manuscript regarding whether
the new paradigm of Women and Health refers to females (infants, girls and
women) or just to “women” (does this refer to adults? If so, starting at what age?)
2. Introduction, paragraph 3: the authors refer to women as “pillars supporting all
levels of health care systems”- this analogy needs to be explained in greater
detail. What exactly do the authors aim to illustrate with the terms “supporting all
levels of health care systems”? In what ways do women do this?
3. The term “unfinished agenda” is used throughout the manuscript yet is never
precisely defined. What makes something part of the unfinished agenda?
4. When discussing the ICPD and Beijing conferences, in the context of W&H, it
seems important also to highlight the shift from a focus on demography/
population control to focusing on women’s health in a comprehensive manner,
sexuality/sexualities, empowerment and rights. When put into practice in health
systems, these new focus areas radically changed the approaches used and the
ways in which “success” has been evaluated.
5. Translate “Fair Start in Life” into Spanish as well; translate “Seguro Popular”
into English as well.
6. Clarify the discussion about obstetric nurses being “reintroduced” (to which
parts of the country, why did they need to be “re-introduced”; and traditional birth
attendants (is this meant to say “traditional midwives”)? Who trained them, how
and when? Include more information here to show how indigenous communities
are being better served.
7. Separate the discussion of the revision of the national family planning policy
from the discussion of maternal mortality. This is a new and very important topic
that merits its own section.
8. More than passing the 2006 law (and include the full name in the manuscript)
has been done as a result of the National Survey on Violence against Women.
Name some of the other structural changes that have been made that affect
gender equity and empower people, especially women.
9. Clarify whether mortality from cervical cancer has decreased over the last
decade because of Seguro Popular, other initiatives? This is implied in the text.
10. What concrete actions have been taken as a result of health reform in Mexico
to reduce ignorance, stigma, discrimination and machismo related to cancer?
Discuss this again to show the real structural changes being made to make a
W&H approach real and effective.
11. Reference 39 is missing from the list of references.
- Discretionary Revisions
1. Delete reference to the “morning after pill” and refer to the medication only as
emergency contraception
2.Change “happy culmination” to “positive culmination” when discussing the
endorsement of EC in Mexico.
3. Cut reference to “domestic abuse” and use the term “intimate partner violence”
throughout the manuscript.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
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