Title: Mapping the health systems response to violence against women:  Key learnings from
five LMIC settings (2015-2020)
Version: 1 Date: 11 Mar 2021
Reviewer's report:
Overall, it is an interesting paper on a very important topic. However, I would recommend some
major revisions that could strengthen the paper.
The aim of the paper is not very clear. In the abstract and in the Background the paper states
(line 90) that 'this paper aims to study how LMIC health systems have operationalized health
systems responses to VAW between 2015 and 2020’. While in line 408-9 it states that ‘the paper
synthesizes a range of evidence to identify the core dimensions of a successful VAW response,
showing what has worked and what has not, over a period of five years in five settings’. You
may want to clarify that you selected 5 settings and in each one a specific service delivery model
that you are going to assess using the HS framework to guide your analysis.
I also wonder the main model presented of a successful response is the One-stop centre, which
has many challenges (also reported in systematic reviews). I wonder if you should refrain from
using ‘successful’ model as One-Stop Crisis centre is not considered successful as there are no
rigorous evaluations on such service delivery model.
The paper would benefit from a clear description of the methodology as it is not stated what
research method has been used and what criteria to chose the evidence presented. The paper
would benefit from a detailed table with summary results for each HS component could be
presented to illustrate some of the key points.
The discussion and conclusion would need to be strengthened with more contextualisation of
the findings within current literature and implications for future HS responses.
Here some specific comments:
Background
Line 56: add reference to WHO global estimates.
Line 67: Please correct this sentence about the HS framework, as it was developed by Colombini
et al 2012 (here the full reference: Colombini M, Mayhew SH, Ali SH, Shuib R, Watts C. An
integrated
health sector response to violence against women in Malaysia: lessons for supporting scale up.
BMC Public Health 2012; 12: 548) and subsequently adapted by WHO in 2015.
Line 74: frameworks should be singular as the author is referring to only one. Also, I would
delete ‘additional’ as you have not mentioned limitations in the paragraphs before.
Line 81: add references about challenges. For example:
a. Colombini M, Mayhew S, Watts C. Health-sector responses to intimate partner violence in
low- and middle-income settings: a review of current models, challenges and opportunities.
Bulletin of the World Health Organization 2008;86(8):635-42.
b. Kirk L, Terry S, Lokuge K, et al. Effectiveness of secondary and tertiary prevention for
violence against women in low and low-middle income countries: a systematic review. BMC
Public Health 2017;17(1):622. doi: https://dx.doi.org/10.1186/s12889-017-4502-6
c. Sapkota D, Baird K, Saito A, et al. Interventions for reducing and/or controlling domestic
violence among pregnant women in low- and middle-income countries: a systematic review.
Syst Rev 2019;8(1):79. doi: 10.1186/s13643-019-0998-4 [published Online First: 2019/04/04]
I think Line 82: H should be in full
Methods section
- This section needs more detailed information about the methodology, as it does not describe
what the objectives are and what specific method was used in the article. I think this is a
document review, though more information should be added on how data searches (from where),
timeline, how many studies/reports were used and how they were selected (inclusion/exclusion
criteria). It should also mention how data gathered was analysed (thematically, using health
systems framework category?). You should also state that you have selected the HS framework
to guide your analysis and for organising your findings.
- It is important to show where the findings are coming from and how they were selected.  You
only describe the selection of the countries, but not about the evidence you used to describe the
HS components.
- The paper uses the health systems framework as the lens to interrogate each of its components
for five specific LMIC settings. However, a clearer explanation should be added of how the
evidence has been interrogated using a systems-lens.
- How did you conduct a comparative analysis?
Results:
• I feel a table is missing on the models and the challenges and facilitators in relation to each
dimension of HS. It would be helpful for the reader to understand the key findings for each
setting and commonalities across countries.
• This section should start by describing the service delivery models of healthcare for VAW in the
countries selected using table 1 (line 106) in the methods section. What models are implemented
in the selected countries, since when and where? I think the table would fit best as part of the
results (unless you purposively selected these models. Then you can present the results by HS
components.
• More information could be added about the context in each country settings to explain the
services offered, what type(s) of VAW services they care for (e.g. SV, IPV etc.) and what
level (primary care versus hospitals (OSC)), when they started HS response to VAW (length
which may show country expertise in HS strengthening (e.g. Brazil has a lot of experience
and many studies were published versus Rwanda or Nepal – with more recent VAW service
implementation). Then you can explain the challenges in each HS component.
• I would recommend that 1a and 1b should be merged and be renamed as ‘Values and Beliefs of
providers’ as this is a HS component. H providers supporting or women centred are not elements
of the HS framework, but principles behind a HS response. You can then mention the importance
of women’s centred approach and how providers often do not follow such principle because of
their beliefs, values and attitudes etc.
• Line 114: Health providers’ section: I feel this section can be strengthened to reflect the range of
issues around healthcare workforce in the selected countries. There is only one reference, though
there are more references that could be added here as studies are available in these countries,
especially in Brazil (e.g. d’Oliveira AF, Pereira S, Schraiber LB, et al. Obstacles and facilitators
to primary health care offered to women experiencing domestic violence: a systematic review.
2020. doi:10.1590/interface.190164.
• Line 154 onwards: 2a. VAW in policy and implementation: leadership and governance: I think
in this section you could also add references around policies on VAW in the study settings, and
the guidelines available (e.g. in Brazil, in Sri Lanka, Nepal). I wonder if you could add this
information to the key findings summary table to show availability of laws and policies and
guidelines in each country to help the reader understand HS governance structure around VAW
in these selected countries.
• HP training.  Line 187: What are ‘implementation plans’ in the contexts? Do they have specific
Plans in each country that delineates the implementation process of the HS response?
• Service delivery section: Line 254-56: this sentence should be moved to the beginning of the
results section when describing the models of care identified in the study settings. Otherwise it
is a bit confusing and the reader won’t know until you reach this point.
• Line 320: leadership and governance: I feel this section is missing evidence on the importance
of guidance and structures to ensure implementation of a HS response. What are the examples
form the selected countries? It does not really say much on these aspects.
• Line 352: I am not sure why HERA study is reported here as it is an ongoing intervention, not
an example of how government is operationalising HS response. Maybe this could be moved to
the background. Here you could mention the strong focus of Brazil VAW response in primary
health care (with the Violence Prevention Nucleo (NPV) and training for staff, etc.).
Discussion
Overall, I would suggest that this section should be strengthened as it is mainly summarising the
results but not contextualising the findings within the larger literature on HS response to VAW.
Summary of the results should only be a couple of sentences here. What are the implications
of your findings? I think implications and discussions of the findings are important and should
be included here.
• It seems that some results are also included here in this section. For ex. Table 2. (see my
comments below) I would suggest that you move Table 2 line 309 and Table on summary of
key findings line 379 to Results. I would suggest that you move table 2 to the section on ‘health
providers supporting women’ as it shows values and beliefs of providers. Table on key findings
should be at the beginning of results section and maybe have a sub-heading on ‘Context’. It
would make the Results section easier to follow.
• I would merge sections on Health providers supporting survivors and responding to survivors
together as this is part of values and attitudes of providers (which is a HS component).
• Line 364: I think this should be part of the Results as the context do influence how HS responses
are designed and implemented. However, I also think that there should be something in the
article explaining how gender equality and VAW are linked. Furthermore, existence of laws and
policies promoting gender equality are as critical.
• Line 381: what do you mean by ‘the most lessons learned’? In this section, it seems that Nepal
is a good model for OSC implementation, and the only one discussed. Why is that? It is not
so evident from the table. Also, OSC implementation in Nepal is still relatively recent in the
country and it is not without challenges – e.g. not all staff in all hospital is trained, designated
staff for OSC, but not paid for their ‘additional’ roles, etc.
• Also, in the table on key summary, I am not sure why it mentions OSC has they do not have
such a model there. I wonder if you should instead mention the primary health care response
and the SV response in hospitals. The VAW
• Top lessons learned: I wonder if these should be phrased more as recommendations, though
your results do not always provide insights on these recommendations. The results section should
ensure to reflect adequate evidence to support such recommendations/lessons learned.
• Line 400: You mentioned links with communities, though you could specify between whom?
OSC and communities (and who in communities)? Are you referring to community health
workers?
Strengths and Limitations
• Line 405-409: this should be moved to the methods section because it clarifies the aim and the
temporal dimension of the evidence and analysis made.
• Line 410-to end of the section: I think you should also mention the fact that most of the
evidence, particularly on OSCs does not evaluate effectiveness of the OSC model, and thus it
may be difficult to discuss lessons learned and limitations when many of these models have not
been evaluated.  I wonder if you could mention what has been done to counterbalance the two
limitations.
Conclusions
• This could be strengthened to mention also implications for future research.