Exploring system drivers of gender inequity in development assistance for health and opportunities for action

A systems approach to gender and health inequities

Systems theory, an interdisciplinary field of science that analyzes the dynamic interactions of interrelated, interdependent parts that make up a complex whole, has gained attention as relevant for health systems analysis and interventions³⁵. Application of systems theory can benefit the exploration of macro-level dynamics affecting complex and protracted issues, making it a useful basis for exploring the drivers of gender and health inequities in DAH^35–37. Systems approaches have been used in social intervention research, such as studies examining interventions that tackle intimate partner violence^38,39. However, there are relatively few studies that use a systems approach to analyze progress in minimizing gender and health inequities. Moreover, the operant dynamics and drivers in the landscape of DAH that reinforce gender bias are poorly documented.

The field of systems approaches is evolving. Diverse approaches are emerging from different fields of study, epistemologies, and contextual boundaries. Many such approaches focus on describing the system, without emphasis on opportunities for change. In contrast, System Acupuncture®^c is a theory and method that enables the design of innovative, actionable, and synergistic interventions that drive deep and sustained transformation of system behaviors and outcomes⁴⁰. The System Acupuncture® approach adds value by enabling engagement of diverse actors in understanding the complexity of system drivers in gender inequity in DAH and identifying opportunities for system-level transformation.

Framing and purpose of this paper

This paper builds on prior work examining the shifts needed in DAH to facilitate a redistribution of power, and coordination and accountability between countries and donors^d in designing health technical assistance (TA) interventions⁴¹. Such shifts are needed to foster more resilient health systems and sustained health outcomes³¹. We anticipate that efforts to redistribute power in ways that center local stakeholders in decision-making and build mutual accountability cannot be fully realized without addressing gender inequities.

The objective of this paper is to identify systemic challenges in DAH that are perpetuating or contributing to gender inequities, with a particular focus on the role of external donors and funders. In this paper, we map and analyze interactions between donors and recipient countries and articulate drivers of gender inequities within the landscape of DAH. As a basis for exploring and identifying actionable steps to improve gender and health equity outcomes, we aim to highlight systemic issues that impede or slow progress in addressing gender and health inequities in DAH.

Study design

The work presented in this paper was conducted as part of a broader initiative led by the Inter-agency Working Group (IAWG) for Capacity Strengthening^e to co-create a systems’ understanding of capacity strengthening in the context of global DAH⁴⁷.

Using the methods and tools from System Acupuncture®, we took a structured process consistent with social constructivist approaches^f to enable system actors to collectively understand and improve a complex adaptive system. For the IAWG initiative and this paper, the scope of the system is defined by the complex relationships of actors and institutions interacting within the landscape of DAH, and the norms that inform their behaviors and decisions.

The IAWG aligned around a set of critical shifts for capacity strengthening (Figure 1), which outlines a vision for more country-driven, coordinated, and equitable health investments. These critical shifts served as a framework to co-create a systems understanding of capacity strengthening and collectively investigate ways to improve programming in DAH. The initiative’s hypothesis was that application and realization of the critical shifts by actors in the system would enhance the capacity of global health institutions to deliver sustained health outcomes. A gender lens was prioritized as part of the process in recognition that gender bias and inequities are manifest throughout the global health landscape, and the critical shifts and desired impact from health investments cannot be fully realized without addressing these factors.

Figure 1. Critical shifts for capacity Strengthening.

Primary data were collected and analyzed via facilitated discussions and visual mapping exercises (described below) to develop and iterate emerging themes, explore insights from stakeholders, and refine the maps to reach a shared understanding of system dynamics across the DAH landscape. The discussions helped articulate and clarify the perspectives and experiences of a diverse set of stakeholders, which included donors, national government ministry representatives, academia, and civil society. This iterative virtual engagement was facilitated by the secretariat over nine months in 2021.

Guided by the System Acupuncture® approach, we undertook the following steps:

Desk Review: We conducted discussions with the IAWG and completed an iterative and non-systematic literature review to inform the system mapping process. The literature review was based on Google Scholar and PubMed searches using multiple permutations of search terms: gender, power, social determinants, social accountability, development assistance for health, donor, and health system. An iterative approach was applied, refining terms and adding articles from sources cited as the review proceeded. Sources were selected on the basis of relevance to the topic of gender, power, and development assistance for health. The literature review was limited to English language sources from the years 2000 to 2022. In total, 52 peer-reviewed journal articles and nine relevant reports and commentaries were reviewed. Systematic analysis of the sources included thematic coding for themes based on questions driving the review, including:

(1) How do gender bias, discrimination and power dynamics manifest in national health systems, and how do gender inequities contribute to poor health?; (2) How do gender bias, discrimination and power dynamics manifest in the landscape of donor assistance for health?; (3) How does donor assistance for health programming succeed or fail to support attention to gender bias and discrimination?

Mapping the system: System maps were used to co-create, describe, and visualize the multi-dimensional view of causal connections between individual drivers in the system.^g Drivers refer to identifiable forces (i.e., structural, policy, and funding decisions or behaviors) that can influence different elements of the system to act in specific ways (in this case, perpetuating gender inequities in the DAH landscape). The maps were then reviewed, discussed, and honed through a virtual co-creation workshop as part of the broader system mapping exercise. The workshop was held over two days in April 2021 and convened 41 people from 13 countries. Participants included representatives of government, civil society, funding institutions, academia, and implementing agencies. The IAWG members and the Secretariat identified participants within their networks who could bring diverse perspectives on how health funding and TA is structured at various levels and how donor processes, models, and norms constrain or amplify health system capacity strengthening and sustainable health outcomes. Participants were selected to ensure diversity in background, institutional affiliation, geography and perspectives in order to co-create a systems view.

A subset of six participants,^h facilitated by a gender expert, explored dynamics and drivers related to gender and health inequities that are slowing or impeding progress in DAH. During the workshop, participants used a collaborative virtual whiteboard tool to capture and depict specific behaviors, dynamics, and characteristics of donor and country stakeholder group interactions that hinder progress to reduce gender and health inequities, as they experienced them in their context⁵⁰.

Synthesizing key challenge areas in the system: We then synthesized the content developed by the workshop participants by spatially arranging the drivers into three broad contexts based on where the policy or funding decisions, behaviors, or actions occur: the donor space, the country space, and the space where they intersect. The synthesis resulted in the identification and mapping of six key systemic challenges (referred to hereafter as 'syndromes') that highlight a collection of system drivers that pose barriers to the critical shifts and ultimately to gender and health equity⁵⁰.

Iteration and expansion of six system syndromes: The same subset of six participants^h from the original workshop and several IAWG and secretariat members participated in two follow-on virtual co-creation sessions to iterate and expand on these six syndromes. In addition, three semi-structured key informant interviews were held with gender experts with expertise in DAH, gender institutional capacity-strengthening or health system capacity strengthening, to validate the findings.

Ethical statement

All data collection was carried out through a facilitated co-creation process, including one virtual workshop and a series of discussions. The process elicited impersonal and anonymous feedback from selected participants. To ensure privacy and confidentiality, participant insights were gathered anonymously via a virtual whiteboard tool.

In the first phase, co-creation workshops, oral consent to collect inputs and record sessions was obtained from all participants at the start of the workshop sessions, per standard practice for minimal risk interactions. Participants were assured of confidentiality and that all findings would be anonymized and provisions made for the protection of privacy and confidentiality of the participants and the information they provided. No individual interviews were conducted. All inputs were collected and analyzed with complete anonymity and are therefore unable to be linked to a single individual. The project team did not seek ethical approval for the first phase because we determined the activities were exempt, given that they did not constitute human subjects research as described under US HHS regulation 45 CFR 46(e)(1). In the case of the workshops, the information obtained was not about the participants, but rather their expert opinions and feedback.

In the second phase, small group discussions, the JSI institutional review board deemed the process and tools exempt from full review under CFR 46.101(b)(2), which covers survey activities without identifiers or sensitive questions that could result in harm; no participants in the study were minors (less than 18 years of age). Written informed consent was obtained from participants during this phase of the initiative, since it involved meetings with a smaller group of participants and thus inputs could not be fully anonymized.

Six syndromes that slow or impede progress in gender equity in DAH

The mapping and co-creation processes resulted in: 1) a series of conceptual maps of the drivers of gender inequities within the landscape of DAH, 2) diagrams describing potential change points, and 3) a graphic representing the participants' views on priority action steps by donors⁵⁰. The six syndromes that emerged from the co-creation process reveal distinct yet interconnected system dynamics driving barriers to achieving gender equity and health outcomes. The term syndrome represents a set of concurrent events that form an identifiable pattern or a group of signs and symptoms that characterize a particular abnormality. By naming the thematic areas syndromes, we ask the reader to consider a metaphor for the system as a body in need of healing. The six syndromes highlight patterns of dysfunction in the system that are badly in need of repair.

Each syndrome is depicted visually (via a system map) and through a narrative summary. The narrative and maps should be read side-by-side to enhance understanding of the system dynamics. In the graphics, each circle represents a driver in the system. The circles are arranged spatially to show where the drivers are in one of three spaces: 1) donor (left); 2) country (right); and 3) interaction (middle) (i.e., between donors and funding recipients). The spatial arrangement of these drivers and their connections is designed to help the reader understand and explore where the drivers originate, and how they interact, for the ultimate purpose of identifying solutions. The lines between circles suggest a causal relationship in the direction of the arrow. The thicker arrows highlight important connections in the system, including feedback loops (i.e., cyclical clusters of drivers that reinforce each other, amplifying their effect and perpetuating a set of system behaviors).

While the six syndromes are depicted separately below, they are interconnected. Thus, while many syndromes touch on overlapping themes, they are explored from different angles. Overall, the syndromes should not be interpreted to reflect the behaviors of particular donors or countries, nor as manifesting in all contexts or donor initiatives. Rather, they represent the synthesis of experiences and perceptions that surfaced through the methods described above.

Syndrome one: Insufficient input, feedback, and leadership from groups most affected by gender bias and discrimination render programs less effective (see Figure 2)

Figure 2. Syndrome 1: Insufficient input, feedback, and leadership from groups most affected by gender bias and discrimination render programs less effective.

There are limited opportunities for community-level groups or civil society organizations with gender expertise to co-create, lead, or give feedback about DAH programming. Health programs and decisions tend to be made by national-level policy makers and technocrats, or international implementers, who often lack sufficient information about gender and health inequities. Short timeframes and insufficient resources limit opportunities for co-creation or consultation with civil society or health system stakeholders with gender expertise. Furthermore, donor funding processes and national health programs lack robust citizen engagement and mechanisms to incorporate the perspectives and leadership of local groups. In particular, women and other socially marginalized groups lack awareness of and access to platforms to voice their concerns, share pertinent information, and assume leadership roles for health system decision-making. Local civil society groups that have compiled research findings, developed local solutions, or even demonstrated achievements in reducing gender inequities in their communities may be partially or fully excluded from health program planning. Without their input and participation, health programs are designed and implemented without a full understanding of local gender and health inequities and their drivers.

Syndrome two: Decision-maker privilege creates blind spots and inhibits capacity to address gender and health inequities (see Figure 3)

Figure 3. Syndrome 2: Decision-maker privilege creates blind spots and inhibits capacity to address gender and health inequities.

Decision-makers at high levels (whether donors, national policymakers, or technocrats) may not sufficiently prioritize actions to remedy gender disparities. One contributing factor is the influence of biases. DAH decision-makers who plan, fund, implement, and evaluate health programs often come from economic or social privilege, and their unearned privilege and power can contribute to inherent bias and blinders about gender and health inequities. For instance, decision-makers may assume that they have the expertise needed to address gender. Furthermore, a biomedical worldview, which tends to under-emphasize sociological sciences, permeates DAH. Such preconceptions can lead to overly mechanistic or simplistic ways of understanding and addressing gender in programs that fail to dismantle the root causes of inequities. The assumption that high-level health experts can remedy local gender inequities also contributes to the underuse of community gender experts, whose input is needed.

Syndrome three: An imbalance in power dynamics contributes to insufficient allocation of resources for and attention to gender priorities in health programming (see Figure 4)

Figure 4. Syndrome 3: An imbalance in power dynamics contributes to insufficient allocation of resources for and attention to gender priorities in health programming.

The imbalance of power in the funder-recipient relationship contributes to the de-emphasis of gender priorities in allocation of resources. Health institutions across the DAH landscape tend to use top-down leadership and operational models. Funding tends to be allocated to government health entities or INGOs, with accountability requirements that incentivize implementing agencies to emphasize donor priorities over those of groups most affected by gender discrimination. Donors tend to underestimate the resources and time needed to address root causes of gender and health inequities, typically relying on a ‘check-box’ approach for integrating gender in program design and measuring progress. Recipients, afraid that resources will be withdrawn, rarely question donor assumptions about timelines and costs for gender priorities. Tensions about who is making decisions, why, and for whom, exist within and among recipient organizations and are particularly acute for those that have small budgets and struggle to survive.

Syndrome four: Donor health funding approaches, conditions, and requirements pose limitations to addressing gender inequities effectively (see Figure 5)

Figure 5. Syndrome 4: Donor health funding approaches, conditions, and requirements pose limitations to addressing gender inequities effectively.

Funding structures for DAH can limit the efficacy of approaches to overcoming gender inequities in a number of ways. First, donor funding is structured to advantage large grants or contracts to reduce administrative costs and time and is tied to accountability measures for specific health outcomes. Local groups with gender expertise typically do not have access to information about availability of the funds or are unable to compete for this funding because of stringent accountability requirements. This contributes to a lack of genuine engagement and co-creation with local civil society organizations and stakeholders who have the requisite expertise. Stringent donor monitoring and evaluation mandates that focus on attribution of the funding to specific health outcomes leaves insufficient time and resources to track gender factors that contribute to social determinants of health. Health program reporting is typically structured for and provided directly to the donor. Critical gender inequity program information is seldom reported to decision-makers or used to share learning about gender issues with program participants and affected populations. This along with funding firewalls also limit the ability to adapt to emerging contextual changes. Beyond these factors, there is general insufficient allocation of time and resources to focus on gender outcomes in health programming and enable holistic, integrated approaches to gender in health system strengthening.

Syndrome five: Fragmented programming contributes to a lack of coordinated and systematic attention to the root causes of gender inequities (see Figure 6)

Figure 6. Syndrome 5: Fragmented programming contributes to a lack of coordinated and systematic attention to the root causes of gender inequities.

Despite significant efforts to achieve better coordination, fragmentation is an enduring feature of health financing and programming. In general, coordinated frameworks or goals related to gender inequities among and across donor organizations are lacking, which contributes to a deprioritization of gender as a crosscutting issue. Donor-funded health programs tend to have limited resources for coordination across sector stakeholders for crosscutting issues like gender inequity, perhaps because they are more difficult for donors to administer. Large funding tranches available to a few competitors can incentivize organizations or consortium groups to work against each other or withhold information, further impeding collaboration and coordination. Government agencies and teams leading gender integration efforts across health or other sectors seldom have adequate staff or financial resources for such coordination efforts, leading to unsystematic attention to gender inequities. Despite this, DAH programs rarely focus on fixing these crosscutting and coordination challenges.

Syndrome six: Vicious cycles in data bias contribute to insufficient understanding of and attention to gender inequities (see Figure 7)

Figure 7. Syndrome 6: Vicious cycles in data bias contribute to insufficient understanding of and attention to gender inequities.

Donors, national policy makers, and health technocrats may rely on incomplete or overly generalizable data to make decisions, which ultimately perpetuates gender and health inequities. DAH programs and national health systems have common gender data weaknesses. Emphasis on siloed programs in global health that focus on singular health or disease areas hinder capacity and resources to understand and overcome system-wide challenges like gender inequity. In national health information systems, data are rarely collected and disaggregated in ways that provide nuance to reveal gender inequities (and other social inequities) and their contribution to poor health outcomes. Data relevant to explaining gender and health inequities (e.g., son preference, women’s mobility and ability to make decisions about their own bodies) may be overlooked by donors or country technocrats when making decisions about health investments. There is also a preference for and overreliance on quantitative over qualitative data, which can limit understanding of gender dynamics. Furthermore, health programs lack input and feedback from populations affected by gender and health inequities, or other gender experts, about whom data are important for decision-making. These factors contribute to insufficient recognition of the role of gender inequities in poor health outcomes, and thus, to the perpetuation of gender and health inequities.

Reflect on institutional biases and move toward approaches that shift or share decision-making power

There are growing calls for global health institutions to face their own biases, shift mindsets of privilege, and adopt practices that correct power imbalances^51,65. Such processes are not amenable to checklists or prescriptive approaches, but require both safe spaces to talk about personal biases, cultural beliefs, and practices, and endorsement of the work by leadership^66–68. An integrated approach to increasing participation and engagement of underrepresented groups is essential to achieving diversity and inclusion within an organization, though other efforts are needed to complement it^52,70. Additionally, DAH needs to move beyond the biomedical paradigm that enables discriminatory health practices. To do this, donors and other global health institutions need to prioritize approaches to health that build on context-specific knowledge and values, with spaces for reflexive learning and dialogue that welcome diverse voices⁷¹.

There is also a need to restructure the donor-recipient relationship. Shifting power dynamics between donors and grantees requires recognizing their complementary skills, expertise, and interdependence in achieving common objectives^72,73. Mechanisms for candid reflection and shared learning, trust-building, and mutual accountability are important components of this. One such approach is a mechanism for confidential and anonymous feedback^72,74. Some donors have implemented community advisory committees in their grant-making processes, which offer a formal platform for transparency about a funder’s plans at the country level and for members of affected populations and civil society organizations that represent them to provide input about the proposed interventions^57,75,76.

Beyond engagement, some donors are embracing participatory grant-making models that aim to shift or share decision-making power about funding. These range from building in more representation of affected groups as advisors and funding decision-making bodies to ceding decision-making power about funding strategies and criteria to the communities and groups that funders aim to serve^76–78.

Create leadership and funding opportunities for groups most affected by gender and health inequities

The leadership of grassroots civil society groups focused on gender issues in program design phases can improve the contextualization of issues that may be missed in standard gender assessments, and ensure that projects are relevant, responsive to the needs of participants, and sustainable⁵⁶. Donors are called on to create opportunities for consultation and leadership of these groups, enabling them to exert influence on health programming⁶².

Where they do not exist, donors can support civil society engagement mechanisms as a foundational step. Such mechanisms can reveal issues of unintended harm or opportunities for program modifications that improve effectiveness⁶². For example, the Global Fund to Fight HIV, TB, and Malaria established dialogues to optimize input and transparency at country level. These dialogues emphasized involvement from a wide range of civil society stakeholders, including most-at-risk populations, in the program design phase⁵⁷. During implementation and evaluation, a country coordination mechanism or community advisory committees provided opportunities for dialogue and feedback from local stakeholders⁵⁷.

Increase and restructure funding to gender and health equity advocates and stakeholder groups, including local women’s organizations

Donor funding that enables collective efforts by country-based or regional health and gender coalitions has been shown to facilitate successful efforts to address gender inequities and achievement of outcomes^9,56,73,79. Donors are called on to increase accessibility of funds to local groups working to achieve health and gender equality^{29,56–58,73}. Mechanisms for increasing accessibility include offering different funding tranche sizes to accommodate needs and capacities of local groups; structuring funding so that it can be accessed by gender advocacy networks, coalitions, and cross-sector working groups; structuring funds in a way that supports core funding; being responsive to the needs of grantees and adaptable to a changing political context; and building in adequate timelines and resources^56,73,79,80. When unable to provide grant funding directly, donors should consider re-granting and other flexible mechanisms that allow funds to be allocated from larger institutions to smaller groups^57,73.

Furthermore, donors can structure funding for planning and exit strategies in ways that build sustainability for gender-focused civil society groups to engage with government health counterparts through specific planning, catalytic, bridge, or exit grants^57,73,81,82. Beyond greater support for local civil society actors, donors should fund crosscutting governmental institutions tasked with integrating gender^9,16,83.

Implement coordinated approaches to reduce fragmentation of gender efforts

Some donors have begun restructuring funding to overcome the challenge of fragmentation in gender and health efforts. For example, the government of Ireland has established standard resources for ensuring cross-sectoral linkages across partners and government sectors on gender issues⁸⁴. The government of Switzerland’s approach includes basket funding for gender-related activities⁸⁴. Other donors have opted to create pooled funding mechanisms via multi-donor collaborations that incorporate incentives for harmonized efforts in addressing gender⁷³.

Donors are also being called on to finance and convene platforms for demand-driven multi-stakeholder co-learning including groups most affected by gender and health inequities⁸⁵. Some donors have added resources for groups typically excluded from DAH, such as grassroots civil society organizations and activists^56,73,74,80. Other donors are providing funding that enables multi-institution efforts to address gender and health inequities, such as supporting networking and coordination across diverse social movement actors^56,74,80.

Generate and improve access to complete, reliable, and useful information for addressing gender and health inequities

Donors can support improved gender and health equity outcomes by enabling equitable analysis of and access to gender-specific data and information. The World Health Organization has partnered with national governments to strengthen capacity to analyze which constituents are missing from health service data and why^86–89. Such tools can help donors and health policy makers set priories by identifying the largest health inequities within a country. However, more in-depth measures and tools are required to explain why inequalities exist. Better measures are needed to examine who has what (access to resources); who does what (division of labor and everyday practices); how values are defined (social norms); who decides (rules and decision-making); and who benefits⁹⁰. Donors are called to support research to design gender-specific measures that can be used to assess structural elements of gender (such as gender norms, policies, and institutional practices), beyond individual aspects of gender discrimination⁹¹. Stronger collection and analysis of data on structural and systemic gender factors will facilitate a deeper understanding of how interventions work and how to evaluate system-wide efficacy^92,93.

Beyond incorporating more explanatory gender measures, donors are called to improve their mechanisms for gathering and using data to make decisions. Donor funding that supports civil society advocacy groups to access and translate health information for policy makers has been shown to support improved health services⁷⁴. Models with more inclusive methods of data collection and open data sharing and sustained human capacity are showing promise in supporting a more equitable data landscape^86,94.

Limitations

The findings presented in this paper were informed by a co-creation process to develop a shared understanding of system drivers of gender inequity in DAH. The results are therefore shaped by the perspectives and insights drawn from the lived experiences of the initiative participants and are not exhaustive or representative of all contexts. For instance, we were not able to engage a wide cross-section of representatives across geographic areas or linguistic backgrounds, or representatives of community groups most affected by gender inequities in low-income countries. While we believe that the broad findings would not be significantly different, engaging more and varied representatives in similar co-creation exercises may yield more detailed and nuanced findings.

The scenarios depicted in the syndrome maps should not be interpreted as an absolute or holistic view of how gender inequity manifests, nor do they reflect the nuances of individual donor modalities or country or community contexts. Rather, the specific drivers and dynamics portrayed in the syndromes are examples of underlying factors of gender inequities in a highly dynamic and complex system.

Areas for additional exploration

This initiative explored systems dynamics affecting gender inequities in health, with a particular focus on the donor space. The six syndromes represent an overview of the drivers; each syndrome would benefit from further analysis. In the dynamic complexity of DAH and global health, a fuller conceptualization and analysis of gender and power, drawing on insights from community members, civil society organizations, implementing partners, and staff and custodians of national health systems is needed. More research on dynamics in the coordination and collaboration spaces between civil society and health system actors that drive gender inequity is needed. An analysis of institutional culture and leadership would be useful to find opportunities for more equitable and inclusive structures for grant-making and health service delivery. Modalities to understand and address gender inequities manifested in national health systems will be vital for improving gender and health equity. Further studies of efforts to improve accountability to achieve more equitable and inclusive DAH strategies are also needed.

Based on these findings, teams responsible for DAH strategies and funding can begin to overcome the barriers to gender equity by asking how their individual and institutional ideologies, practices, and structures can be shifted to advance fairer, more inclusive, and gender-transformative programs and systems (see Figure 8). The answers to these questions can inform more effective health investments.

Figure 8. Questions to prompt donor reflection on development assistance for health strategies.

Underlying data

Zenodo: Exploring system drivers of gender inequity in development assistance for health and opportunities for action. https://doi.org/10.5281/zenodo.6612438⁹⁴.

This project contains the following underlying data:

Data are available under the terms of the Creative Commons Attribution 4.0 International.