Exploring system drivers of gender inequity in development assistance for health and opportunities for action [version 2; peer review: 1 approved, 2 approved with reservations]

Background: Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions: Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs

Making health insurance responsive to citizens: learning from six low-income and middle-income countries

Background: Many low-income and middle-income countries have introduced public health insurance systems, whereby, thanks to government subsidies, selected groups are entitled to receive insurance coverage even if not paying direct contributions into the system. These efforts towards achieving universal health coverage were often undermined by difficulties in enrolment and registration, barriers to health service utilisation or complicated rules around service packages. Governmental and non-governmental accountability initiatives have been established to overcome these barriers in order to make health insurance programmes responsive and to empower citizens. This paper examines evidence and synthesizes lessons from 20 accountability initiatives in six selected countries to understand how these achieved (or not) these goals. Methods: We systematically analysed six final reports and five published papers which were part of a multicountry research programme from 2019 to end of 2022 studying accountability initiatives. Between June 2023 and September 2024, we systematically extracted data and synthesised findings from the reports and papers based on a conceptual framework, adapted from a framework developed by Molyneux, which had been adopted by the country teams to guide their studies. We coded the extracted data and identified the content, context and process factors that enabled or hindered the accountability initiatives in achieving their intended goals. We present and discuss factors that were present in at least two initiatives. Results: Governmental initiatives were in most instances established in conjunction with the health reforms that introduced the health insurance programmes they address. Whereas some of these initiatives were effective, many were undermined by poor outreach to citizens, inadequacy of resources, conflicts of interest and power imbalances and lack of fidelity to original design. Non-governmental initiatives often emerged to fill existing gaps in government services and programmes. Many of the non-governmental initiatives had several features which helped them in contributing to citizen empowerment, and these included embeddedness in and being trusted by the local communities, flexibility in operating and reaching out to people and the underlying motivation of people working in them. Conclusions: The effective implementation of accountability initiatives requires transparency, trust-building measures, active outreach and community engagement and adequate resources. These elements can ensure that initiatives achieve their intended goal of enhancing citizens\u27 access to their health insurance entitlements. Further research is needed to understand how best collaboration between governmental and non-governmental initiatives can be fostered to build synergies between the two toward the achievement of common goals