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

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.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance.

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Constructs of power and equity and their association with contraceptive use among men and women in rural Ethiopia and Kenya.

Using samples of reproductive aged men and women from rural Ethiopia and Kenya, this study examines the associations between two scales measuring balances of power and equitable attitudes within relationships and modern contraceptive use. The scales are developed from the Sexual and Reproductive Power Scale (SRPS) and Gender Equitable Male (GEM) scale, which were originally developed to measure relationship power (SRPS) among women and gender equitable attitudes (GEM) among men. With the exception of Ethiopian women, a higher score on the balance of power scale was associated with significantly higher odds of reporting modern contraceptive use. For men and women in both countries, a higher score on the equitable attitudes scale was associated with significantly higher odds of reporting modern contraceptive use. However, only the highest categories of the scales are associated with contraceptive use, suggesting a threshold effect in the relationships between power, equity and contraceptive use. The results presented here demonstrate how elements of the GEM and SRPS scales can be used to create scales measuring balances of power and equitable attitudes within relationships that are associated with self-reporting of modern contraceptive use in two resource-poor settings. However, further work with larger sample sizes is needed to confirm these findings, and to examine the extent to which these scales can be applied to other social and cultural contexts.

Pile sorting innovations: exploring gender norms, power and equity in sub-Saharan Africa.

Understanding gender norms, power and equity is important for developing successful sexual and reproductive health interventions. However, little attention has been given to how to capture the gender ideals and imbalances that inform these relationships in low resource settings. Pile sorting exercises were conducted in four gender-segregated focus groups in Ethiopia and Kenya. Each group received cards illustrated with a man, woman and man and woman together and cards labelled with duties and decisions. Participants discussed and decided together whether men, women or both performed each duty and decision and assigned the cards accordingly. Participants then reflected on and physically manipulated the piles to challenge gender norms, investigate role flexibility and identify agents of social change. Data collected included photographs of the pile sorts and recordings of the discussions. Conducting pile sorting within focus group discussions enabled comparative analyses of gender norms, while enriching data by focusing discussions and encouraging consensus building. Innovative applications facilitated participants' abilities to engage abstract concepts, reflecting on issues of gender norms, power and equity.

The influence of perceptions of community norms on current contraceptive use among men and women in Ethiopia and Kenya.

The paper uses data from Ethiopia and Kenya to examine how perceptions of community norms differentially shape contraceptive use among men and women. Women whose current number of sons is lower than their perception of the community ideal had lower odds of reporting contraceptive use, while women whose own personal ideal number of sons is lower than the community ideal had greater odds of reporting contraceptive use. Men and women in Kenya were influenced more by their perception of their social network's approval of family planning than by their own approval of family planning. Results highlight the importance of place, conceptualized as the place-specific perceptions of fertility ideals, when conducting reproductive health research. Identification of people who use contraception in the face of pervasive pronatalist community norms presents a point for future intervention.