Research report: Gender-transformative action as a strategy for health system strengthening: a framework for advancing equity, accountability, and resilience

A viewpoint published in the International Journal for Equity in Health argues that health systems cannot be considered strong when they reproduce gender inequality through their leadership, financing, workforce policies and everyday clinical practice. Drawing on purposively selected evidence from diverse settings, Morie Vandi and Augustus Osborne propose a three-domain framework for gender-transformative action: the capacity of workers and institutions to recognize bias, the structures that distribute authority and resources, and the social conditions that determine whether people can use services and participate in health-sector work. The framework is presented as an analytic and planning aid rather than an empirically validated model, and the authors caution that its proposed benefits remain arguments for a direction of travel rather than established effect estimates.

The distinction among three levels of intervention provides the framework’s central test. Gender-sensitive approaches recognize gendered differences and inequalities but may not act on them. Gender-responsive approaches act on those differences by adapting services, staffing or outreach.

Gender-transformative approaches deliberately contest and redistribute the norms, roles, incentives and power relations that generate inequality. A training course teaching clinicians to notice bias is therefore gender-sensitive, while redesigned consultations, triage and violence-response protocols are gender-responsive. The approach becomes transformative only when gender-equitable competence is attached to institutional consequences, including licensing, accreditation, promotion criteria and supervisory review, so that neglect carries a cost for the institution rather than for a patient or junior worker who raises a concern.

Capacity is the first domain. Health workers may be poorly prepared to interpret gendered patterns in data, respond safely to disclosures of violence, or recognize how gender influences symptoms, care-seeking and clinical reasoning. Managers may lack preparation in gender-responsive supervision or inclusive workforce planning, while data teams may not know how to use sex-disaggregated or gender-relevant indicators in routine planning.

The authors illustrate the potential consequence of this gap through a hypothetical encounter in which a woman presenting with recurrent abdominal pain and erratic adherence is recorded as non-compliant rather than assessed for intimate partner violence. They also cite an analysis of 2,377,028 outpatient visits to a national referral hospital in Delhi during 2016, excluding obstetrics and gynecology, which found 1.69 male visits for every female visit. The ratio rose with distance from the hospital, from 1.41 among Delhi residents to 1.98 in Uttar Pradesh and 2.37 in Bihar, implying approximately 402,000 missing female visits, equivalent to 49% of the female visits actually recorded from those four states; the fourth state was not identified in the supplied text.

Institutional structure is the second domain, encompassing promotion systems, leadership pathways, pay, workplace safety, procurement and budgets. The viewpoint reports that women constitute an estimated 67% of the health workforce across 104 countries with comparable data and about 70% of the wider health and social sector, yet hold approximately one-quarter of its senior leadership positions. It also cites an average 28% gap in earnings between female and male health workers.

Of that difference, 9.9 percentage points are attributable to occupational segregation and 6.9 percentage points to differences in working hours, leaving an unexplained 11.2 percentage points between women and men in the same occupation working the same hours. The authors argue that a headline gap alone conceals distinct mechanisms requiring different remedies, including biased promotion, unequal unpaid care burdens, interrupted career trajectories, informal patronage networks, harassment and assumptions about who is suitable for leadership. Context determines whether formally available entitlements can become usable.

Gender norms influence education, mobility, control of money, time available for care-seeking, exposure to violence and autonomy in decision-making. The article cites maternal-service use in Uganda, where distance and cost interact with limited control over household resources and expectations that male partners authorize spending or accompany care-seeking. It also notes how gender norms in India intersect with caste, poverty and geography to shape nutrition, adolescent health, reproductive choices and access to formal care.

In conflict-affected Syria, insecurity, displacement and restrictions on movement have made sexual and reproductive health services especially precarious for women and girls. These examples show why clinics cannot resolve inequity alone: a formally available service may remain inaccessible when people cannot travel, obtain money, speak safely or seek care without permission. Gender-diverse people face mechanisms of exclusion that cannot be reduced to the disadvantages experienced by women.

The paper distinguishes devaluation within systems that formally admit women from exclusion that begins with legal and administrative non-recognition. Five mechanisms receive attention: identities that cannot be consistently recorded; mistreatment, refusal of care and inappropriate clinical questioning; inadequate provider preparation; data systems that either render gender-diverse people statistically invisible or collect sensitive information without safeguards; and failures of confidentiality and physical safety. These barriers can compound with poverty, disability and migration status.

A merely responsive response teaches respectful treatment while preserving legal and data structures that continue to exclude. A transformative response removes registration barriers, permits lawful and confidential recording with explicit access controls and creates complaint routes that do not require disclosure to a hostile institution. Four mutually reinforcing action areas emerge from the framework.

The first combines gender-sensitive training with structured mentorship for clinical, managerial and leadership practice. Training should extend beyond brief awareness sessions to pre-service and in-service education on gender bias, violence response, adolescent health, gender-diverse care and the organizational dynamics that silence junior staff. Mentorship can counter patronage networks, but pairing junior women with senior colleagues is not transformative by itself.

It becomes so when sponsorship, budget control and appointment authority move toward those women and mentoring is recognized and remunerated rather than treated as invisible additional labor. Suggested indicators include reporting confidence, promotion trajectories, retention, perceptions of safety and fairness, and patient-reported experiences of respectful care. The second action area is structural reform through equitable governance, workforce policy and gender budgeting.

Women’s representation can be encouraged through targets or quotas, but numerical parity does not guarantee influence. Reforms must also address transparent promotion criteria, parental leave, flexible career pathways, protection against retaliation and credible anti-harassment mechanisms outside the management chain. Gender pay audits, transparent salary bands and correction mechanisms could become routine features of public-sector workforce governance.

Gender budgeting can reveal whether financing patterns neglect services important for equitable access. The transformative test is whether institutional seats carry control over budgets, appointments, promotion criteria and audits, and whether finance officials must justify allocations that entrench inequity rather than requiring advocates to justify those that reduce it. The third priority is community engagement and norm change, while the fourth is stronger digital gender data.

Programs with women’s groups, adolescents, local leaders and men can challenge restrictions around unpaid care, reproductive control, mental distress, violence and permission to seek care. Effective initiatives should be locally grounded, begin with lived experience and combine community health workers, civil-society organizations and accessible media with nearby facilities. Extending clinic hours accommodates a constraint, whereas transformative action contests the household and community rules determining whose time is available, who authorizes spending and who may seek care without permission.

Digital systems may improve visibility of waiting times, costs, referral completion, safety incidents, absenteeism and workforce patterns, but dashboards alone are not transformation. Information must lead to reallocated subsidies, staffing or outreach, while privacy protections, manageable interfaces and safeguards against exclusion are essential, especially for data on violence, reproductive care and discrimination. Measurement becomes meaningful only when responsibility and consequences are explicit.

The paper proposes assigning obligations to named officials, district health management teams, facility managers and governing boards, then attaching gender-equity indicators to national health plans, management performance agreements and funding. Recurring independent audits, public reporting, external complaint mechanisms, legislative gender-budget tracking, licensing requirements and community scorecards can prevent institutions from evaluating themselves without accountability. Failure can trigger mandatory remediation plans, published timelines, escalation to supervising authorities, funding conditions or accreditation consequences.

The wider package must connect capability, power, norms and data: training without institutional reform can isolate newly aware workers, governance reform without community engagement may create rights that cannot be exercised, and digital monitoring without political commitment may become another reporting exercise. The authors call for longitudinal, mixed-methods research comparing different combinations of training, mentorship, governance reform, community engagement and digital monitoring across settings affected by conflict, displacement, rural disadvantage, disability or severe workforce shortages. Quantitative measures could track pay gaps, leadership composition, budget allocation, service uptake, referral completion and staff retention, while qualitative research could assess safety, trust, respect and whether nominal representation translates into influence.

These are proposed research priorities, not findings from a comparative evaluation. The viewpoint itself is not a systematic review: its literature was selected purposively, illustrative examples come from a limited set of settings, and the framework, its boundaries and its proposed indicators have not been empirically validated or tested for feasibility and susceptibility to gaming. Its central claim is therefore a reasoned proposition for reform, not a demonstrated effect: durable equity requires health systems to change who holds authority, who bears institutional costs and what leaders are accountable for correcting.

Subject of Research: A proposed framework for integrating gender-transformative action into health-system strengthening.

Article Title: Gender-transformative action as a strategy for health system strengthening: a framework for advancing equity, accountability, and resilience

Article References: Vandi, M., & Osborne, A. (2026). Gender-transformative action as a strategy for health system strengthening: a framework for advancing equity, accountability, and resilience. International Journal for Equity in Health, 25(1), Article 249. https://doi.org/10.1186/s12939-026-03070-z

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03070-z

Keywords: health equity, gender-transformative action, health systems, workforce equity, health governance, gender budgeting, gender data, community engagement, universal health coverage, Gender-transformative, action, strategy