Pathways to gender-transformative women's health aid: Comparative evidence from five donors

Abstract

Motivation: Gender equality and women's health remain priorities, yet recent fiscal retrenchment and shifting geopolitical agendas have narrowed the space for gender-transformative programming. Despite growing donor endorsement of gender-transformative approaches, substantial gaps persist between rhetorical commitment and operational practice, particularly in women's health ODA. This raises a critical policy question: under constrained resources, which forms of gender-focused health aid are most likely to generate meaningful and durable outcomes? Purpose: This study examines how gender-transformative approaches are operationalized within women's health ODA and asks two questions: how do women's health ODA projects integrate gender-transformative principles in practice, and what combinations of institutional, programmatic and participatory features are associated with improved women's health outcomes? Approach and Methods: The study analyses 100 completed women's health ODA projects funded by five bilateral donors (Australia, Germany, Sweden, the United Kingdom, and the United States). Projects were coded across five dimensions of gender-transformative practice: gender analysis, donor support, alignment with health needs, comprehensive health orientation, and community participation. A crisp-set qualitative comparative analysis was applied to identify recurring pathways through which different combinations of these elements are associated with positive outcomes. Findings: Successful projects combine three core elements: gender analysis, donor institutional support, and alignment with health needs, while comprehensive health approaches and community participation function as critical enhancers. Distinct pathways emerge across donors, reflecting different institutional logics; some emphasize system-level health integration, while others rely on intensive community engagement. Policy Implications: For donors, the challenge is not whether gender-transformative principles matter but how they are combined in practice. Embedding gender analysis into institutional incentives, aligning projects with national health priorities, and strategically investing in systemic reform or participatory mechanisms can improve impact under fiscal and political constraints. Gender-transformative health ODA is most effective when treated as a structural design choice rather than an add-on.