Gender is an important determinant of health status – influencing, at a minimum, rates of risk-exposure to common drivers of ill-health, health-care seeking patterns, and the nature of the health system’s response to illness. It is with the latter that we are concerned in this paper. We focus on global public-private partnerships for health (GPPPH) since they are an important component of the global health architecture, are seen as having significantly increased the resources available for global health [1,2,3,4], and are promoted by some as offering critical opportunities to improve “efficiency, equity, value for money, and outcomes in global public health” [5]. Moreover, the public-private partnership approach has been encouraged as a mechanism for overcoming failures of both market and state [6] as well promoting efficiency in service delivery [6] and innovation in and access to technological resources [7]. Given the importance of the GPPPH model within global health activities, and the central role that gender plays as a determinant of health, the question we address in our paper is how and to what extent the GPPPH focus on issues of gender within their priorities, policies and programmes.
The GPPPH have become increasingly powerful actors within global health: funds allocated to the two largest GPPPH (Global Fund to Fight AIDS, TB and Malaria –GFATM- and GAVI) have increased from US$1.67 billion to US$4.9 billion over the 10-year period 2005 and 2015 – an almost three-fold rise. In total, these two partnerships currently receive 14% of external global health financing [8]. Nonetheless, the partnership model has been criticised as implying privatisation by stealth [9], of disrupting the focus and governance of country level health systems [10,11,12], of unduly influencing international norm-setting [13, 14] and of promoting an overly narrow technical focus on solutions for health problems [15, 16] . Notwithstanding such criticism, public-private-interaction is likely to grow across all sectors, including health, as countries and international organisations mobilise to achieve the sustainable development goals (SDG) by 2030. The United Nations Agenda 2030 for Sustainable Development actively advocates for countries to “Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships.” [17] . Moreover, the Addis Ababa Agenda on Financing For Development identifies a critical role of private finance for development, including through the mechanism of public-private partnerships [18].
Although there are no agreed upon definitions of GPPPH [19] a commonly used definition was proposed by Buse and Harmer as “relatively institutionalised initiatives, established to address global health problems, in which public and for-profit private sector organisations have a voice in collective decision-making.” [20] We use this definition for identifying GPPPH for inclusion in our analysis.
Gender is recognised as a significant driver of health outcomes – both as an influence in its own right, and through its interaction with other determinants of inequity and vulnerability. Payne [21] has characterized gender influences on health in three domains: differences in exposure to social determinants of health (e.g., poverty or the health risks of employment); health behaviours (e.g., diet, tobacco or alcohol use, patterns of care seeking); and the response of the health system to the different needs of men and women.
Despite the profound influence that gender exerts on health, the ability of global health institutions to recognise, understand and address the influence of gender on health outcomes has been characterised as “missing, misunderstood and sometimes mainstreamed” [22]. Gender mainstreaming - a strategy for promoting gender equity through “research, legislation, policy development and in activities on the ground” [23] - has been part of global policy discourse for more than 35 years [24] and the United Nations (UN) Economic and Social Council agreed to mainstream a gender perspective in all UN policies and programmes with the ultimate goal of gender equality [25] . The concept and practice of gender mainstreaming is contested. Critics in particular emphasise how an ‘integrationist’ and ‘technocratic’ approach adopted by state and international bureaucracies, waters down its transformative intent [26]. Yet, the contributions of GM in placing gender as “a critical axis of power” (ibid) and improving effectiveness of policies “by making visible the gendered nature of assumptions, processes and outcomes” [27] are widely acknowledged.
Reviews of how international health organisations “do gender” have predominantly focused on major intergovernmental agencies [21] and to date there have been few evaluations of how the GPPPH take gender equity into account when prioritising the focus of their work, their governance structures, or their ways of implementing activities. Hanefeld et al. reviewed the impact of three global health initiatives on health equity, with a specific focus on HIV and women, but concluded that there was little evidence of long-term impact on equity [28]. More recently, Gideon and Porter reviewed public-private partnerships with an emphasis on women’s health, and noted the lack of evaluation of partnerships with respect to their impact on various aspects of equity, including gender [29].
Within this paper we take a holistic approach to gender equity in health and analyse how the GPPPH address gender– both as a determinant of health, and as an influence on health system priorities. We use the methodology of gender analysis to systematically identify and critically appraise gender policies and commitments of GHPPP to assess key gaps and address gender related health inequities [30].
