Investments in this strategy aim to improve gender equity in policy and decision-making throughout the health system, from providers to policymakers. The below high-level overview and associated metrics pack are intended as a gender lens complement to the Navigating Impact Health theme.


Dimensions of Impact: WHAT

Investors interested in deploying this strategy should consider the scale of the addressable problem, what positive outcomes might be, and how important the change would be to the people (or planet) experiencing it.

Key questions in this dimension include:

What problem does the investment aim to address? For the target stakeholders experiencing the problem, how important is this change?

Research has documented gender inequity across global health systems:

  • Clinical trials consistently recruit significantly more male than female patients, meaning that the reported effectiveness and impact of medical products and other treatments disproportionately reflect male bodies (1).
  • Policies of health systems are consistently biased by gender. The World Health Organization (WHO) has recommended that gender inequities be “identified and included in all strategic agendas in the health sector” (2, 3).

Investments in this strategy aim to improve the gender equity of outcomes in health-system policy and decision-making by collecting gender-aware data, sharing these data among providers and policymakers to coordinate and deliver care, and increasing the representation of women in health system policymaking to improve decision making, particularly where those decisions involve gender-specific health needs. Investments in this strategy can:

  • inform health system policy from the perspective of gender;
  • raise the importance and profile of existing gender inequities in health systems for decision-makers, and enable policy changes to address those inequities; and
  • improve health and well-being for women, girls, transgender persons, and people of non-binary gender.

What is the scale of the problem?

Few national and regional health systems have documented practices to address gender inequities in data collection, policy, or decision-making. Yet universal access to healthcare requires full coverage of all needed health services—including health promotion, treatment, rehabilitation, and palliation—and the consideration of factors such as physical accessibility, financial affordability, and social acceptability (4). Around the world, basic yet life-saving interventions for health issues that affect women and girls—from immunizations to skilled birth attendants to screenings for cervical cancer—either do not exist or cannot be accessed (5).


Dimensions of Impact: WHO

Investors interested in deploying this strategy should consider whom they want to target, as almost every strategy has a host of potential beneficiaries. While some investors may target women of color living in a particular rural area, others may set targets more broadly, e.g., women. Investors interested in targeting particular populations should focus on strategies that have been shown to benefit those populations.

Key questions in this dimension include:

Who (people, planet, or both) is helped through investments aligned with this Strategic Goal?

Women and Girls: Investments to build health policy and delivery systems that address gender-related power imbalances and inequities can improve women’s access to health care that reflects their needs and priorities. The sexual and reproductive health (SRH) needs of adolescents and unmarried women are often particularly unmet, neglected, or denied by existing service providers. Increasing access to SRH services and information can decrease maternal, newborn, and child mortality related to largely preventable SRH problems (6).

Men and Boys: While gender inequities disproportionately impact women and girls, they can simultaneously perpetuate damaging stereotypes and expectations of men. Men and boys would benefit from investments that take into account gendered norms that can deter them from seeking care.

Women and Girls Living with Illness or Disability: Women and girls living with disability or illness especially need health services that are effective, respectful, and equitably responsive to their needs. For example, women living with HIV need effective, unbiased, and rights-based health systems and services that protect their privacy and anonymity. Gendered stigma and discrimination, such as the belief that HIV is punishment for women’s sexual decisions, can limit access to respectful and human-rights-oriented treatment. Such cultural beliefs have even led to forced sterilization of women with HIV in several countries (7). Investments to increase their access to care can therefore greatly improve physical and mental health outcomes.

Transgender, Intersex, and Non-Binary Individuals: In the absence of concrete policies and planning to address their rights, transgender, intersex, and non-binary individuals are routinely violated. Investments to improve provider knowledge of and sensitivity to the specific social and health needs of these vulnerable groups can dramatically improve their access to health services and their quality of health, reducing mortality (8).

What are the geographic attributes of those who are affected?

This strategy applies to all geographies and to both developed and emerging markets. Its application must be tailored to the specific geographic context, sociocultural environment, and organizational structure of the targeted health system.


Dimensions of Impact: CONTRIBUTION

Investors considering investing in a company or portfolio aligned with this strategy should consider whether the effect they want to have compares to what is likely to happen anyway. Is the investment's contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How much and Who?

Key questions in this dimension include:

How can investments in line with this Strategic Goal contribute to outcomes, and are these investments’ effects likely better, worse, or neutral than what would happen otherwise

Investments in this strategy—with the implementation of policies and practices that eliminate persistent and structural gender inequities in health systems—could significantly improve gender equality and the health and well-being of women, girls, and people of non-binary gender. Such investments will likely lead to better outcomes if they are designed in cooperation with women and if they encourage gender-equitable decision-making.

How Much

Dimensions of Impact: HOW MUCH

Investors deploying capital into investments aligned with this strategy should think about how significant the investment's effect might be. What is likely to be the change's breadth, depth, and duration?

Key questions in this dimension include:

How many target stakeholders can experience the outcome through investments aligned with this Strategic Goal?

Every woman in the world—more than 3.7 billion in total—has an inherent need and human right to access health services and products. Building health systems that systematically and thoroughly incorporate gender-based perspectives—known as gender-equity mainstreaming—would improve how health systems function for all women and make health outcomes more equitable. 

Effective and equitable health services and support can lead to broader societal benefits, including stronger and more productive economies (8). Meeting the need for holistic and effective health services could lead to:

  • An estimated 75% decline in unintended pregnancies, a 74% decline in induced abortion, and a 73% decline in maternal deaths by meeting modern contraception and quality care needs (1).
  • Significant progress toward the SDGs through the elimination of gender-based violence, which has been called a major public health problem by the World Health Organization (3).
  • Ensuring good health and well-being in older populations through ensuring universal coverage for health care, including prescriptions and gender-specific considerations (6).

How much change can target stakeholders experience through investments aligned with this Strategic Goal?

Access to a quality health system is vital to the well-being of entire populations, particularly for otherwise-marginalized groups who often face disproportionate exposure to health challenges at work and in their personal lives. Health systems that recognize and address gendered inequities—such as those described above—promote dignified and high-quality care for all, resulting in healthier populations. Investments aligned with this strategy can lead to change such as the following:

  • In Cambodia, there has been major investment in maternal and newborn health services since 2005, particularly in supporting midwifery education (2). These investments in both private and public care have resulted in major increased in the number of births attended by a skilled attendant. In 2011, 71% of all births were assisted by a skilled birth attendant, up from 44% in 2005.
  • In South Africa, the Intervention with Microfinance for AIDS & Gender Equity (IMAGE) study showed a 55% reduction in physical and/or sexual violence by an intimate partner for program participants two years after the program ended. The study focused on women living in some of the poorest households in rural areas of Limpopo Province, where financial services were made available alongside training and skills-building workshops on gender and cultural norms, communication, intimate partner violence, and HIV prevention. Men and boys were encouraged to participate in the program as well.
  • In Sweden, the availability of services covered under the social safety net means fewer out-of-pocket expenditures, increasing access to care for those in need. Rates of economic vulnerability impacting health among older adults are at 3%, some of the lowest in the world (5).


Dimensions of Impact: RISK

Key questions in this dimension include:

What impact risks do investments aligned with this Strategic Goal run? How can investments mitigate them?

External Risk: Even if a health institution builds an evidence-based framework or plan of action to address gender inequities, broader societal patterns may influence its success. Gender norms influence both who seeks professional positions within health systems and who is given opportunities to rise to positions of responsibility within health systems. Some women will still be affected by gender biases ingrained in law or customary practices, restricting them from fully exercising their fundamental human right to health.

Identification of where gender inequities influence health outcomes and the health care workforce around the world can inform investment risk calculations. DHS Program’s Gender Corner and WHO’s Gender Portal provide a place to start based on the context within which investors work.

What are likely consequences of these impact risk factors?

Failure to adequately address these risks could dilute positive impact and, in some cases, lead to unintended negative impact. For instance, in cases where women's rights are restricted or where their safety is at risk, interventions in this strategy that do not account for the External Risk and put adequate protections in place for clients and/or target beneficiaries could put women's lives in danger.

Illustrative Investment

Have an illustrative investment we should consider? Let us know!

Draw on Evidence

This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.

Using a Gender-Responsive Approach to Generate Policy, Systems, and Environmental Changes to Improve Women's Health Burke, Jodi, Wendy Lombard, Laurie Lachance, Patrick Kelly, Margaret Wilken, and Sandra Waddell. "Using a Gender-Responsive Approach to Generate Policy, Systems, and Environmental Changes to Improve Womens Health." World Medical & Health Policy 9, no. 3 (2017): 358-76. doi:10.1002/wmh3.236.

This case study investigated a gender-responsive approach that is designed to increase social connectivity as a means to improve health and foster well-being among women in the community. Initial implementation outcomes indicate that a gender-responsive approach to community health improvement initiatives is a promising model for how coalitions can purposefully adapt and evolve to incorporate gender-based considerations into programmatic and policy change efforts that equitably benefit all residents.

CHARM, a gender equity and family planning intervention for men and couples in rural India: protocol for the cluster randomized controlled trial evaluation Yore, Jennifer, Anindita Dasgupta, Mohan Ghule, Madhusadana Battala, Saritha Nair, Jay Silverman, Niranjan Saggurti, Donta Balaiah, and Anita Raj. "CHARM, a gender equity and family planning intervention for men and couples in rural India: protocol for the cluster randomized controlled trial evaluation." Reproductive Health 13, no. 14 (2016). Academic OneFile (accessed June 6, 2019).

By conducting a two-armed cluster randomized controlled design study across 50 mapped clusters in rural Maharashtra, India, the authors found that women from the CHARM condition, relative to controls, were more likely to report contraceptive communication at a 9-month follow-up and modern contraceptive use at 9 and 18-month follow-ups, and were less likely to report sexual IPV at 18-month follow-up.

The More Gender Equity, the Less Child Poverty? A Multilevel Analysis of Malnutrition and Health Deprivation in 49 Low- and Middle-Income Countries. Ekbrand, Hans, and Björn Halleröd. "The More Gender Equity, the Less Child Poverty? A Multilevel Analysis of Malnutrition and Health Deprivation in 49 Low- and Middle-income Countries." World Development 108 (2018): 221-30. doi:10.1016/j.worlddev.2018.01.028.

This analysis is based on a combination of macro- and micro-data from 49 low- and middle-income countries to analyze the relationship between gender equity and malnutrition, and gender equity and health deprivation among children. The results indicate that gender equity in education and employment decreases child malnutrition, and that women’s empowerment decreases health deprivation for children with unschooled mothers.

Equity Improvements in Maternal and Newborn Care Indicators: Results from the Bardiya District of Nepal. Nonyane, Bareng As, Ashish Kc, Jennifer A. Callaghan-Koru, Tanya Guenther, Debora Sitrin, Uzma Syed, Yasho V. Pradhan, Neena Khadka, Rashed Shah, and Abdullah H. Baqui. "Equity Improvements in Maternal and Newborn Care Indicators: Results from the Bardiya District of Nepal." Health Policy and Planning 31, no. 4 (2015): 405-14. doi:10.1093/heapol/czv077.

The literature presents a multi-level regression analysis of equity improvements after the implementation of a Community Based Newborn Care Package (CBNCP) in the Bardiya district of Nepal. Based on a ex-ante district-level survey, the results show that CBNCP creates significant improvements in equity for facility delivery, knowledge of at least three newborn danger signs, breastfeeding within one hour, at least one antenatal visit with a skilled provider, at least four antenatal visits from any provider and birth preparedness.

Each resource is assigned a rating of rigor according to the NESTA Standards of Evidence.

Define Metrics

Core Metrics

This starter set of core metrics — chosen from the IRIS catalog with the input of impact investors who work in this area — indicate performance toward objectives within this strategy. They can help with setting targets, tracking performance, and managing toward success.

Additional Metrics

While the above core metrics provide a starter set of measurements that can show outcomes of a portfolio targeted toward this goal, the additional metrics below — or others from the IRIS catalog — can provide more nuance and depth to understanding your impact.