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

Gender inequity is embedded in the organisation, financing, leadership, and everyday practice of health systems. It shapes who receives care, who provides it, who advances into decision-making roles, whose labour is undervalued, and whose safety is treated as negotiable. While health systems are often presented as neutral institutions, they frequently reproduce the gendered hierarchies of the societies in which they operate. This viewpoint argues that gender-transformative action should be treated as a core strategy for health system strengthening rather than as a peripheral equity concern. It proposes a three-domain framework for understanding and addressing gender inequity in health systems: capacity, institutional structures, and contextual barriers. Capacity refers to the ability of health workers, managers, educators, and policymakers to recognise and respond to gender bias in policy and practice. Institutional structures refer to the formal and informal rules that shape leadership, pay, career progression, workplace safety, budgeting, and accountability. Contextual barriers refer to the wider social conditions that influence whether people can access services and whether workers can participate equitably in institutional life, including restrictive gender norms, unpaid care burdens, violence, insecurity, and economic dependence. Drawing on purposively selected evidence from diverse settings, the paper examines how inequity is reproduced across these domains and outlines four practical areas for action: gender-sensitive training and mentorship, equitable governance and workforce reform, community engagement and norm change, and strengthened digital gender data systems. It argues that isolated or symbolic interventions are unlikely to produce durable change unless they alter the distribution of power, resources, and institutional recognition. Gender-transformative action is therefore not an optional addition to health policy, but a practical requirement for building health systems that are more equitable, accountable, resilient, and capable of advancing universal health coverage and the Sustainable Development Goals. As a viewpoint, the framework is offered as an analytic and planning aid rather than as an empirically validated model. Evidence on how gender-transformative reforms interact across domains remains limited, and the claims made here about what such reform can achieve should be read as arguments for a direction of travel rather than as established effect estimates.