“Building the plane while flying it”: Co-designing gender integration in an established sexual and reproductive health program in South Africa
1
SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF THE WESTERN CAPE, CAPE TOWN, South Africa
2
University of KwaZulu-Natal, DURBAN, South Africa
3
HUMAN SCIENCES RESEARCH COUNCIL, CAPE TOWN, South Africa
4
Maastricht University, MAASTRICHT, Netherlands
5
SOUTH AFRICAN MEDICAL RESEARCH COUNCIL, CAPE TOWN, South Africa
6
Walter Sisulu University, MTHATHA, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1821
ABSTRACT
BACKGROUND:
Participatory approaches such as co-design can support gender integration through inclusive analysis and design, and increased contextual responsiveness. However, limited literature describes how co-design is enacted and sustained in practice within complex programme architectures, particularly in LMIC settings. This paper addresses this gap through a qualitative case study of a multi-stakeholder co-design partnership that sought to strengthen gender integration within an established health programme in South Africa between 2022 and 2025.
METHODS:
Data sources included a review of 37 sets of project documents, participant reflections from 36 project engagements, and 12 semi-structured interviews with key informants across three partner organisations. Analysis traced co-design processes longitudinally, examining how collective sensemaking, iterative adaptation, and negotiation of roles and constraints unfolded. Data analysis was informed by literature on participatory design, gender integration, and partnership synergy.
RESULTS:
Co-design functioned as an iterative, relational mechanism through which partners navigated programme realities and pursued gender integration over time. Structured spaces for collective sensemaking enabled gender analysis, surfaced contextual constraints and power dynamics, and supported shared decision-making. Iterative adaptation allowed the partnership to recalibrate plans in response to implementation realities and to identify and implement opportunities for gender integration within the programme. Sustaining this work required substantial time, an enabling collaborative environment that supported power shifting, continuity of appropriately skilled staff, flexible funding arrangements, and sustained relational labour. Co-design was constrained by fixed and complex programme architectures, the temporary exclusion of a key partner from early-stage planning, human resource limitations, and hierarchical accountability systems.
CONCLUSIONS:
Co-design can support gender integration within established programmes, but it is neither a linear nor a purely technical process. Rather, it operates through sustained sensemaking, adaptation, and relational work. These findings provide practice-based insight into what is required to enact and sustain co-design for gender integration within complex, established health programmes.
Participatory approaches such as co-design can support gender integration through inclusive analysis and design, and increased contextual responsiveness. However, limited literature describes how co-design is enacted and sustained in practice within complex programme architectures, particularly in LMIC settings. This paper addresses this gap through a qualitative case study of a multi-stakeholder co-design partnership that sought to strengthen gender integration within an established health programme in South Africa between 2022 and 2025.
METHODS:
Data sources included a review of 37 sets of project documents, participant reflections from 36 project engagements, and 12 semi-structured interviews with key informants across three partner organisations. Analysis traced co-design processes longitudinally, examining how collective sensemaking, iterative adaptation, and negotiation of roles and constraints unfolded. Data analysis was informed by literature on participatory design, gender integration, and partnership synergy.
RESULTS:
Co-design functioned as an iterative, relational mechanism through which partners navigated programme realities and pursued gender integration over time. Structured spaces for collective sensemaking enabled gender analysis, surfaced contextual constraints and power dynamics, and supported shared decision-making. Iterative adaptation allowed the partnership to recalibrate plans in response to implementation realities and to identify and implement opportunities for gender integration within the programme. Sustaining this work required substantial time, an enabling collaborative environment that supported power shifting, continuity of appropriately skilled staff, flexible funding arrangements, and sustained relational labour. Co-design was constrained by fixed and complex programme architectures, the temporary exclusion of a key partner from early-stage planning, human resource limitations, and hierarchical accountability systems.
CONCLUSIONS:
Co-design can support gender integration within established programmes, but it is neither a linear nor a purely technical process. Rather, it operates through sustained sensemaking, adaptation, and relational work. These findings provide practice-based insight into what is required to enact and sustain co-design for gender integration within complex, established health programmes.
| eISSN: | 2654-1459 |
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