Actors’ perspectives on navigating context when co-designing gender integration in an established adolescent 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):A1819
ABSTRACT
BACKGROUND:
Gender inequality is an intersectional determinant of health that remains insufficiently integrated into health programmes and policies. Participatory design approaches show promise in strengthening gender integration for health, but limited evidence describes how such partnerships navigate contextual elements and power dynamics in low- and middle-income countries. This study examines these processes within an established health programme in South Africa.
METHODS:
We conducted a qualitative, exploratory case study of a co-design partnership between three organisations that aimed to strengthen the gender focus of an established health programme between 2022 and 2025. Data were drawn from a review of 37 sets of project meeting documents, participant reflections collected following 36 project engagements, and 12 key informant interviews. Analysis was informed by literature on context, organisational logics, gender, and power, and guided by a macro–meso–micro context analytical framework.
RESULTS:
Three interlinked contextual levels shaped the partnership. Macro-level donor funding arrangements and accountability structures created hierarchical pressures, constraining participatory and gender-responsive work. Meso-level divergent organisational logics - between compliance-driven implementation partners and a more reflective research partner - generated misalignment with co-design processes. However, micro-level action by a small group of boundary-spanning individuals played a critical enabling role in building trust, sustaining engagement, and supporting gender integration despite structural constraints. Interactions across levels revealed how institutionalised power and hierarchies shaped co-design processes and limited what was feasible for gender integration within the programme.
CONCLUSIONS:
Co-design partnerships can support gender integration within established health programmes, but their effectiveness depends on enabling macro-level funding conditions, deliberate navigation of meso-level organisational logics, and sustained micro-level relational work. Without attention to context and power across levels, participatory intent risks being undermined by hierarchical system structures. Further research and advocacy should support adaptive funding models and institutional arrangements that enable gender-responsive co-design in LMIC health systems.
Gender inequality is an intersectional determinant of health that remains insufficiently integrated into health programmes and policies. Participatory design approaches show promise in strengthening gender integration for health, but limited evidence describes how such partnerships navigate contextual elements and power dynamics in low- and middle-income countries. This study examines these processes within an established health programme in South Africa.
METHODS:
We conducted a qualitative, exploratory case study of a co-design partnership between three organisations that aimed to strengthen the gender focus of an established health programme between 2022 and 2025. Data were drawn from a review of 37 sets of project meeting documents, participant reflections collected following 36 project engagements, and 12 key informant interviews. Analysis was informed by literature on context, organisational logics, gender, and power, and guided by a macro–meso–micro context analytical framework.
RESULTS:
Three interlinked contextual levels shaped the partnership. Macro-level donor funding arrangements and accountability structures created hierarchical pressures, constraining participatory and gender-responsive work. Meso-level divergent organisational logics - between compliance-driven implementation partners and a more reflective research partner - generated misalignment with co-design processes. However, micro-level action by a small group of boundary-spanning individuals played a critical enabling role in building trust, sustaining engagement, and supporting gender integration despite structural constraints. Interactions across levels revealed how institutionalised power and hierarchies shaped co-design processes and limited what was feasible for gender integration within the programme.
CONCLUSIONS:
Co-design partnerships can support gender integration within established health programmes, but their effectiveness depends on enabling macro-level funding conditions, deliberate navigation of meso-level organisational logics, and sustained micro-level relational work. Without attention to context and power across levels, participatory intent risks being undermined by hierarchical system structures. Further research and advocacy should support adaptive funding models and institutional arrangements that enable gender-responsive co-design in LMIC health systems.
| eISSN: | 2654-1459 |
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