Effectiveness of donor supported leadership development interventions intended to promote women’s leadership in health in low- and middle-income countries: a scoping review

ABSTRACT

Women remain underrepresented in health leadership. Promoting women’s leadership in development has resulted in the proliferation of donor-supported leadership development initiatives to address barriers to women’s participation. There is limited evidence synthesis regarding their effectiveness. This scoping review aimed to summarise evidence regarding the efficacy of donor strategies in this field. Seven of 3365 studies were identified. Findings were overwhelmingly positive however there was an overreliance on anecdotal evidence, and short evaluation periods. Overall, evidence is lacking on the effectiveness of such initiatives. More robust evaluation designs are needed to determine best practices to overcome gender inequality in leadership.

KEYWORDS:

• Global health
• women’s leadership development
• gender equality
• aid donors
• low- and middle-income countries
• scoping review

Introduction

Gender inequality in leadership is a pervasive problem including in health (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019). Women remain underrepresented in leadership and management including in executive and senior roles across all levels of the health system despite accounting for the majority (approximately 70%) of the global health workforce (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019; Dhatt et al. 2017; Javadi et al. 2016). Barriers to women’s participation in health leadership are multifactorial including individual and structural such as biased organisational gender norms and practices in recruitment and promotion (Newman et al. 2017; Dhatt et al. 2017). Women’s disadvantage pertaining to leadership is further compounded by the intersection of gender with other social stratifiers such as age, ethnicity and race (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019; Morgan et al. 2018).

Gender imbalances in the global health workforce persist despite widespread commitments to a range of policy and legal frameworks which espouse gender equality such as the Convention on the Elimination of All Forms of Discrimination Against Women, Beijing Platform for Action, and Sustainable Development Goals (SDGs) (United Nations Human Rights Office of the High Commissioner (UN OHCHR) 1979; United Nations (UN) 1995; United Nations Department of Economic and Social Affairs (UN DESA) 2015). Women’s lack of participation in decision-making has important implications for global health systems not least being policy formulation and responsiveness to the health needs and concerns for women (Javadi et al. 2016; Downs et al. 2016; Australian Government Department of Foreign Affairs and Trade (DFAT) 2019). Moreover, it undermines progress towards the health-related SDGs and Universal Health Coverage UHC) which cannot be achieved without equality (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019; World Health Organization (WHO) 2016; World Health Organization (WHO) 2018). Conversely, women’s engagement in leadership is known to be beneficial on multiple fronts. Previous research has found that women’s leadership is associated with positive health outcomes and greater investment in health care including antenatal care and immunisation services (Downs et al. 2014). In addition, female leaders tend to adopt inclusive policies and expand the health agenda, thus promoting health for all including women and children (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019; Global Education Monitoring Report Team 2018; Peña, Aguayo, and Orellana 2012). Dividends from women’s leadership extend beyond health benefits to include socio-economic ones including economic growth and stability associated with having a healthy population (World Health Organization (WHO) 2018; Gill et al. 2009; World Health Organization (WHO) 2016).

As such, accelerating progress on gender equality in leadership is a development imperative which has been brought into sharper focus by SDG 5.5 which aims to ensure women’s full and effective participation in leadership at all levels of decision-making (United Nations (UN) Women 2020). Promoting women’s leadership also features prominently in gender equality policies of prominent aid donors such as the Australian Government’s Department of Foreign Affairs and Trade (DFAT) and the United States Agency for International Development (USAID) (Australian Government Department of Foreign Affairs and Trade (DFAT) 2016; United States Agency for International Development (USAID) 2012). Leadership development programs (LDPs) (both women-focused and gender-inclusive initiatives) have been used to an increasing extent by donors as a means of supporting development through enhancing women’s leadership capacity and participation (Gill et al. 2009; Lyne de Ver and Kennedy 2011; Governance and Social Development Resources Centre (GSDRC) 2012). Donor efforts to promote women’s leadership are highly varied in their aims and approaches partly due to differences in conceptualisations or definitions of leadership with some programmes viewing leadership as an individual attribute whilst others understand it to be a shared or political process (Lyne de Ver and Kennedy 2011; Governance and Social Development Resources Centre (GSDRC) 2012; Howard 2019). From the perspective of leadership as an individual attribute (the level targeted by many women’s leadership development initiatives), leadership capacity is enhanced through approaches such as education and training, experiential learning, mentoring and networking opportunities (Governance and Social Development Resources Centre (GSDRC) 2012; Lyne de Ver and Kennedy 2011; McLeod 2015). Programmes that adopt a political understanding of leadership focus more on promoting coalition-building and supporting leadership coalitions or networks to drive sustainable change, although in practice few donors take a longitudinal approach due to challenges with measuring change over the long term including time and resource constraints (Governance and Social Development Resources Centre (GSDRC) 2012; Lyne de Ver and Kennedy 2011; Howard 2019).

In addition, there is growing interest in gender transformative approaches which have a broader conceptualisation of leadership beyond individual capacity or agency that also consider the structural and relational factors that influence women’s leadership (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019; Hillenbrand et al. 2015); Pederson, Greaves, and Poole 2015; Australian Government Department of Foreign Affairs and Trade (DFAT) 2014). These programmes recognise that achieving meaningful change regarding women’s participation in leadership requires critical changes across the individual, structural and relational dimensions. As such, they take a broad approach working across these interrelated levels to transform discriminatory structures and unequal power relations that reinforce inequality, in addition to strengthening the individual capacity of women (Australian Government Department of Foreign Affairs and Trade (DFAT) 2014; Rao and Kelleher 2005; World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019). This is enabled through the implementation of integrated strategies which include consciousness raising, skills development, collective action and advocacy (Rao and Kelleher 2005; Rao, Kelleher, and Miller 2015; Australian Government Department of Foreign Affairs and Trade (DFAT) 2014). Taking a transformative approach is increasingly recognised as essential for enhancing women’s leadership in global health particularly in low- and middle-income countries (LMICs) where gendered leadership gaps are more pronounced (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019). We synthesised these conceptualisations along with key assumptions into a logic model for LDPs and gender transformative programmes in Figure 1.

Figure 1. Theory of change.

Whilst several studies have examined the effectiveness of donor efforts to promote women’s leadership (Gill et al. 2009; Lyne de Ver and Kennedy 2011; Governance and Social Development Resources Centre (GSDRC) 2012; Australian Government Department of Foreign Affairs and Trade (DFAT) 2014; Reinelt and Russon 2004), there is limited evidence synthesis regarding donor investments in women’s leadership in health. Given how integral women’s participation in health leadership is to population health and development, understanding the efficacy of donor leadership development initiatives is essential to help inform progress in this area. Thus, this scoping review aimed to identify and summarise existing literature on the types and effectiveness of donor funded LDPs intended to enhance women’s leadership in public health systems in LMICs.

Methods

The scoping review was based on Arksey and O’Malley’s methodological framework which comprises the following key steps: 1) identifying the research question, 2) finding relevant studies, 3) study selection, 4) data charting and 5) collating, summarising and reporting results (Arksey and O’Malley 2005). The scoping review is an increasingly popular method to reviewing health-related research evidence as it provides a rigorous and transparent approach for the mapping and synthesis of heterogeneous evidence to inform policy (Arksey and O’Malley 2005; Levac, Colqhoun, and O’Brien 2010). Furthermore, we chose this approach as it is useful for examining a topic which has not yet been extensively reviewed (as in this case) and identifying gaps in knowledge.

Search strategy and selection criteria

A systematic search for relevant literature was conducted on January 2020 using PubMed, SCOPUS, ProQuest and PsycINFO. A combination of key terms was used, which were grouped according to key concepts – health sector, women, leadership development and LMICs using truncation, proximity and Boolean operators ‘AND’ or ‘OR’. The search string was developed and refined in Scopus in consultation with a librarian and adapted for the other databases (refer to supplementary material for search string). We excluded non-English publications and restricted our search to papers published after 2000. The date range 2000–2020 was chosen as a point of reference as it encompasses a period of proliferation of LDPs intended to promote women’s leadership. Database searches were supplemented by hand searching of reference lists of identified articles. We also searched websites including Google and Google Scholar for non-peer-reviewed literature. Additional grey literature was identified through searching websites of key bilateral and multilateral development aid donors including DFAT, the United Kingdom Department for International Development, USAID and the Swedish International Development Cooperation Agency. These organisations were purposively sampled from among the Organisation for Economic Co-operation and Development top contributors of aid in support of gender equality and women’s empowerment both in relative and absolute terms.

Title and abstract screening was conducted by a single reviewer (SM) with cross-validation of a random sample by a second reviewer (NS). The same approach was taken for full text screening of relevant articles. A third independent reviewer (EL) was available for consultation to resolve any conflicts which arose. Studies were included if they were evaluations of donor-supported leadership development interventions, based in public health sectors in LMICs, and included female participants in leadership and/or managerial roles. We excluded studies if they described evaluations of non-donor-funded LDPs, or donor-supported interventions implemented beyond the scope of public health sectors in LMICs. Theses, dissertations, book reviews, commentaries/opinion pieces, editorials and conference papers were also excluded. For the purpose of the review, we defined the public health sector as public entities at the national and sub-national levels which deliver health services including government ministries of health and health care institutions (i.e. hospitals and primary health care facilities) (Ayeleke et al. 2016). Women’s leadership refers to women in formal leadership and/or managerial roles across the health sector, and aid donors refer to agencies which finance development interventions in LMICs including bilateral and multilateral sources.

Data extraction and analysis

Data were extracted from eligible studies by two reviewers (SM, NS) using an agreed extraction template which addressed general study characteristics, and outcomes and impacts of interventions including evaluation challenges. Studies were not assessed for quality or risk of bias as the scoping review approach provides an overview of all relevant literature regardless of study design (Arksey and O’Malley 2005). However, limitations of the included studies were identified and discussed, and future directions for research articulated including the types of studies or evaluation designs which could be used to assess the effectiveness of women’s leadership interventions. A numerical summary of study characteristics was provided, and key outcomes and methodological challenges were summarised using a narrative synthesis. In addition, we analysed the gender composition of included evaluations based on participants demographic characteristics. We developed a theory of change for leadership development and gender transformative programmes to guide our data analysis and synthesis (see Figure 1).

Results

A total of 3365 articles were identified of which seven were included in the review (see Figure 2). These comprised two quantitative (Terzic-Supic et al. 2015; Uduma et al. 2017), two qualitative (Kwamie, Van Dijk, and Agyepong 2014; Ajeani et al. 2017) and three mixed-methods study designs (Nankumbi et al. 2011; Stover et al. 2014; Mutale et al. 2017). Table 1 provides a summary of study characteristics, and Figure 3 shows the proportion of evaluation respondents by gender.

Figure 2. PRISMA flow diagram.

Figure 3. Proportion of evaluation respondents by gender.

Table 1. Study characteristics.

Characteristics	Number (n = 7)
Geographic region
African	6
European	1
Publication year
2010–2015	3
2015–2020	4
Study design
Quantitative	2
Qualitative	2
Mixed-methods	3
LDP type
Capacity building	7
Gender transformative	-
Designed specifically for women	-
Gender inclusive	7
Donor type
Bilateral	3
Multilateral	1
Private (NGOs or philanthropic)	3
Setting (health sector level)
District + health facility	4
District	1
Health facility	2
Intervention duration (mean; range)	15 months
Evaluation period
Short-term (≤1 year)	6
Medium-term (1–3 years)	1
Long-term (≥3 years)	-

Study characteristics

A majority of the evaluation studies (n = 6) were carried out in Sub-Sharan Africa (SSA), and of these, two were conducted in Uganda with one each in Ethiopia, Tanzania, Ghana and Zambia. Only one study was undertaken in Europe which was in Serbia. Bilateral and private donors each accounted for 43% of aid sources for the interventions, whilst multilateral aid agencies comprised 14% of donors. LDPs primarily targeted health leaders and managers at the district and health facility levels. Majority of programmes (n = 4) included individuals from both district health managements teams (DHMTs) and health facility management, two interventions focused exclusively on facility managers, and one targeted only personnel from the DHMT. The programmes tended to have a multi-disciplinary focus with most participants having a medical or nursing background.

Only gender-inclusive LDPs were identified all of which were capacity building initiatives, and no evaluations of gender transformative interventions were found.¹ The majority of included studies (n = 4) comprised mostly of female respondents (Uduma et al. 2017; Kwamie, Van Dijk, and Agyepong 2014; Ajeani et al. 2017; Nankumbi et al. 2011). Interventions were generally team based (n = 4) and tended to use multi-faceted approaches to promote the management and leadership capacity of participants. These included didactic and practical training elements such as workshops and action learning complemented with mentoring or coaching. Intervention components were generally short in duration with most (n = 5) ranging from 6 to 12 months whilst the longest lasted for three years (Nankumbi et al. 2011). The studies included in the review were all primary research and comprised a mix of large and small n evaluations. Forty-three per cent used mixed-methods, whilst quantitative and qualitative approaches accounted for 29% each of the eligible reports. Most of the evaluations (n = 4) were quasi-experimental which used before-and- after designs and the remainder were non-experimental. Only one used a comparison group (Uduma et al. 2017).

Medium- to long-term follow-up was rare with most evaluations (n = 6) measuring change in the short term (less than or equal to 12 months). Only one evaluation, that by Kwamie, Van Dijk, and Agyepong (2014), assessed change in both the short and medium terms to determine whether positive outcomes were sustained. Most of the studies (n = 5) used survey-based questionnaires to evaluate the effectiveness of interventions and of these, three complemented surveys with key informant interviews. Only two studies used exclusively qualitative data collection methods including key informant or in-depth interviews (Kwamie, Van Dijk, and Agyepong 2014; Ajeani et al. 2017). Two of the studies that conducted surveys used indices or scales adapted from previously validated instruments to assess change, whilst the reminder used outcome measures which were specifically developed for the evaluation. Commonly assessed outcomes included individual competency levels (e.g. knowledge, skill and confidence), job motivation, behaviour, and workplace environment and performance (e.g. service delivery, health outcomes).

Key outcomes, impacts and methodological limitations

Identified evaluation studies mainly focused on short-term outcomes, particularly change at the individual level (e.g. leadership knowledge, skills and confidence), and there was a lack of evidence regarding relational and structural transformations (e.g. shift in unequal gender power dynamics and gender discriminatory norms and practices). Reported individual level change was mostly based on participants’ self-assessments of competency levels, job motivation and behaviour. Evaluations generally reported positive changes in participants competence including knowledge, skills and confidence. Similarly, improvements in job motivation and leadership and management practices such as supportive supervision, strategic planning, and human resource management were evidenced across the evaluation studies. For example, the study by Uduma et al. (2017) provided evidence of improved supervisors’ competencies and performance in supportive supervision as a result of the intervention when compared with the control group. Terzic-Supic et al. (2015) reported significant positive improvements in the quality of strategic planning and management at the end of the training programme. The evaluation by Ajeani et al. (2017) found that participants productivity increased as a result of improved skills and confidence in maternal and newborn health care (MNHC). Three studies noted unintended consequences of interventions including increased workload due to participants having to balance programme requirements with their routine daily activities (Kwamie, Van Dijk, and Agyepong 2014; Ajeani et al. 2017; Nankumbi et al. 2011).

Some studies attempted to measure changes in workplace performance and climate as a result of interventions including an enabling environment supportive of women’s leadership development and participation in decision-making. Most studies (n = 6) reported on changes in the workplace environment which was generally perceived to have improved due to the intervention. For example, results of a workplace climate survey conducted by Mutale et al. (2017) suggested that the environment was positively impacted by the management and leadership training programme. Similarly, the evaluation by Stover et al. (2014) reported significant improvements in leadership and workplace culture in support of continuous quality improvement practices at the organisational level. Impacts on organisational performance including service delivery were generally positive. Participants in the evaluation study by Ajeani et al. (2017), for example, perceived the programme had a positive effect on the delivery and quality of MNHC services in participating districts. Likewise, evidence from the study by Nankumbi et al. (2011) suggested service delivery for HIV patients improved with the exception of paediatric services. Few evaluations (n = 3) noted impacts on health outcomes and in each of these instances, interventions had a positive impact on outcomes related to maternal and newborn health (MNH) (Kwamie, Van Dijk, and Agyepong 2014; Ajeani et al. 2017; Stover et al. 2014).

Most of the evaluations did not explicitly articulate a theory of change or process through which desired changes were achieved. Only one study examined in detail the mechanisms by which leadership was developed as part of evaluating programme effectiveness. The qualitative case study by Kwamie, Van Dijk, and Agyepong (2014) used a realist approach to uncover the underlying mechanisms and related contextual influences that produced the changes in outcomes observed. The intervention reportedly had a positive effect on management and leadership practices and team performance in the short term. This was due to the novelty of the programme among managers with limited formal training in management which disposed them to being more receptive to training and adopting LDP practices. Over time, however, the effects of the programme were minimised due to a non-conducive environment characterised by high uncertainty and rigid hierarchical authority which stifled organisational learning and programme institutionalisation. Less detailed descriptions of how outcomes were achieved were provided by some of the other studies such as that by Ajeani et al. (2017) with respect to improved patient management and Terzic-Supic et al. (2015) regarding managers enhanced strategic planning.

Several methodological limitations were identified including reliance on anecdotal evidence, attribution issues and inadequate evaluation periods. Most studies (n = 5) relied on participants self-reporting of perceived changes as a result of the intervention. Only three evaluations incorporated objective measures of competency outcomes including pre- and post-knowledge quizzes, and independent assessors (Terzic-Supic et al. 2015; Ajeani et al. 2017; Mutale et al. 2017). Two studies documented organisational performance based on objective assessments of service delivery related to MNH (Kwamie, Van Dijk, and Agyepong 2014; Stover et al. 2014). Another limitation was that of attribution of identified effects to the intervention including among the large n evaluations most of which did not have a comparison group to compare the impact of the programme making it impossible to fully attribute findings to the intervention (Mutale et al. 2017; Terzic-Supic et al. 2015; Stover et al. 2014). Only one study that by Uduma et al. (2017) had a control group which meant that the positive outcomes identified could be attributed to the intervention. Attribution was also reported as a challenge by some of the small n evaluations (Nankumbi et al. 2011; Ajeani et al. 2017), although this is not unusual for these types of studies which tend to lack comparison groups to rule out rival explanations for outcomes observed. Effectiveness of interventions was mostly measured in the short term (≤12 months), making it impossible to know whether positive effects were sustained in the long term. Multiple endpoints were reported only in one study which assessed effects of the programme in the short and medium term and found that the positive outcomes had diminished over time (Kwamie, Van Dijk, and Agyepong 2014).

Discussion

This review mapped out and synthesised existing literature on the effectiveness of donor LDPs in regard to promoting women’s leadership capacity. Only seven articles reported on evaluation outcomes of donor-supported LDPs. Previous research has similarly highlighted a paucity of evidence on women’s leadership beyond political participation including in health (Governance and Social Development Resources Centre (GSDRC) 2012; Australian Government Department of Foreign Affairs and Trade (DFAT) 2014). None of the interventions evaluated were designed specifically for women leaders or sought to effect transformative change to enhance their participation in leadership, suggesting clear gaps in the evidence base. Additionally, reported outcomes predominantly encompassed short-term changes at the individual level highlighting substantial gaps in the literature regarding relational and structural transformations as well as the long-term impact of interventions. Studies were mostly implemented in SSA which may reflect the substantial health assistance this region receives relative to other parts of the world. Strengthening health governance and leadership in this context is a key priority due to gaps in leadership capacity which partly stem from individuals assuming leadership roles with little formal training (Oleribe et al. 2019; Mooketsane and Phirinyane 2015; Nakanjako et al. 2015; Amde et al. 2019). This is because progression into decision-making roles is usually on account of clinical expertise and consequently managers and leaders are ill equipped to execute their managerial and leadership functions and responsibilities. This is further compounded by gendered opportunities for further study and training which puts female leaders at a disadvantage with respect to leadership capacity (Dhatt et al. 2017). As such, the absence of gender-specific and transformative programming among the included studies is a concern as it suggests underinvestment in these approaches that are deemed essential for promoting women’s participation in leadership (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019). Similar findings have been found by other reviews (World Health Organization (WHO) Global Health Workforce Network Gender Equity Hub 2019; Australian Government Department of Foreign Affairs and Trade (DFAT) 2014) which underscores the need for greater donor investment in this space. More specifically, there is a need for innovative and contextually relevant transformative approaches aimed at tackling structural barriers with rigorous evaluation to provide an evidence base for the most effective way of promoting women’s participation in decision-making structures. Whilst developing leadership capacity is important and a necessity, doing so to the exclusion of transforming discriminatory gender norms and structural inequality only serves to perpetuate gender gaps in health leadership (Australian Government Department of Foreign Affairs and Trade (DFAT) 2014). Moreover, failing to invest in structural change not only maintains inequality but also undermines the well-being and productivity of female leaders who have to work in unsupportive environments (Australian Government Department of Foreign Affairs and Trade (DFAT) 2014).

Our analysis of the literature found considerable heterogeneity concerning donors and study design. Aid sources for the LDPs comprised a variety of bilateral, multilateral and private donors of which the former accounted for the majority of the aid sources for the LDPs. Evaluations predominantly used mixed-methods and quasi-experimental approaches relying on before-and-after designs to assess intervention outcomes. Studies tended to evaluate the effectiveness of programme at the individual and organisational levels which is consistent with findings from other evaluations of LDPs both within and beyond the health sector (Frich et al. 2015; Straus, Soobiah, and Levinson 2013; Collins and Holton 2004). Whilst the evidence reviewed was overwhelmingly positive, these findings must be interpreted in light of several limitations in the evidence base. First, there was an overreliance on participants self-reporting of perceived changes which was a commonly acknowledged limitation among the included studies. Second, the studies generally did not have a control or comparison group, thus making it challenging to attribute the identified effects to the programme. Third, most evaluations assessed the effectiveness of interventions immediately after the programme rather than over a longer period of time as such it is unclear whether reported benefits were sustained in the long term. In addition to these methodological issues, most studies did not perform a process evaluation as part of assessing programme effectiveness and consequently there remains a lack of in-depth and detailed understanding about mechanisms and contextual influences leading to positive outcomes.

Key research gaps

We identified a remarkably limited evidence base which examined the effectiveness of donor-supported LDPs in public health sectors in LMICs. More specifically, there is a paucity of studies on interventions designed specifically for women in health leadership, and on gender transformative programmes. Given the growing interest in the latter, the existing evidence gap presents an opportunity for future research on these interventions including examining the type that is most successful in overcoming structural barriers to gender equality. In addition to promoting the sharing of best practices, such research will help broaden and deepen the evidence base on donor investments in women’s leadership in global health.

Our analysis of the literature also found that few studies examined the processes of change and contextual factors influencing programme outcomes. Evaluations largely focused on cause and effect relationships between interventions and their participants and only one explicitly examined the underlying mechanisms by which the intervention outcomes were produced and circumstances in which this occurred. Although understanding the effects of a programme is important, this has limited practical value for policy-makers as compared to evidence of how and why a programme works, and in what context (Batliwala and Pittman 2010; Westhorp 2014). Thus, there is a need for more evaluation studies of women’s leadership development interventions that take a broader and in-depth approach to evaluating effectiveness which includes measures of process to identify aspects of the intervention and related contextual factors that contribute to its success or failure. Possible types of study design which could be used for future evaluations include realist evaluation, outcome mapping, most significant change, case study and ideal-type analysis. These qualitative approaches which are particularly suited to small n evaluations can be used to better understand a programme’s contribution to changes in observed outcomes as they enable a more in-depth and contextualised analysis of outcomes and mechanisms of change.

Finally, findings from our review indicate a limited use of objective measures of programme results, lack of comparison groups, and short evaluation periods. This makes the case for more research which includes externally verifiable data, and use of comparators including by interventions with large number of participants, to better assess programme effectiveness. Furthermore, longitudinal studies are needed to assess effectiveness both in the short and long term. The results of studies included in the review were not disaggregated by gender making it impossible to assess programme effects on women leaders or make comparisons between genders, displaying the need for more gender-disaggregated evidence to better understand persistent gender gaps in leadership.

This study has some limitations. First, we did not use an exhaustive number of databases and donor organisational websites for our search of the literature, as such we may have missed relevant studies not captured in the reviewed data sources. However, the likelihood of this is not substantial given the broad search strategy we employed to locate the existing evidence. Second, only English language articles were considered for our study which may have resulted in the omission of non-English publications.

Conclusion

Our analysis of the literature indicates a paucity of evidence on the effectiveness of donor programming in women’s health leadership in LMICs. In addition, our findings point to positive outcomes associated with donor-supported LDPs. Whilst we did not identify any interventions designed specifically for women leaders, we can assume that the favourable effects reported applied to many of the female participants as most of the evaluations were comprised largely of women. Furthermore, our review suggests other important gaps including a lack of programming in gender transformative strategies, a deficiency in robust evaluation designs which include process measures, and an overreliance on anecdotal evidence.

As demand for and cost of quality health services increases, resilient and responsive health systems with inclusive governance are essential. Persistent gender gaps in leadership risk undermining efforts to strengthen health systems in LMICs. This has important implications for health outcomes, especially for women, and ultimately for the achievement of health-related SDGs and UHC. Based on our findings, donor agencies need to take more of a gender transformative approach to the strengthening of health leadership in these contexts which not only focuses on empowering individual women but also addresses structural factors that limit women’s equal and full participation in decision-making processes. Furthermore, robust evaluations of such investments are necessary including determinants of success to enable sharing of best practices.

Data sharing

All the data are available in the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Sethunya Matenge

Dr Sethunya Matenge is a PhD Candidate at the Department of Health Services Research and Policy within the College of Health & Medicine, Australian National University. Her research focuses on the intersection between gender and governance in health and identifying best practices to promoting women’s participation in formal health leadership and decision-making in low-and middle-income countries. Between November 2020 to June 2021 Sethunya was on secondment to the Australian Government Department of Health where she was working as an Action Researcher with the COVID-19 Primary Care Response Group. This included undertaking rapid reviews and evidence synthesis to help inform the COVID-19 policy response. Sethunya holds a Master of Public Health from Harvard University and a Bachelor of Medicine from the University of Newcastle, Australia. She has experience working in clinical medicine and public health in diverse contexts including Australia, Botswana and the Solomon Islands.

I Nyoman Sutarsa

Dr I Nyoman Sutarsa is a senior lecturer at the Department of Population Health, Medical School, College of Health & Medicine, Australian National University. He is a public health physician with extensive working experiences across the academia, government sector and non-government institution, including international donor agencies. His core expertise is on health systems, primary care and public health. He is an advisory board member of the ANU Indonesia Institute and a member of the editorial board of the Public Health and Preventive Medicine Archive.

Emily Lancsar

Professor Emily Lancsar is Head of the Department of Health Services Research and Policy. She is an economist with particular interests in understanding and modelling choice, preferences and behaviour of key decision makers in the health sector, priority setting in the health system, economic evaluation and policy analysis. She is a member of a number of government advisory committees, is an Associate Editor of Health Economics and a past Vice President of the Australian Health Economics Society.

Notes

1. An evaluation report on gender-responsive interventions including gender transformative programmes was identified in the literature search; however, it did not meet the eligibility criteria as it was not specific to health leadership.