We identified 4 primary themes that represent the process of problem identification and prioritization associated with women’s and girls’ health across UN agencies: 1.) the influence of political forces, 2.) the challenge of finite financial resources and funding, 3.) the role of scientific evidence and data, and 4.) the purpose of differentiated scopes of work. To capture perspectives on these interconnected concepts, we will describe each theme using descriptions and insights provided by the participants.

Table 1 illustrates the general topic that their work focuses on. This table is meant to assist in contextualizing the presentation of direct quotes while maintaining the anonymity of participants.

Table 1 Participant topic areasThe influence of political forces

Participants described the effects of political forces across subnational, national, and international levels and the influence that they exert on problem identification and prioritization processes. Political forces were characterized by actions of local or state governments and international relations between states that had the capability to shape or determine the creation and implementation of the global development agenda. Several participants noted that these political forces included member state agendas including normative frameworks related to health and gender, stalled progress towards established goals due to their status as lower priority, and the feeling that the UN is transitioning through a period of change that is being shaped by changing norms on a global scale, which was noted as resulting in oft-perceived pushback against policy interventions (i.e., policy related to reproductive health rights).

Member State Agendas

Member state agendas were identified as a key force in determining global agendas. Participant 4 shared their perspective on the impact of different ideas on their work: “the member states that provide the ideas, they also have different internal policies, foreign policies. So of course, that influences the discourse and our work.”

Participant 5 reflected on examples of these discourses: “We will need to do better on... Predicting, understanding and disrupting the forces of resistance that are increasingly consolidated, they're increasingly better organized, that are rolling back grand progress on sexual reproductive health and rights, gender rights, including the rights of gender and sexual minorities.” This participant also noted that: “It used to be that the multilateral system was a hotbed for a lot of this dialogue at the place for grant negotiations to take place, for vigorous dialogue and push back and forth to happen. It feels as though these conversations have now skipped the multilateral system entirely and have been taken down to the ground in the member states, and so you find that communities are now having conversations about things that typically in the past have been very obvious and not controversial.”

Most participants reflected on the relationship between their UN agency, as well as the wider UN system, and the member states in which they serve: Participant 8 shared that “We’re a UN agency - we work with the government, so whatever is happening politically has definitely to fit into our work… I mean, they are the ones getting the strategic vision.”

The role of normative frameworks related to both gender and health in shaping the work of UN agencies was frequently discussed across the interviews. These frameworks include a changing understanding of women’s and girls’ health (i.e. moving beyond focus on sexual and reproductive health and considering the impact of gender on multiple facets of health) and the subsequent identified priorities of the global health agenda, with Participant 2 explaining that: “The whole agenda of women’s global health let's say it is still evolving. I think that everyone has a different perspective on it, and I feel that... that maybe till now, there's been too much focus on reproductive health issues as women's health issues, as if that's the only thing that matters to women.” Participant 4 follows this sentiment reflecting on the tendency to focus on women and their status as mothers, entrenching gender roles, rather than their inherent right to good health – and how doing so hinders meaningful progress for women who are not mothers: “Yet we're not talking about women who are not pregnant or who are not breastfeeding. We're still in the realm when we're talking about women as a bearer of children, right. So, it's more about the child than the woman herself. We're not talking about all those women who are beyond reproductive age or at reproductive age, but not willing or not able to have a baby.” The interview guide did not explicitly reference sexual and reproductive health, but most interviewees discussed it immediately when asked about gender and health, and continually did so throughout the interview. This may be explained by some of the participants’ employment or expertise background, but a notable observation, nonetheless.

$$Structures + Bias + Low\,Priority = Slow\,Progress$$

Many participants reflected on frustration with the slow pace of progress due to perceived political constraints and other barriers related to social, cultural, or economic factors. These constraints ranged from being more broadly related to persistent inequity worldwide to concerns about their impact on the concrete work of the UN. Participant 4 shared:

“I feel like it's more about the structures we are finding ourselves in that are not conducive to change. And unless we look into what that is, what the biases are, that are institutional biases or systemic barriers… Until we address those, I think it will be a kind of one person battle or a couple of persons battle against the system rather than something more coherent”

Participant 6 noted the impact of global poly-crises on the pace of progress and the challenges they present externally and internally: “You know, we thought we would get there at some point, but now with COVID, the wars, the, you know, global economic downturn, climate crisis, it seems that we are not going to get there in terms of addressing, you know, harmful practices.”

This participant went on to add: “But at this point in time, Member States are grappling with their own internal situations, if you will. So, their collaboration with the UN in terms of contributions has been impacted”.

Reflecting on the social contexts that uniquely shape the health of women and girls, Participant 4 reiterated that, “even with all the elevation of the importance of addressing transformative norms, there is a severe lack of focus on the underlying issues leading to inequality”. This participant went on to add that progress is slow and noted their unhappiness.

Participant 7 shared an example of their experiences of actions not reflecting the work of advocates, echoing frustrations about misplaced priorities creating barriers to what they and advocates in their field would perceive as progress: “This [referring to appeasing lobbyists] is where the priorities are being set, but they're not matching what is happening and what is being discussed among advocates.”

Participant 8 shared their input on the ‘push and pull’ of norms in their field of work in relation to the context of the states they work with: “So the issue is staggering […] there's that push and pull of our work in the programmatic non-profit sector, but then there's influence within the social spheres of the population by traditional leaders or religious leaders telling them otherwise. So there really needs to be that cooperation.”

Multiple participants situated these frustrations and concerns in relation to a broader regression in women and girls’ health governance. Participant 5 shared: “It feels as though something in the tone and tenor of our public debate changed. It's not a Global North phenomenon. It's a fully global phenomenon.” Participants 5 and 4 felt that this period of change is marked by regression in the agenda around women and girls’ health: “There is a lot more convergence [of politicization of health and equality] in a terrible way… there's a way that these conversations are all converging and that is not a mistake. It's not an error. There are specific institutions and forces that are advancing specific agendas” and “With the turnover of, I don't know, political party power, we could see a big shift in foreign policy on women’s rights, gender equality, what countries think and what they say in the international sphere. So... the sort of rollback is so quick.”

Participant 3 captured this situation noting that the “The health issues attended to is political will.” The findings on the politics of agenda setting and slow progress being observed was intertwined with resource allocation and financing, another key dimension of the problem identification and prioritization process.

The challenge of limited funding

A few key ideas emerged when discussing the effects of financing and allocation decisions with participants. These include: the notion that funding often comes with strings attached, the desire to ensure high programmatic efficiency within resource constraints, the recognition that finite resources and decisions made based on priority allocation will determine the degree to which nations can adopt certain initiatives, and the tensions between priorities self-identified by countries and those identified by donors.

Participant 5 expressed concern for the changes in priorities and initiatives that can occur with insufficient funding, and if these changes will limit the realization of gender equality:

“We are paying attention to principles of efficiency in a time of scarce global funding. Increasingly, we are hyper sensitized to the need to have coherent responses to the present and critical concerns of our time, one of these being the worrying trend of reversals and stagnation and threats to girls and women's rights, their gender rights, their sexual and reproductive rights globally.”

Concerns about ‘strings attached’ funding were expressed across several interviews. Participant 1 shared their thoughts on donors creating stipulations for their financial support:

“If it's a donor, who says, because you'll get our funds, for example, you're told – ‘our interest is in family planning or abortion or so on and so forth’. Let's say OK, but the priorities that have been identified by the countries are to reduce maternal death […] OK, the donor wants to do this and then the country may say yeah, just give us the money then, if those are the conditions.”

This description, along with anecdotes from other participants’ experiences, highlight the entwined role of financing in shaping agendas related to women’s and girls’ health within state and international boundaries. Agencies, states, and community organizations are limited by what resources they are given, and powerful countries with predetermined agendas for advancing development can reify a power dynamic of wealth and influence on an international scale. Participant 1 adds:

“We are an agency that depends on donor funds. And so, what's available for us to perform the work is driven by… we're given funds… but a lot of times they give funds with clear very clearly, articulated preferences of what they want their money to do […] for many countries that don't have funds to invest in their own health, or who don't invest enough in their own health, and they accept what comes from elsewhere -- they're going to have to toe the line and do what the donor wants, because then you have to report. And if you don't, if you're not doing well, you're blacklisted and all those things.”

Participant 1 expressed their agency’s interest in preserving the self-identified priority of a member state when they are offered funding, if they are at odds with what has been stipulated:

“I mean, in a sense, we also try to ensure that what our communities have said is their priority does not get ignored, so there will be situations where the funds that are available are as they are, and where governments are strong, they will say ‘we don't want that money’.”

Reflecting on the slow progress of eliminating HIV/AIDS in children, Participant 3 shared their insight on the role of limited funding across key priority problems:

“Preventing HIV in children, you’ve got the same problem preventing malaria in children, got the same problem in preventing malnutrition -- there's so many, you know why prioritize just this one problem? And so catching the attention of, you know, very, very limited and very, very stretched health spending budgets is a major setback.”

Participant 9 shared that their organization is largely concerned with preserving the priorities of the state government by financially supporting their self-identified needs: “I’ve seen questions like ‘Why can't you support this organization and country?’ And the answer is always, generally, because we are bound by our mandate where we have to bend to governments. We cannot. You know, we cannot work with specific agencies, and it has to be the government.” P9 went on to elaborate on the case of a country having to address an underlying structural issue before receiving support from a financing agency: “I can see how that might look as ‘strings attached’, but again there are issues that are underlying, structural issues that really need to be addressed, I wouldn’t say it’s particularly without reason.”

Certain kinds of evidence can influence which issues receive funding and which issues are identified as the greatest priorities, as Participant 8 shared: “I think if our topics are relegated or stagnating and are not prioritized, it might be because they might be seen as less urgent.” To this end, several participants noted the importance of evidence and data in policymaking and agenda development.

The role of scientific evidence and data

There is an established expectation across the UN system to undertake extensive data collection and measurement and/or to base policy decisions on existing evidence. Some participants described the expectations for member states to commit to data collection and measurement, and that these expectations are at times difficult to meet depending on the circumstances of a country. Participants noted that on one hand it can be difficult to collect data in countries and on the other the challenge collecting the right data to drive agendas forward.

One example of how biases or barriers manifest is the example of sex-disaggregated data and the perceived lack of gender-specific reports that include sex-disaggregated data where relevant. This discussion in particular highlighted frustration with other agencies with more technical foci, with P4 asking: “Why don't we publish this data? Why is it not regularly published in this [annual technical report]?” and noting the juxtaposition against frequent male-centric reports. Participant 1 echoed the importance of data disaggregation by gender and age but did not necessarily attribute its inadequate measurement to institutional barriers.

Participant 4 reflected on the heightened emphasis on evidence and scientific standards for policymaking, such as randomized controlled trials:

“Sometimes, it’s a curse. Sometimes it's a blessing. Curse in the sense that… we always get asked, what's your evidence? Or did you do the randomized control, you know, things like that or like, we need to see change in six months and they can only show us in five years.”

In providing an alternative to rigorous data-based research, this participant described the community-engagement strategies of their agency and the value they identified within it:

“We invested in training and going hand in hand with communities so they can talk to their peers and get their hands on information and then analyze it in a way that speaks to them. And then we created the spaces and facilitated spaces for them to disseminate the findings, and I think that was closer to our heart as more being the advocate, rather than researchers.”

Participant 2 highlighted the issue of member states being expected to collect and measure data and the tensions of practicality and utility: “we are creating more and more indicators to be monitored while we at the same time also know that let's say many systems will not be able to actually implement it.” The same participant shared personal experiences working with member states, reflecting on pushback against measurement policies:

“I think the interest in measurement is very much a global obsession […] I think the pushback […] at a country level, let's say the pushback has always been, oh, there's way too many indicators, and that we [the UN agency] should identify a core set of 25 indicators that the Ministry of Health [of member state] should monitor and that's it.”

However, the importance of data in gaining a clearer picture of areas for improvement as well as indicators of success is well-established, further highlighting the tension between practical, reasonable expectations and perceived standards of accountability and sustainability:

“If we want to support ministries and at the same time be able to hold ministries accountable for what they are doing, we need to have a basic set of indicators and targets. That will allow us to a.) to plan in order to achieve those targets and b.) allow them to be able to be held accountable”

Furthering this idea and the utility of data for driving agendas forward, Participant 6 highlighted the role of data and evidence in gaining the crucial support of member states: “Our interventions are informed by what happens in a particular country context, and that basically deals with data and evidence […] then we present the data and evidence to policymakers, to the government and try and get government buy-in into the process because anything that we at the country level has to be in collaboration with a particular countries government. We cannot just work in a vacuum, the UN, any UN agency, cannot work in a vacuum.”

Participant 5 expressed that data quantifies gender inequality in a powerful way: “The data speaks loudly, it speaks volumes and there is no complaining or misunderstanding what is happening to women and girls in all contexts.” However, a different participant, Participant 7 was critical of where data comes from, and whether they are being evaluated closely enough:

“I think that we see it a lot within this field at the UN specifically, like a statistic will be picked up and then like reported by like a million different places. And there's not really like a deep dive into like where that's coming from. How did you get this and where is this coming from?”

Differentiated scopes of work

The final theme was associated with the complementary work being conducted across agencies. Almost all participants described that the mandates of different agencies are well-established and designed to work together in complementary ways. Participants described this as a means to generate a system of accountability as well as provide opportunities for different agencies to invest resources in their specific field of work.

The differentiated scope of work was described as allowing agencies to identify priority issues within their field and share their findings with other agencies in hope of collaborating and finding policies or initiatives that can address the greatest number of high-priority issues efficiently. According to Participant 3, “each of the constituent agencies, the constituent agencies bring to the table…. their respective focus expertise.” Participant 5 reflected on the role of the whole system in ensuring the rights of women and girls collaborative: “if we are doing our job as a system, every single one of us is defending girl’s sexual reproductive health and rights in every context”.

Different agency mandates, goals, and technical responsibilities allow for cross-agency enhancement to better achieve goals. Participant 5 explained “We are committed to the principle of working as one. Making sure that we are able to enhance each other's mandate without duplicating responsibilities.” In a similar way Participant 1 shared that “all UN agencies at the highest level are aligned to the SDGs”.

Agency mandates shape the problem representation and prioritization process throughout the UN system, with different agencies contributing different dimensions of this process. Participant 6 shared that “WHO is overall responsible for the health agenda, if you will, of the UN. So, there's a complementary of efforts here. We do a lot of work with UN Women, because UN Women in a way is responsible for doing the policy level work when it comes to women's rights issues, including at the UN, and it’s got a normative agenda. While again, we have the implementation agenda.”

Collaboration was highlighted as a key process in each agency’s line of work, whether it involved units of one agency, inter-agency work, or cross-sectoral collaboration with the academic, private, and public sectors. On collaborating with other agencies daily, Participant 4 shared: “To explain, it's not like a single meeting. It's like daily work of mine. We have different levels of meetings.” Participant 5 described the different teams involved in daily work and their collaborative nature: “There are regional support teams, and there are country support joint teams, you know as part of that, as well as a regional specialist and as a country specialist… we really have a changing, dedicated team of specialists.”

Participants commonly spoke about agencies other than the one they worked or had previously worked within with respect and admiration and many participants echoed sentiments about a united goal or vision to achieve the SDGs and other overarching goals such as eliminating HIV/AIDS globally. Participant 3 shared:

“They're all [other agencies] impressive and they're all impressive in what they do, and in the, you know, in the contribution to the SDGs we have, we have joint planning, which always, always sticks close to the SDGs”

Participant 3 added that there is accountability in the HIV/AIDS strategy: “For the most part, there is a common accountability for goals that are set strategy and that's a global AIDS strategy.”

The common vision across UN agencies facilitates collective action and inspires the need to act on key issues affecting women and girls while shaping conceptualizations of the women’s and girls’ global health agenda.