Five interrelated themes emerged from our research. 1) The interpretations and perceptions of concepts including gender equality, equity, mainstreaming, and leadership, 2) the presence of armed conflict and its impact on the context, 3) women’s leadership in health systems, including barriers and enablers 4) the emerging relationship between women’s leadership, health systems, and peacebuilding, 5) donors approaches and policies, which highlighted external influences common in conflict settings. The connections between these themes suggest that there are a range of barriers and opportunities to advancing women’s leadership to strengthen the health for peace agenda which require further exploration through research, programmatic initiatives and strategies, and theoretical framing.

Interpretations and perceptions of gender equality, equity, and mainstreaming

The perceptions and comprehension of concepts including gender equality, equity, mainstreaming, and leadership varied across participants and contexts.

“The word ‘empowering’ may have 1000 interpretations.”—M, KII, Senior Management, National, Syria

Few participants linked the misunderstanding that assumes a contradiction between gender equality and some religion’s interpretations and that the goal of gender equality is not to strengthen women against men and destroy society, but to achieve equity for both men and women to work and lead in their communities. Here, it is necessary that local communities are consulted in finding suitable definitions that are contextually appropriate and do not create hostile conditions that expose women to further vulnerabilities.

“Men and women are different from birth, but this difference women only involves the genitalia […] all rights and duties must be equal for men and women[…] there is no difference between them, and Islam urges such equality.” -F, KII, Middle Management, national, Yemen

For some participants, gender equality was defined as the affirmative action taken to promote equal representation, equal opportunities, flexibility, creating an equal environment for both men and women. While for other participants, including both men and women, gender equality is perceived as creating conditions and a work environment that go beyond fair representation, including creating policies that ensure positive discrimination for women in workplaces; greater understanding of gender equality within the health system, not only limited to access to health services and the burden of diseases from a gender dimension, but also achieving gender equality in promotion, employment and leadership representation, access to opportunities and information within the sector; adopting integrated gender equity across sectors; awareness of the challenges and problems that pursuing gender equality might create; ensuring equality amongst all people from different ethnic groups and genders within the same context; accountability of the power distribution and dynamics in society and including community participation in change, with attention to addressing the root causes that led to the existence of this problem; recognising and addressing toxic masculinity within the health system. Gender equality has also been linked to human rights, peace, and long-term development.

Perceptions about gender mainstreaming differs across contexts. Few participants expressed they are not familiar with the term and its meaning. We found a disparity in access to information about the term between local humanitarian workers and those working with UN organisations. Some participants defined gender mainstreaming as creating a work environment that ensures equal opportunities for women to participate in employment and decision-making.

“We usually talk a lot about gender inequality. But gender mainstreaming […], ensuring […] that the definitions of gender and the understanding around gender issues is being streamed through different programmes, it doesn’t have to be a certain programme or a certain intervention that talks around gender, but ensuring that gender understanding and definitions are being disseminated across different programmes in different sectors”-F, KII, Senior Management, International, Egypt

Other participants defined it as a broad concept meaning inclusion of gender equality in all programs; awareness of how gender affects work and implementation plans and the need to include the gender lens in intervention’ planning, monitoring and evaluation, and providing gender-sensitive assessment tools for analysing indicators and data; rethinking of gender and sexual orientations in a specific humanitarian context; analysing all sources of violence, power relations, access to resources and challenges experienced by people along gender lines and including this analysis in the national development policy framework and strategies as an essential step for achieving gender equality and preventing discrimination.

“By including […] gender, it is possible to raise the profile of other types of violations that historically have been hidden. So, being able to include a gender perspective will allow a broad, meaningful analysis which recognises the violations which the people have been exposed to..” – F, KII, Field worker: health, national, Colombia

Gender, social, and cultural norms guide the perception of leadership across contexts and who is considered a leader, and what kind of decisions they can make. Women are largely still perceived as less capable to take political decisions for health.

“I think the leader we see worldwide tends to be a more masculine form of leadership like this idea of the strong, uncompromising strong man, that’s what power is about the sort of populace like culture, personality, unwilling to compromise. […] I think there’s a lot [who] suggested that model of leadership isn’t what builds peaceful societies that peaceful societies are built on the willingness to listen, to be inclusive, to bring people and to admit when you’re wrong, all of those kinds of things, which tend not to be associated with what strong leadership looks like” F, KII, Senior Management, international, Lebanon

In a similar manner to that of defining equity, equality, and mainstreaming, note that very few of the participants were able to recognise and mention at least one of the three initiatives, WPS, GHPI, or HDP nexus. Those who did appeared to be more experienced in terms of applying these initiatives rather than having a deep understanding of the theory behind them.

The dual role of armed conflict

Armed conflict affects women healthcare providers’ lives and career choices. We found that conflict itself is both a barrier and an enabler for women’s leadership in health. In Syria, the conflict reinforced prior gender inequities, including restrictions on movement and consequently women’s access to leadership and coordination positions in the humanitarian health response. While in Somalia, conflict facilitated women’s movement and hence women played a leading role in coordinating the humanitarian health response between the different areas of conflict.

“In fragile contexts like Somalia, the NGOs or the health facilities that work in conflict zones tend to be mostly headed by women. The fact being that they are non-combatant they are not seen as a threat have better access, ability, or freedom to move across borders.”- M, KII, Middle Management, National, Somalia

“Security was, I believe the second factor after the social factor […] the social played together with the security to push women away from the leadership.” – M, KII, Senior Management, National, Syria

Security concerns are a barrier that prevent women from accessing leadership positions or developing their skills and experiences, which leads to gendered access to information. Security concerns mentioned include fear of being kidnapped or rape or sexual abuse, or being targeted during military operations.

Political barriers in conflict settings also play an important role in restricting women’s access to leadership, where the rise of some political parties and de facto authorities led to the implementation of practices and policies aimed at excluding women from decision making. For example, separation of men and women in workplaces, preventing women’s movement without a male guardian, restricting women’s/feminist organisations, and limiting women’s roles to ineffective positions within the governance structures. These practices led to the exclusion of women from political spaces, interfering with health policies’ designing, and participating in health response decisions as in the case of COVID-19 responses in Yemen and Syria.

We did not systematically examine the traumatic situations and coping strategies to overcome the trauma that healthcare providers face during the conflict. However, the need for mental health support was discussed in several contexts, as a way for people to cope with traumatic experiences during armed conflict without resorting to familiar patterns of violence; addressing macroaggressions; and improve organisational culture.

“[On ways to address obstacles to women’s leadership] are topics of psychosocial accompaniment to all men and all women. Because we have a life story, and that life story is what brings us…if we have not healed internal things it leads us to attack the other, […] and this [psychosocial accompaniment] improves the organisational climate.” – F, KII, Senior Management, National, Colombia

The need to provide mental health services with an intersectional feminist approach emerged to address the connections between the socio-economic and political and personal barriers, especially since women suffer from violence in these contexts two-fold – direct conflict or war violence and indirect patriarchal violence. Providing mental health services was seen as contributing to peacebuilding, by supporting people in decision-making, bringing perspectives together, and enhancing dialogue opportunities at the community level. In South Sudan, women adopt certain psychological support strategies, such as storytelling about the violence that women or their children face as a way to conflict prevention and resolution.

“We know that part of this is the necessity of psychological support, and assistance in overcoming the trauma of war and of a patriarchal society, but we have not got much capacity here. We would like to make referrals to other institutions, but we feel the lack of psychological support in general, and the lack of a feminist approach, and a great deal of reluctance to deal with male and female survivors as survivors and not as victims. In other words, the feminist approach is an investment.”- F, KII, Senior Management, National, Syria

Women’s leadership in health systems

The health workforce in conflict settings, like other settings, reflects a strongly gendered pattern where women are clustered in mid and lower-level cadres, and health leadership is mostly occupied by men. This was echoed in our research findings, where the gendered division of labour emerged as a key barrier to leadership. In most settings, we found women face systematic and structural barriers to participating in and advancing leadership positions in the health system, similar to the wider literature on women’s leadership in health systems [54]. Advancing women’s leadership in conflict settings is exacerbated by security issues and systems wide patriarchal attitudes emboldened by the presence of conflict [47, 55, 56]. Lack of political will to enhance women’s leadership in health, alongside the policies adopted by de facto authorities in some contexts, contributed to reversing the privileges that women have recently achieved regarding access to leadership positions. For instance, in Afghanistan, the Taliban policy of gender separation of men and women systemically excludes women from entry, progress, leadership, and decision-making in health.

“The systemic exclusion of women is politically driven. We heard in some provinces, issued regulations, strict rules for NGOs, they must have separate offices for female and male staff. And the women have to be covered even during office hours, and […] accompanied by the male family member who has to wait for them inside the office.” -M, KII, Middle Management, International, Afghanistan

Our research found that addressing structural and systemic challenges contributes to retention and fostering women’s leadership in health systems in conflict within organisations. In Egypt, Syria, Libya and Yemen, the governance system of the public health system and/or parallel health system lacks the protection dimension that structurally offers favourable working environments for women. Lack of implementation of accountability mechanisms regarding sexual harassment was mentioned, alongside using sexual harassment as an exclusion practice that forces women to not seek health leadership positions. Human resources are also an area where INGOs and national and/or parallel health systems diverge, this creates additional disparities in enhancing women’s leadership even in the same context. KII and FGD participants stated that Human Resources departments of INGO and UN agencies go beyond administrative issues and focus on protection and empowerment policies by developing and enforcing women’s empowerment policies, zero-tolerance policies, and ways to encourage women.

“The HR department (in INGOs) cares about these issues and works to address these challenges. The public institutions with their unawareness of these issues results in them acting in this way, so if the public institutions would dedicate a department… in fact there is a department already for human resources we call it staff management department but they are very far from these policies that we see in international organisations..” F, KII, Middle Management, National, Libya

Women also face organisational barriers in the public sector that fail to promote gender mainstreaming and women’s leadership. INGOs and UN agencies demonstrated gender-sensitive organisational culture and working environments in comparison with national organisations. In fact, in Libya and Yemen, the organisational culture of the public sector is deemed discouraging and disempowering to women. Gender discrimination policies in both governance and human resource structures, alongside the gendered access to information, including training opportunities were found to be key barriers to advancing women’s leadership.

“When the Taliban came to power, the women were removed. So maybe they kept the title. But they put a man. […] Like, the woman knows that she can’t really open the mouth. If the male colleague say something, then she has to obey. So I think they should have they should put more women into [health] departments.” – M, KII, Middle Management, International, Afghanistan

Social and individual barriers intersected with organisational and structural barriers to create additional obstacles for women’s leadership in the public sphere and within health systems. Across contexts, social norms, and cultures, patriarchy emerged as key challenge. The gendered division of labour within workplaces and households, caring responsibilities, and lack of family support were cascaded for understanding leadership in the health sector. Religious interpretations also emerged as a barrier to women’s workplace advancement. Framing women as beneficiaries and victims rather than leaders was also detrimental in advancing leadership capabilities.

“The statements saying that women are incapable of leading rely on some religious interpretations which are fictional ones.” M, KII, Senior Management, international, Yemen

“There’s this conception that women are not tough enough to take political decisions. [Men] think that we mix our emotions when [we make decisions]” F, KII, Field worker, National, Cameroon

As a result of the barriers, women are underrepresented in leadership in all contexts in health systems. These barriers intersect and may create additional context- specific barriers. For example, in the Syrian context, the humanitarian response for the northwest is led by the WHO cluster in Gaziantep in Turkey. We found women are underrepresented in headquarters in health-based NGOs with limited access to contributing to political decisions for health. Women in northwest Syria face double discrimination in accessing health leadership positions on the ground, as well as the ability to influence the political decision for health led by health-based NGOs in Turkey. Thus, in this context, we find an additional obstacle to women’s leadership related to the geographical presence of women.

To overcome these barriers, women, as individuals and feminist NGOs, have adopted various coping mechanisms to push towards meaningful representation of women in leadership positions and implement gender-sensitive human resource policies. Solidarity, creating networks, long-term investment in women’s leadership, and volunteerism, outside and inside the workplace, was adopted by individuals, women’s organisations and coalitions to continue efforts in awareness raising and advocating for women at the local and international levels.

“[Women] are not the leaders, they are not always the spokespeople, but the act of varying the voices helps. We have a significant process in […], we’re creating a network of female protection builders. And these women are doing an incredible job.” F, KII, Senior management, National, Colombia

Women’s leadership, health systems, and peacebuilding nexus

Across all contexts, we found strong evidence of an emerging instrumental relationship between women’s leadership, health systems, and peacebuilding in conflict-affected settings. Our findings demonstrate that there is an understated value in advancing women’s leadership in health systems, while implementing activities that actively expand the link with health and peace. This requires a multifaceted approach, in which women are provided with the opportunities to advance as health systems leaders while also being actively involved in developing peacebuilding skills.

“The great status that female doctors enjoy enables them to participate in peacebuilding. The people who work with them feel very positive […] Therefore, if there is an effective peacebuilding training programme where female doctors are trained to be an integral part of it, in this way we will be hitting two birds with one stone.” – M, FGD, Senior Management, National, Syria

At this nexus, health is framed as a sign of stability and a key pillar of establishing peacebuilding initiatives in conflict settings, as illustrated in Afghanistan, Yemen, Libya, Syria, and Iraq. The nexus highlights the right to health, as in the case of South Sudan, where war is framed as a public health issue. It furthermore shows how community health, in general, cannot be achieved without addressing all socioeconomic, gender, and political inequalities. We found evidence that health services are also linked to achieving stability and a sense of community belonging, since health broadly, ensures the involvement of all individuals on a large scale in developing coping mechanisms in conflict and reconstruction efforts in post-conflict.

“These two things [health and peacebuilding] are tied together. If you are already a leader in health system, you should be a leader in peacebuilding. The only thing is that correlation has not been explored. But by design that correlation already exists […], at least in our context. Health workers are trusted.” M, KII, Middle management, national, South Sudan

While health systems have been weaponised and subsequently politicised in various conflict contexts, participants stated the health system cannot be ideologically divided like other sectors [57, 58]. It is a common interest of all citizens to access health services regardless of political affiliation. Therefore, this nexus can be used as a tool to create a dialogue with communities as health professionals are trusted, highlighted in the cases of Syria and South Sudan. In South Sudan, one interviewee stated that stand alone peacebuilding projects are prone to political manipulation, therefore health can be used as entry point to peacebuilding given its relative neutrality. The presence of health coordinating bodies contributes to creating a common space for healthcare workers and leaders from different areas of influence in the same setting. Key informants and FGD participants emphasised how women play an important role in direct communication with communities and across different areas of influence, where women are considered peaceful, which ensures their freedom of movement, as in Somalia.

“When a Health Partner goes out to deliver services, they can cross lines of battle and go and access communities from the other side […] even in the most difficult, the most polarised communities, you still have that opportunity to deliver services across these lines. That means you also have an opportunity to deliver peace across the same lines.” – M, KII, Middle management, national, South Sudan

Donors’ approaches and policies

Donors’ policies and approaches were well-examined in our research, given their influence in conflict-settings. Participants expressed a lack of connection between contexts and donors, explicitly noting that there is often significant disconnect and lack of engagement with local organisations, whereby donors might be engaged with INGOs but not directly local organisations which exacerbates the disconnect between the context and the donor.

Donors across contexts adopted the following approaches and practices:

• Scarce funding available for women’s leadership.

• Blueprinting across contexts without developing contextually relevant and tailor-made policies and projects.

• Lack of commitment to ensure sustainability of funding, which has a particularly negative impact on women and exposes them to greater vulnerability.

• Adopting protection policies that focus overwhelmingly on gender-based violence that beneficiaries, not healthcare providers, face.

• The competitive nature of funding means donors are often the ones setting the agenda for funding requirements. Local and international organisations, therefore, tailor projects to the needs of donors rather than local populations.

• Condoning organisational policies imposed by local partners that are discriminatory against women’s participation and leadership.

Funding programmes and organisations that support women’s leadership, education and capacity strengthening emerged as a key finding to empower women. This includes women-led civil society organisations, as well as national health systems, such as Ministries of Health and directorates of health to address the gap in women’s leadership and the limited gender responsiveness of health systems. For example, the partnership between a feminist organisation and the Idlib Health Directorate in north west Syria contributed to the co-design and co-delivery of a programme to increase the number of women in the health sector based on attention to the sensitivities of the local community. This further opened the door to discussions on the importance of the gender dimension in designing programmes aimed to strengthen the health system and build human health resources.

Participants emphasised the need for donors to engage with local women’s initiatives as this may support increasing the connection between donors and the realities on the ground. Furthermore, creating an accountability system to measure the real impact of women empowerment programmes, and shifting toward feminist intersectional funding approaches. Participants noted the importance of developing contextualised evidence-based research as a tool to advocate and turn research into policy, especially GBV within the health system.

Diplomatic leverage combined with affirmative action and advocacy efforts will ensure stronger women’s representation in health responses and health systems. In Afghanistan, there is an initiative to build an in-country advocacy coalition for a gender-responsive health system and to strengthen women’s leadership in health.

“I think a large impact can be made particularly on the allocation of funds determined in Brussels for example, if women were present in senior official meetings, it would make a lot of difference.” Syria, FGD, Middle Management, F