Advancing gender equity in primary health care: Lessons from integrating gender-responsive strategies into service delivery in Ethiopia

Gender inequities remain a major barrier to women's access to reproductive, maternal, newborn, and child health (RMNCH) services. To address this gap, the Improve Primary Health Care Service Delivery (IPHCSD) project integrated a set of gender-responsive strategies into primary health care (PHC) systems. This paper presents lessons from implementing gender-responsive strategies that empowered women and communities while enhancing access to essential health services. A quasi-experimental embedded implementation research with a participatory mixed-methods approach was employed. The study combined controlled before-and-after household studies, phenomenological research, gender analysis, and stakeholder engagement to identify gender-related barriers and co-design contextually appropriate interventions. A mixed-effect logistic regression model was fitted to estimate the net effect using a difference-in-difference (DiD) approach. The study identified substantial gender-related barriers to RMNCH service utilization, including restrictive social norms, high workloads for women, limited decision-making power and control over resources, and inadequate male involvement. In response, the project implemented a comprehensive gender integration strategy. This included strengthening women's participation through learning and action groups, establishing gender-sensitive service standards, and expanded home visits and targeted outreach and promoting male engagement. These strategies demonstrated strong transformative potential of enhancing women's agency and improving RMNCH service delivery and utilization. Quantitatively, the intervention significantly improved women's agency in agrarian settings (DiD: + 13.6 percentage points; p < 0.001). Uptake of maternal and newborn health services also increased significantly: DiD of +15.8 percentage points (p < 0.001) and +12.3 percentage points (p = 0.031) under the community-based MNH delivery strategy, and +29.0 (agrarian) and +15.9 (pastoral) under the PLA strategy. Gender-integrated approaches strengthened women's agency, improved access to and use of RMNCH services, and contributed to universal health coverage. Integrating gender considerations and enhancing men and youth involvement into PHC is essential for reducing disparities and building more inclusive health systems in vulnerable communities.