Background

Women experience a disproportionate burden of cancer morbidity and mortality globally, shaped by gendered social roles, power relations, and structural barriers within health systems. The Lancet Commission on Women, Power, and Cancer (2023) underscored the need to embed gender-responsive approaches across cancer research, policy, and practice. However, empirical evidence on how gender analysis can be operationalised within health system strengthening—particularly in low- and middle-income countries (LMICs)—remains limited. A critical gap persists between global gender equity recommendations and their translation into locally led, system-level interventions capable of informing policy and practice.

Objectives

To examine how participatory research and multi-level partnerships translate gender analysis into actionable, gender-responsive cancer health system strengthening in LMIC settings, and to identify enabling mechanisms for policy-relevant uptake.

Methods

GRACE (Gender-Responsive Analysis for Cancer Equity) is a multi-country participatory research and implementation initiative delivered under City Cancer Challenge (C/Can)’s Women and Health Strategy (2024–2030), with technical support from Global Focus on Cancer and local academic partners. Structured, in-person, one-day stakeholder consultations were conducted in three demonstration cities—Tbilisi (Georgia), León (Mexico), and Nairobi (Kenya)—with purposive recruitment across clinical services, health-system management, research, civil society, policy, and patient advocacy.

The analytic approach combined the Social Ecological Model (SEM) to examine barriers at patient, provider, health-system, and policy levels, with the Jhpiego Gender Analysis Framework (GAF) to interrogate gendered access to resources, norms, institutional arrangements, and power relations. Facilitated breakout discussions (90 minutes) followed a structured guide organised by SEM level and GAF domain. Findings were synthesised into cross-city comparative matrices to identify shared and context-specific gendered barriers and to translate results into implementation priorities integrated within C/Can technical cooperation workplans.

Results

(1) City consultations: Across the three sites, 112 stakeholders participated (Tbilisi n=20; León n=37; Nairobi n=55), reflecting diverse cancer ecosystem perspectives. Consultations identified multi-level gendered barriers insufficiently captured by routine indicators, including financial vulnerability and indirect costs, unpaid care burdens affecting treatment continuity, workforce inequities, constraints on decision-making, and limited representation of women in cancer governance, with context-specific manifestations across cities.

(2) Integration into technical cooperation and early implementation: Gender analysis directly informed the design of system-strengthening interventions, including adaptations to patient navigation and referral support, service organisation and communication practices, and workforce capacity development, enabling the transition from evidence generation to early implementation.

(3) Evidence gaps: Substantial gaps in contextually relevant, sex- and gender-sensitive data were identified, particularly regarding patient experience, informal care, workforce conditions, and governance participation. These gaps justify further locally led research within GRACE to characterise the status of women across the cancer continuum and to co-create and iteratively refine gender-responsive interventions aligned with local priorities.

Conclusions and Implications

This study demonstrates that structured, theory-informed city consultations can generate actionable gender analysis that is directly integrated into cancer health system strengthening. Embedding participatory gender analysis within technical cooperation translates lived realities into implementation priorities while revealing critical evidence gaps, positioning city-level platforms as effective intermediaries for advancing gender-responsive cancer systems and policy-relevant evidence generation in LMICs.

Topic guide used for city gender consultations, structured by the Jhpiego Gender Analysis Framework (GAF). The figure presents exemplary guiding questions used in facilitated breakout group discussions, organised across adapted Social Ecological Model (SE