438339

2012

CSI0010.1177/0011392112438339Kuhlmann and AnnandaleCurrent Sociology

CS

Article

Mainstreaming gender
into healthcare: A scoping
exercise into policy transfer
in England and Germany

Current Sociology
60(4) 551568
The Author(s) 2012
Reprints and permission: sagepub.
co.uk/journalsPermissions.nav
DOI: 10.1177/0011392112438339
csi.sagepub.com

Ellen Kuhlmann

University of Aarhus, Denmark

Ellen Annandale
University of Leicester, UK

Abstract
Across the globe the concept of gender mainstreaming is indicative of substantive
transformations, and healthcare is a particularly important policy arena. Yet existing
research reveals only modest success in the implementation of gender policies in
national healthcare systems, despite the availability of complex tools and guidelines.
This article introduces an approach that links gender mainstreaming with approaches
into policy transfer as dynamic processes of translation involving active players. In a
scoping exercise the authors select England and Germany as case studies and draw on
document analysis, other secondary sources and additional expert information. The
analysis reveals varieties of translation of gender mainstreaming into national healthcare
systems even within the legal framework of the European Union and the crucial
relevance of feminist actors. The study raises more general questions on the nature of
international policy-making in relation to national and local healthcare institutions and
policy entrepreneurs.
Keywords
England and Germany, gender mainstreaming, healthcare, health policy, policy transfer,
policy translation

Corresponding author:
Ellen Kuhlmann, Department of Political Science, University of Aarhus, Bartholins All 7, DK-8000 Aarhus
C, Denmark.
Email: e.kuhlmann@em.uni-frankfurt.de

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Introduction
Across the globe, the concept of gender mainstreaming is indicative of substantive political and social transformations, and healthcare is a particularly important policy arena.
Closing the quality and equality gaps in healthcare now ranks high on the international
policy agenda, and improving gender equity and equality is one of the Millennium
Development Goals (Abdool et al., 2010; Payne, 2009; Sen et al., 2007). The concept of
mainstreaming gender is adopted by all leading international organizations, such as
WHO (2002, 2009, 2011) and the United Nations (1999), and is also part of European
law and policies (Council of Europe, 1998, 2005; genSet, 2010). Furthermore, the need
for gender-sensitive healthcare is increasingly also acknowledged within leading academic journals in the fields of medicine and public health (Nature, 2011; Sim and
Mackie, 2011).
Being a world traveller, gender mainstreaming clearly tells a success story at the
level of international organizations but this turns out to be more difficult when tracing
policy transfer further down the line towards national governments and health systems.
Existing research reveals only little success in the implementation of gender policies in
national contexts, despite the availability of gender-sensitive tools and guidelines in
healthcare research and practice (Celikab et al., 2011; Ghodsee et al., 2010; Woodward,
2008).
In this article we suggest a fresh approach that moves beyond the debates into success
or failure of the international concept of gender mainstreaming in national healthcare
systems, to explore how policies are transferred and thereby transformed in order to fit
national contexts and actors. We introduce an approach that links gender mainstreaming
research with approaches into policy translation. Understanding policy transfer as
translation is interesting for the purpose of our study, because it brings its dynamic nature
and the relevance of actors into view (Sahlin and Wedlin, 2008). Furthermore, this
approach helps us to unpack activity at the different levels of international, national and
local institutions, all of which shape the specific outcome of policy transfer (Burau et al.,
2011; Kirkpatrick et al., 2011).
In our scoping exercise we chose England and Germany as case studies. The cases
reflect similar developments in two Western European countries which have adopted a
legal framework of European gender mainstreaming legislation but have different
traditions of welfare states and healthcare systems. England represents a liberal welfare
state with a centralized National Health Service (NHS) and Germany a conservative
corporatist welfare state with a decentralized Statutory Health Insurance (SHI) system
based on partnership governance (Kuhlmann and Allsop, 2008). In terms of method,
we apply a context-sensitive comparative approach and a case study design drawing on
document analysis and other secondary sources and additional expert information
(Burau, 2007; Wrede, 2010).
The article begins by discussing policy transfer as processes of translation and how
this approach may be connected to gender mainstreaming. We continue with an overview
of the international concept of gender mainstreaming. This is followed by an exploratory
assessment of how gender mainstreaming is translated into the institutional configurations of the healthcare systems in England and Germany. We conclude by highlighting

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key findings that raise more general questions about the tensions between transnational
policies and national healthcare states and the significance of feminist actors in the
policy process.

Making connections: Gender mainstreaming and the

translation of policy
Gender mainstreaming has provoked much scholarly debate but this has mainly been
concerned with the outcomes of the new mainstreaming policies, including monitoring,
evaluation and overall efforts to improve the quality of statistics. Controversy remains
especially around whether and how the critical potential of gender may be able to survive
mainstreaming attempts (Bacchi and Eveline, 2010; Daly, 2005; Debusscher, 2011).
For example, feminisms critical acuity may be tempered as it is mainstreamed within
alliances, coalitions and merged projects of civil society institutions and the state
(Walby, 2011: 148).
However, little attention has been paid to the processes of policy-making; this is true
for the critical junctions between global and local policy in healthcare as well as for the
actors involved and the mediations between different institutional actors and interests.
This problematic shortcoming of gender mainstreaming research therefore results in a
double disconnection: public policy research broadly ignores gender mainstreaming
policies, and feminist scholars working in this area rarely look at the healthcare sector.
We suggest closing this gap by connecting gender policies and public (health) policy
research; this will enable a better understanding of the opportunities and limitations of
implementing new mainstreaming policies in the healthcare sector. Here, recent debates
into policy transfer are especially useful. Policy transfer is not a uniform concept; rather
it is the host for different approaches that seek to highlight the complexity and procedural
nature of policy-making. One strand, for example, has focused on policy learning and
policy diffusion; this research has highlighted the many policy hurdles and the overall
unevenness of policy processes (Djelic, 2004; Freeman, 2007; James and Lodge, 2003).
Others have challenged the assumption of rationality and linearity in policy transfer
(Dwyer and Ellison, 2009).
Especially interesting for the purpose of our study of gender mainstreaming in healthcare is the notion of translation in policy transfer (Sahlin and Wedlin, 2008). This
approach is interesting for two reasons: it brings the active nature of policy transfer into
perspective, thereby opening the door for actor-centred approaches; and it allows for
more context-sensitive and dynamic approaches. For example, in their study into medical manager roles in European hospitals, Kirkpatrick et al. (2011: 4) apply the concept of
translation to explore local translations of a global template. In a similar vein, Burau et al.
(2011), in their cross-country research into primary care policy transfer, suggest that we
distinguish between two phases of policy transfer: the transfer of ideas or knowledge
from the international to the national arena; and the transformation of ideas or knowledge
into policies within the national arena. Kirkpatrick et al. furthermore argue that the
concept of translation can be utilized to link micro-practices such as the development
of medical-manager roles and institutional contexts (2011: 5).

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In summary, the new emergent concept of policy translation can help to explore
translations between different national contexts as well as different institutional logics
(Kirkpatrick et al., 2011: 6; see also Burau et al., 2011). This makes it a potentially very
useful approach for context-sensitive comparative research into gender mainstreaming
policies. To highlight some of the possible connections:
Gender mainstreaming is a global template for improving gender equity and
equality that may show up in different forms when applied to local institutions
of healthcare systems. Supranational institutions like the EU act as the most
powerful facilitators of gender mainstreaming approaches, while national governments often resist implementation (Council of Europe, 1998; Woodward, 2008).
And, to further complicate things, driving forces may also operate beyond formal
institutions, for instance in the creation of more gender-sensitive expert knowledge in the context of international and European research agendas (genSet, 2010;
Klinge, 2010; Payne, 2009).
Gender mainstreaming meets with new forms of governing the health professions
and organizing the healthcare sector through meso-level (organizational) governance practices, especially performance management and target setting.
Consequently, governance practices may serve as critical junctions for implementing gender mainstreaming policies in healthcare organizations, such as hospitals.
At the same time, there may also be other rationalities of organizations that counteract gender policies, including mere ignorance as well as overt conflict of interest with powerful male actors (zbilgin et al., 2011; Van den Brink, 2011).
In order to achieve transformative potential, gender mainstreaming needs the
support of a range of actors. The most obvious actors internationally have been
feminists (Zalewski, 2010). However feminist knowledge and action is dynamic
and contested. Feminists are increasingly committed to diverse ideas and strategies
of gender equality, such as intersectional approaches (see, for instance, Hankivsky
and Cormier, 2011), that may have different implications for mainstreaming,
including questioning the master status of gender or affecting womens and
mens healthcare differently (Annandale and Kuhlmann, 2012).
In our scoping exercise we take on the concept of policy translation but expand the focus
to include actors, including policy entrepreneurs, who are only loosely connected to the
institutions of the healthcare system. In the next sections we investigate the translation of
gender mainstreaming policies by drawing on developments in England and Germany.

The international concept of gender mainstreaming

Based on the 1995 Beijing platform of the fourth International World Conference of
Women, the concept of gender mainstreaming serves as a host for new approaches to
both gender equality and policy-making. As such it is open to various definitions and
political strategies. In international health policy the definition provided by the World
Health Organization (WHO) is indicative and adapted in a similar vein by the European
Union and individual member states:

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. . . the process of assessing the implications for women and men of any planned action,
including legislation, policies or programmes, in any area and at all levels. It is a strategy for
making womens as well as mens concerns and experiences an integral dimension in the
design, implementation, monitoring and evaluation of policies and programmes in all political,
economic and social spheres, such that inequality between men and women is not perpetuated.
The ultimate goal is to achieve gender equality. (WHO, 2002: 6)

Gender mainstreaming is closely linked with the changing governance of the public sector (Woodward, 2008) and assigned a double role in healthcare: as an approach to reduce
social inequalities in health which, at the same time, improves the quality and efficiency
of healthcare systems (Kuhlmann, 2009). Also important is that gender mainstreaming
operates as a top-down approach, and therefore needs to be tacked to institutions and
organizations and must adopt the new managerialist toolset of governance. In healthcare,
the major junctions are standardization, target setting and clinical guidelines and evidence-based medicine.
Another important aspect of the international concept of gender mainstreaming is that
it expands the scope of action towards mens healthcare and male actors (Smith et al.,
2009; WHO, 2007). This opens up new opportunities for mens health activists, which
include not only much needed improvements in healthcare for men, but also potential
competition with feminist approaches and womens healthcare needs (Annandale and
Riska, 2009; Wadham, 2002). At the same time, WHO and other international organizations show an overall strong focus on womens healthcare, especially in resource-poor
countries (WHO, 2009; see also Abdool et al., 2010; Standing, 2006). Within the
European context, womens health is also an important focus, but the mainstreaming
concept is more diverse.
In summary, the international mandate for gender mainstreaming provides a flexible
toolset for the institutions of national healthcare states and local communities, and may
therefore be translated differently: as womens healthcare needs such as, for instance, in
the areas of sexual violence or maternity care or mens healthcare needs in areas that
counteract traditional masculinities such as mental healthcare, as well as gender-sensitive
healthcare that may benefit either men or women, or both, as social groups.
The European Union is a particularly interesting case for exploring policy transfer.
It consists of member states with different healthcare systems under the authority of
national legislation that, at more or less the same point in time, have adopted common
gender mainstreaming legislation. So the international concept of gender mainstreaming
is translated into a legal framework relevant for all EU member countries, which, in turn,
raises the questions, what was it that created divergent trends in policy transfer? And who
are the main actors in the different countries in these processes?

Gender mainstreaming policies in England and Germany

Introduced by the Treaty of Amsterdam, gender mainstreaming came into force in 1999
as a key policy goal and new strategy for equal opportunities in all European member
states. Despite the legal commitment and the identification of gender mainstreaming as
the most effective strategy to reduce health inequalities between men and women, in

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2001 WHO concluded that very few member states have translated this international
political commitment into clear policy at the national level (WHO Euro, 2001). This
situation has not significantly improved since WHO brought these problems into view
(Woodward, 2008).
In the next section we will further explore how national healthcare systems may act
as a filter for transferring gender mainstreaming into healthcare systems. We focus on
new forms of governing through standardization and performance management in the
field of primary care for chronic illnesses that have been introduced in both England and
Germany over the last decade (Kuhlmann and Allsop, 2008): namely, the National
Service Frameworks (NSFs) in England and the Disease Management Programmes
(DMPs) in Germany, both of which are (or were) mandatory programmes.

Germany
In Germany gender mainstreaming was introduced in 1999 when the federal government signed the Amsterdam Treaty. In 2000, under the authority of the Federal Ministry
of Family, Youth, Women and Elderly (Bundesministerium fr Familie, Jugend,
Frauen und Senioren), a working group was established in order to launch different
pilot projects and to coordinate gender activities across the various ministries. This was
supported by the establishment of a new Centre for Gender Competence in order to
provide scientific advice and evidence on how to introduce gender mainstreaming in all
areas of public services. Within this context healthcare was one of the areas where pilot
projects were introduced. Characteristically, these initiatives were insufficiently linked
to new health policies, such as for instance the Disease Management Programmes
(DMPs) or to the restructuring of key regulatory bodies of the Statutory Health Insurance
(SHI) care system or to the recent attempts to improve the coordination and collaboration of different provider groups (SVR, 2009).
The government has supported mainstreaming efforts by launching a website on
gender mainstreaming which provides useful information on a broad range of areas,
including healthcare (www.gender-mainstreaming.net/). Yet in healthcare there is no
systematic monitoring and coordination of gender mainstreaming approaches across
the various institutions concerned. Different policy authorities and governing bodies
are responsible for overseeing the management of various aspects of performance; thus,
gender issues may easily get lost in the jungle of network-based governance in the
healthcare system.
The regulatory structure of corporatist governance (Kuhlmann, 2006) may serve to
legitimize that the government does not take comprehensive action towards the implementation and evaluation of gender mainstreaming policies. This is, for instance, obvious
in a governmental statement in response to criticism from the Green Party on a lack of
gender mainstreaming in DMPs (Deutscher Bundestag, 2007). This statement stresses
that, from the viewpoint of the government, there is no need for action because gender
mainstreaming has already been introduced in the DMPs. DMPs mark a major effort
towards improving standardization and quality of care for chronic conditions (Gre et al.,
2006; Kuhlmann, 2006). First, the programme agreements are strongly based on

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evidence-based policy-making and the Federal Committee regularly reviews available

information, including gender-sensitive data, and updates guidelines; second, DMPs
attempt to put users first, thus taking account of individual demands. This statement is in
line with the network-based governance structure and delegation of power to public law
institutions. However, while the government increasingly takes an interventionist stance
in health policy, it has not taken over responsibility for gender mainstreaming.
In this situation, the opportunities are shaped by the pillarized configuration of
SHI care and negotiations on meso-levels of organizations and self-governing professional bodies. An important weakness of these network-based governance arrangements in Germany is a lack of coordination between different institutional actors and
strategies (SVR, 2009), and this may also cause instability of successful mainstreaming
practices.

England
In England, by contrast, the concept of gender mainstreaming as applied at the European
level is on first glance missing from the policy agenda. This may be an effect of an
overall stronger resistance against integrated tools of European social policy in England,
and more generally in the UK, and not necessarily a sign of missing initiatives. Moreover,
attempts to improve gender sensitivity have mainly been submerged within equality laws
with increasingly different strategies in England and Wales, Scotland and Northern
Ireland. This approach was dominant from the start and increasingly shapes present
policy.
The NHS Constitution stipulates that the NHS provides a:
. . . comprehensive service, available to all irrespective of gender, race, disability, age, sexual
orientation, religion or belief. It has a duty to each and every individual that it serves and must
respect their human rights. At the same time, it has a wider social duty to promote equality
through the services it provides and to pay particular attention to groups or sections of society
where improvements in health and life expectancy are not keeping pace with the rest of the
population. (DoH, 2010a: 3)

The Government Equalities Office (GEO), a unit within the Home Office, operates
across government and takes the lead on issues relating to women and gender equality,
sexual orientation and transgender equality matters. Under the Labour government, in
April 2007, a new statutory public sector Gender Duty was introduced as part of the
2006 Equality Act (EOC, 2006). Defined at the time as the biggest change in sex equality
legislation in 30 years, it brought into force new regulatory bodies taking forward a
policy of centralized governance and the merging of gender into a broader framework
of the reduction of social inequalities. However, a recent analysis on behalf of the
Equality and Human Rights Commission (EHRC, 2011a: 7) raised serious concerns
about the performance of the equality duties. The large majority of the Strategic Health
Authorities and Primary Care Trusts studied had failed to set clear gender objectives, and
inequalities arising from gender differences were unaddressed. The report revealed that
very little attention was given to the crucial issue of how the duties were, or were not,

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achieved in practice, with most engaging in tick-box exercises. Interestingly, there are no
signs of systematic linkages between the gender duties and other forms of duties
defined by compulsory health policy programmes, such as for instance the National
Service Frameworks (NSFs).
The new and most recent Equality Duty, brought into force in April 2011 (under the
Equality Act of 2010) by the Coalition government, which came into office in May
2010, replaced the existing specific race, disability and gender equality duties (EHRC,
2010). Those subject to the Duty, such as the NHS, are, among other things, in the exercise of their functions, expected to have due regard to advance equality of opportunity
between people who share a protected characteristic and those who do not. Although,
within this Act, sex is a protected characteristic (EHRC, 2011b: 43), the potential visibility accorded to gender under the old Gender Duty disappears. Moreover, government equality strategy turns attention away from potential discrimination based on
group characteristics, towards individuals. Thus, the recent equality strategy sets out a
new approach to equalities, moving away from identity politics of the past to an
approach recognising peoples individuality; rather than treating people as equality
strands , emphasis is given to recognising that we are a nation of 62 million individuals (Equalities Office, 2010: 6, 8).
When comparing the gender policies in our two countries, different policy discourses
of mainstreaming in Germany and equality/diversity in England come into view.
Interestingly, however, in both cases, a discourse of individualization and user demand
serves the government to outflank more systematic and complex gender mainstreaming
efforts. In the next section we further explore how these policy discourses translate into
practice.

Tracing the translation of gender mainstreaming in

healthcare systems
One of the key characteristics of the gender mainstreaming concept is the close linkage
with sector-specific developments and policy reform. Over recent years, both countries
have faced significant transformations in their governance arrangements (Table 1). In
the centralized NHS, hierarchical governance is increasingly complemented with more
plural stakeholder arrangements, mixed forms of publicprivate funding and an overall
extension of governance practices towards the level of local organizations (for example,
healthcare trusts). This will be taken further, if the Coalition reforms proposed currently
going through parliament (DoH, 2010b) become law. In Germany, we can observe opposite trends with an increasingly more interventionist state and direct steering efforts in a
decentralized system of public law institutions (Kuhlmann and Allsop, 2008).
Our case study material reveals that the institutional arrangements of the two healthcare systems do not easily predict the outcome of policy transfers when it comes to
mainstreaming gender. As mentioned previously, we have chosen from among the most
comprehensive policy programmes in the two countries aiming at standardization of
services for an in-depth exploration: the implementation of National Service Frameworks
(NSFs) which ran between 2000 and 2010 in England, and Disease Management
Programmes (DMPs) in Germany. Specifically, our focus is on healthcare services for
people with coronary heart disease (CHD) because this area has been the subject of
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Table 1. Governance arrangements in the UKa and Germany.
UK/England

Germany

Funding

Tax funded with some private

provision

Provision

Gatekeeping system (via GPs)

Governance

Governance through the

state and subordinate tiers of
governance and regulation

Regulatory bodies
and arrangements

Nine councils governing the

health professions (UK);
Council for Health Regulatory
Excellence (UK);
a range of regulatory bodies of
various professional groups; new
bodies that coordinate activities;
new forms of stakeholder
involvement in decision-making

Statutory Health Insurance (SHI)

system, mainly funded through
employers and employees with
some private provision
Free choice of provider (GP and
specialists); incentives towards
voluntary gatekeeping via GPs
Governance through a network
of public law institutions with
physicians associations and SHI
funds as key stakeholders
Restructuring of the Joint
Committee, inclusion of user
representatives and the German
Hospital Society; new bodies in
the context of DMPs;
no statutory recognition of other
than medical professions; lack of
coordination of services

New agencies of
control

NICE (England and Wales);

National Patient Safety Agency
(England, Wales and NI);
Care Quality Commission
(England)

Institute of Quality and Efficiency

in Healthcare; part of SHI
system, main goal is to improve
evidence-based information for
policy-makers and patients

aFor the UK this characterizes the overall regulatory framework but takes devolution into account. Note
that the focus of our empirical analysis in on England.
Source: Modified from Kuhlmann and Allsop (2008).

considerable interest regarding the relevance of gender. Both NSFs and DMPs
introduced a number of new managerial procedures that can easily be connected with
the implementation of gender mainstreaming approaches, as outlined, for instance, in
numerous guidelines provided by the European Union and WHO (Abdool et al., 2010;
Klinge, 2010; Lin and LOrange, 2010). The two country examples allow for a comparative approach because they follow similar goals, the monitoring procedures were
introduced at a similar time and a gender assessment report exists also for both countries (Doyal et al., 2003; Kuhlmann, 2004). Looking at most similar cases helps us to
better understand the factors that further divergent trends.

The limitations of policy transfer:The case of coronary heart disease care

Across countries CHD care is one of the most dramatic examples of the negative impact
of male-bias in healthcare systems (Nature, 2010). Masculinities shape all areas of
care from CHD prevention to clinical care and rehabilitation, and also medical and public health research and the attitudes of patients and citizens. This mainly neglects
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womens healthcare needs but may also impact negatively on men who do not seem to fit
the model of hegemonic masculinity (Riska, 2010). Although age differences between
men and women suffering from CHD are important, they do not explain gender differences in outcomes.
To give only some examples: with reference to the UK, women are under-represented
in cardiac rehabilitation. The British Heart Foundation (2010) reports that, if men and
women were taking part in rehabilitation in proportion to the case rates for heart attack,
we would expect there to be 63% men and 37% women. However, women made up 32%
of referrals but only 26% of participants. The report estimates that if the uptake rate for
rehabilitation had been equal, another 3500 women would have benefited from rehabilitation in 20082009 (see Kuhlmann, 2004, for similar results in Germany). There is now
accumulated evidence that physicians are less likely to recognize the clinical signs of
CHD in women; standard diagnostic procedures and drug therapies are less effective in
the group of women compared to men; and women may receive angiographs and cardiac
surgery less seldom than men, although such interventions vary significantly between
countries and there is no uniform pattern of gender differences (Bnte et al., 2008;
Kuhlmann, 2004).
In establishing standardized programmes, such as the NSF and DMPs for CHD,
both countries intended to provide clear guidance and standards, thereby reducing
unwarranted variation in services, among other things. However, they broadly neglected
existing research into gender-based bias in healthcare, thus failing in the goal of providing guidance for professional performance. The NSF on CHD (DoH, 2000) in its
opening pages recognized that rates of CHD vary by social circumstances, gender and
race, but as Doyal et al. conclude there is no discussion of how these variations should
be reflected in preventive or curative care (2003: 27). These authors were able to demonstrate evidence of gender differences and a need for sensitive indicators for each of
the 12 standards comprising the NSF.
With respect to the German DMP for CHD, in its first version, even the category sex
was missing from the key documentation form; this was altered in 2003/2004 and the sex
category included in all forms. By contrast to gender-blind policies, in both the German
SHI funds and the medical associations there was some interest in gender-sensitive care
for CHD and an overall call for more evidence-based information; also, a survey of
office-based doctors revealed some support for gender-specific information and care
(Kuhlmann, 2004).
Following these early reports and other criticism of gender-blind policies for CHD
care and an overall growing body of gender-sensitive research and data, we can observe
some transformations in both countries. In England, the need for gender-sensitive CHD
care was mentioned and some guidance was provided in the Sectoral Guidance for
Health from the then Equal Opportunities Commission (now Equality and Human
Rights Commission; EOC, 2007). A preliminary review of the annual progress reports on
the NSF for CHD by the Healthcare Commission (2007) (since superseded by the Care
Quality Commission) did show some signs of improved gender sensitivity, while at the
same time the gender-blind approach seems to persist. For example, the progress report
for 2007 (DoH, 2008) failed to provide male/female breakdowns for most key data.

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Further, a particularly dramatic decline in premature mortality from CHD for men is
mentioned, while a steady and less significant decline for women occasions no comment.
The most recent progress report (DoH, 2009) pays no attention to gender at all. This
underlines a general trend in the UK, namely that gender inequalities in healthcare
come second to, or are subsumed under, socioeconomic inequalities which have been
considerably higher on the political agenda. Results also point towards insufficient policy
coordination and knowledge exchange between different regulatory bodies that must be
explored in further research.
In Germany, information on CHD risks for women and prevention has significantly
improved in all stakeholder groups. Indeed, there are a number of good practice
examples, such as, for instance, the development of a gender-sensitive evidence-based
guideline for CHD rehabilitation by the medical profession (Rauch et al., 2007) and
gender-sensitive health reports (RKI, 2007). At the same time, there are also clear signs
of resistance and continuing ignorance. Thus is, for example, obvious in the assessment of the DMP for CHD and recommendations for change by the Institute of Quality
and Efficiency in Healthcare (IQWiG, 2008). Despite the growing body of literature
that reveals evidence of gender differences in CHD care, IQWiG has not adopted a
clear gender mainstreaming policy and, much like the NSF progress reports, this report
demonstrates gender blindness and male-bias in CHD care.
Taken together, neither NSFs in England nor Germanys DMPs have systematically
integrated gender mainstreaming approaches. Neither country has developed any
systematic policy and monitoring approach of the implementation of gender equality
in the major regulatory bodies and the new agencies of public control.
The case study material points towards similar weaknesses in policy transfer of an
international model of gender mainstreaming in the more centralized NHS system in
England as well as in the decentralized, corporatist German system. Both healthcare
systems have failed to adequately link their new managerial tools with the goals of
gender equality, as the concept of mainstreaming would require (WHO, 2002, 2011).
Furthermore, women, in general, are heavily under-represented in the key regulatory
bodies and this reduces the chances that feminist players are directly involved in the
macro-level of health policy-making.
Exploring gender mainstreaming through the lens of policy transfer has serious
limitations, however. Our case study material illustrates that from this perspective we
can explore macro-level mainstreaming and policy outcomes but easily lose sight of
the wider translations of an international concept that may happen further down the
lines of the policy process, and that may even transform the concept itself.

How policy translation matters

The top-down approach of mainstreaming may face various different forms of translation on its way into practice. Here, the institutional arrangements of the two healthcare
systems and the position of feminist and other actors come into play.
To begin with, corporatist governance is usually identified as a barrier towards innovation and the main reason for the overall slow motion in Germanys healthcare system
(for an overview, see SVR, 2009). However, there are also some interesting examples of

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good practice: for instance, the Robert Koch Institut a quasi-governmental institution
responsible for health statistics and reports in Germany has introduced clear gender
mainstreaming policies and developed standards for gender-sensitive data collection and
reports (RKI, 2007).
Furthermore, within the context of a major merger of hospitals, gender mainstreaming
approaches were introduced as a means of competition for both qualified staff and high
quality care for patients (www.klinikum-muenchen.de/unternehmen/chancengleichheit/
gleichbehandlung/). Overall, hospitals increasingly present themselves as women-friendly
and family-friendly employers in order to attract qualified staff, especially women doctors, and this is supported by governmental action (BMFSFJ, 2009). In a similar vein, a
large sickness fund has adopted mainstreaming policies; this includes gender-sensitive
patient information and specific actions for women as well as attempts towards improving
gender equality within the organization. Thus, in a competitive climate of healthcare systems different corporatist actors may refer to gender mainstreaming, using certain elements
of this concept as a market tool to attract women as both clients and staff members.
A further example is the inclusion of gender research in the development of a clinical
guideline for cardiac rehabilitation (Rauch et al., 2007); here, too, change in the wider
healthcare system, like the introduction of new measures of performance, served as an
avenue of gender mainstreaming into the practice of healthcare. Added to this, within the
medical profession mainstreaming is also supported by various efforts by the Womens
Physician Association. Importantly, in all these cases, feminist actors (either women or
men supportive of feminist approaches and gender-sensitive healthcare) played a major
role in the policy process and were in leadership positions.
In England, the spur to increased visibility of gender issues within healthcare held out
by the Gender Duty (Zalewski, 2010) has dissipated with the new more inclusive and
individualized approach to equality embodied in the Equality Act of 2010. The relative
lack of direct interest by centralized regulatory bodies in gender leads to missing connections between the different levels of governance, and the various stakeholders involved
seem to be the major hurdles for the diffusion of the new gender policies and monitoring
of their implementation. However, the recent emphasis on third sector engagement, shared
by the prior Labour government and present Coalition government, provides at least a
potential open door to influence and hence policy translation. The charity Mens Health
Forum, formed in 2001, became a national voluntary sector partner to the Department of
Health for three years in 2009/10; and the Womens Health and Equality Consortium
(WHEC) (a network of six partners), which formed in 2008 expressly in response to the
Department of Healths call for strategic third sector partners, became a partner in 2010/11.
Both organizations have responded to the proposed changes to the NHS (DoH, 2010b)
from a gender perspective (MHF, 2010; WHEC, 2011). Each expresses general support
for the emphasis on greater patient choice in the provision of care, but emphasizes that
more attention needs to be given to the health of men (MHF) and women (WHEC).
WHEC (2011) points out that patient choice alone will not reduce the gap in health inequalities due to the barriers to access faced by women such as those associated with
inequality in power and resources, knowledge of their rights and caring responsibilities.
Thus WHEC argues for attention to be directed to barriers as well as choices. MHF takes
as its starting point the disadvantage of men in relation to women which, it is argued, is
reflected in their less frequent use of health services and taking of preventative actions.
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This reflects the common approach by mens health activists of advancing the cause of
mens health by comparisons to women, who, more often than not, are presented as
better off (Wadham, 2002).
Thus, in comparison to Germany, mainstreaming is far less evident in England.
Central government equality policies bestow certain equality duties on NHS institutions, but provide minimal steer on how they should be met or the approach that should
be taken towards progress monitoring. Recent evidence raises serious concerns about
equality performance (EHRC, 2011a; see also Annandale et al., 2007).

Conclusions
This article has attempted to explore gender mainstreaming policies through the lens of
policy transfer. We have introduced the concept of policy translation and have suggested
ways for how this concept might be applied to empirical research. Some conclusions
drawn from our scoping review suggest several different things. Our study highlights
the relevance of institutional configurations and governance arrangements of healthcare
systems that create varieties of a global template of gender mainstreaming, even if the
concept itself is not common currency, as in England.
In the German case, gender policies unfold within the decentralized, network-based
framework of Statutory Health Insurance (SHI) care. In this situation, bottom-up alliances between different policy players and certain organizational interests are more
likely to activate the transformative potential of gender mainstreaming than is top-down
governmental action. Consequently, strong feminist or women-friendly actors in leadership positions of the respective institutions, organizations and medical associations
are crucial. Here, the corporatist governance arrangements embody opportunities for
policy entrepreneurs acting beyond the macro-level of politics. These lower levels of
policy-making in organizations and associations may be more permeable for women
and/or feminist actors in leadership positions who then make a difference in the translation of gender policies, as illustrated by the examples of good practice.
By contrast, in England regulatory frameworks generally are becoming more plural
with the state acting as a navigator of the organization and delivery of care. However,
hierarchical governance remains strong but does not appear to be adequately linked to
the more plural subordinate tiers. In this situation, to have transformative potential,
gender equality policy, such that exists, needs strong policy players in governmental
bodies and increasingly competes with other groups also claiming public support
for their interests. The emphasis of recent governments on third sector engagement
provides a potential route of influence for policy translation on the part of voluntary
sector groups at national level, though a division into mens and womens health
lobbies may inhibit the development of shared policy objectives. Such competition is
overall weaker in Germany and activities are more focused on gender inequality and
specific issues of womens health, while in England mens health is increasingly
promoted and, beyond specific issues such as maternity care and maternal child health,
womens healthcare issues are less evident on the policy agenda.
A comparative approach helps us to better understand how the governance
arrangements of healthcare systems create (or block) specific windows of opportunity

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for feminist and other actors, thereby modelling policy translation. Consequently, there
is a need for context-sensitive approaches into gender mainstreaming that take the
importance of actors into account and that connect macro- and meso-/micro-levels of
gender policies in healthcare (Annandale and Kuhlmann, 2012). Our analysis furthermore reveals more general problems of global policy-making that challenge the
assumption of policy convergence and, instead, turn the spotlight onto the complexity
of policy transfer and the various forms of translating global policy into local action.
Funding
Funding support was provided by the Department of Sociology, University of Leicester seed grant
scheme.

Acknowledgements
Earlier versions of this article were presented at various conferences, including the 2010 ISA
Conference in Sweden. We wish to thank our colleagues for discussions and comments, especially
Ivy Bourgeault, Viola Burau and Sirpa Wrede. We are also very grateful to our key informants in
both countries.

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Author biographies
Ellen Kuhlmann is currently a Guest Professor in the Department of Political Science, University
of Aarhus, Denmark, and Visiting Professor at University Campus Suffolk, UK. She holds a PhD
in Sociology and MA Public Health from the University of Bielefeld, and a Habilitation from the
University of Bremen, Germany. She is Vice-President of the European Sociological Association
and author of Modernising Health Care and co-editor (with Ellen Annandale) of The Palgrave
Handbook of Gender and Healthcare, 2nd edn.
Ellen Annandale is Professor of Sociology at the University of Leicester, UK and the Editor-inChief of Social Science and Medicine. She holds a PhD in Sociology from Brown University,
USA. Her work focuses on the relationship between feminist and gender theories and the way that
questions about the health of women and men are framed and studied. Her most recent publications

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are Womens Health and Social Change (Routledge, 2009) and the co-edited (with Kate Hunt)
four-volume work Gender and Health (Routledge, 2011).

Rsum
Partout dans le monde le concept dintgration des genres est indicatif de transformations
significatives. La sant est un terrain particulirement important de ces changements.
Nanmoins les recherches existantes ne rvlent que de modestes russites dans la
mise en place de politiques de genre dans les systmes de sant nationaux, malgr la
disponibilit doutils complexes et de directives. Nous prsentons une approche qui relie
lintgration des genres aux approches de translation de politiques comme un procd
dynamique de transfert impliquant des acteurs actifs. Dans le cadre de notre dfinition
de primtre, nous avons choisi lAngleterre et lAllemagne comme tudes de cas, nous
analysons de documents, dautres sources secondaires et des informations dexperts
supplmentaires. Notre analyse rvle des varits de translations dintgration de
genres dans les systmes de sant nationaux, mme dans le cadre lgal de lUnion
Europenne, et le bien-fond crucial des acteurs fministes. Ltude soulve plus de
questions dordre gnral sur la nature de la prise de dcision politique internationale
en relation avec les institutions de sant nationales et locales et les dcideurs politiques.
Mots-cls
Angleterre et Allemagne, intgration des genres, politique de sant, systmes de sant,
transfert de politique, translation de politique
Resumen
A nivel mundial, el concepto de mainstreaming de gnero es indicativo de
transformaciones sustanciales y dentro de stas, la atencin sanitaria es un escenario
poltico particularmente importante. An as las investigaciones existentes revelan
nicamente un xito modesto en la implementacin de polticas de gnero en el servicio
de atencin mdica a pesar de la disponibilidad de herramientas y directrices complejas.
Introducimos un enfoque que conecta el mainstreaming de gnero con estrategias de
transferencia de polticas como un proceso dinmico de traduccin en el que participan
agentes activos. En nuestro estudio de alcance seleccionamos Inglaterra y Alemania
como casos prcticos, nos basamos en anlisis de documentos, otras fuentes secundarias
e informacin especializada adicional. Nuestro anlisis revela la variedad de translacin
del mainstreaming de gnero en los servicios de atencin mdica primaria incluso
dentro del marco legal de la Unin Europea y la relevancia crucial de los sujetos
activos feministas. El estudio plantea cuestiones ms generales sobre la naturaleza de la
creacin de polticas internacionales en relacin a las instituciones locales de atencin
mdica y a los gestores del cambio de polticas.
Palabras clave
Atencin sanitaria, Inglaterra y Alemania, mainstreaming de gnero, polticas en materia
de salud, traduccin de polticas, transferencia de polticas
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