Mainstreaming as rhetoric or reality? Gender and global health at the World Bank.

Background: Over the past decade gender mainstreaming has gained visibility at global health organisations. The World Bank, one of the largest funders of global health activities, released two World Development Reports showcasing its gender policies, and recently announced a $1 billion initiative for women's entrepreneurship. However, the development of the Bank's gender policies and its financing for gender programmes have never been systematically analysed by external researchers in the context of global health. We use the Bank as a case study of how global health organisations frame their gender policies and measure their success. Methods: We constructed a timeline of the Bank's governance of gender, through a review of published articles, grey literature, and Bank documents and reports. Additionally, we performed the first health-focused analysis of two publicly available Bank gender project databases, and tracked the Bank's financing of gender projects in the health sector from 1985-2017. Results: The Bank's gender policy developed through four major phases from 1972-2017: 'women in development' (WID), institutionalisation of WID, gender mainstreaming, and gender equality through 'smart economics'. In the more inclusive of the two Bank project databases, gender projects comprised between 1.3% (1985-1989) and 6.2% (2010-2016) of all Bank commitments, which is significantly less than the Bank's claim that 98% of its lending is gender informed. Most funding targeted middle-income countries and particular themes, including communicable diseases and health systems. Major gender-related trust funds were absent from both databases. Conclusion: The Bank focused most of its health sector gender projects on women's and girls' issues. It is increasingly embracing private sector financing of its gender activities, which may impact its poverty alleviation agenda. Measuring the success of gender mainstreaming in global health will require the Bank and global health organisations to reconsider their use of gender indicators.