Understanding the intersectional landscape

Intersectionality has proven to be a valuable approach to analyse social structures, shed light on the dominant biomedical frame used in global health that disregards Indigenous and other sources of knowledge, and unpack health inequities [15–20]. To comprehensively address the complexity of health inequities, it is essential to grasp the intricate interplay of power dynamics and interconnected structural determinants such as gender, race and class [12, 13, 21]. These structural determinants, also referred to as social determinants of health (SDOH) inequities by Solar and Irwin [5], influence individuals’ and groups’ (lack of) opportunities and (in)access to specific resources, leading to structural discrimination of marginalised populations [5, 22]. Structurally embedded power hierarchies that directly impact the global health agenda and individual health outcomes are manifested at the political level, leaving policymakers and political systems with a significant impact on health and wellbeing. For instance, Safaei [23] examined that democracy, grounded in human rights, advances gender equality and improves health outcomes for women.

By considering the multidimensionality of power regimes, including racism, patriarchy and capitalism, an intersectional perspective unveils the deep-seated roots of oppression and the resulting power asymmetries, which in turn lead to the persistence of adverse health outcomes and inequities which are reproduced globally [8, 10, 11, 24, 25].

For instance, the COVID-19 pandemic exposed how intertwined racist and colonial attitudes, merged with capitalist aspirations, resulted in severe vaccine inequities, with the pharmaceutical industry and supporting countries prioritising profits over lives [26–28]. Reproductive justice is a poignant example of the intersectionality inherent in policies that impact sexual and reproductive health and rights (SRHR). Throughout history, interconnected sexist, racist and capitalist aspirations at the political level have impacted the realisation of SRHR [10, 29]. Policies undermining SRHR provide the state with power over an individual’s sexuality and bodily autonomy, like in the case of abortion and its widespread criminalisation, the criminalisation of HIV transmission, or several cases of forced sterilisation of Indigenous women [30–32]. Based on an intersectional understanding, reproductive justice considers underlying power regimes and the complexity of SRHR by acknowledging multiple and intertwined layers of discrimination, inequities and lack of access to basic services [29].

The call for a Feminist Global Health Policy

Despite an increasing body of knowledge on feminist approaches to foreign and development policies [33–35], the global health policy sphere often fails to adequately acknowledge these perspectives. For instance, the enhanced ability of intersectional feminist health research to identify barriers in access to healthcare for women to healthcare that are often overlooked in traditional research and formulate appropriate measures to overcome them has been proven [36]. Highlighting the importance of intersectional approaches to policy, Hankivsky and colleagues [37] developed the Intersectionality-Based Policy Analysis Framework to provide a tool for operationalising intersectionality in health policy analysis for more equitable policies.

This research study aims to explore the contours of a Feminist Global Health Policy (FGHP) and to initiate a debate among global health practitioners, policymakers, communities and researchers. While meaningful information on intersectional feminist approaches is available, the relatively new topic of FGHP currently lacks an action-oriented focus. In order not to remain an abstract construct, concrete and practical instructions are required. Rooted in decoloniality and anti-racism, an intersectional feminist approach to global health policy seeks to dismantle existing hierarchies and challenge entrenched inequities [38–40]. By encompassing holistic, inclusive principles, a FGHP aims to reshape health policies to be responsive to the most marginalised communities and individuals [41] and seeks to advance the transformation of health systems to make them more resilient and better prepared for health risks [42].This research intends to bridge the gap between theoretical understandings and practical implementation of FGHP by examining the research question:

How can a feminist approach to global health policy be meaningfully implemented to reduce health inequities?

This study aspires to offer a framework for a FGHP that establishes principles and components of a FGHP, along with guidance for its concrete implementation. The intention is to ensure a link between the strategic, global level and an action-oriented, local level. The unique contribution provided by this research derives from the participatory, intersectional feminist approach. By listening to diverse voices and acknowledging and building on lived experiences, the findings of this study go beyond a literature review and add to the nascent discourse on feminist global health policy. Highlighting the need to challenge existing research and knowledge paradigms, this study attempts to take a first step in this direction, aware of the related challenges and shortcomings.

Spotlighting the need for an intersectional feminist approach, this article underscores the urgency of addressing power imbalances and their impact on health inequities. By examining the complexities of global health policies through the lens of intersectionality, we can pave the way toward a more equitable and inclusive future. The subsequent sections of this paper will delve into the framework for a FGHP, considering both global principles and sensitivity to local specifications.

Study design

A qualitative study was conducted to answer the research question, provide a political framework for a FGHP, and open the discussion for alternative approaches in global health policy. This research was guided by an interdisciplinary, participatory approach consistent with feminist research principles [43, 44]. Acknowledging that research is not value-free and objective but rather shaped by existing power hierarchies and embedded in a social context [43, 45], feminist research is inherently action-oriented, emphasising participation and empowerment [44, 46, 47]. The choice of research methods is grounded in fundamental principles, i.e. ontology, epistemology and methodology, that reflect on how the world is perceived and knowledge produced [48]. This research was based on a critical, constructionist ontology to underline that existing structures are modifiable [48]. Consequently, this study adopted a postmodern epistemology, rejecting the notion of an objective truth and perceiving reality as socially constructed and subjective [43, 47]. Postmodernism assumes that reality is relative, depending on the social and political context, which further shapes knowledge and experiences [47]. Emphasis is on power relations and their implications [43, 48]. By considering multiple standpoints, a postmodern epistemology is well suited to research intersectionality. In line with postmodernism, this research project followed an interpretivist methodology focusing on understanding and considering power and context [48, 49].

Qualitative methods, with their acknowledgement of lived experience and consideration for context and setting, were deemed to be the most aligned with the underlying feminist principles. As such, the qualitative methods applied in this research build on the choice of a constructionist ontology, postmodern epistemology, and interpretivist methodology. To assess the suitability of different methods and value of the research, the work was guided by the eight criteria for qualitative research identified by Tracy [50]: (1) worthy topic, (2) rich rigour, (3) sincerity, (4) credibility, (5) resonance, (6) significant contribution, (7) ethics and (8) meaningful coherence. They were incorporated throughout the research process to allow for this study’s maximum possible added value. For instance, to avoid objectifying and exploiting study participants, data for this research project was obtained through focus group discussions (FGDs) in an interactive, collaborative approach, which sought to reduce hierarchies within the research process and centre participants [44, 51, 52].

Data collection

Three focus groups (FG1, FG2, FG3) with a total of 11 participants were convened between August and September 2022 using the online meetings platform Zoom. Participants were recruited through purposive sampling to obtain the most appropriate composition in relation to the research question, i.e. with regard to geographical diversity and knowledge–through lived experience or work–on relevant topics, including global health, feminism, intersectionality, decoloniality or inequities. Gender was not primarily an inclusion or exclusion factor because a feminist global health policy intends to benefit everyone. However, particular attention was given during the sampling process to ensure that representatives of structurally marginalised groups constituted the majority of respondents. To achieve global representation, participants from all WHO regions attended, with particular emphasis on individuals from across the so-called Global South. Since the FGDs were conducted in English, only English-speaking participants could be included. Recruitment was undertaken by the principal investigator (HE). The fact that she decided who could participate in this study and the exclusion of people not fluent in English potentially created power hierarchies with implications for the findings, a consideration discussed further in the limitations section.

The recruitment period spanned from 16 June, 2022 to 22 August, 2022. 33 potential participants were contacted via e-mail. Of those, 12 people responded. Due to one no-show, 11 participants (FGD facilitator not included) attended the discussions and meaningfully contributed to the conversations.

The choice of three FGDs was intended to link the global strategic-academic level with the local and action-oriented level. By including different standpoints, the focus was on what is genuinely feasible and required by people on the ground. FG1 comprised six participants affiliated with the strategic and/or academic level related to global topics, such as multilateral organisations, universities and global health institutes. FG2 and FG3 were composed of three and two participants, respectively, who were actively engaged at the local level, including members of civil society organisations, social movements, activists, and marginalised populations. Given the high heterogeneity of the latter, two FGDs were convened with participants active at the local level to enable a richer exchange and a deeper engagement with their respective expertise and experience. Scheduling conflicts due to the large geographical scope also required the convening of three FGDs. Separating the two levels was intentional, as homogenously composed groups are preferred for FGDs [53, 54]. However, this differentiation bears the risk of amplifying socially constructed classifications. The intention was to provide room for both levels, particularly for the local perspective. This approach also allowed for analysing whether the two group types gave different inputs.

The principal investigator facilitated the FGDs, which entailed introducing the research, facilitating participant introductions, and providing discussion prompts. While having conceptualised the FGDs, the principal investigator mainly remained in the background during the discussions, in the sense that she asked the questions and probed to clarify points but not intervene in the conversation. Guiding questions on components, actors and actions regarding a FGHP were developed in advance (see S1 Appendix) to ensure some consistency between FGDs, but with sufficient flexibility to ensure a participant-driven discussion.

Data analysis

Based on the audio-video recordings, the FGDs were transcribed employing a literal transcription approach, neither phonetic nor summarised (see S2 Appendix). The analysis was conducted according to Kuckartz’ [55, 56] qualitative content analysis with the QDA-software MAXQDA. A deductive-inductive code formulation was employed. The data analysis process is visualised in Fig 1. Starting from a deductive approach, emerging codes were added with an inductive approach. As such, the final codes were developed iteratively (see S3 Appendix). When the main and subcodes were considered final, the entire material was recoded with the differentiated code system (Fig 2).

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Fig 1. Data analysis process.

https://doi.org/10.1371/journal.pgph.0002959.g001

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Fig 2. Visualisation of the code system with thematic main and sub codes.

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Reflexivity

To ensure non-exploitative feminist research throughout the process, mechanisms to enhance reflexivity were integrated [43, 57]. A first draft of the results as well as the raw data, including transcripts and video recordings, were sent to the FGD participants, encouraging feedback and requests for changes regarding the analytical process. Member reflection allows for more meaningful and practicable results, which do not solely serve the researcher. Since the results are contextual, this approach ensures that participants agree with the findings and shifts power to them while acknowledging their positionality [50, 58]. The focus group participants were further invited to become co-authors of this article. Therefore, the co-authors of this article are the principal investigator (HE), eight FGD participants (SC, SE, MM, SM, AN, ER, YKS, OLU) and the two study supervisors (AK, TG).

Consistent with postmodernism, the socially constructed reality of the researchers and its influence should be considered, not least to identify persisting power regimes in the research process. The principal researcher and facilitator of the FGDs was a 26-year-old white, middle-class woman from Germany. Her interest in the research topic is strongly motivated by personal and professional experiences and it was part of her master’s thesis. She identifies as female, her pronouns are she/her, and society also perceives her as female. She is keenly aware of her highly privileged positions and the consequences of her positionality on this research. Given her prominent role in the research process, power hierarchies persisted despite attempts to reduce and reflect them. In particular, the fact that less participatory approaches were employed in the design of the FGDs and the selection of participants caused an imbalance. Although multiple standpoints were included in this research, most decision-making power concerning implementing the study and the analysis remained with the principal investigator. In accordance with postmodernism, the analysis and findings are subjective and contextualised and should be interpreted accordingly.

Ethics statement

Ethical approval for this study was obtained from the Ethics Committee of Bielefeld University (Nr. 2022–169). All participants were informed via a Data Protection Information form and a Participant Information form in advance about the procedure, content, purpose, their rights, use of data and data security. Formal consent was obtained in written form, with all informed consent forms signed by the participants before the FGDs.

Power regimes

All focus groups perceived the role of power to be of utmost importance in analysing existing problems and generating feminist alternatives. Reference to power was made in relation to its negative aspects, i.e., problematic power hierarchies and the unequal distribution of power and its consequences, as well as from a forward-looking perspective, i.e., how existing power regimes can be changed to achieve equity.

Participants criticised the structural power inequities embedded within global health, apparent, for instance, in colonial continuities and global classism. These intersecting inequities arise from power hierarchies that rely on controlling, dehumanising, and feeling superior towards perceived "others", leading to restricted access to healthcare, especially for marginalised groups. The participants further emphasised the gendered dimension of these power imbalances, underscoring that women and non-binary people are particularly affected.

The unequal distribution of power in global health was considered to be closely linked to the privatisation of healthcare and prompted by a capitalist profit orientation, which was referred to as the biggest threat in global health. Concerns were raised about the influence of the private sector and the lack of strong accountability mechanisms:

"They have more power than most of our governments." (FG2)

Unlike governments, the private sector is not accountable to society. Funding decisions do not need to be based on human rights or transparent principles and are, therefore, not necessarily beneficial for patients and communities. The participants depicted how privatisation, resulting from capitalism, intersects with other oppressive power regimes that increase inequities with multiple negative impacts at national and global levels. Capitalistic profit-orientation, in contrast to prioritising health, was portrayed as a threat leading to deleterious health impacts by endangering affordability and equal access to healthcare, whilst neoliberal structures were deemed to exacerbate the exploitation of (female) healthcare workers.

A lack of political will fosters the absence of regulation of the private sector to interfere. This unwillingness to change the system and policymakers’ preference for the status quo was a recurring topic in all FGDs, because questioning the current state and intending change would imply a radical transformation. The participants collectively agreed that those in positions of power are generally unwilling to relinquish their power, thus blocking any progress. Privatisation perpetuates this consolidation of power. This seems to be particularly true for authoritarian regimes, which were identified as major threats to health equity:

"I think that political leaders who are not held to democratic checks and balances are much more likely to enter into sweetheart deals with corporations […] and so the erosion of democracy and the erosion of political checks and balances […] is so profoundly linked to the kind of corporate capture of healthcare because ultimately it’s the decisions of political leaders in countries with weak governance and weak rule of law and rising authoritarianism that permit corporate capture of public goods. So in some ways those two issues of authoritarianism and corporate capture are very linked." (FG1)

Hence the discussion revealed that the challenges of privatisation and lack of political will are profoundly interrelated with power and uphold structural inequities.

The participants further elaborated that power is related to whose interests are being served, who is included, and who is able to speak. Considering the persistence of power hierarchies, radical change as part of a framework for FGHP was demanded because only by transforming structures progress can be achieved. A shift in power was regarded as essential in all FGDs. Referring to the remark that "power inequities are really baked into the global health architecture" (FG1), it is imperative to first address the global health system. The discussions also included meta-level discourses, questioning whether power is an infinite resource or if shifting power is associated with someone losing power.

Intersectionality

Intersectionality, as well as power, was an overarching theme that related to both the challenges and the way forward. The participants reflected on multiple intersecting power imbalances that constitute a barrier to healthcare, disproportionately affecting marginalised people. Multiply oppressed individuals are faced with adverse health outcomes, for example due to restricted access to healthcare or a differential treatment based on discrimination. The genuine achievement of universal health coverage, including healthcare that is available, accessible, acceptable and of decent quality, was referred to as an issue requiring an intersectional lens. A holistic approach to address root causes was regarded as essential to eliminate structural inequities and improve health outcomes.

The relevance of intersectionality as a comprehensive frame for a FGHP was frequently emphasised in all discussions and considered pivotal for achieving health equality. To this end, the acknowledgement and inclusion of diverse standpoints at a political level was considered crucial:

"I do also think that including all genders and all backgrounds in terms of an intersectional approach is absolutely essential. We need to mirror society also in the policy-making processes." (FG3)

According to the participants, intersectionality enables the recognition of different needs and how to adequately respond to these by developing alternatives. Consistently, a FGHP must be inherently intersectional. The participants highlighted the critical importance of engaging with feminism itself first when dealing with feminist approaches to policy. The colonial and racist history of the feminist movement, which was shaped by predominantly white, Western, middle-class educated women, was recognised as an important concern in the discussions. The impact is still visible today, as the broader movement struggles with power hierarchies and exclusionary visions, practices and mechanisms. The participants suggested internal improvements, including: reflecting on power asymmetries; aligning words with action; improving communication; recognising that plural feminisms exist; and, a genuine embrace of intersectional feminist approaches.

Knowledge and discourse

Considerations about knowledge and discourse were part of the discussions, including meta-level questions regarding knowledge production as well as more direct approaches to knowledge, discourse and language. It was highlighted that fundamental assumptions must be considered and rethought, since knowledge paradigms are not neutral but shaped by power:

"Because those who are in power in shaping this discursive power of knowledge, of beliefs, of setting the norms in health are really, you know, unchallenged" (FG1)

The discussions indicated that this entails thinking outside of common frames in terms of what accounts for knowledge as well as the use of language. Reflections on knowledge and discourse were perceived as closely associated with colonialism, since existing knowledge paradigms are influenced by a Western perspective, often devaluing other knowledge systems. The participants further outlined that dominant knowledge paradigms favour a narrow quantitative and biomedical focus in global health. The preference for simple, measurable indicators and solutions instead of considering the complexity of SDOH and valuing lived experiences was strongly criticised:

"Our notions of excellence, and how we recognise excellence are so wedded to one particular way, predominantly kind of an Anglo-European approach or a Western approach of what evidence is, that we discard vast amounts of really important data when we’re thinking about effects in health policy" (FG1)

Furthermore, coloniality determines by whom and how the discourse is shaped. The continuing influence of colonialism was underscored in the discussion, referring to "the very fact that we’re having this conversation in English, yet we are from three different continents" (FG2). Hence, the analysis revealed that for the conceptualisation and implementation of a FGHP, reflections on who is part of the conversation and listened to are essential.

Objectives and principles of FGHP

The FGDs addressed overall objectives of FGHP and underlying fundamental principles. A focus on solutions was not deemed appropriate, as this indicates single, easy-to-achieve mechanisms. Instead, the participants preferred the term ’alternatives’ to emphasise the complexity and multiplicity of new approaches and challenges.

Objectives

The two major objectives of FGHP elaborated by the participants were health equity and reproductive justice. Structural change, including power transformation, was perceived as indispensable to achieve these objectives. The participants indicated that health equity implies an improvement of legal and political rights, access to healthcare and enhanced health outcomes. More specifically, universal health coverage is to be achieved, as well as the fulfilment of SRHR. Intersectional feminist approaches were considered valuable and suitable for overcoming current challenges:

"I could not agree more that feminism takes us from a narrow focus on biomedical solutionism to a broader focus on wellness and health as a complete state of psychological, physical, mental, spiritual wellbeing, and an emphasis on the social determinants of health." (FG1)

Closely related to health equity, the concept of reproductive justice—encompassing social justice, the importance of the political level, and the relevance of power—was emphasised. Laws and policies tremendously impact SRHR–sometimes with detrimental consequences. To underline this, one participant was referring to the punitive laws in her home country Uganda. At the same time, laws provide an opportunity to accomplish reproductive justice. In this regard, alternative approaches aligning with a FGHP were perceived to advance health equity and reproductive justice.

Guiding principles

Four fundamental, interconnected principles were considered as essential for FGHP: Human rights, equality, democracy and decoloniality. While contextualisation is of major importance for FGHP, overarching guiding principles that are globally accepted were deemed necessary by the participants. Such principles represent a common, non-negotiable denominator. However, there may be different approaches on how to achieve these principles, which underlines the pluriversality within global health. It was noted that as with every framework, FGHP has to be flexible and adaptable:

"It has to be work in progress […] it’s going to be something that allows people to take what they want, add, eject, shape, reshape, you know. […] Like clay where you can keep moulding and re-moulding it." (FG2)

The principles of human rights, equality, democracy and decoloniality must be acknowledged and accomplished at the political level. This implies reflection and change of current power asymmetries, as well as the active participation of society. Aligning with these principles was regarded as fundamental to address current challenges in global health and advance FGHP. Participants from all FGDs highlighted the importance of human rights, enshrined in the Universal Declaration of Human Rights [59]. Their fulfilment must be at the core of this approach, including the notion of health as a human right. Respecting human rights requires an intersectional lens and is closely related to equality.

The principle of equality is integral when considering health equity. Striving for equality means acknowledging underlying power hierarchies that cause social inequities and acting according to everyone’s (heterogenous) needs. The overarching principle of equality is critical for a FGHP to be genuinely holistic and to leave no one behind. Participation and inclusion are integral mechanisms for ensuring equality and also form the basis of democracy.

The significance of democracy for a FGHP was highlighted in the FGDs, as meaningful engagement, the distribution of power and accountability mechanisms are inherently linked to this political system. Since the (national) political context is decisive for adopting a FGHP, democracy is a crucial premise for the substantive implementation of such a policy. It was further noted with concern in the discussions that non-democratic, authoritarian states are more prone to privatisation of healthcare as well as supporting anti-feminist movements. In this respect, the political system of a state impacts healthcare and the health outcomes of its population.

An explicitly intersectional feminist global health policy must feature decoloniality as one of its guiding principles. The discussions underlined the importance of awareness about coloniality, including reflection on intrinsic colonial assumptions. Decoloniality requires tackling persistent power asymmetries and instituting accountability mechanisms to ensure equality, justice and the fulfilment of human rights for everyone. The participants emphasised that advancing decoloniality is a complex task, demanding radical transformation. There is no blueprint for decoloniality; rather, plural approaches were considered necessary.

Components and implementation of FGHP

Reflecting on concrete implementation, the discussions indicated that emphasis should be on local adaptation, guided by the four guiding principles mentioned above. Based on the recognition that the current system is not functioning and persisting power regimes inherent in societies reproduce inequities, the participants demanded a radical transformation to implement FGHP and to deliver critical improvements in health and equity. The relevance of acknowledging SDOH and local circumstances were strongly emphasised by all participants. Furthermore, all participants agreed that a FGHP can only be successful by involving communities and civil society because they are embedded in and aware of the context:

"We need to start listening. So we need to stop looking to people in power and who currently hold power and don’t have the lived experience of the systems of oppression to provide solutions. Because they actually don’t know. […] Yet those who are in those positions of poverty and inequality, they actually know. And so we’ve got to shift who we listen to." (FG2)

Meaningful engagement with people on the ground was one of the most discussed topics in the FGDs, with participants emphasising that promoting health equity requires the adoption of participatory approaches.

Contextualisation further entails understanding the political context at every level–locally, nationally and globally. To genuinely shift power, governments must assume the responsibility of ensuring inclusion and participation throughout policy-making processes. Participants emphasised that this is an iterative, continuous process, which is time-consuming, but rewarding and essential. Referring to the 2030 Agenda strapline to leave no one behind [1], the inclusion of those experiencing multiple and intersecting layers of oppression in policy fora was highlighted.

The importance of awareness raising to facilitate social change was a also explored by participants. This includes ensuring communities know their rights to and to promote action to realise those rights. Policymakers likewise need to be aware of good practice methodologies to engage with communities, because this "would equate to more participation on every level" (FG3), whilst acknowledging power hierarchies. Participants further discussed the importance of acknowledging reflexivity and positionality, which entails a reflection process about privileges and responsibility. Education and awareness raising within the health system was also discussed as highly relevant, considering harmful power asymmetries that are persistent and continuously reproduced in the health education system and workforce:

"This sensitisation process in the medical education, where from the beginning, everyone starts to rethink on what are we taught, and who has shaped medicine and medical curricula throughout the ages. Having this critical view upon it, that will also change how we practice medicine in the future ideally […] and in the end, ideally, the patient will profit from it. But I do think that’s a very long process." (FG3)

As highlighted in the quote, a consciousness-expanding process among healthcare personnel was perceived as important to avoid the reproduction of power hierarchies within the health system, as well as sensitisation for the SDOH and contextualised knowledge.

Regarding the challenges related to privatisation and capitalism, a shift in funding was considered essential for a FGHP. Without adequate funding, a framework cannot be meaningfully implemented. The FGD participants demanded that health, as opposed to profits, should be at the centre of funding decisions, which should also align to feminist principles [60–62]. A shift in funding was linked to the transformation of power since money often confers power and incentivises particular behaviours. Again, engagement with community organisations–which are often underfunded–was considered crucial to achieve a meaningful impact. Different mechanisms were proposed in the discussions, including redistributive mechanisms, different taxation systems and more allocation for healthcare and other social sectors. Moreover, multilateral organisations were considered to be important funders if acknowledging the ethical dimension and acting accordingly.

The findings further revealed that present documents and mechanisms could be used as references for FGHP, particularly, the Universal Declaration of Human Rights [59], the Convention on the Elimination of All Forms of Discrimination Against Women [63] and the Beijing Declaration and Platform for Action [64]. Moreover, national and regional agreements can serve as orientation for FGHP and need to be taken into account for local implementation.

Actors in FGHP

The focus group participants identified relevant actors for a FGHP and elaborated on their roles and responsibility. Furthermore, questions of accountability were discussed. The participants emphasised that different actors should not be viewed in isolation. Rather, cooperation and participation are crucial for a purposeful FGHP. Community and civil society were regarded as the primary actors for FGHP, the importance of their participation was endorsed in all FGDs, highlighted by this participant:

"So for me the number one actor could be community because we are the owners of this framework" (FG3)

Consistent with an intersectional understanding, community was not perceived as a homogenous group but as a diverse and inclusive set of actors. Community-based and grassroot-level organisations were considered the most essential because of their local presence and context-specific knowledge:

"For me it is really community-based organisations, which have or follow feminist ideology and principles. They, I feel, are key. Because they are the ones who are in the community. They have the trust with the community […] So for me, those, they are very key players. Civil society at large yes, but specifically community-based organisations, which have a presence, and subscribe to feminist ideology." (FG1)

Meaningful engagement of community, and beyond that, the acknowledgement of this sector as a key actor, was associated with improved health care and outcomes by study participants. This also applies to the global context, where inclusion of various communities is important, while acknowledging different backgrounds. In addition to community and civil society, participants emphasised the relevance of national policymakers for FGHP. Encompassing states and governments, as well as individual policymakers, their decision making mandate with respect to policies and laws concerning health, equity, and reproductive justice renders them key actors. Participants of all FGDs identified that accountability for FGHP resides at state level, since "the states are the duty bearers" (FG1). Given the many current challenges at the political level, participants demanded systemic change and the transformation of political decision-making.

Besides community and national policymakers, the participants recognised the relevance of multilateral organisations. These organisations are required to develop and monitor universal guidelines and global standards. They are also powerful convenors, with the potential to bring states together and to establish or deepen linkages between the different levels and actors required for a FGHP. Moreover, participants noted that they are influential actors because of their availability of resources, particularly for funding, which again raises important questions about accountability mechanisms.

The discussions identified academia as a secondary actor. As the academic sphere educates the future health workforce, consciousness about its responsibility and mechanisms to restructure the system were considered critical. Academia has the potential to foster change and improve healthcare and health outcomes. The participants implored universities to transform the current neoliberal, quantitative system that neglects meaningful alternatives:

"Another challenge that I would also like to touch upon is really the entire medical education and the way in which this education is given. So you know the principles of human rights, and all of that are not taught to medical practitioners […] The lack of these skills, which you could call soft skills, are very important, they’re critical. But they’re not part of the medical education." (FG1)

Gendered and racist hierarchies within the health workforce are reinforced and upheld by this education system. Acknowledging inherent power asymmetries and acting adequately and in collaboration was considered necessary.

Funding mechanisms must be transformed and adjusted to align with the principles of FGHP. In this respect, feminist economists and funders were introduced as relevant additional actors. Feminist economists advocate for different perspectives on health economies that contrast with the current capitalistic system and its exploitative, oppressing characteristics. Regarding FGHP, the private sector was not considered an integral actor, since it was overwhelmingly associated with challenges in the global health system. However, the participants emphasised that private sector actors must be held accountable and acknowledge their responsibility and–often detrimental–consequences of their actions.

Strengths and limitations

As with any research endeavour, this study has its strengths and limitations. The inclusion of multiple standpoints in the FGDs presents a major strength and reflects a participatory and intersectional approach by acknowledging interlinked determinants, privileges, and oppression [88–90]. Considering coloniality in global health and the urgent need for transformation, participatory research in the form of focus groups is highly relevant [91]. According to the WHO categorisation [92], this research can count as gender-transformative, since power regimes and resulting structural (gendered) inequities were addressed in the FGDs and are challenged in the framework. Moreover, this research is intended to foster transformative change in global health policy. The application of feminist methods using intersectional lenses facilitated a decolonial, participatory approach, providing a valuable space for diverse voices to be heard. The appropriateness of focus groups as a data collection instrument was also highlighted by the participants themselves; the dynamic flexibility of focus groups allowed for nuanced insights and vivid discussions, which would not necessarily have emerged in individual interviews [54, 93]. Online focus groups in particular feature a higher level of accessibility: participants could attend irrespective of their geographical location without the need to travel and almost free of costs. It is a great added value of this study to have involved and connected people and perspectives from different regions of the world to discuss FGHP.

However, some limitations of this study must be acknowledged. The scope of the participatory approach was by necessity limited to the data collection and dissemination of results, rather than involving participants in the entire research process. To fully realise the potential of participation and reduce power hierarchies, future research may explore more comprehensive participatory research approaches, without overstretching the resources of–and thus exploiting–the participants [94]. Finding a balance between genuine participation and not demanding too much energy, time and effort from the participants was a challenge of this research and a compromise to this end was sought. Regarding the principal researcher’s positionality and her role as facilitator of the FGDs, not all power hierarchies could be dismantled during the research process, even if the decision for focus groups and a participatory approach reduced power asymmetries. This strongly influences the findings.

Some specific limitations refer to the conduct of focus groups. The non-response rate for focus groups is considerably high and was two-thirds in this study. The inclusion and exclusion criteria also reflect some limitations. The focus groups had to proceed in English (as the contemporary international lingua franca), to ensure communication and mutual understanding between participants. However, this can be regarded as a shortcoming with respect to perpetuating coloniality in global health. Individuals not proficient in English at a high level were excluded. Such an approach risks inadvertently excluding or bypassing meaningful contributions of community members and people with lived experiences. Consequently, the discussions and thus the results were shaped by people adept at talking about the topics examined. While the study participants also spoke on behalf of structurally excluded people and communities and took their perspectives into account by being feminist activists or belonging to community-based NGOs, marginalised people were not directly represented in the majority in this study. By not adequately including these voices, not all power imbalances within the study could be eliminated. In addition, only those with access to a stable internet connection could attend, which further excluded potential participants [93]. Connectivity issues also caused difficulties during the focus groups, including problems related to power outages and non-attendance without notice. The online format of the focus groups, while enabling broader participation, may have affected interaction and the establishment of a familiar atmosphere among participants [93]. Multiple affiliations of participants further complicated the organisation and allocation of the focus groups. This emphasises the complexity of the social world as well as intersecting identities. The context and positionality of the FGD participants could have been highlighted more throughout the research. This implies that a different group composition could have resulted in slightly divergent outcomes [54]. It also raises the questions of how many focus groups and participants are adequate, considering that saturation is not an anticipated criterion in a postmodern perspective. Rather, this research can be understood as providing insights for a continuing process that is not completed with this work.