Navigating context, power and politics: A qualitative case study of co-designing gender integration in South Africa.

Gender is an intersectional determinant of health that remains insufficiently integrated in programmes and policies. Sustained processes of dialogue and collaboration, including participatory approaches such as co-design, are needed to effect gender integration. However, the contexts and power dynamics through which co-design may support gender integration are not well understood. This qualitative case study examined a co-design partnership that undertook gender integration within an established adolescent sexual and reproductive health programme in South Africa from 2022-2025, drawing on (n = 37) project documents, (n = 36) post-meeting reflections, (n = 2) annual project group reflections, and (n = 12) key informant interviews. Analysis was deductive-inductive and informed by theories of context, organisational logics, gender, and power. Three interlinked contextual levels influenced the partnership. Macro-level funding arrangements and accountability structures created hierarchical pressures that constrained participatory and gender-responsive work. Meso-level organisational logics differed across partners, creating misalignment with the reflective co-design approach and between partner organisations. At the micro-level, boundary-spanning individuals enabled trust-building and adaptation. Interactions across levels revealed how institutionalised power shaped feasible forms of participation and gender integration. Co-design partnerships can strengthen gender integration in programmes but require macro-level enabling systems, institutional support, and navigation of meso-level organisational logics alongside sustained micro-level action.