Addressing gender (in)equality in the health sector: gender-responsive budgeting as an accounting process for creating public value

Ensuring gender equality (GE) fosters a fair, prosperous and inclusive society. By prioritising GE, public institutions and organisations contribute to the collective well-being and uphold fundamental human rights. Moore (1995) asserted that public organisations should create desirable social outcomes, such as welfare, well-being, social inclusion and equity. Thus, promoting GE is essential to creating public value (PV), as GE is a fundamental element directly contributing to its formation (Sharma and Kaur, 2024) and driving sustainable development and societal progress (Kolovich et al., 2020; Belingheri et al., 2021). GE enhances labour productivity and economic performance by reducing inefficiencies and optimising talent allocation (O’Hagan and Klatzer, 2018). Moreover, gender-equitable societies strengthen democratic participation through high social trust and civic engagement.

PV, variously conceptualised (Hartley et al., 2017), shifts the focus from efficiency to outcomes (Alford and Yates, 2014; van Gestel et al., 2024), with attention to equity, ethics and accountability issues (Broucker et al., 2018; Steccolini, 2019a). PV requires addressing stakeholders’ needs while maintaining economic balance (Meynhardt, 2009; Cluley and Radnor, 2021). It also has ethical and narrative dimensions, reinforcing commitment and sustainability (Fischer and Grant, 2013; Alford and O’Flynn, 2009; Gherardi et al., 2021). However, research on stakeholder involvement in PV creation remains limited (Oppi and Galizzi, 2024; Sharma and Kaur, 2024).

Moore’s (1995) PV strategic triangle has been widely studied (e.g. Alford and Greve, 2017), yet the role of accounting in PV creation remains underexplored (Bracci et al., 2019; Spano, 2009). Accounting is crucial in identifying, shaping and translating diverse stakeholder perspectives, particularly for marginalised groups (Bracci et al., 2014). Sharma and Kaur (2024) emphasised PV’s connection with equity, accountability and ethos. In this context, gender-responsive budgeting (GRB) supports GE by embedding gender considerations into financial decisions and fostering accountability for GE commitments (Sharp, 2003; Rubin and Bartle, 2005; Kalifha and Scarparo, 2021). Despite its potential to enhance PV (Oppi and Galizzi, 2024), GRB implementation remains uncertain in public organisations (Polzer et al., 2023). Limited research on GRB exists in public management, especially within the health sector (Galizzi et al., 2021; Khalifa and Scarparo, 2021; Nolte et al., 2020; Siboni et al., 2016). The health sector remains highly gender segregated because of structural and cultural factors (European Institute for Gender Equality [EIGE], 2017a, b; World Health Organization [WHO], 2019b). However, there is little research on the conditions facilitating or hindering GRB from being an effective tool for advancing GE in this sector. Therefore, this study addresses the following research question:

Using Moore’s strategic triangle as an analytical framework (Höglund et al., 2021), this study examines GRB implementation in the health sector. It explores the facilitating and hindering conditions identified in other fields (Galizzi et al., 2023; Polzer et al., 2023) and applies them to a case study involving three Italian health organisations. This initiative represents a novel example of interorganisational GRB implementation, supporting claims that PV requires collaboration among multiple institutions (Benington, 2009; Bryson et al., 2017). This study contributes to the accounting literature by positioning GRB as an accounting and managerial tool for fostering GE in the health sector. It also provides a unique case study within a gender-segregated public sector.

The rest of the paper is structured as follows. Section 2 reviews the background on GRB and PV, and Section 3 outlines the research design. Section 4 presents the findings, and Section 5 discusses the results. Finally, Section 6 concludes with directions for future research.

The public sector accounting literature has seen an increasing application of the gender perspective (McDonald et al., 2024). From its mere acknowledgement as a variable (Parker, 2008), organisations and research have moved to radicalise the gender perspective in the agenda (Broadbent, 2016) and incorporated it into the budgeting process through GRB (Rubin and Bartle, 2023). GRB extends beyond incorporating gender considerations into budgets for GE and resource allocation (O’Hagan and Klatzer, 2018; Sharp, 2003). Instead, it scrutinises organisations’ internal structures and community needs through a gender lens, evaluating policy impacts on GE (Rubin and Bartle, 2005).

GRB is structured in four phases: (1) context analysis using gender indicators to identify disparities within the organisations and their activities’ impacts, (2) formulation of strategies and resource allocation, (3) implementation and monitoring and (4) measurement of impact (Rubin and Bartle, 2005; Steccolini, 2019b; Galizzi et al., 2023). The first phase results in a Gender Report that informs policy development and execution.

Over time, GRB has been implemented in various countries and organisations using diverse approaches (Galizzi et al., 2021; Brenton, 2023; McDonald et al., 2024). The standardisation of GRB remains challenging because of the contextual nature of gender inequalities (Acker, 1990, 2006) and the contested nature of GRB metrics (Khalifa and Scarparo, 2021; McDonald et al., 2024). The absence of clear benchmarks risks misinformation and weakens accountability, necessitating participatory approaches to define relevant indicators and ensure legitimacy in budgeting practices. Accordingly, legitimate stakeholders should collaboratively determine which aspects should be budgeted and accounted for (McDonald et al., 2024).

Despite the significance of GRB, studies on it in public sector accounting remain scarce (e.g. Polzer et al., 2023), particularly in the health sector (Leoni et al., 2021). Crespí-Lloréns et al.’s (2021) review identified a lack of sex-disaggregated data and gender inequality indexes, impeding effective policy development. Other studies have emphasised the limited empirical evidence of GRB’s impact on health outcomes (Cassano and Fornasari, 2022; Naciti et al., 2022; Gupta et al., 2024). Research predominantly focuses on low- and middle-income countries, where gender disparities in health access persist (Nolte et al., 2020). In these contexts, Gupta et al. (2024) revealed that increased health expenditures and universal health coverage have reduced inequalities. However, in Western countries, gender disparities in workforce composition and service delivery remain despite the large amount of funds allocated to healthcare (WHO, 2019a; EIGE, 2021). In these settings, GRB can help ensure equitable resource distribution and address internal workforce disparities.

Prior studies have identified the facilitating and hindering conditions challenging GRB implementation (Galizzi et al., 2023; Martìnez Guzman, 2024a). Institutionalising GRB enhances its effectiveness (Steccolini, 2019b), requiring legal frameworks and regulatory support (Galizzi et al., 2021; Moser and Korac, 2021; Martìnez Guzman, 2024a). Traditional budgeting derives legitimacy from laws and regulations (McDonald et al., 2024), and GRB also requires visibility for gender issues (Steccolini, 2019b; Khalifa and Scarparo, 2021). Participatory and inclusive approaches are crucial, as normative values shape budgeting decisions (McDonald et al., 2024).

A GE-friendly climate is essential for GRB adoption. This climate is ensured by political commitment to GE, a legal framework and financial support (Galizzi et al., 2023; Jorge et al., 2023). Successful integration into accounting systems depends on civil servants’ engagement (Galizzi et al., 2018) and tailored management practices (Steccolini, 2019b). The availability of gender-disaggregated data is vital for defining gender indicators and assessing policy impacts (Steccolini, 2019b; Galizzi et al., 2023). In some cases, external expertise can aid GRB adoption, offering insights and training (O’Hagan and Klatzer, 2018).

In European case studies, leadership is crucial for successful GRB implementation, with political support aiding diffusion but not guaranteeing full potential realisation (Elomäki and Ylöstalo, 2021; Polzer and Seiwald, 2021). In South Korea, GRB was introduced because of external pressures, but it lacked internal consensus (Martìnez Guzman, 2024b). Resistance among civil servants also affects GRB adoption. Fernandez-Gutierrez and Van de Walle (2019) found that European public officials prioritise efficiency over equity. These conditions, taken individually, are not determinants or deterrents of GRB success but interact dynamically within a complex system without any order of priority.

This study investigates the facilitating and hindering conditions that interact in the implementation of a GRB initiative within three Italian health organisations. As previous research has demonstrated the utility of Moore’s triangle in analysing management control practices (Höglund et al., 2021), we apply it to provide an in-depth understanding of the dynamics influencing the pursuit of GE as PV creation.

According to Moore (1995), public managers and civil servants must create PV, supported by managerial, accounting and accountability tools. An accounting tool like GRB alone cannot create PV, but the implementation process can contribute to achieving GE as a form of PV. Moore’s strategic triangle emphasises that PV is the ultimate objective and an integral part of the process. Thus, implementing GRB has the potential to shape organisational practices in a way that aligns the pursuit of GE with PV creation. While some PV scholars, such as Benington and Moore (2011, p. 14), have highlighted its broad societal relevance as what the public values, Moore’s strategic triangle focuses on the internal and managerial dynamics of PV creation.

Moore traces the boundary of the PV frame within three dimensions: (1) PV created within the socioeconomic system, which produces objectively valid results for stakeholders; (2 legitimacy and support for public action from citizens and different types of internal and external stakeholders (which include governance, managers and civil servants), who provide financial resources, consensus and support; and (3) the operational capacity of public organisations to deliver services efficiently. Moore considered the triangle’s three vertices fundamental for conceiving of a sustainable, value-creating strategy. These dimensions must be aligned and mutually supported, without a top-down hierarchy along them. Indeed, the three vertices are interdependent and connected through bidirectional arrows, indicating dynamic and continuous interaction. Each dimension is essential and mutually reinforces the others to generate PV effectively. This configuration suggests that achieving PV relies on the synergistic balance between legitimacy, operational capacity and the strategic alignment of the organisation’s goals towards PV. Accordingly, governance is a collaborative effort in which public organisations, citizens and stakeholders unite to create PV. It also emphasises the role of policymakers and public managers in creating PV, supporting policy definitions and undertaking goal-setting activities (Bryson et al., 2017).

Therefore, Moore encouraged the management of public organisations to “manage upwards” to the formal authorising environment, to “manage outwards” to the public and other stakeholders and to “manage inwards” to ensure that the organisation has the operational capacity to deliver PV (Bryson et al., 2017).

While the PV literature has largely overlooked the importance of understanding PV in accounting (Bruns, 2014; Bracci et al., 2019; Steccolini, 2019a), a body of research has started applying Moore’s strategic triangle to empirical cases (e.g. Williams and Shearer, 2011; Hartley et al., 2017). In the public management literature, some studies have challenged the positions of public managers and policymakers in creating PV by adapting the strategic triangle to multi-actor contexts (Bryson et al., 2017; Chohan and Jacobs, 2017). These studies emphasise the role of politics in strategising PV and supporting the alignment of the strategic triangle’s dimensions. Spano (2009) and Höglund et al. (2021) found that performance measurements tend to create a misalignment among the three dimensions and that negotiations between politicians, central officers and public managers tend to generate short-term goals and an increased focus on measurable output, hence depriving PV creation. Oppi and Galizzi (2024) reported that in Italian higher education institutions, GRB primarily serves as a tool for stakeholder accountability. Here, GE strategies were based on a top-down approach rather than an iterative process between organisations and their internal and external stakeholders. The scarce visibility of the GE strategy results in a misalignment in stakeholders’ involvement and emphasises the shortcomings of operational capacity.

Empirical research is needed on the alignment of strategic dimensions with public managers’ actions, the conditions shaping this alignment and its impact on effective management (Hartley et al., 2017). Further investigation into the role of accounting in PV creation, particularly through Moore’s strategic triangle, is needed. However, the contribution of accounting to the health sector has received inadequate attention compared to its contribution to PV creation in the public sector (Bracci et al., 2014; Höglund et al., 2021). It is therefore crucial to explore how organisations in the health sector can leverage accounting instruments to pursue strategic objectives while accommodating stakeholders’ needs and expectations from a gender perspective. Gender accounting tools, such as GRB, have the potential to address this issue, particularly nowadays, when there is an increasing urgency to mitigate social challenges (Bebbington and Unerman, 2020; Carnegie et al., 2024).

The health sector exhibits significant gender segregation, shaped by structural and cultural factors. Women represent 70% of the global health workforce but remain underrepresented in leadership, holding only 18.2% of the top roles in Italy (Italian Ministry of Health, 2017; WHO, 2019a). Occupational segregation is particularly deep, with men dominating technical and executive positions (Boniol et al., 2019). Gender norms contribute to persistent horizontal and vertical segregation in the European Union (EU) (EIGE, 2017a, b), where the gender pay gap in healthcare is 29% higher than that in other sectors, limiting women’s career advancement (WHO, 2019b). These disparities extend to healthcare access and outcomes—women face longer waiting times, economic barriers and caregiving burdens, leading to higher unmet healthcare needs and poorer health despite longer life expectancy (Collicelli, 2022; EIGE, 2021). Gender biases in clinical practices further exacerbate these inequalities (Collicelli, 2022).

Italian regulations mandate public organisations to promote GE through mechanisms such as the Guarantee Committee for Equal Opportunities (Italian acronym: CUG), which is responsible for proposing Positive Action Plans (PAP). Since 2009, GRB has been integrated into performance systems. Public organisations must develop a Gender Equality Plan (GEP) and disclose gender-disaggregated organisational data. From 2022, the first phase of the GRB process (Gender Report) became mandatory for Italian public organisations for hiring and funding under the National Recovery and Resilience Plan, aligned with the European Gender Equality Strategy (2020–2025).

Although there are no penalties for noncompliance, adherence is crucial for public funding. A lack of standard guidelines leaves organisations unable to navigate GRB implementation independently, thus limiting its adoption.

Since 2022, three Italian health organisations have voluntarily implemented GRB, collaborating on a joint Gender Report, which forms the basis of our case study. These organisations include a local health authority, a university hospital and an orthopaedic institute, all public and part of the Italian National Health Service, with distinct roles, specialised qualifications and separate data systems.

An explanatory case study approach (Creswell, 2009; Yin, 2017) was used to examine the GRB initiative. The chairs of the three CUGs started the Gender Report process through a semi-bottom-up approach involving the staff. Two academic experts (among the authors) served as trainers in GE accounting and as facilitators for the initiative’s development (Parker, 2017). This close involvement provided insight into both formal and informal organisational dynamics (Merriam and Tisdell, 2016; Yin, 2017).

The GRB initiative was structured into three units of analysis, each aligned with a PV strategic triangle dimension (Figure 1), to allow for an in-depth examination of interactions, facilitating/hindering conditions and management types.

Data collection relied on multiple complementary sources (Scapens, 1990) and various qualitative methods to ensure validity (Stake, 1995). It covered the entire GRB initiative, including document analysis, participant observation, focus groups, interactive feedback tools and field notes.

The qualitative analysis followed Gioia et al.’s (2013) framework, which prioritises participants’ descriptions of their experiences and in which researchers act as sense makers, ensuring that theory development is deeply grounded in empirical data (Eisenhardt, 1989). The collected material was analysed using thematic analysis (Lehner et al., 2022). The coding was conducted without a hierarchical structure (Saldaña, 2016). Through a deductive approach, predefined categories were established concerning GRB’s hindering/facilitating conditions (category A), Moore’s PV strategic triangle dimensions (category B) and managing types (category C). An inductive approach combined these three categories into a matrix to facilitate analysis by applying a fuzzy matching logic (Ragin, 2008). It was also used to map the content of empirical research into predefined categories, identify emerging patterns and reveal their complex interplay. Figure 2 presents the coding scheme developed, which served as a framework for analysing the collected materials.

The findings were derived from both the prevalence of categories and their interconnections, allowing for an exploration of relationships and dynamic interactions. To ensure a critical perspective, the third author, who did not participate in the data collection, reviewed the materials and the coding categories, providing an outsourcing perspective reinforcing the research’s analytical rigour (Vaismoradi et al., 2016).

The document analysis confirmed that GRB is formalised through regulatory frameworks, aligning with legitimacy and support dimension. In the Gender Report pathway, the focus was on strengthening operational capacity to facilitate PV rather than achieving it immediately. Conversely, plenary and subgroup interactions, aimed at enhancing operational capacity, primarily emphasised PV creation, highlighting GRB’s transformative impact on organisations and society.

Documents formalising GRB implementation reflect facilitating conditions from the literature, mainly tied to legitimacy and support (19 instances) through GRB institutionalisation and to operational capacity (10 instances) via tailored management practices. Table 1 provides illustrative quotes on this interplay.

In detail, CUG’s formalisation in 2016 marked a commitment to GE initiatives through active collaboration “to harmonise their gender equality initiatives, aiming to standardize practices and behaviours for employees across the city’s healthcare system” (Deliberation, 2018 of the General Director of the Local Health Authority). This collaboration evolved through successive PAPs and GEPs, culminating in the 2023–2025 GEPAP, which merged both frameworks to minimise redundancy and foster alignment across the diverse missions of the three organisations and address both internal needs and broader societal shifts. As noted in the GEP (2022–2024), “Through this collaboration, they create synergies and multiply resources and opportunities to achieve the objectives outlined in the GEP”.

Integrating regulatory adherence with strategic engagement reveals a nuanced understanding of GE’s benefits. One key quote explains, “Gender equality is, primarily, a matter of protecting a fundamental right, but it is also a matter of technological development and progress, of widespread improvement of human living conditions, and of economic growth” (GEP, 2022–2024). Beyond compliance, they use external mandates as opportunities to embed GE into broader strategic priorities.

GE is thus portrayed as central to fostering inclusive organisational cultures and enhancing workforce well-being. Initiatives in this arena extend beyond obligatory measures; they promote economic growth and human development through participatory approaches that engage staff extensively, thereby strengthening the legitimacy of the strategies. Concurrently, tailored bottom-up and interorganisational practices build operational capacity, ensuring that GE efforts lead to tangible improvements in both the workplace and the broader community.

The document analysis highlights key facilitating conditions, including regulatory provisions, collaboration and political commitment. Contrary to expectations (Martínez Guzman, 2024b), external pressures did not play a significant role, as strong internal consensus prevented these conditions from becoming either triggers or hindrances to GRB implementation. In this study, external pressures were exerted solely by national and supranational bodies mandating gender reporting tools, while internal alignment was strong. Additionally, this stage of the GRB initiative faced no resistance from civil servants, a hindrance identified by Fernandez-Gutierrez and Van de Walle (2019), that impacts Operational Capacity.

Ambivalence also characterises other facilitating and hindering conditions. Tensions between mandatory compliance and voluntary engagement have sometimes complicated internal acceptance and slowed implementation (Martínez Guzman, 2024b). For instance, “For research entities, adopting a GEP became a prerequisite for accessing funding—not because it affects project evaluations, but because it is required when signing the Grant Agreement” (GEP, 2022–2024). Consequently, governance within the three organisations empowered the CUG chairs to launch the GRB initiative, culminating in the Gender Report and building on established practices.

Efforts to integrate various frameworks aim to streamline processes, as noted by Elomäki and Ylöstalo (2021) and Polzer and Seiwald (2021), but they also introduce complexities in harmonising objectives and preventing redundancies. Divergent institutional mandates further complicate this balance between integration and differentiation. As one resolution states, “The inter-organizational Gender Equality Plan Team is tasked with potentially revising objectives and actions across different intervention areas based on the implementation status in the three organizations and in close coordination with the inter-organizational governance board” (Various documents).

Another significant challenge is the availability of gender-disaggregated data, which are crucial for planning and monitoring according to EU guidelines (Steccolini, 2019b). As one document emphasises, “To meet the requirements of the European Commission, it is, therefore, necessary to indicate gender equality actions specifically and to adopt these actions based on a programming and monitoring process that must be based on gender-disaggregated data” (GEPAP, 2023–2025). The health sector faces difficulties because of a lack of standardised methodologies, rendering collecting and analysing such data a challenging task.

In summary, compliance requirements, external mandates and strong institutional backing confirm legitimacy and support as the key drivers of the GRB initiative. Their central role is evident in the continuous adaptation of GRB tools to align with broader frameworks. The operational capacity dimension emerges from an ingrained organisational propensity for collaboration that, while already established for other purposes, is now directed towards advancing GE goals.

Rather than managing up to the formal authorising environment (Bryson et al., 2017), the three public organisations align with the GE orientation promoted by external institutions and internal governance. They focus on managing inwards to ensure the capacity required for effective PV delivery and on managing outwards to reconcile their diverse missions with the community’s and other stakeholders’ needs.

The Gender Report process outlines key steps, specifying timing, tasks, actors and settings (Table 2). Categorisation relies on an inductive approach and fuzzy logic. The observational nuances recorded in the field notes column suggest that a descriptive analysis is more suitable than frequency counts.

Academic experts provided knowledge that was not available internally. As noted in the 2022 Gender Report, “This includes original elements: (1) no established model exists for such a report in the health sector; (2) no prior experience unifies the activities of diverse health organizations; (3) no precedent in developing a Gender Report that combines health research with healthcare services”.

Maintaining an interorganisational approach, the CUG chairs employed a semi-bottom-up strategy to engage staff, involve experts and keep governance informed, securing approval for key steps like the report’s table of contents and final document. While experts guided the participants, the initiative was formally led by the CUG chairs, who represented GE policy at every meeting. External expertise not only supported the GRB initiative (O’Hagan, 2018) but also enhanced the process by motivating staff and legitimising the final product: “This work is further qualified by the support of the University of (…), represented by (…), highlighting the value of collaboration between institutions, especially to avoid starting from scratch each time, as if there were no established practices already in place” (2022 Gender Report).

The CUG chairs selected approximately 40 civil servants across the three organisations to draft the report. Academic experts conducted four plenary meetings with chairs and participants to build gender knowledge and foster commitment to the GRB process. These sessions aligned internal efforts towards GE, activating operational capacity. During these meetings, the participants formed informal, self-managed working groups to propose a table of contents, considering the relevance and feasibility of gender inequalities in healthcare. This approach strengthened interorganisational relationships and tackled the challenge of gender-disaggregated data—a significant hindering condition noted in the literature (Steccolini, 2019b). Experts consolidated subgroup discussions into a proposed table of contents, which was submitted to CUG chairs for approval and then further refined in a plenary session with all the participants, reinforcing internal and external legitimacy.

Following approval, the scope of analysis, financial and nonfinancial data requirements and a working schedule were defined. The schedule assigned responsibilities and designated offices and deadlines, ensuring participants’ collaboration and engagement, thereby reinforcing operational capacity.

In March 2023, the CUG chairs submitted the finalised table of contents for governance approval, a step corresponding to managing upwards and activating legitimacy and support.

Subsequently, four thematic improvement groups were established, covering (1) human resources, (2) research and publications, (3) healthcare services and (4) service production costs (with 6–15 people each). Some participants joined later without prior plenary training. Their inclusion was communicated through emails and calls to senior managers, an example of managing inward, which intersects legitimacy and support with the operational capacity to create PV.

In the first round of focus group meetings, the participants addressed gender-disaggregated data availability and identified substitute data where necessary. Academic experts processed these data, which were refined in the second round of meetings. Discussions ensured that information representation reflected each organization’s characteristics, with co-designed indicators emphasising gender-related issues. Operational capacity was reinforced through stakeholder engagement, aligning efforts with the PV dimension.

Academic experts then analysed the data, sending the output for group feedback. After two rounds of revisions, the Gender Report was finalised. The CUG chairs and experts jointly reviewed the document by the end of 2023, further activating legitimacy and support, as well as a form of managing outward. At this stage, experts, acting as external stakeholders, assessed whether initial objectives aligned with final outcomes, as literature suggests.

The Gender Report was subsequently approved by governance bodies, followed by dissemination events organised by the CUG chairs. An internal presentation to the organisations’ staff occurred in November 2023, coinciding with the International Day for the Elimination of Violence against Women. Then, a public presentation in May 2024 involved stakeholders, such as institutions, trade unions, patient associations and the press. During this event, future actions derived from the report were discussed through a roundtable with the general directors of the three organisations, the city’s councillor for welfare and health and the equality plan coordinator, with academic experts providing an overview of the process. This reinforced legitimacy and support by managing inwards to benefit internal staff, managing upwards to institutional figures ensuring PV for the community and managing outwards to align broader efforts towards PV creation.

Operational capacity was central in the initial stages. Legitimacy and support became more significant later, particularly during governance approval and dissemination. The PV dimension remained integral throughout, as the Gender Report aimed to promote GE and generate positive organisational and societal impact.

Operational capacity functioned as the driving force, with organisations managing inwards to develop the expertise and engagement necessary for PV creation (Bryson et al., 2017). Meanwhile, managing upwards strengthened legitimacy in governance, and managing outwards validated outcomes with external stakeholders and communicated findings to the wider community.

Plenary meetings emphasised the rationale behind the GRB initiative, which was primarily tied to compliance with institutional funding requirements. This relates to the legitimacy and support dimension, ensuring adherence to governance and regulations. Although this dimension reflects a political commitment to GE, it does not play a proactive role. During a plenary presentation, academic experts detailed the regulatory measures requiring GRB, and the audience frequently requested access to these slides, indicating limited prior knowledge. Conversely, when gender disparity data in science and healthcare were presented, the participants displayed full awareness, suggesting an existing GE-friendly climate based on prior experiences and ethical perspectives.

When existing Gender Reports in healthcare were introduced, some participants confidently stated, “We will do much better than these!” This confidence likely stemmed from past interorganisational collaboration and an innovation-driven mindset. During the plenary meetings, expectations regarding the final document were collected through an interactive tool. These responses, categorised in Table 3 according to PV triangle strategic dimensions, highlighted key expectations. The legitimacy and support dimension called for accurate and action-driven Gender Report with measurable and verifiable commitments. Operational capacity emphasised data access, advanced reporting tools and progress tracking over time. The PV dimension focused on social impact, improving working conditions and cultural change. Therefore, the Gender Report was perceived not only as a monitoring tool but also as a driver of inclusive workplace transformation.

The analysis revealed that legitimacy and support played a lesser role than the transparency and communication of gender policies within and outside the organisations, while operational capacity was crucial in creating a robust and practical tool. The PV dimension emerged as a key driver, reinforcing the commitment to GE and employee well-being as the foundation of the Gender Report initiative.

Some facilitating and hindering conditions emerged, although less prominently than in Moore’s strategic triangle analysis. Stakeholder engagement, a GE-friendly climate, tailored management practices and previous GE initiatives were identified as interlinked facilitators. The second group demonstrated heightened sensitivity to GE issues, focusing on research and publication metrics. This area was novel, given the dual role of these organisations as healthcare providers and research institutions, resembling universities more than hospitals. The group also navigated gender-disaggregated research funding regulations, in which such data are often absent despite known gender segregation. Their approach balanced building on past experience with the desire to set a benchmark for similar organisations.

The institutionalisation of GRB was closely tied to staff expertise, based on previous GE documents. Across all groups, veteran participants reacted strongly when newcomers questioned well-established metrics. Data extraction delays also emerged when this task was assigned to external staff. This confirmed that including civil servants from the outset is a crucial facilitating factor (Galizzi et al., 2023).

While many digital datasets were immediately processable by gender, some relevant data were unavailable because of gaps in information systems. This issue was tied to the political commitment to GE. For example, the participants sought transparency in career progression and leadership access, but discussions revealed the absence of public repositories for managerial applications and selection committee compositions. Addressing such data gaps required additional efforts, often necessitating senior manager authorisation, which was not always granted because of operational or political priorities.

Operational and political considerations also influenced data systems differently across the three organisations. For example, data on staff exposure to aggression and work-related injuries varied between institutions because of differing reporting protocols. Similar discrepancies emerged for the staff of universities, whose policies followed separate gender regulations, and gender pay gap calculations. Measuring tenure-based glass ceiling effects across staff categories posed additional challenges.

At times, existing gender-disaggregated data were deemed irrelevant by group members, reflecting gender bias or insensitivity despite supporting literature. This issue was observed in discussions about emergency room waiting times and patients leaving before being diagnosed. While collaboration remained high overall, this aligns with the literature describing civil servant resistance as a hindering factor (Fernandez-Gutierrez and Van de Walle, 2019). Despite these challenges, collaboration and structured discussions facilitated problem resolution. Clear task division and timelines effectively reduced workload burdens.

Leadership support played an ambiguous role—while CUG chairs primarily participated as peers, they assumed a more directive stance when resolving deadlocks. Their continuous presence, active participation and facilitation of fieldwork with academic experts were key facilitating factors.

The semi-bottom-up approach proved essential to the GRB initiative. It fostered synergy across all three PV dimensions and effectively implemented managing upwards, inwards and outwards, reinforcing the legitimacy, operational capacity and PV creation of the Gender Report.

This study focuses on how GRB, as a process of incorporating a gender perspective into the accounting system to improve GE, can contribute to creating PV in the health sector. As such, the paper seeks to address both the lack of GRB studies in public sector accounting and the limited attention given to the health sector in terms of GRB and PV creation research. Using Moore’s strategic triangle as a theoretical and analytical framework to improve the understanding of the conditions fostering and hindering GRB, this study provides interesting insights into the delicate interplay between the different stakeholders and dimensions involved in PV creation. It facilitates an improved understanding of the GRB process and its accounting implications in PV creation and contributes to managerial practices related to strategic GRB and PV processes.

Triangulating the collected material revealed some novel elements (Figure 3). The legitimacy and support dimension frames the legal requirement for GRB as a facilitating condition, but it is primarily compliance driven rather than a proactive or voluntary effort, as interpreted in the literature (Galizzi et al., 2021; Martínez Guzman, 2024a; Moser and Korac, 2021). The lack of GRB experience in the Italian health sector thus far suggests that neither the legal framework nor the financial subsidy per se is sufficient to establish a GRB initiative. Undoubtedly, in this case, the GRB initiative has taken place thanks to the organisations’ political commitment, who commissioned the three CUGs. In their statements, compliance to secure public funding is masked as a commitment towards GE.

In their institutional role and GRB commitment, the CUG chairs have been crucial in advancing the process towards the organisations’ governance and effectively implementing it. Aligning with prior literature (Elomäki and Ylöstalo, 2021; Martínez Guzman, 2024b; Polzer and Seiwald, 2021), leadership support is a facilitating condition. The CUG chairs ensured the participation of civil servants, which was essential for developing the Gender Report, even though it represented an additional workload.

In the case studied, maintaining interorganisational collaboration has paved the way for institutionalising GRB, which subsequently ensures the visibility of gender issues and supports decision making and resource allocation (Galizzi et al., 2023; Khalifa and Scarparo, 2021; Steccolini, 2019b). This collaboration triggers the organisations’ political commitment to GE (Elomäki and Ylöstalo, 2021; Jorge et al., 2023; Polzer and Seiwald, 2021). The GE-friendly climate (Jorge et al., 2023) also stems from prior experiences and the staff’s innovation-oriented mindset.

The involvement of both internal and external stakeholders ensures the feasibility and sustainability of GRB initiatives (Galizzi et al., 2018), particularly through liaisons with academic experts and the external presentation of the final output.

Within the operational capacity dimension, gender-disaggregated data availability is crucial (Steccolini, 2019b) as both a facilitating and a hindering condition. Data availability is closely tied to the political commitment to GE, including the internal commitment of the staff responsible for producing such data. Conversely, resistance from civil servants (Fernandez-Gutierrez and Van de Walle, 2019; Martìnez Guzmàn, 2024b) can arise from a lack of understanding of the motivations underlying GRB initiatives. Moreover, hindering conditions were encountered when data extraction was entrusted to staff external to the groups’ members. Thus, including civil servants early in the GRB process is a key facilitator.

The staff’s willingness to pursue the initiative fosters tailored management practices (Galizzi et al., 2023; Steccolini, 2019b; Galizzi et al., 2023), consistent with the organization’s innovation-oriented mindset). The civil servants’ engagement played a crucial role, given their cooperation in selecting the data, defining metrics, and data extraction and interpretation according to the peculiarities of the three organisations. Accordingly, the semi-bottom-up approach supported the participants’ motivation and collaboration and set a positive competition mode. Indeed, participants were willing to see the gender inequalities addressed in their workplace, which legitimated the GRB process.

This approach reinforced their commitment to quality, comparable data for identifying gender imbalances while easing the workload of adopting a new accounting tool. Additionally, external support from academic experts, a bottom-up approach and CUG chairs’ monitoring were essential to the process.

In this case, external pressures came only from institutional mandates for GRB, facilitating conditions without internal disagreement (Martínez Guzman, 2024b). Resistance from civil servants (Fernandez-Gutierrez and Van de Walle, 2019), a hindering factor in operational capacity, was minimal.

From a crystallisation perspective, these findings form a prism (Table 4), offering multiple angles of analysis rather than a triangle converging on a single truth (Murphy and Maguire, 2011). This prism highlights the dynamic interplay of PV dimensions, facilitating and hindering conditions and managing types—all interacting dynamically rather than remaining confined to specific dimensions.

While primarily linked to legitimacy and support, managing upwards also influences operational capacity by securing resources and institutional commitment. It extends to PV by establishing external trust and credibility. Managing inwards strengthens operational capacity through internal collaboration and tailored practices while reinforcing legitimacy by demonstrating the initiative’s viability. Its outcomes feed into PV by producing tangible results that resonate with external audiences. Managing outwards, closely tied to PV, also reinforces legitimacy through transparent communication and strengthens operational practices by encouraging feedback and continuous improvement. Furthermore, this prism highlights the interconnectedness of facilitating and hindering conditions across dimensions and management approaches. This interplay allows the GRB initiative to navigate organisational complexities, foster internal consensus, and amplify its external impact.

Reading the GRB initiative through Moore’s triangle highlights these interdependencies while addressing the facilitating and hindering conditions within each dimension. Among the facilitating conditions, regulatory frameworks and political commitment stand out as foundational. Clear mandates and support from national and supranational institutions provide legitimacy and support to the initiative, ensuring alignment with external expectations. This alignment is further strengthened by the collaborative propensity within the organisations, which supports the operational capacity needed to implement GE goals. Staff expertise, especially from those with prior experience in similar initiatives, fosters a culture of shared knowledge and innovation. Leadership participation, particularly the active involvement of CUG chairs, is also key. Leaders act as mediators, ensuring group cohesion and facilitating progress while leveraging their institutional knowledge to guide decision making. Transparency in reporting and the emphasis on gender-disaggregated data further enhance stakeholder engagement, building internal and external trust and reinforcing the initiative’s alignment with broader societal expectations.

As for the hindering conditions, fragmented data systems and inconsistencies in reporting across organisations slow progress and undermine operational capacity. Scepticism about the relevance of certain metrics and a lack of sensitivity to gender-related issues occasionally disrupt collaboration and highlight underlying biases. Gaps in gender-disaggregated data, particularly in areas like leadership composition and research outputs, weaken the initiative’s ability to measure potential gender disparities. These gaps not only hinder transparency but also limit accountability capacity.

Within the prism, managing upward benefits from regulatory support and political commitment, which bolster legitimacy and support. However, the absence of transformative external pressures limits opportunities to challenge and resolve organisational ambivalence. Managing inwards is driven by collaborative practices and expertise, which strengthen operational capacity, but data fragmentation and occasional resistance expose vulnerabilities that require careful attention. Managing outwards, focused on engaging stakeholders and demonstrating impact, amplifies the PV dimension but is constrained by data gaps, undermining the initiative’s ability to present comprehensive results.

This study describes the Gender Report implemented jointly by three Italian health organisations, which is the first phase of the GRB initiative, aimed at GE awareness among the governance and stakeholders within the organisations (Rubin and Bartle, 2005). The initiative has been analysed using the PV strategic triangle as a theoretical and analytical framework to understand facilitating and hindering conditions in depth. This research provides a foundation for advancing both the theoretical understanding and the practical application of GRB as a tool for achieving GE and creating PV.

This work extends the literature on PV and GRB in the health sector, a context with significant gender segregation that is underexplored in both PV and GRB research. It contributes to the literature by proposing a prism framework that explores the interplay of Moore’s strategic triangle dimensions in the context of GRB. Unlike a static triangle with fixed vertices, the prism reveals the dynamic interactions between the dimensions and managing types. This perspective enriches the understanding of how facilitating and hindering conditions are interconnected with PV creation, offering a nuanced view of the alignment and trade-offs required in complex organisational contexts, such as the health sector.

The findings underscore the value of integrating GRB in health organisations through a semi-bottom-up approach that enhances stakeholder engagement and institutional collaboration. However, its effectiveness depends on a cooperative environment. Challenges include the lack of standardised GRB metrics, data inconsistencies and weak GE mandates. External expert support remains crucial.

For policymakers, the study underscores the importance of a supportive regulatory framework, political commitment and stakeholder engagement to institutionalise GRB. It emphasises that external pressures alone, without internal alignment and operational capacity, are insufficient. The findings advocate creating standardised guidelines and improving gender-disaggregated data systems to ensure effective implementation.

This research is based on a single case study of three Italian health organisations, which may limit generalisability. In addition, the study focuses exclusively on GRB preparers’ perspectives. Although this limitation is closely related to the theoretical framework, as Moore’s strategic triangle primarily considers an internal perspective of PV creation (Benington and Moore, 2011), further research may consider both internal organisational dynamics and external societal perceptions, such as those of patients in the health sector, when analysing GRB implementation.

Future research could also explore GRB implementation across diverse sectors and regions to validate the findings and understand the influence of varying institutional and cultural contexts. The interplay between facilitating and hindering conditions warrants further exploration, particularly in diverse organisational settings with varying readiness levels, resource availability and stakeholder engagement. This could uncover how different combinations of conditions affect the trajectory and success of GRB initiatives. Lastly, developing standardised frameworks for GRB metrics and gender-disaggregated data collection is essential to enhance comparability and effectiveness. These frameworks would address current data collection and reporting inconsistencies, offering clear guidelines that facilitate organisations to better measure, monitor, and communicate their progress toward gender equity. Standardisation would also facilitate cross-sector and cross-national comparisons, contributing to a cohesive body of evidence in the field.

The authors would like to thank the General Directors of the three health organisations involved in the study, with special appreciation to the Chairs of the CUGs – Sabrina Colombari, Lorena Landi and Elisa Porcu – and all participants in the Gender Report process for their valuable contributions. Acknowledgement is also given to Giorgia Angelini, undergraduate student in Economics at the University of Bologna – Forlì Campus, for her support in note-taking during the focus groups. The authors also wish to acknowledge the constructive feedback provided by the anonymous reviewers of the Journal of Public Budgeting, Accounting and Financial Management, which contributed to improving the quality of the manuscript. This paper is one of the research outputs of the grant “A performance measurement system to the health care and research outputs for evaluating IRCCSs” co-funded by the Department of Management of the University of Bologna. Paola Canestrini is profoundly grateful for the financial support received during the preparation and publication of this research.