Evaluation of Health Canada’s Sex and Gender Action Plan 2017-18 to 2019-20 

Table of Contents

• Executive Summary
• Management Response and Action Plan
• 1.0 Evaluation Scope
• 2.0 Program Profile
  • 2.1 Program Context
  • 2.2 Action Plan: Background and Approach
  • 2.3 Action Plan Timeline
  • 2.4 Program Resources
• 3.0 What difference did the Action Plan make?
  • 3.1 Individuals within each branch improved their knowledge of SGBA+
  • 3.2 Some governance elements were put in place to support SGBA+ integration
  • 3.3 There was greater application of SGBA+ in some departmental and branch processes
• 4.0 Program Strengths
• 5.0 What gaps or challenges still exist in the systemic integration of SGBA+ across Health Canada?
  • 5.1 Knowledge
  • 5.2 Accountability
  • 5.3 Branch-level integration of SGBA+
• 6.0 Conclusions
• 7.0 Recommendations
• Appendix 1 - Evaluation Scope and Approach
• Appendix 2 - Data Collection and Analysis Methods
• Appendix 3 - Health Canada Sex and Gender Action Plan Logic Model
• Appendix 4 - Health Canada Sex and Gender Action Plan Placemat
• Appendix 5 - Action Plan Branch Priority Initiatives (2017-2020)
• Appendix 6: Average Knowledge of GBA+ and SGBA+ by Branch and Area of Work (2020)
• Appendix 7: Application of GBA+ and SGBA+ by Area of Work (2020)
• References and End Notes

List of Acronyms

CIHR-IGH

Canadian Institutes of Health Research - Institute of Gender and Health

GBA

Gender-Based Analysis

GBA+

Gender-Based Analysis Plus

MRAP

Management Response and Action Plan

PHAC

Public Health Agency of Canada

PMRA

Pest Management Regulatory Agency

SGBA

Sex and Gender-Based Analysis

SGBA+

Sex and Gender-Based Analysis Plus

Executive Summary

Background

Health Canada's Sex and Gender Action Plan was launched in May 2017 with the aim of systematically integrating sex and gender considerations into all of Health Canada's research, legislation, policies, regulations, programs, and services. Doing so would help to maximize the positive impacts of Health Canada's programs, while reducing the risk of inadvertent harm to the health of some Canadians. The Action Plan is a Health Canada-wide initiative that is managed by the Gender and Health Unit (GHU) of the Strategic Policy Branch. It includes a Coordinating Committee of branch representatives as part of its governance structure.

The initial focus of the evaluation was to provide guidance to the Gender Health Unit (GHU) to inform planning for the renewal of the Action Plan. Particular attention was paid to branch priority initiatives and the Policy-Research Partnership with the Canadian Institutes of Health Research - Institute of Gender and Health (CIHR-IGH). Considerations were given to the governance structures and activities that supported the goals of the Action Plan.

Summary of Findings

Overall, there are clear indications that understanding and application of SGBA+ across the Department has improved in those areas where staff are directly involved in Action Plan activities, as well as areas where application is part of a required corporate process. However, a broader cultural change leading to the systematic integration of sex, gender, and diversity considerations into all of Health Canada's policies, programs, legislation, regulations, services, research, and workplace initiatives has not yet occurred.

To date, there are early indications that Action Plan activities have led to some success, as well as to more concerted effort to include Sex and Gender-Based Analysis Plus (SGBA+) in corporate activities, such as developing Cabinet documents, budget proposals, and performance measurement frameworks (e.g., Performance Information Profiles). Knowledge and awareness of SGBA+ has increased among Health Canada employees directly involved in the Action Plan's priority initiatives, networking, and training. There has also been some increased integration of SGBA+ into organizational processes, thanks to the tools and resources created or enhanced through the Action Plan. These successes can be linked to the flexible design of the Action Plan, which allowed branches to take a tailored approach to their participation, enabled by the GHU and its CIRH-IGH partnership. While COVID-19 response efforts interrupted the second phase of the Action Plan, the GHU was able to pivot quickly and provide SGBA+ expertise to support the response.

While the Action Plan has resulted in a maturing of how some groups have incorporated SGBA+ into their work, more needs to be done to achieve a broader cultural shift of integrating SGBA+ across the Department. There remains a lack of accountability, branch-level planning, and adequate knowledge among some other groups when it comes to applying SGBA+. It is unclear who should be responsible for systematically integrating SGBA+ into key processes within each branch. To move beyond a reliance on demonstration projects, branches will now need to consider when and how they can further incorporate SGBA+ into their specific lines of work. Furthermore, there is wide variation in staff understanding of SGBA+ concepts, especially intersectionality, and their relevance across branches and functional areas. With enhanced branch-level accountabilities for SGBA+, the GHU can continue to support branches in their integration of SGBA+ and knowledge development across the Department.

Recommendations

SGBA+ activities are the collective responsibility of all branch heads, in line with the Health Portfolio SGBA Policy. It is the responsibility of senior management to provide the leadership necessary to ensure the implementation of SGBA+ within their Health Portfolio organizations. On the other hand, the successful implementation of SGBA+ requires the participation of all Health Portfolio staff.

This evaluation was undertaken to provide guidance to the Strategic Policy Branch's GHU to inform the next phase of the Action Plan. However, both progress and challenges related to the systematic integration of SGBA+ across Health Canada involve all branches, as each branch is responsible for ensuring the integration of SGBA+ into their respective organizational processes. The GHU will continue to be the centre of expertise for the Department.

The three recommendations developed in this evaluation should support the envisioned cultural shift of integrating SGBA+ within each branch. While the GHU will continue to be a centre of expertise for the Department, it will not be solely responsible for implementing these recommendations; in fact, much of the work will be done within the branches themselves. Therefore, the Strategic Policy Branch will be the representative branch signing off on the MRAP on behalf of the other branches in the Department.

Recommendation 1: Renew the governance structure for SGBA+ to oversee the integration of SGBA+ within each branch.

The SGBA+ Network is the current body tasked with enabling a Department-wide SGBA+ culture change. It provides a forum for branches to learn from each other, but its members do not have the necessary authority to stimulate the systematic integration of SGBA+ within each branch. In order to empower staff within each branch to continue advancing the integration of SGBA+, the Strategic Policy Branch could renew SGBA+ Network membership by requesting that branch heads nominate representatives who would be tasked to work across their branches on integrating SGBA+.

In addition, progress on the integration of SGBA+ is not being considered at the Executive Committee level on a regular basis. Doing so would demonstrate the importance of SGBA+ to the Department, while giving executives the opportunity to give strategic direction to implementation plans. The Strategic Policy Branch could facilitate regular senior management discussion on the progress of SGBA+ integration within each branch and across the Department.

Recommendation 2: Support branch-led planning to integrate SGBA+ into their organizational processes.

Each branch is responsible for ensuring the integration of SGBA+ into their organizational processes. While gains have been made, there remains a need to enhance the consistency and quality of its application across branches and functional areas. In order to ensure a lasting cultural shift, branches should move beyond pilot projects to integrate SGBA+ into key organizational processes, as appropriate. Each branch should develop its own targeted SGBA+ integration plan with performance indicators (i.e., level of knowledge, extent of application). The GHU could support branch-led planning, including facilitating collaborations with experts where it would be strategically advantageous to do so.

Recommendation 3: Address key knowledge gaps by clarifying SGBA+ concepts and supporting SGBA+ training specific to different branches and functional areas.

The relevance of SGBA+ concepts, including the 'plus' (intersectionality), appears difficult for many employees to understand. This presents a fundamental challenge to achieving systematic integration of SGBA+ across Health Canada. Furthermore, different branches and functional areas (e.g., science, regulation, communications) have specific challenges and opportunities in applying SGBA+ to their work, and these should be recognized in branch-level SGBA+ planning, leading to tailored communications and training. This will ensure a greater level of understanding among all Health Canada staff of the relevance of SGBA+ to their specific lines of work, as well as a better understanding in terms of when and how it may be appropriate to consider sex, gender, and diversity in the context of their work.

Management Response and Action Plan

Evaluation of Health Canada's Sex and Gender Action Plan

Recommendations	Response	Action Plan	Deliverables	Expected Completion Date	Accountability	Resources
Recommendation as stated in the evaluation report	Identify whether program management agrees, agrees with conditions, or disagrees with the recommendation, and why	Identify what action(s) program management will take to address the recommendation	Identify key deliverables	dentify timeline for implementation of each deliverable	Identify Senior Management and Executive (DG and ADM level) accountable for the implementation of each deliverable	Describe the human and/or financial resources required to complete recommendation, including the source of resources (additional vs. existing budget)
Renew the governance structure for SGBA+ to oversee the integration of SGBA+ within each branch.	Agree	Establish Branch Head-level accountability with periodic reporting to EC on SGBA+ progress. Revitalize the SGBA+ Network with appointed branch and functional network (e.g. science, regulatory, policy) representatives who are accountable to their Branch Heads.	Annual agenda item at EC, highlighting SGBA+ integration, informed by DG level discussions at science, regulations, policy and planning tables. Reconfigured Network whose members include Branch Head appointed representatives with TORs that outline assigned roles and responsibilities.	First EC discussion to take place in Q3 2022-23 Representatives appointed and TORs approved in Q4 2021-22	All Branch Heads DG HPSI, SPB to lead the reconfiguration of Network All Branch Heads to appoint Network representatives	Actions undertaken by GHU can be completed using existing resources. Each branch will need to assess its own HR and/or financial resource requirements.
Support branch-led planning to integrate SGBA+ into their organizational processes.	Agree	Develop branch specific SGBA+ integration plans. Deliver annual progress and performance report to EC based on branch SGBA+ integration plans. Strengthen SGBA+ integration into Performance Information Profiles (PIPS).	SGBA+ integration plans with activities, expected outcomes and their associated performance indicators are developed by Branches with guidance from the GHU. Information session(s), templates and other resources and guidance, as required, to support plans. Annual report with key dashboard indicators presented to EC with Branch input compiled by GHU. Programs are supported by GHU and CFOB to revise/enhance their PIPS, where possible, with indicators that can be disaggregated by sex, gender and diversity factors.	Q4 2021-22 and updated annually thereafter Q3 2021-22 Q3 2022-23 and annually thereafter Q1 2021-22 and annually thereafter	All Branch Heads DG HPSI, SPB All Branch Heads All Branch Heads	An SGBA+ focal point will be required in each branch. Branches will need to assess their specific HR and/or financial resource requirements. Actions undertaken by GHU can be completed using existing resources. Actions undertaken by GHU can be completed using existing resources, but require branch cooperation and input. Actions undertaken by GHU can be completed using existing resources. Branches will need to assess their specific HR and/or financial resource requirements.
Address key knowledge gaps by clarifying SGBA+ concepts and supporting SGBA+ training specific to different branches and functional areas.	Agree.	Update the Health Portfolio SGBA Policy to include the 'plus.' Develop a communications plan focussed on increasing employee understanding of SGBA+ and associated concepts (e.g. diversity, intersectionality, inclusion) and how it can apply to their work. Develop an SGBA+ learning path that will build on existing training and resources to support the development and delivery of a suite of enhanced SGBA+ tools and learning products to enable Health Canada employees to increase their knowledge and skills in applying SGBA+ (intersectionality, diversity and inclusion) concepts to their work.	Revised policy which explains and reflects the importance of intersectional analyses and makes explicit our collective roles and responsibilities to integrate SGBA+ into our work. Communications plan developed by GHU and CPAB, that reflects an enriched view of SGBA+ and which provides clarity on how lenses and strategies interconnect. GHU to put in place enhanced training and resources that are customized according to employees' roles, functions and responsibilities.	Q3 2021-22 Q4 2021-22 Q4 2021-2022 to Q4-2022-23	DG HPSI, ADM, SPB DG HPSI, SPB DG HPSI, SPB	Actions undertaken by GHU can be completed using existing resources. Actions undertaken by GHU and CPAB can be completed using existing resources. Actions undertaken by GHU can be completed using existing resources with possible additional assigned branch focal points and use of experts.

1.0 Evaluation Scope

The evaluation was conducted to provide guidance to the Gender and Health Unit (GHU) in Health Canada's Strategic Policy Branch, in order to inform the next phase of the Sex and Gender Action Plan. The evaluation covered activities under the five elements of the Action Plan (described in Section 2 below) from 2017-18 to 2019-20, with a particular focus on branch priority initiatives and the Policy-Research Partnership with the Canadian Institutes of Health Research - Institute of Gender and Health (CIHR-IGH).

The following questions were developed to guide the evaluation, in consultation with evaluation stakeholders:

1. What impact have all five Health Canada Sex and Gender Action Plan elements had on advancing the integration of sex, gender, and diversity considerations in Departmental research, legislation, policies, regulations, programs, and services?
2. What opportunities and challenges should be considered as part of the Action Plan moving forward?
3. To what extent has the management of the Action Plan supported the achievement of outcomes?
   1. Has the Action Plan's governance structure facilitated engagement with internal and external stakeholders, supported decision making, and ensured transparency?
   2. Does Health Canada have the appropriate methods and performance measures in place to assess the Action Plan? Are there any gaps?

More details on the evaluation scope, questions, and approach can be found in Appendix 1. The evaluation used the following methods in order to gather and analyze information on the Action Plan: document review, interviews with key informants, analysis of results from the Health Portfolio Sex and Gender-Based Analysis (SGBA) Employee Survey (from 2016, 2018, and 2020), and a limited scan of academic literature. Further details on data collection and limitations are presented in Appendix 2.

2.0 Program Profile

2.1 Program Context

The Government of Canada has recognized that biological, economic, and social differences between diverse groups of women and men contribute to differences in health risks, health services use, health system interaction, and health outcomes; and this is reinforced by widespread academic research.^{Footnote i} The 2012 Chief Public Health Officer's Report on the State of Public Health in Canada notes that symptoms, diagnostic tools, treatment effects, and access to care are affected by sex and gender. For example, while the prevalence of hypertension is equal among men and women in Canada, based on biological sex, there are different experiences in diagnosis and treatment, based on gender.^{Footnote 1} While women are more likely to engage with the health system, hypertension may be more frequently misdiagnosed. On the other hand, men are less likely to seek treatment, so are less likely to be aware of their hypertension.

There is a long history of federal commitments^{Footnote ii} at the national and international level, including the Canadian Charter of Rights and Freedoms, to reduce discrimination based on gender and promote gender equality (displayed in Figure 1). The Government of Canada adopted Gender-Based Analysis (GBA) through a Cabinet commitment as a result of the 1995 UN World Conference on Women. This commitment was implemented through the Federal Plan for Gender Equality (1995), which included a systematic approach to the integration of GBA across all federal departments and agencies.

Figure 1 - Text Equivalent

This image provides a sample of initiatives on gender equality, branching off a large red arrow pointing right and displaying decades from 1980 to 2020. Above the arrow are multiple text boxes describing federal government initiatives by year. Below the arrow are multiple text boxes describing Health Canada initiatives by year.

In 2009, the Health Portfolio, which includes Health Canada, the Public Health Agency of Canada, and the Canadian Institutes of Health Research, added biological sex distinctions to GBA concepts, given its role in health issues. This expanded term was incorporated into the Health Portfolio Sex and Gender-Based Analysis Policy, developed to advance the integration of sex and gender-based considerations into the analysis of health issues, the development of science, and the implementation of programs and policies. It has helped to inform and shape the current approach across the Health Portfolio and to develop Health Canada's Sex and Gender Action Plan.^{Footnote iii} In 2011, GBA concepts were expanded by Status of Women Canada, now the Department of Women and Gender Equality, to include additional diversity identifiers, represented by the 'plus' (i.e., "GBA+") in recognition of the many factors that contribute to an individual's identity (e.g., biological sex, age, ethnicity, level of income). As such, the term Sex and Gender-Based Analysis Plus (SGBA+) is now used across the Health Portfolio.^{Footnote 2} This term now also includes the concept of Intersectionality (see spotlight explanation).

Spotlight: Intersectionality

Intersectionality is a framework rooted in feminist, critical race, and postcolonial theories for understanding how aspects of a person's social and political identities combine to create different modes of discrimination and privilege, such as gender, race or ethnicity, age, sexuality, disability, and religion, and how these may affect inequity. The term was first used in a 1989 paper by law professor Kimberlé Crenshaw.Footnote iv,Footnote v

More recent developments include requirements that all Treasury Board submissions include a GBA component beginning in 2007, incorporation of GBA+ in ministerial mandate letters as of 2015, and a TBS requirement for GBA+ in departmental performance reporting in the 2016 Policy on Results.^{Footnote vi} These requirements are examples of a 'push' from central agencies and the Department of Women and Gender Equality to compel the adoption of GBA+ in key corporate processes.

2.2 Action Plan: Background and Approach

The aim of the Action Plan was to encourage and support the systematic application of sex, gender, and diversity lenses to all of Health Canada's policies, programs, legislation, regulations, services, research, and workplace initiatives (see the Action Plan Logic Model in Appendix 3). The Action Plan's activities were anticipated to lead to improvements in staff knowledge and awareness of SGBA+, enhanced SGBA+ accountability in reporting and decision making, and greater use of SGBA+ in internal processes.

To achieve these desired outcomes, three priorities were identified: build Departmental capacity, strengthen the evidence base, and increase accountability for applying SGBA+ (shown in the Action Plan Placemat diagram in Appendix 4). To carry out these priorities, activities were planned under five key areas ("elements"):

1. Enhance guidelines, processes, tools, and resources;
2. Increase SGBA+ promotion and provide targeted training for key priority areas;
3. Use priority initiatives to enhance SGBA+ capacity and improve sex-sensitive and gender-sensitive expertise and advice;
4. Partner with the Canadian Institute of Health Research's Institute of Gender and Health (CIHR-IGH) to embed SGBA+ research expertise into priority initiatives; and
5. Increase governance, accountability, and transparency in the integration of SGBA+ in Health Canada decision making.

The Action Plan was designed to be flexible, allowing each branch to tailor its priority initiative to its own unique needs, while expanding upon previous work to integrate SGBA+. A novel component of the Action Plan was the establishment of a partnership with the CIHR-IGH to provide branches the option of accessing research expertise in support of their priority initiatives. See Appendix 5 for the list of the thirteen branch priority initiatives that were active or completed as of March 2020.

2.3 Action Plan Timeline

A timeline of key Action Plan activities and milestones is shown in Figure 2. Notably, two Sex and Gender Symposiums, co-hosted by Health Canada and CIHR-IGH, were held in 2018 and 2020, providing branch staff the opportunity to showcase their work on priority initiatives, as well as listen to experts. In addition, the SGBA Employee Survey^{Footnote 3} was conducted in 2016, 2018, and 2020, providing the GHU and Evaluation Team with data on changes in employee awareness and application of SGBA+ over the course of the Action Plan. The emergence of the COVID-19 pandemic in early 2020 forced most groups across the Health Portfolio to reassess their activities. As a result, the GHU's work on the Action Plan, including preparations for a new phase, was deferred.

Figure 2 - Text Equivalent

This image provides a summary of Health Canada milestones in relation to the Sex and Gender Action Plan, branching off a large red arrow pointing right and displaying the years 2016 to 2020. Above and below the arrow are multiple text boxes describing program milestones by year.

2.4 Program Resources

From a Departmental point of view, the budgetary investment in the Action Plan was relatively small ($2.5M over three years), with the majority of the investment directed to the salary of the GHU team of approximately 4.5 full-time positions, and the partnership with CIHR-IGH (see Table 1 below). Information was not readily available on resources associated with branch priority initiatives, but it is understood that there were no staff assigned to carry out SGBA+ efforts on a full-time basis.

Table 1: Financial Resources for the Health Canada Sex and Gender Action Plan 2017-18 to 2019-20

Fiscal Year	Salary	O&M (Meeting and Symposiums)	Partnership IGH and branch initiativesFootnote 4	Total
2017-2018	$346,216	$1,280	$300,000	$647,496
2018-2019	$373,757	$37,768	$625,000	$1,036,525
2019-2020	$450,677	$40,063	-	$490,740
Total for evaluation period	$1,170,650	$79,111	$925,000	$2,174,761

3.0 What difference did the Action Plan make?

Activities under the five elements of the Action Plan directly engaged some individuals and units within each branch in learning about and integrating SGBA+ into their specific lines of work. This was particularly evident in terms of changes to individual awareness and knowledge of SGBA+, the development of some governance structures that supported SGBA+ work, and enhancements to existing organizational processes. Taken together, they speak to improvements in the uptake of SGBA+ across Health Canada.

3.1 Individuals within each branch improved their knowledge of SGBA+

One of the goals of the Action Plan was to increase awareness and understanding of SGBA+ among Health Canada staff. Individuals in different branches across Health Canada gained knowledge and experience from their participation in different elements of the Action Plan. For example, the GHU facilitated a training series that focused on specific functional areas and organized other training sessions to support specific branches and subject areas (e.g., the Climate Change and Innovation Bureau). These sessions gave some staff the opportunity to see how SGBA+ was linked to their specific lines of work and were seen to be of high value, as reported by several key informants (branch staff and research partners). In addition, the GHU facilitated two well-attended Sex and Gender Symposiums, with over 250 staff participated in 2018, and over 450 in 2020. The Symposiums provided participants with an opportunity to share updates on their branch priority initiatives, as well as hear from experts in the field of sex, gender, diversity, and health. Attendee reports showed that the Symposiums enabled networking and some knowledge transfer between branches. Lastly, a Deputy Minister Recognition Award for SGBA+ was launched at the annual HC Science Forum to promote the concept within the Department's research community.

Interviews with many branch representatives involved in implementing the Action Plan highlighted an enhanced awareness and understanding of SGBA+ concepts and how they applied to their work. There were reports that, among certain branches, conversations on SGBA+ have shifted from whether there is a need to apply it, to discussion on approaches for applying SGBA+ (see the Spotlight below on one branch's experience). To support employees in applying SGBA+, the GHU developed the Health Portfolio SGBA+ GCPedia page, and improved the joint Health Canada-PHAC intranet page, in order to provide resources on SGBA+ policies, events, data, analytic tools, and supplementary training.^{Footnote vii}

Spotlight: Pest Management Regulatory Agency

The Pest Management Regulatory Agency (PMRA) has long used sex-disaggregated data in its scientific evaluations and risk assessment activities.Footnote 5 However, other aspects of SGBA+ did not appear to be very relevant in their initial Action Plan discussions with GHU. Subsequently, through attendance at a SGBA+ capacity-building workshop, PMRA participants were able to define more clearly SGBA+ for themselves, leading to examples of how different vulnerable subgroups could be at risk when using pesticide products and should be considered in future analyses. Furthermore, PMRA became aware of the Health Products and Food Branch's SGBA+ work related to gender influences on the interpretation of product labels at the 2020 Symposium, and identified that this could also be applicable to the labelling of pesticide products.

Despite the positive influence of the Action Plan, the level of knowledge of SGBA+ remains relatively low across Health Canada. The SGBA Employee Survey shows that, since 2016, there has been an increase in the proportion of respondents who reported being somewhat or very knowledgeable about GBA+ and SGBA+, from 12% in 2016 to 36% in 2020. However, approximately two-thirds of respondents still reported being not very, or not at all knowledgeable (see Figure 3 on the next page).

3.2 Some governance elements were put in place to support SGBA+ integration

A feature of the Action Plan was its emphasis on increasing accountability for the integration of SGBA+. The Departmental Executive Committee endorsed the Action Plan in February 2017, which prompted the participation of each branch. The GHU subsequently collected information on different activities, primarily as updates from branches on priority initiatives, their own assessment of the quality of SGBA+ analyses in Cabinet documents, and data from the SGBA Employee Survey. Progress reports to the Deputy Minister were submitted in 2017 and 2018, and were then posted to the Department's public-facing website.^{Footnote vii} In addition, two new committees were created to involve the branches in achieving the Action Plan's objectives:

• a Coordinating Committee to provide advice and report on the implementation of Action Plan initiatives; and
• the SGBA+ Agents of Change Network to support the systematic integration of SGBA+ within each Branch.

Figure 3 - Text Equivalent

This image is a graph composed of three horizontal bars. Each bar is divided into colours based on the percentage of knowledge of GBA+ and SGBA+ among Health Canada staff. The bottom bar shows results for 2016, the middle bar for 2018, and the top bar for 2020.

The percentages are: 2016: 2% Very knowledgeable (green); 10% Somewhat knowledgeable (light green); 16% Not very knowledgeable (yellow); 12% Not at all knowledgeable (red); 61% Don't know/no response (gray)

2018: 4% Very knowledgeable (green); 23% Somewhat knowledgeable (light green); 32% Not very knowledgeable (yellow); 41% Not at all knowledgeable (red)

2020: 5% Very knowledgeable (green); 31% Somewhat knowledgeable (light green); 34% Not very knowledgeable (yellow); 30% Not at all knowledgeable (red)

Some branches also developed internal accountabilities to oversee the work of their priority initiatives. The Health Products and Food Branch established a working group for their prescription drug lifecycle management project to monitor progress on the initiative, while also providing a venue for members to share SGBA+ knowledge, which they then shared with their home teams. It is important to note that senior management authorization for activities under the Action Plan was enabled by the Health Portfolio SGBA Policy, which has informed efforts to integrate SGBA+ in the Department since 2009.

3.3 There was greater application of SGBA+ in some departmental and branch processes

It was expected that the Action Plan would improve the systematic application of SGBA+ in all facets of Health Canada's work (i.e., policies, programs, legislative and regulation services, research, and workplace initiatives). Certain organizational-level processes have been enhanced as a result of the Action Plan and GHU expertise, especially Cabinet Documents^{Footnote 6}, Budget proposals, and departmental performance measurement frameworks (Departmental Results Framework and Performance Information Profiles).

The Action Plan resulted in changes to how some units approached their work. For example, the Corporate Services Branch updated several forms to include disaggregated SGBA+ data as part of their initiative on considering sex and gender in the workplace. This enhanced data is expected to improve the Employee Assistance Program for Health Canada's diverse workforce (e.g., policies, procedures, services).

The integration of SGBA+ has also occurred beyond the original initiatives included in the Action Plan. For example, an Opioid Response Team pilot study of peer assistance at supervised consumption sites found that gender was a factor in harm reduction among individuals requiring assistance. Furthermore, the Health Products and Food Branch has created an external Scientific Advisory Committee on Health Products for Women (see Spotlight below).

Spotlight: Scientific Advisory Committee on Health Products for Women

As part of its Action Plan on Medical Devices, announced in December 2018, Health Canada established a new external Scientific Advisory Committee on Health Products for Women (SAC-HPW). As stated on its website, the Committee is intended to provide Health Canada with "timely patient-centered, scientific, technical, medical, and clinical advice on current and emerging issues regarding women's health and the regulation of medical devices and drugs. The Committee will examine issues such as breast implants) across the product lifecycle, from development to real-world use, with a focus on patient perspectives and experiences." Footnote viii The establishment of the Advisory Committee is an expression of the need for SGBA+ in the development of public health guidelines, policies, and regulations, as highlighted by the Deputy Minister at the 2020 Sex and Gender Symposium.

The SGBA Employee Survey shows that the application of GBA+ and SGBA+ by Health Canada staff in their work increased over threefold between 2016 and 2020. In 2016, only 10% of respondents reported sometimes, often, or always applying GBA+ and SGBA+, while that percentage has increased to 31% in 2020. However, the majority (70%) of Health Canada respondents still reported rarely or never having applied GBA+ and SGBA+ consistently in their work where this analysis was relevant or appropriate (see Figure 4). This is likely linked to difficulties in understanding SGBA+ concepts and their relevance to specific lines of work, as discussed in Section 3.1.

Figure 4 - Text Equivalent

This image is a graph composed of three horizontal bars. Each bar is divided into colours based on the percentage of consistent application of Sex and Gender-based Analysis by Health Canada staff. The bottom bar shows results for 2016, the middle bar for 2018, and the top bar for 2020.

The percentages are: 2016: 2% Always (green); 3% Often (light green); 5% Sometimes (yellow); 4% Rarely (orange-red); 14% Never (red); 71% Don’t know/Not applicable/No response (gray)

2018: 3% Always (green); 5% Often (light green); 9% Sometimes (yellow); 11% Rarely (orange-red); 38% Never (red); 34% Don’t know/Not applicable/No response (gray)

2020: 7% Always (green); 10% Often (light green); 14% Sometimes (yellow); 21% Rarely (orange-red); 49%; Never (red)

Note: "Don't know/Not applicable/No response" was removed as an option in the 2020 SGBA Employee Survey.

4.0 Program Strengths

The successes of the Action Plan were enabled by the early engagement of senior management, a flexible design that allowed branches to tailor their participation, and the ongoing support provided by the GHU, including making research capacity available through the Policy-Research Partnership with CIRH-IGH.

The early engagement of Health Canada's senior management signaled strong support for the Action Plan and the application of SGBA+ in branch work. The importance of senior management engagement was further reflected in the SGBA Employee Surveys (2016, 2018, and 2020), where respondents reported that the most important factors supporting the application of SGBA+ in their work were accessible resources, supervisor or management support, and understanding that SGBA+ is an important federal government and Health Canada priority, as shown in Figure 5. A scan of SGBA+ literature reinforces the finding that commitment by senior management is an essential factor in achieving compliance within government departments.^{Footnote ix}

Another defining feature of the Action Plan was its flexibility in allowing each branch to select a priority initiative. This approach acknowledged the differences in branch mandates and their current areas of focus. This flexibility was evident in the variety and scale of projects. For example, PMRA committed to posting a short explanation of how sex is currently applied to pesticides (a smaller project), while the Health Products and Food Branch committed to three actions on improving SGBA+ in product labelling and lifecycle management (a larger project).

Figure 5 - Text Equivalent

This image is a graph composed of three horizontal bars for each supporting factor. Each bar is divided into colours based on the year and number of respondents who applied GBA+/SGBA+ according to surveys conducted in 2016, 2018, and 2020.

The GHU provided support to branches during the implementation of the Action Plan, as well as responding to changing Departmental priorities. GHU re-prioritized its activities quickly in response to the COVID-19 crisis, which included developing guidelines on the consideration of SGBA+ in COVID-19 responses (now available on GCPedia). Despite its small size, many interviewees praised GHU for their leadership on SGBA+. One key informant noted that "the expertise of GHU is a crucial support to [our Branch]." Finally, the GHU responded to many ad-hoc requests for help in applying SGBA+. These requests have increased since the Action Plan began, further indicating that GHU's support is seen as valuable.

The Policy-Research Partnership with CIHR-IGH was a largely productive experience, as branch staff benefited from the development of multiple research and policy development tools, while research partners were able to produce academic publications and presentations. One key informant noted that partnerships were a great opportunity for two-way capacity building as researchers learned about government processes, while Health Canada employees benefitted from increased research capacity. Several interviewees (branch representatives and researchers) also indicated that the collaborations were strongest when the project was scoped realistically, had limited Health Canada staff turnover, and when there was a shared understanding of how the research partner could add value to the priority initiative. One such example is the shared initiative between the Controlled Substances and Cannabis Branch and the Communications and Public Affairs Branch on applying SGBA+ to Cannabis awareness and education. Several initiative updates resulted from the collaboration with their CIHR-IGH researcher, including changes to media and campaign messaging, and updates to survey questionnaires.

5.0 What gaps or challenges still exist in the systemic integration of SGBA+ across Health Canada?

Despite the early positive results of the Action Plan and the strength of its design, important challenges remain with respect to the level of knowledge of SGBA+ concepts, the authority and responsibility (governance) for applying SGBA+, and its integration into key processes across Health Canada.

5.1 Knowledge

The 2020 SGBA Employee Survey showed that there are wide variations in the level of knowledge of SGBA+ between different branches and functional areas. Those in enforcement, compliance, and inspection (78%), product evaluation (76%), and human resources (74%) self-reported as being "not very" or "not at all knowledgeable" about GBA+ and SGBA+. Many key informants noted that this may result from individuals not being aware of various policy requirements, or of certain groups failing to see the relevance of SGBA+ to their work. The graphic in Appendix 6 gives a visual example of the differences between branches by functional area in the form of a 'heat map.'

Both GHU staff and participant key informants (branch representatives and researchers), as well as branch senior management reported that turnover at all levels of Health Canada has hampered the momentum of some branch priority initiatives. This highlights the need to engage and train new managers and staff on SGBA+ concepts and their branch's specific activities to integrate SGBA+.

Many key informants asserted that some individuals and groups have not understood that diversity factors beyond sex and gender (i.e., the 'plus') should be included in SGBA+ analyses. A scan of recent literature showed that key terms such as GBA, GBA+, gender mainstreaming, and gender equality are confusing, complex, and sometimes "ill defined," which has made it difficult to translate such terms into action.^{Footnote x} Some key informants suggested that there is a need for a rebranding of SGBA+ concepts, which has opened the door to considering more inclusive ways of thinking about and explaining SGBA+, such as 'intersectionality', as well as engaging different groups to apply it in their specific lines of work.^{Footnote xi}

While approximately half of the 2020 SGBA Employee Survey respondents were aware of SGBA+ training resources, use of these resources remains low. The majority (70%) of survey respondents have never completed any kind of SGBA+ training.^{Footnote xii} Many key informants agreed that there is a need for further training of Health Canada employees. However, while further uptake of generic training, such as that offered by the Department of Women and Gender Equality, could be beneficial in raising further awareness of SGBA+ concepts, some key informants explained that more specialized training is also needed to address specific contexts and subject areas, building on the efforts described in Section 3.1.

5.2 Accountability

The engagement of senior management is crucial for incorporating SGBA+ into departmental structures through directing resources and championing efforts; this point is echoed in the literature.^{Footnote xiii} However, a few key informants pointed out that, after 2017, senior management became less visible due to leadership turnover and minimal involvement with branch priority initiatives beyond the Action Plan launch event. Although central agencies continue to require SGBA+ through various policies, two key informants pointed out that senior leadership is still needed to motivate staff to engage with these challenging concepts.

Members of the two committees established through the Action Plan were limited in their ability to advance SGBA+ beyond the scope of their priority initiatives. Reasons suggested for this included a confusion between the purpose of the two committees, a high degree of member turnover between meetings, the limited authority of working-level representatives to influence change within their branches, and the time needed for roundtable updates from the large membership. There are examples of department-wide structures supporting SGBA+ in other federal organizations that could be examined, such as the distribution of accountability at Finance Canada, and the provision of expert assistance to branches at Employment and Social Development Canada.

Although some useful performance measurement data was available (listed in Section 3.2), it did not provide evidence of how the Action Plan's five elements have advanced Health Canada's integration of SGBA+ as illustrated in the logic model.^{Footnote xiv} A few key informants suggested that improvements could be made through the ongoing integration of SGBA+ indicators into Performance Information Profiles (PIPs), which would provide more systematic performance data at the branch level. Furthermore, the previous suggestion of strengthening a Departmental SGBA+ committee could facilitate regular branch-level reporting on the results of planned SGBA+ initiatives (i.e., training, projects), as well as gathering information about what did and did not work.

5.3 Branch-level integration of SGBA+

Despite requirements from central agencies to integrate GBA+ into specific processes, there was no information on the extent and quality of that integration at Health Canada, except for the GHU's assessment of Cabinet documents. That said, the SGBA Employee Survey showed that staff in specific functional areas were applying SGBA+ less frequently than others, as shown in Appendix 7. In 2020, the areas of work sometimes, often, or always applying SGBA+ were policy (including regulatory and legislative development), program design and delivery, and research (between 59% and 42% of respondents in these functional areas). Those areas reporting rarely or never applying SGBA+ were procurement, enforcement/compliance/
inspection, and administrative functions.

There was also limited capacity to assist branches in implementing their priority initiatives. For instance, the GHU's small team experienced some capacity issues managing multiple areas of the Action Plan, including supporting each branch's SGBA+ efforts, implementing the five elements of the Action Plan, and fulfilling their corporate challenge function for verifying the quality of SGBA+ in Cabinet documents or other processes. Furthermore, although the Policy-Research Partnership with CIHR-IGH gave branches the opportunity to increase their own capacity to implement SGBA+ projects, some key informants identified challenges related to the CIHR competitive process, differences between staff and researchers (perception of the project's scope, deliverables, timelines, and approval requirements), staff turnover, and limited time and investment (see Endnotes for more details).^{Footnote xv}

6.0 Conclusions

Overall, there are clear indications that understanding and application of SGBA+ across the Department has improved in those areas where staff are directly involved in Action Plan activities, as well as areas where application is part of a required corporate process. However, a broader cultural change leading to the systematic integration of sex, gender, and diversity considerations into all of Health Canada's policies, programs, legislation, regulations, services, research, and workplace initiatives has not yet occurred.

To date, there are early indications that Action Plan activities have led to some success, as well as to more concerted effort to include Sex and Gender-Based Analysis Plus (SGBA+) in corporate activities, such as developing Cabinet documents, budget proposals, and performance measurement frameworks (e.g., Performance Information Profiles). Knowledge and awareness of SGBA+ has increased among Health Canada employees directly involved in the Action Plan's priority initiatives, networking, and training. There has also been some increased integration of SGBA+ into organizational processes, thanks to the tools and resources created or enhanced through the Action Plan. These successes can be linked to the flexible design of the Action Plan, which allowed branches to take a tailored approach to their participation, enabled by the GHU and its CIRH-IGH partnership. While COVID-19 response efforts interrupted the second phase of the Action Plan, the GHU was able to pivot quickly and provide SGBA+ expertise to support the response.

While the Action Plan has resulted in a maturing of how some groups have incorporated SGBA+ into their work, more needs to be done to achieve a broader cultural shift of integrating SGBA+ across the Department. There remains a lack of accountability, branch-level planning, and adequate knowledge among some other groups when it comes to applying SGBA+. It is unclear who should be responsible for systematically integrating SGBA+ into key processes within each branch. To move beyond a reliance on demonstration projects, branches will now need to consider when and how they can further incorporate SGBA+ into their specific lines of work. Furthermore, there is wide variation in staff understanding of SGBA+ concepts, especially intersectionality, and their relevance across branches and functional areas. With enhanced branch-level accountabilities for SGBA+, the GHU can continue to support branches in their integration of SGBA+ and knowledge development across the Department.

7.0 Recommendations

SGBA+ activities are the collective responsibility of all branch heads, in line with the Health Portfolio SGBA Policy. It is the responsibility of senior management to provide the leadership necessary to ensure the implementation of SGBA+ within their Health Portfolio organizations. On the other hand, the successful implementation of SGBA+ requires the participation of all Health Portfolio staff.

This evaluation was undertaken to provide guidance to the Strategic Policy Branch's GHU to inform the next phase of the Action Plan. However, both progress and challenges related to the systematic integration of SGBA+ across Health Canada involve all branches, as each branch is responsible for ensuring the integration of SGBA+ into their respective organizational processes. The GHU will continue to be the centre of expertise for the Department.

The three recommendations developed in this evaluation should support the envisioned cultural shift of integrating SGBA+ within each branch. While the GHU will continue to be a centre of expertise for the Department, it will not be solely responsible for implementing these recommendations; in fact, much of the work will be done within the branches themselves. Therefore, the Strategic Policy Branch will be the representative branch signing off on the MRAP on behalf of the other branches in the Department.

Recommendation 1: Renew the governance structure for SGBA+ to oversee the integration of SGBA+ within each branch.

The SGBA+ Network is the current body tasked with enabling a Department-wide SGBA+ culture change. It provides a forum for branches to learn from each other, but its members do not have the necessary authority to stimulate the systematic integration of SGBA+ within each branch. In order to empower staff within each branch to continue advancing the integration of SGBA+, the Strategic Policy Branch could renew SGBA+ Network membership by requesting that branch heads nominate representatives who would be tasked to work across their branches on integrating SGBA+.

In addition, progress on the integration of SGBA+ is not being considered at the Executive Committee level on a regular basis. Doing so would demonstrate the importance of SGBA+ to the Department, while giving executives the opportunity to give strategic direction to implementation plans. The Strategic Policy Branch could facilitate regular senior management discussion on the progress of SGBA+ integration within each branch and across the Department.

Recommendation 2: Support branch-led planning to integrate SGBA+ into their organizational processes.

Each branch is responsible for ensuring the integration of SGBA+ into their organizational processes. While gains have been made, there remains a need to enhance the consistency and quality of its application across branches and functional areas. In order to ensure a lasting cultural shift, branches should move beyond pilot projects to integrate SGBA+ into key organizational processes, as appropriate. Each branch should develop its own targeted SGBA+ integration plan with performance indicators (i.e., level of knowledge, extent of application). The GHU could support branch-led planning, including facilitating collaborations with experts where it would be strategically advantageous to do so.

Recommendation 3: Address key knowledge gaps by clarifying SGBA+ concepts and supporting SGBA+ training specific to different branches and functional areas.

The relevance of SGBA+ concepts, including the 'plus' (intersectionality), appears difficult for many employees to understand. This presents a fundamental challenge to achieving systematic integration of SGBA+ across Health Canada. Furthermore, different branches and functional areas (e.g., science, regulation, communications) have specific challenges and opportunities in applying SGBA+ to their work, and these should be recognized in branch-level SGBA+ planning, leading to tailored communications and training. This will ensure a greater level of understanding among all Health Canada staff of the relevance of SGBA+ to their specific lines of work, as well as a better understanding in terms of when and how it may be appropriate to consider sex, gender, and diversity in the context of their work.

Appendix 1 - Evaluation Scope and Approach

The evaluation was conducted to provide guidance to Health Canada's Gender and Health Unit (GHU) to inform future priorities and planning related to SGBA+. The evaluation covered all five elements of the Health Canada Action Plan, from 2017-18 to 2019-20, with a particular focus on the branch priority initiatives and the Policy-Research Partnership with CIHR-IGH. It also examined branch SGBA+ activities that fell outside of the initial purview of the Action Plan (subject to the availability of documented information), as these speak to the broader impacts and applications SGBA+ has had across the Department.

It was conducted outside of the requirements of the Financial Administration Act.

Evaluation Issues and Questions

Relevance and Performance
Issue Area	Questions
Results	1.1 What impact have all five Health Canada Sex and Gender Action Plan elements had on advancing the integration of sex, gender, and diversity considerations in Departmental research, legislation, policies, regulations, programs, and services? 1.2 What opportunities and challenges should be considered as part of the Action Plan moving forward?
Design & Delivery	2.1 To what extent has the management of the Action Plan supported the achievement of outcomes. 2.1.1 Has the Action Plan's governance structure facilitated engagement with internal and external stakeholders, supported decision making and ensured transparency? 2.1.2 Does Health Canada have the appropriate methods and performance measures in place to assess the Action Plan? Are there any gaps?

Appendix 2 - Data Collection and Analysis Methods

Evaluators collected and analyzed data from multiple sources. Data collection started in July 2020 and ended in December 2020. Data was analyzed by triangulating information gathered using the different methods listed below. The use of multiple lines of evidence and triangulation was intended to increase the reliability and credibility of the evaluation findings and conclusions.

Literature scan:

A search of peer-reviewed research articles on Gender Mainstreaming and Gender-Based Analysis in the Canadian and global public health context was conducted to identify relevant publications for consultation in the development of the evaluation report. Thirteen documents were reviewed to explore best practices in the applications of Gender-Based Analysis, lessons learned from their implementation, and potentially to inform recommendations for the Action Plan moving forward.

Program document and file review:

The evaluation team reviewed a series of documents to inform findings related to the relevance, effectiveness, and efficiency of the Action Plan program. Thirty-nine documents were selected to be reviewed, including background reports, Action Plan overview and progress reports, project profiles, and event and stakeholder consultation reports.

Survey data review:

Response data from three editions of the Health Portfolio Sex and Gender-Based Analysis Employee Survey (2016, 2018, and 2020) were obtained and analyzed to examine the situation in 2020 and changes since 2016. It should be noted that the 2020 Survey had a response rate of 34% for Health Canada. The Department of Women and Gender Equality also shared data from a 2018-19 interdepartmental GBA+ implementation survey with the evaluation team.

Key informant interviews:

Key informant interviews were conducted to gather in-depth information related to the relevance, effectiveness, and efficiency of the Program. Interviews were conducted in a semi-structured manner, based on a predetermined questionnaire. A total of 22 interviews with 23 key informants were conducted with senior management (n=1), GHU management and staff (n=3), Branch representatives (n=10), CIHR-IGH (n=2), academic researchers (n=4), and representatives of the Treasury Board Secretariat and the Department of Women and Gender Equality (n=3). The list of interviewees was developed in consultation with the GHU. Once the list was developed, the GHU and the Office of Audit and Evaluation (OAE) communicated with all individuals on the list, informing them of the evaluation and the request for an interview, with the exception of the central agencies who were contacted only by the OAE.

Limitations and Mitigation Strategies:

Most evaluations face constraints that may have implications on the validity and reliability of evaluation findings and conclusions. The table below outlines the limitations encountered during the implementation of the methods selected for this evaluation, as well as the mitigation strategies put into place to ensure that the evaluation findings can be used with confidence to guide program planning and decision making.

Limitation	Impact	Mitigation Strategy
Some key informants were not available due to turnover or did not respond to the invitation to participate in an interview.	While the evaluation succeeded in interviewing a representative from each branch, some key informants had little perspective to share on their branch's initiative, other SGBA+ activities, or other elements of the Action Plan.	A critical mass of interviewees was achieved in terms of obtaining observations on the Action Plan. This was confirmed in the analysis of interview data when repetition of key points was observed. In addition, triangulation of other lines of evidence was used to substantiate or provide further information on branch-level SGBA+ activities.
Key informant interviews are retrospective in nature.	As interviews are retrospective in nature, this may lead to the provision of recent perspectives on past events. This can affect the validity of assessing activities or results relating to improvements in the program area.	Triangulation of other lines of evidence was used to substantiate or provide further information on data received from interviews.
Performance measurement data on Action Plan activities was limited.	The data available consisted mainly of descriptive information, as well as the SGBA Employee Survey, which was not directly linked to the Action Plan.	Triangulation of other lines of evidence was used to substantiate or provide further information on performance measurement data received from the Program.
SGBA Employee Survey may have a non-response bias.	It is unknown to what extent results are representative of all Health Canada employees given that many did not volunteer to complete survey.	Survey results have been interpreted as indications of current issues with SGBA+ integration and triangulated with other lines of evidence.

Appendix 3 - Health Canada Sex and Gender Action Plan Logic Model

Appendix 3 - Text Equivalent

This image presents a logic model, which is a series of text bubbles connected by arrows, each one explaining different aspects of the program, from inputs, to activities, to outcomes.

Appendix 4 - Health Canada Sex and Gender Action Plan Placemat

Appendix 4 - Text Equivalent

This image presents an overview of Health Canada's Sex and Gender Action Plan. Under the title is a sentence explaining the goal of the Plan. Below that are the Priorities, which are divided into three columns: Build Department Capacity, Strengthen Evidence Base and Expertise, and Increase Accountability. Under this is a series of five text boxes for Key Elements. At the bottom of the image are three text boxes for Outcomes.

Appendix 5 - Action Plan Branch Priority Initiatives (2017-2020)

Branch	Initiative
Chief Financial Officer Branch (CFOB)	Application of SGBA lens in Departmental Results Framework (DRF) and Performance Information Profiles (PIPs)
Corporate Service Branch (CSB)	Considering Sex and Gender to Support a Psychologically Healthy Workplace: Stream A, Mental Health and Wellness Training, Marketing and Promotions
Corporate Service Branch (CSB)	Considering Sex and Gender to Support a Psychologically Healthy Workplace: Stream B: Employee Assistance Services
Controlled Substances and Cannabis Branch (CSCB)	Implementing a New Framework for Vaping Products in Canada (Started at HESCB)
Controlled Substances and Cannabis Branch (CSCB) & Communications and Public Affair Branch (CPAB)	Applying a Gender-based Lens to Cannabis Risk Perceptions, Public Education and Awareness
Healthy Environments and Consumer Safety Branch (HECSB)	Research to Support the Chemicals Management Plan
Health Products and Food Branch (HPFB)	Applying SGBA+ to investigate consumer perceptions of health product labelling
Health Products and Food Branch (HPFB)	Applying an SGBA+ lens to medical device lifecycle management *Funded in second round of Policy-Research Partnership funding for 2020-21
Health Products and Food Branch (HPFB)	Applying a sex and gender-based lens to prescription drug lifecycle management *Funded in second round of Policy-Research Partnership funding for 2020-21
Office of Audit and Evaluation (OAE)	Piloting the use of the PHAC Evaluation Health Equity Tool for an HC program evaluation
Pesticide Management Regulatory Agency (PMRA)	Sharing information on PMRA's existing science-based consideration of sex and gender
Regulatory Operations and Enforcement Branch (ROEB)	Applying a GBA+ Lens to a Reorientation of Health Canada Risk Communications for Health Products
Strategic Policy Branch (SPB)	Digital technology to support informal caregivers: Matching the tools to the needs

Appendix 6: Average Knowledge of GBA+ and SGBA+ by Branch and Area of Work (2020)

Appendix 6 - Text Equivalent

This image presents a colour-coded “heat map” of the varying levels of knowledge of GBA+ and SGBA+ by branch and area of work within Health Canada. Each colour represents a level of knowledge, from red (Not at all knowledgeable) to green (Very knowledgeable), as well as gray for “no data/not applicable”. These colours are applied by branch and area of work within that branch.

Appendix 7: Application of GBA+ and SGBA+ by Area of Work (2020)

Appendix 7 - Text Equivalent

This image presents a colour-coded bar graph representing the frequency with which GBA+ and SGBA+ are applied by area of work at Health Canada. Each line is separated by colour, from red, meaning “Never”, to green, meaning “Always”, and by percentage of employees per area of work who apply GBA+ and SGBA+ by category of frequency.

Note: the majority of respondents in the 'Evaluation' area of work are involved in assessment of consumer or health products.

References and End Notes

Pinto, A. et. al. Routine collection of sexual orientation and gender identity data: a mixed-methods study. Canadian Medical Association Journal (CMAJ) 191, E63-8 (2019).

Public Health Agency of Canada. Health Inequities Data Tool. Government of Canada (2018).

Hankivsky, O. Gender Mainstreaming: A Five Country Examination. Politics & Policy 41, 5: 629-655 (2013).

Hankivsky, O., Mussel, L. Gender-Based Analysis Plus in Canada: Problems and Possibilities of Integrating Intersectionality. Canadian Public Policy 44, 4: 303-316 (2018).

Scala, F., Paterson, S. Bureaucratic Role Perceptions and Gender Mainstreaming in Canada. Gender, Work and Organization 24, 6 (2017).

Calgar, G. Gender Mainstreaming. Politics & Gender 9: 336-334 (2013).