Variations in the health of men and women are well known: men have poorer life expectancy than women in virtually every country, and there are diff erences between women and men in patterns of morbidity across the life course. These variations refl ect both biology and gender, and health systems play a part through the services they off er. In recent years a number of national governments and international bodies have paid increasing attention to gender inequalities, and gender mainstreaming has been adopted by as a key policy objective at various levels of governance. While gender mainstreaming has resulted in some successes, analysis of the depth of change suggests a less optimistic view, refl ecting the persistence of barriers to gender mainstreaming in health, which include a lack of resources, uncertainty over the goals of gender mainstreaming, and notional rather than genuine adoption of gender mainstreaming principles. Underlying these barriers however, is the use of bureaucratic and systems-based approaches to gender mainstreaming. The failure to challenge underlying gender relations of power allows gender strategies to become technocratic exercises which achieve results in terms of the boxes ticked, but not in relation to what matters: the health and health opportunities of both women and men.