Special Evaluation/Report

CARE Malawi COVID Vaccine Delivery Situation January 2022

“The vaccines are here but support for delivery is most needed, especially at the last mile.” – District Health Management Team member, Ntcheu
As of January 10, 2022, Malawi had delivered 1.84 million doses of vaccine out of the 3.12 million doses it has received so far.1 Many doses in country have rapidly approaching expiration dates, and if they do not get to people fast, they risk expiring on the shelves. To make sure the 1.26 million doses left go to the people who need them most, we must invest more in communication, engagement, and delivery. The $37M granted by the World Bank over the past year is sufficient for covering only 8% of Malawi’s total population. What is more, as the highly contagious Omicron variant spreads worldwide, it is even more critical that more people are vaccinated now. We cannot assume that the Government of Malawi and its current health system can do it alone.

The government and other health actors in Malawi are working tirelessly to vaccinate people, while facing multiple health crises. The health system is building on a base of committed (if overstretched) health workers, an openness to community feedback, and a long expertise of delivering The government is coordinating closely with many actors to reduce gender gaps, get vaccines to the last mile, and keep existing health services open. Nonetheless, the Ministry of Health is under-resourced, and operating in a global system where the vaccine supply that arrives may be close to expiring. For example, doses of the Astra-Zeneca vaccine had to be destroyed in the spring, after arriving in Malawi with only two and a half weeks left before their expiration date.

More investment is needed. To take just one example, the national government has been able to provide one van per district to support mobile vaccination sites, to get vaccines to the last mile. Mobile vaccinations are the most effective way to serve people who live far away from health centers and do not have access to easy forms of transportation. That means that in Ntcheu, one van is expected to serve a target population of 214,929 people living over 3,424 square kilometers. One van cannot serve those people fast enough to make sure vaccines get where they need to in time, especially when an inconsistent and unpredictable vaccine supply could have doses expiring at any time. Read More...

Dignified and Violence-Free World of Work: A Study on Women Working in Informal Sectors in Nepal

A significant percentage (66.5%)1 of women in Nepal work in informal sectors and are vulnerable to all forms of violence and exploitation. The violence experienced by women in informal sectors ranges from physical, sexual, and verbal harassment to labor and economic exploitation by employers, co-workers and family members. Existing legal provisions such as Sexual Harassment (Elimination) at Workplace Act, 2015 do not have specific provisions for informal sectors whereas other mechanisms to address violence against women, in general, remain ineffective in implementation. In addition, socio-cultural norms and structures limit women’s access to justice-seeking mechanisms. Despite pervasive instances of violence and harassment experienced by women in informal sectors, there is a dearth of comprehensive documentation and evidence building on this issue. In this light, the paper examines the existing status, nature and experiences of violence faced by women working in diverse areas of the informal economy. It also critically analyses key gaps in existing legal provisions/policies and barriers to implementation from the perspective of informal sector workers.
The paper is based on the findings from 36 case studies of women working in 15 different informal sectors, Gendered Political Economy Analysis (GPEA) with community and policy stakeholders and desk review of relevant policies/legal provisions. The paper shows that women’s gendered social roles, lack of collectivisation and representation in decision-making bodies puts them in a weaker bargaining position to voice against instances of violence or to make it a priority agenda of advocacy for policymakers. Similarly, the findings of the paper indicate that lack of adequate and effective polices/provisions on safe working conditions and their implementation leads to invisiblisation of violence at the workplace, enabling powerholders to continue cycles of violence and exploitation without accountability. The paper contributes towards mainstreaming discourses around dignified work for women in the informal economy. It also serves as an evidence-based advocacy document to influence governments to ratify ILO Violence and Harassment Convention No. 190, which is a binding international treaty that protects all workers in formal and informal economy. Read More...

Nepal COVID-19 Vaccine Costing Study

By December 6, 2021, 19.2 million doses of COVID-19 vaccines have been administered in Nepal, enough for 36% of the population to have gotten at least one dose of vaccine. After a rough road with unpredictable vaccine supply, the government has been able to procure several million vaccine doses. Now delivery at the last mile is the biggest hurdle they face. Nepal’s Minister of Health says, “We are not going have shortages of vaccines anymore, but our main concern and focus now is on getting these vaccines to all corners of the country, including the remote mountain areas.”

Based on national data, and in-depth studies in 2 health districts, CARE estimates that delivery costs from “tarmac to arm” for vaccines in Nepal are $8.35 (1,019 NPR) per dose of vaccine administered, or $18.38 (2,241 NPR) per person fully vaccinated.

This is nearly 5 times more expensive than current global estimate for delivery costs. These costs range from $11 per fully vaccinated person in easier to reach areas, to $33 per dose in remote, difficult to reach areas. Gaps in vaccine coverage are particularly acute for mountainous areas, people with low mobility, and communities far from health centers. Even the lowest-cost estimates for the easiest to reach areas are nearly 3 times higher than global average estimates.

70% of these costs are personnel needs to ensure vaccines reach people at the last mile. This points to a major need to improve investments in vaccine delivery, especially the health care workers who administer vaccines and ensure everyone gets vaccinated.

Don’t Leave Them Behind: Global Food Policies Continue to Fail Women (December 2021)

811 million people in the world are going hungry, half a million of whom are on the brink of starvation. Clearly, current approaches are simply not enough to meet the scale of the crisis we are facing. If we continue to do what we have always done, we will continue to see the same problem: people going to bed hungry. We must find better solutions to prevent and end hunger—especially if we are going to meet the Sustainable Development Goal of Zero Hunger by 2030.

One of the first things we can do is consider who is going hungry. Using the term “people” hides part of the problem: gender inequality. Globally, women are 10% more likely to go hungry than men, and that gap is growing. In Somalia, for example, men are eating smaller meals; women are skipping meals altogether. We see this inequality play out at the international level, too—global solutions consistently ignore women, their rights, and the critical role women play in food systems.

Of 84 global policies and plans designed to address hunger released between September 2020 and December 2021, only 4% refer to women as leaders who should be part of the solution or provide funding to support them. 39% overlook women entirely. This is unacceptable. Ending hunger will take everyone’s talents, opinions, and work. It requires promoting equality, respecting rights, and truly listening to the people who are on the frontlines of the problem. Local food producers and leaders—especially women—must be a core part of the solution.

Gender Gaps in Vaccines November 2021

COVID-19 vaccinations are quickly becoming a story of inequality. Gender inequality is a critical part of this story. In 22 of 24 countries where CARE has data, women are less likely to be vaccinated and less likely to feel vaccines are safe.

There are massive local and global gaps in who can get vaccinated. Only 4.5% of people in low-income countries are vaccinated, and 79% of vaccinations have been in wealth countries. Tragically, wealth and geography are just two factors that skew access to vaccines. Another is gender. In many low and middle-income countries, women are less likely to get COVID-19 vaccines than men are. This compounds gender inequality women are already facing in health and decision-making Read More...

Who pays to deliver vaccines? An Analysis of World Bank Funding for COVID-19 Vaccination and Recovery

The World Bank is one key source of funding in the global push to vaccinate 70% of the world’s population against COVID-19. Many actors point to this as the funding that will cover any additional delivery needs for COVID-19 vaccines that national governments cannot meet. With $5.8 billion in funding already approved out of a $20 billion commitment, the World Bank funding is an important part of the picture, but the World Bank alone cannot cover the full gap in vaccine delivery needs.

Reviewing 60 funding agreements from the World Bank on COVID-19 vaccination and recovery shows the following insights.

• There is still a gap in delivery funding. The World Bank is currently funding $1.2 billion in vaccine delivery—10% of the total funding allocated for COVID-19 recovery. If that trend applies to the rest of the $20 billion commitment, World Bank funding will cover a between $2 and $4 billion—well below the $9 billion that ACT-A estimates as the lowest possible investment to vaccinate 70% of the world’s population. In contrast, $3.1 billion is going to purchase vaccines.
• Health workers remain underfunded. Only 15 of 60 agreements, just 25% detail provisions to pay health workers. Of those, 7 explicitly fund surge capacity, 3 provide for ongoing salaries, and 4 allow for hazard pay to health workers.
• Countries are taking on debt to rollout COVID-19 vaccinations. 86% of the funding in this analysis is in the form of loans. That gives countries debt that may weaken future pandemic preparedness rather than reinforcing health systems.
• All funders should adopt the World Bank’s commitments to investments in gender equality. 90% of the agreements in this analysis refer to gender inequality and many make corresponding investments—like requiring that 60% of vaccine leadership positions are women—to overcome these barriers. Earmarking exact funds going to advance gender equality would provide further transparency. Nevertheless, this consistent and concrete commitment is commendable, and all actors should strive to replicate it.

Enquête Trimestrielle pour le Rapportage du Plan de Mesure de Performance Projets “OLAM VSLA” & “TOUTON VSLA”

Dans le cadre de cette enquête trimestrielle, la méthode d’échantillonnage utilisée est le sondage aléatoire systématique stratifié au premier degré. La taille de l'échantillon de l'enquête trimestrielle des projets OLAM VSLA et TOUTON VSLA a été calculée et s’établit à 339 membres de VSLA. [7 pages] Read More...


L’intervention du PROMEESS III est soutenue par l'analyse genre détaillée en tenant compte des spécificités des participants en termes des différents besoins, rôles, relations, risques de protection dynamiques de pouvoir entre les femmes/hommes/filles/garçons. Read More...

Learning to Listen: Regional Partnerships and Impacts

In 2017, CARE asked, “What will it take to scale our impact by 10 times more than we currently do? What about 100 times?” Part of the answer to that, with significant unrestricted investments from 2017-2020, were CARE’s Impact Growth Strategies. These aim to address the “missing middle” by supporting the skills, staff, and connections needed to bring our work together across regions and partners.
A recent review of these 4 regional platforms—Equal value, equal rights (EVER) in LAC; Women on the move (WoM) in West Africa; Her harvest, our future (HHOF) in Southern Africa; Made by Women in Asia Pacific—shows significant return on the investment. These returns merit continued investment in regional platforms that take creative approaches to partnership, local leadership, and the evolution of CARE’s operating models.
• Contributing to impact for 12 million people, with potential impact for 78 million more people impacted over the coming years.
• Paving the scaling pathways by demonstrating different models of partnership, design, evidence, impact, and fundraising. These experiences provide valuable experience and evidence of what works (and doesn’t) and how to continue our ambition of sustainable impact at scale.
• Demonstrating concrete tools and ability to center the voices of the people we serve, in new partnership models, feedback systems, power structures, and evidence. This includes crucial lessons on how to live out our strategic goal of being locally led and globally connected.
• Mobilizing resources by contributing to roughly $100 million in new restricted and flexible funding.

Cost-efficiency analysis Conditional Cash for Education and Protection

This case study summarizes an analysis conducted by CARE using the Dioptra tool to generate cost-efficiency estimates for Conditional Cash for Education and Protection in Jordan. The analysis revealed that:
● Conditional Cash for Education and Protection cost $1,474 per child on average, across nine projects within the program portfolio.
● Tweaking the transfer size and frequency can affect cost-efficiency by more than 30 percent. It can free up funds to reach at least 40 percent more children with conditional cash, or allow existing recipient households to benefit from other economic resilience interventions.
● Providing awareness sessions on the importance of education is a small cost component of conditional cash that could be cost-effective.
● Different interventions are required for different groups of children. At minimum, the children receiving conditional cash should be differentiated by age: young (6-11) and old (12-16).
● Providing conditional cash for the full school year of at least 10 months is believed to be more effective and protective for children in need.
● Despite its effectiveness, cash incentives are unlikely to be a sustainable intervention to ensure children’s school attendance. It could benefit from other supporting interventions that address social barriers preventing children from attending school.
● Based on further assessments on different approaches and best practices, the program team intends to test a gradual reduction in transfer amounts for 10 months per year over 3 years, differentiated by age group, including livelihoods support for all recipient households, and referrals to Emergency Cash Assistance for highly vulnerable households.
Cost-efficiency estimates are cited for learning purposes only, and should not be used as the sole basis for future budgeting or benchmarking. All cost-efficiency estimates include Direct Project Costs, Direct Shared Costs, and Indirect Costs. Read More...

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