Special Evaluation/Report

Women at the last mile: How investments in gender equality have kept health systems running during COVID-19

Even before COVID-19, investments in health systems—and especially female health workers—were too low. In 2019 the world had a gap of 18 million health workers. Two years and fifteen million deaths later, we have at least 26 million fewer health workers than we need. , This leaves us severely underprepared for future pandemics and other major shocks to the health system, including conflict and climate change. We must invest in health systems that don’t just meet the needs of today, but that are also resilient in the face of future shocks.

Pandemic preparedness requires gender equality: equal recognition, support, and fair pay for ALL health workers. Globally, 70% of health workers are women, but half of their work is unpaid. We must do more to support these health workers. The glimmers of success in COVID-19 built on previous investments in women health workers, their skills, and equality in health systems. Pre-existing investments in equality helped systems respond to COVID-19. Increased investments will build better resilience for the crises that come next.

This report highlights case studies and lessons learned from 20 countries during COVID-19. The evidence shows that we must invest in gender equality in health systems to prepare for and respond to the next pandemic. Health worker training is not enough. Focusing only on health workers working within the formal health system is not enough. We need to work for equality.

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At the last mile: Lessons from Vaccine Distributions in DR Congo

The Democratic Republic of the Congo (DRC) has one of the lowest COVID-19 vaccination rates in the world, with just 0.87% of people in DRC having received even one dose. While the country has received 8.2 million doses of COVID-19 vaccine, it has managed to administer 528,000 of them—just under 11% of vaccines available. In April of 2021, DRC became one of the first countries to return 1.3 million COVID-19 doses to COVAX because they could not deliver them to people before the vaccines expired.

The challenges that risked more than a million doses expiring are still in play for most of the country. In both January and February 2022, 114,705 vaccines expired in country because there was not enough investment in systems and health workers to deliver vaccines. To reach 70% of the population—62.7 million people—DRC will need to drastically scale up and accelerate COVID-19 vaccination.

CARE is working with 4 vaccination sites—2 in Butembo and 2 in Goma—to support with community mobilization in partnership with local leaders, health center operations, and training. With joint action and communication plans developed with chiefs, religious leaders, and local authorities, and additional equipment to protect health workers, those sites had vaccinated 1,132 people. In those 4 sites, we have also conducted several rounds of research and problem-solving using community dialogues between health workers and clients using the Community Scorecard, as well as the Social Analysis and Action tools, which provides the insights for this case study. The team has also supported local vaccination teams with IT infrastructure, personnel costs, and creating locally adapted COVID-19 communications plans.

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La République démocratique du Congo (RDC) possède un des taux de vaccination les plus bas dans le monde avec la lutte contre COVID-19. Seulement 0,87% des personnes en RDC ont reçu même une seule dose du vaccin. Alors que le pays a reçu 8,2 millions de doses de vaccin contre la COVID-19, il n’a réussi qu’à en administrer 881,204, soit un peu moins de 11% des vaccins disponibles administrés. En avril 2021, la RDC est devenue l’un des premiers pays à restituer 1,3 million de doses de COVID-19 à COVAX parce qu’elle ne pouvait pas les administrer aux personnes avant l’expiration des vaccins.

Les défis qui risquaient d’expirer plus d’un million de doses sont toujours en jeu pour la majeure partie du pays. En janvier et février, 114,705 doses ont expiré dans le pays parce qu’il n’y avait pas assez d’investissements dans les systèmes et les agents de santé pour livrer des vaccins. Pour atteindre 70 % de la population, soit 62,7 millions de personnes, la RDC devra considérablement intensifier et accélérer la vaccination contre la COVID-19.

CARE travaille avec 4 sites de vaccination – 2 à Butembo et 2 à Goma – pour soutenir la mobilisation communautaire en partenariat avec les leaders et structures locaux, les opérations des centres de santé et la formation. Ces sites avaient vacciné 1 132 personnes. Dans ces 4 sites, nous avons également mené plusieurs séries de recherches et de résolution de problèmes à travers des dialogues communautaires entre les prestataires des services et les clients avec la Carte Communautaire et l’analyse et l’action sociale, à l’aide de la carte de pointage communautaire, qui fournit les informations nécessaires à cette étude de cas. On a aussi appuyé les missions de supervisions avec l’infrastructure pour la connexion internet, la motivation des prestataires, et l’élaboration des plans de communication adaptes aux contextes.
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Tackling Vaccine Hesistancy and Expanding Vaccine Access in Tanzania with Community Health Workers in the Lead

Since September 2021, CARE Tanzania has worked as a partner to the Government of Tanzania to improve vaccine access across the country. CARE’s logistical support has helped the government to cover large, underserved geographical areas. To increase vaccine uptake, CARE staff has also engaged local Community Health Workers (CHWs) to address vaccination misconceptions and developed improved health communication and data management tools. An initial training took place in November 2021 and trained 217 CHWs in the Tabora region. With these new resources, these health workers on the front lines have put in place two new strategies. First, COVID-19 vaccination is now integrated with other basic health services at local facilities. CARE supported COVID-19 vaccine distribution in 268 health facilities in Tabora Region. These facilities distributed 20,287 COVID vaccines in areas supported by CARE. Second, the CHWs are now conducting targeted outreach informed by local concerns to address vaccine hesitancy in women and children. Now, not only are vaccinations being provided, CHWs have confirmed that women have increased their acceptance of vaccination shots. Read More...

Recipe for Response: What We Know About the Next Global Food Crisis, and How to Fight it

The genesis of the present hunger crisis goes back farther than February 2022 and is due to a combination of global and localized factors. Globally, climate change has compromised agricultural livelihoods and led to displacement, especially in regions like the Horn of Africa and Central America’s Dry Corridor, where famers struggle to produce yields that meet the needs of local markets. The global economic fallouts associated with COVID-19, and inadequate social safety nets, have led to record unemployment and growing poverty—especially for women and women-led households (UN Women 2021)—so that even where food is available, high prices put basic items out of reach for many. Armed conflict is also driving food insecurity, for example by making it difficult for farmers to cultivate their lands, or damaging or disrupting vital agricultural infrastructure—such as transportation, storage and distribution sites—and reducing access to markets and assistance.
Women and girls are disproportionately impacted by food insecurity and related shocks. Gender norms and roles mean that women are often responsible for their households’ food security, including shopping for and preparing food, yet they might also be the ones to eat “last and least” in their household. Women are also more likely to be excluded from decision-making when it comes
to addressing hunger in their communities (CARE 2020). These types of gendered imbalances hurt entire communities: in a 2021 assessment in Sudan, CARE found that 82% of people living in female-headed households reported recently skipping a meal, compared with 56% of people living in male-headed households. Read More...

How Bangladesh Is Getting COVID-19 Vaccines to the Last Mile

Bangladesh has been one of the fastest countries receiving COVAX support to scale up vaccines, delivering more than 221 million vaccines by March 14, 2022. 54% of Bangladesh’s population is fully vaccinated, and another 22% have received at least one dose. Bangladesh is on track to meet its goal of 70% of the population fully vaccinated by September 2022.

Close coordination across multiple actors—from the Government of Bangladesh to INGOs like CARE to local health entrepreneurs—have been one of the keys to success. Working closely with the government-led National Vaccination and Deployment Plan and innovating when there have been gaps and challenges have helped achieve this success. These strategies continue to make sure that vaccines reach the people who need them most.
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Advancing gender equality in coral reef social-ecological systems

Gender equity is considered to be a foundation for the resilience and wellbeing of people dependent on coral reef social-ecological systems. Nonetheless, gender inequality persists, and many interventions are still struggling to meet in practice the commitments they make on paper. Gender transformative approaches (GTAs) are considered the frontier of gender research and development because they challenge and shift the invisible social constructs that underpin and perpetuate inequities. A collaboration between the ARC Centre of Excellence for Coral Reef Studies at James Cook University, WorldFish, and CARE International sought to determine the extent to which GTAs have been applied alongside or within the management and conservation of coral reefs. The intent of our work is to increase awareness of and knowledge about GTAs among funders, researchers, development agencies, and fisheries and conservation stakeholders who seek to advance gender equality in coral reef-social ecological systems. Read More...

She Told Us So (Again)

COVID-19’s impacts around the world are worse than they were in September 2020. Far from a return to “normal,” women and girls CARE works with around the world are saying that their situation continues to get worse as COVID-19 drags on amid other crises. Fati Musa in Nigeria says, “Women have suffered a lot during the pandemic, and we are not yet recovering from this hardship.” 55% of women were reporting gaps in their livelihoods as a priority in 2020. Now that number is 71%. For food insecurity, the number has jumped from 41% to 66%.
Since March of 2020, CARE—and more importantly, the women CARE works with—have been warning that COVID-19 would create special challenges for women and girls, above and beyond what men and boys would face. Tragically, these women were exactly right. What they predicted even before the WHO declared a pandemic has come true. In September 2020, CARE published She Told Us So, which showed women's and men's experiences in the pandemic so far. In March 2022, updated data shows that the cost of ignoring women continues to grow. For more than 22,000 people CARE has spoken to, COVID-19 is far from over. In fact, the COVID-19 situation has gotten worse, not just for women, but for men, too.
Ignoring the voices of women, girls, and other historically marginalized groups has worsened the situation for everyone—not just for women. Men are more than twice as likely to report challenges around livelihoods, food insecurity, and access to health care as they were in 2020, and are three times more likely to report mental health challenges—although they are still only two-thirds as likely as women to report mental health as a priority. As women burn through their coping strategies and reserves, men are also facing bigger impacts over time.

Women have stepped up to the challenge—especially when they get support from each other and opportunities to lead. They are sharing information, preventing COVID-19, and using their resources to support other members of their communities. 89% of women in savings groups in Yemen are putting some of their savings to help others. Women are stepping into leadership roles, "We are women leaders in emergency . . . we have the capacity to say: I have a voice and a vote, I am not going to stay stagnant . . . (participant, Colombia). In Niger, women are saying, “Now we women are not afraid to defend ourselves when a decision does not suit us. We will say it out loud because our rights are known and we know the ways and means to claim our rights.”

Those accomplishments are impressive, but they come at a cost. The constant struggle for their rights, and for even the most basic necessities, is taking its toll. Women are almost twice as likely to report mental health challenges as they were in 2020. As one woman in Iraq describes, “If any opportunity appeared, the man would be the favorite . . . This psychologically affected many women, as they turned to household work which included preparing food and cleaning only.”

To understand these challenges and create more equitable solutions, CARE invests in listening to women, men, and people from marginalized groups to understand the challenges they face, what they need, and the ways in which they lead through crisis. This report represents the voices of more than 22,000 people in 23 countries since September of 2020.
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The Cost of Delivering COVID-19 Vaccines in Zambia

While Zambia aims to deliver COVID-19 vaccines to 70% of its people by June 30, 2022, the road to getting there is uncertain. The Zambian Ministry of Health reports that, as of February 21, 2022, 21.6% of people were fully
vaccinated. Vaccine doses available in the country are slowly rising, with 6.2 million doses arrived as of February 11, but less than half of those doses have made it into people’s arms. By February 23, only 2.77 million doses had gotten to people. By December 31, 2021, only 7.2% of people had gotten a vaccine, compared to a goal of 40%. Without significant investments in last mile delivery, especially for people at highest risk, Zambia risks missing its next COVID-19 vaccine targets.
CARE estimates that in Zambia, vaccine delivery costs a minimum of $17.18 per fully vaccinated person, or $7.30 per dose delivered. That is 7.2 times more than current global estimates. Even with its robust childhood vaccination system—93% of Zambian children got their first measles vaccine in 2019—Zambia has not been able to get enough COVID-19 vaccines to the last mile. Read More...

POST PROJECT SUSTAINABILITY (PPS) STUDY FOR VISTAR-II PROJECT

CARE Nepal and Handicap International implemented a community-based disaster risk reduction project called VISTAR-II in Kailali, Dadeldhura, Kanchanpur, and Dang districts under the DIPECHO-VIIII cycle. This project was for a period of 22 months from March 1, 2015, to December 31, 2016. The project aimed to strengthen the resilience of communities and institutions to natural disasters through building leadership and management capacities from the community level to the national level. After five years of the VISTAR-II intervention, a Post Project Sustainability Study was carried out in two randomly selected intervention districts, namely Kailali and Kanchanpur. out of the four districts. Read More...

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...

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