health systems
Rapid Gender Analysis TO SUPPORT THE GOVERNMENT OF SIERRA LEONE TO STRENGTHEN ITS HEALTH SYSTEM
This Rapid Gender Analysis (RGA) report presents findings from the gender and power analysis carried out in November and December 2023 in Falaba, Kambia, Bonthe, Tonkolili, Kenema, Karene, Kailahun, and Pujehun districts of Sierra Leone. The purpose of the RGA is to understand how gender and social norms, roles, relationships, and dynamics influence health outcomes and health-seeking behavior in Sierra Leone, especially for vulnerable populations. The report will inform the development of CARE’s future health programming and proposed interventions for health funding opportunities.
The document is structured into four primary chapters – Background, Methodology, Findings: Results and Analysis, and Recommendations—each containing sub-chapters. The background section outlines the study’s purpose, objectives, and underlying rationale. The methodology section describes the research design, applied approaches, data collection methods and participant information. The study’s key findings are categorized into distinct thematic areas aligned with CARE's Good Practices Framework for Gender Analysis and includes the following Core Areas of Inquiry:
• Household decision-making, division of labor and control of productive assets
• Control over one’s body
• Access to public spaces and services
• Claiming rights and meaningful participation in public decision-making
The RGA also applies the above domains related to health outcomes, behaviors, and health-seeking behavior, including gender dynamics within the Sierra Leone health system with recognition that unequal gender dynamics gaps impact health care providers and their ability to deliver quality services. Finally, the recommendations section outlines actions or interventions CARE should consider in future programming.
Key Findings:
* Men have more influence over decisions for the household than women—including the seeking of healthcare—and women lack control over key decisions related to sex, marriage, and children, including if and when to use contraception. Women’s mobility is limited by social norms which require male permission for movement.
• Contraceptive use is low. Despite around 70% of people knowing about contraceptives and where to get them, only 50% are currently using them. Many community members believe modern forms of family planning are haram or unhealthy, with anecdotal evidence suggesting there is perception that it promotes extramarital affairs.
• Front Line Health Workers (FLHW) face major barriers to effective service delivery: almost half of FLHWs interviewed are unpaid, effectively operating as volunteers, struggle with difficult living conditions and lack of supplies, and report inequitable treatment between male and female workers.
• There is a lack of evidence-based health information for pregnant women: only 27% of pregnant women in the study reported having received any information related to sexual and reproductive health or associated risks.
• Despite generally positive health-seeking behavior, both women and men are concerned by lack of availability of medicine. Read More...
The document is structured into four primary chapters – Background, Methodology, Findings: Results and Analysis, and Recommendations—each containing sub-chapters. The background section outlines the study’s purpose, objectives, and underlying rationale. The methodology section describes the research design, applied approaches, data collection methods and participant information. The study’s key findings are categorized into distinct thematic areas aligned with CARE's Good Practices Framework for Gender Analysis and includes the following Core Areas of Inquiry:
• Household decision-making, division of labor and control of productive assets
• Control over one’s body
• Access to public spaces and services
• Claiming rights and meaningful participation in public decision-making
The RGA also applies the above domains related to health outcomes, behaviors, and health-seeking behavior, including gender dynamics within the Sierra Leone health system with recognition that unequal gender dynamics gaps impact health care providers and their ability to deliver quality services. Finally, the recommendations section outlines actions or interventions CARE should consider in future programming.
Key Findings:
* Men have more influence over decisions for the household than women—including the seeking of healthcare—and women lack control over key decisions related to sex, marriage, and children, including if and when to use contraception. Women’s mobility is limited by social norms which require male permission for movement.
• Contraceptive use is low. Despite around 70% of people knowing about contraceptives and where to get them, only 50% are currently using them. Many community members believe modern forms of family planning are haram or unhealthy, with anecdotal evidence suggesting there is perception that it promotes extramarital affairs.
• Front Line Health Workers (FLHW) face major barriers to effective service delivery: almost half of FLHWs interviewed are unpaid, effectively operating as volunteers, struggle with difficult living conditions and lack of supplies, and report inequitable treatment between male and female workers.
• There is a lack of evidence-based health information for pregnant women: only 27% of pregnant women in the study reported having received any information related to sexual and reproductive health or associated risks.
• Despite generally positive health-seeking behavior, both women and men are concerned by lack of availability of medicine. Read More...
Gender and Power Analysis on CoVID-19 Health System Strengthening Project (CoHSiS)
From July 2022 to April 2025, the COVID-19, and Health System Strengthening Support Project (commonly known as CoHSiS) will be in operation. This three-year initiative, funded by the Japan Social Development Fund (JSDF) and administered by the World Bank Group, aims to empower municipalities to prepare for and respond to COVID-19 and other health emergencies. Specifically, CoHSiS’s implementation is focused on two municipalities: Covalima and Viqueque. To ensure gender equality, the project will incorporate CARE's Gender Equality and Women’s Voice Framework into all its intervention. As part of its planning process, the project aims to conduct a comprehensive gender analysis on six key areas of inquiry: (i) Sexual/gender division of labour, (ii) household decision-making, (iii) claiming rights and meaningful participation in public decision-making, (iv) access to public space and services, (v) control over productive assets, and (vi) violence and restorative justice using both primary methods which include utilising SAA methodology in focus group discussions, key interviews with key stakeholders as key informants and individual survey with the community and secondary data sources.
Key findings
Sexual/Gender Division of Labor
Timor-Leste is predominantly a patriarchal society with strong social and gender norms and gendered power imbalances that lead to gender inequality. At the household level, women and girls are overburdened with work as they perform most of the household chores and child and elder care; and spend their time on agriculture or horticulture work as well as contributing to community or cultural events. On the other hand, based on the primary data analysis, men are expected to be breadwinners for the family and women are expected to take care of the household. In cases where men have performed chores outside their prescribed roles, for example, the daily clock showed caring for babies, taking care of the children, and doing household activities like cooking and fetching water, women and the community at large have stigmatised men. When men try to take up roles that are already defined as women's roles, women and the community can even call men "gay". Additionally, women spend an average of 12 hours daily (5 am – 10 pm) on household chores while men spend an average of 9 hours daily on productive work (6 am – 10 pm) taking out resting time from both males and females. Self-confidence and belief in their own abilities are key components that aid women in negotiating for a fairer household division of labour with their partner.
Despite the existence of negotiation between partners for sharing household chores, tasks remain gendered and resistant to change. Men and boys who challenge these norms by performing household chores face backlash and stigmatization. However, there is some evidence of shifting trends, with more men participating in traditionally female chores.
Household Decision-Making
Generally, women have less decision-making power in households, with their scope often limited to daily matters like food consumption and management of finances for daily expenses. Men tend to make the more substantial decisions regarding matters like buying and selling large animals, land, and generally making agricultural choices.
The division of decision-making power varies depending on the marriage system, with some communities adhering to matrilineal traditions where women have more influence, but even in such cases, significant decisions still require consultation with males within the family.
The study highlights that attending traditional ceremonies and making decisions about children's futures, education, and financial matters can lead to conflicts if not handled jointly. While discussions with community members indicated the importance of mutual consultation in women's negotiation for decision-making, the study also found that women who make independent decisions without consulting their husbands are blamed if the outcomes are unfavourable.
Control over productive assets
In Timor-Leste, control over productive assets, including agricultural land, crops, and animals, poses a significant challenge for women. Men predominantly hold control over big productive assets, such as buffalos and horses, and are the primary decision-makers for household assets. There's a clear distinction between "big assets" and "small assets," with women primarily owning the latter, which includes items like Tais (traditional weavings) which have a lower monetary value.
However, there are signs of change, with recent developments, such as training and activities by NGOs and the government, leading to increased participation of women in decisions about household and productive assets. Joint decision-making, especially on assets with lower monetary value, is now more common. In some cases, men are giving women more autonomy over these assets.
Strategies employed by women to negotiate control over productive assets include mutual agreement, open communication, temporary changes in responsibilities, and shared responsibility.
The study also identifies differences in ownership and control of assets between patrilineal and matrilineal societies, where practices can vary significantly. For example, in patrilineal societies, the presence of a male family member often automatically bestows inheritance rights, while in matrilineal societies, women are prioritized for inheritance, particularly regarding land. However, the study notes that it is essential to consider the specific context of individual families. Read More...
Key findings
Sexual/Gender Division of Labor
Timor-Leste is predominantly a patriarchal society with strong social and gender norms and gendered power imbalances that lead to gender inequality. At the household level, women and girls are overburdened with work as they perform most of the household chores and child and elder care; and spend their time on agriculture or horticulture work as well as contributing to community or cultural events. On the other hand, based on the primary data analysis, men are expected to be breadwinners for the family and women are expected to take care of the household. In cases where men have performed chores outside their prescribed roles, for example, the daily clock showed caring for babies, taking care of the children, and doing household activities like cooking and fetching water, women and the community at large have stigmatised men. When men try to take up roles that are already defined as women's roles, women and the community can even call men "gay". Additionally, women spend an average of 12 hours daily (5 am – 10 pm) on household chores while men spend an average of 9 hours daily on productive work (6 am – 10 pm) taking out resting time from both males and females. Self-confidence and belief in their own abilities are key components that aid women in negotiating for a fairer household division of labour with their partner.
Despite the existence of negotiation between partners for sharing household chores, tasks remain gendered and resistant to change. Men and boys who challenge these norms by performing household chores face backlash and stigmatization. However, there is some evidence of shifting trends, with more men participating in traditionally female chores.
Household Decision-Making
Generally, women have less decision-making power in households, with their scope often limited to daily matters like food consumption and management of finances for daily expenses. Men tend to make the more substantial decisions regarding matters like buying and selling large animals, land, and generally making agricultural choices.
The division of decision-making power varies depending on the marriage system, with some communities adhering to matrilineal traditions where women have more influence, but even in such cases, significant decisions still require consultation with males within the family.
The study highlights that attending traditional ceremonies and making decisions about children's futures, education, and financial matters can lead to conflicts if not handled jointly. While discussions with community members indicated the importance of mutual consultation in women's negotiation for decision-making, the study also found that women who make independent decisions without consulting their husbands are blamed if the outcomes are unfavourable.
Control over productive assets
In Timor-Leste, control over productive assets, including agricultural land, crops, and animals, poses a significant challenge for women. Men predominantly hold control over big productive assets, such as buffalos and horses, and are the primary decision-makers for household assets. There's a clear distinction between "big assets" and "small assets," with women primarily owning the latter, which includes items like Tais (traditional weavings) which have a lower monetary value.
However, there are signs of change, with recent developments, such as training and activities by NGOs and the government, leading to increased participation of women in decisions about household and productive assets. Joint decision-making, especially on assets with lower monetary value, is now more common. In some cases, men are giving women more autonomy over these assets.
Strategies employed by women to negotiate control over productive assets include mutual agreement, open communication, temporary changes in responsibilities, and shared responsibility.
The study also identifies differences in ownership and control of assets between patrilineal and matrilineal societies, where practices can vary significantly. For example, in patrilineal societies, the presence of a male family member often automatically bestows inheritance rights, while in matrilineal societies, women are prioritized for inheritance, particularly regarding land. However, the study notes that it is essential to consider the specific context of individual families. Read More...
RAPPORT D’EVALUATION FINALE PROJET PEREN Programme de Poursuite des Engagements pour la Résilience à l’Extrême Nord
RAPPEL-INTRODUCTION
Porté par le consortium : ACF-CRF-CARE, le projet PEREN a pris effet sur un peu plus de 2 ans avec la volonté de pérenniser, sur 6 communes de l’Extrême Nord, une partie des actions du projet RESILIANT qui l’avait précédé pendant 4 ans. Il vise à renforcer la gestion des crises alimentaires et nutritionnelles par les institutions, tout en améliorant les conditions de vie des ménages. Le présent rapport est le résultat de l’évaluation finale réalisée en mai 2023 à partir
d’une revue bibliographique, de rencontres et de visites de terrain, ainsi que de 2 restitutions en présence des acteurs et des partenaires du projet.
PRESENTATION EN QUELQUES CHIFFRES CLEFS
PEREN est intervenu via un package d’activités comprenant : l’appui à l’élaboration du Plan National de Réponse alimentaire et nutritionnelle (PNR), le soutien à la coordination de ce secteur dans l’Extrême Nord, l’accompagnement à la gouvernance des 6 communes, l’appui aux systèmes de productions agricoles à travers notamment l’accompagnement de 10 coopératives, 200 AVEC et 41 CEP. Il est intervenu dans 145 localités, auprès de plus de 9900 bénéficiaires pour le soutien à l’économie des ménages dont 75% sont des anciens bénéficiaires du RESILIANT. Avec le volet accès à l’eau potable, le nombre de bénéficiaires passe à plus de 20 000 ménages et plus de 170 000 personnes.
LA GESTION DES CRISES ALIMENTAIRES ET NUTRITIONNELLES PAR LES INSTITUTIONS
Planifier la réponse au niveau national et coordonner l’action dans l’Extrême Nord Le PNR a été élaboré, de façon participative et consensuelle. Avec la version révisée en 2023 (PNR2), le MINADER dispose d’un outil essentiel pour structurer la réponse et mobiliser les moyens nécessaires car actuellement le plan est financé à hauteur de 50% seulement.
Parallèlement, le GTSA de Maroua a été réactivé, il permet des échanges réguliers entre les acteurs du secteur et des perspectives plus ambitieuses sont tracés pour la suite : mener des actions conjointes, éditer un bulletin trimestriel d’information… Appropriations, pérennisation des bonnes pratiques par les institutions La collaboration du PEREN avec les communes a été positive et constructive. De nombreux volets d’actions ont été activés : réunions CCODES, révision des PCD, activation des FDE/MAE, renforcement des équipes avec du personnel qualifié (ACDES), élaboration de plans Genre… Des MOU ont été signés pour mener des actions conjointes mais leur durée a été compressée à +/-1 an. Cela n’a pas permis de tout accomplir comme prévu et de sécuriser toutes les actions souhaitées comme : envisager une meilleure utilisation du 1% nutrition, consolider les FDE/MAE qui restent embryonnaires, appuyer les partenariat OSC qui débutent, soutenir la dynamique CCODES qui est fragile et inscrire les plans « genre » dans les budgets des communes. Read More...
Porté par le consortium : ACF-CRF-CARE, le projet PEREN a pris effet sur un peu plus de 2 ans avec la volonté de pérenniser, sur 6 communes de l’Extrême Nord, une partie des actions du projet RESILIANT qui l’avait précédé pendant 4 ans. Il vise à renforcer la gestion des crises alimentaires et nutritionnelles par les institutions, tout en améliorant les conditions de vie des ménages. Le présent rapport est le résultat de l’évaluation finale réalisée en mai 2023 à partir
d’une revue bibliographique, de rencontres et de visites de terrain, ainsi que de 2 restitutions en présence des acteurs et des partenaires du projet.
PRESENTATION EN QUELQUES CHIFFRES CLEFS
PEREN est intervenu via un package d’activités comprenant : l’appui à l’élaboration du Plan National de Réponse alimentaire et nutritionnelle (PNR), le soutien à la coordination de ce secteur dans l’Extrême Nord, l’accompagnement à la gouvernance des 6 communes, l’appui aux systèmes de productions agricoles à travers notamment l’accompagnement de 10 coopératives, 200 AVEC et 41 CEP. Il est intervenu dans 145 localités, auprès de plus de 9900 bénéficiaires pour le soutien à l’économie des ménages dont 75% sont des anciens bénéficiaires du RESILIANT. Avec le volet accès à l’eau potable, le nombre de bénéficiaires passe à plus de 20 000 ménages et plus de 170 000 personnes.
LA GESTION DES CRISES ALIMENTAIRES ET NUTRITIONNELLES PAR LES INSTITUTIONS
Planifier la réponse au niveau national et coordonner l’action dans l’Extrême Nord Le PNR a été élaboré, de façon participative et consensuelle. Avec la version révisée en 2023 (PNR2), le MINADER dispose d’un outil essentiel pour structurer la réponse et mobiliser les moyens nécessaires car actuellement le plan est financé à hauteur de 50% seulement.
Parallèlement, le GTSA de Maroua a été réactivé, il permet des échanges réguliers entre les acteurs du secteur et des perspectives plus ambitieuses sont tracés pour la suite : mener des actions conjointes, éditer un bulletin trimestriel d’information… Appropriations, pérennisation des bonnes pratiques par les institutions La collaboration du PEREN avec les communes a été positive et constructive. De nombreux volets d’actions ont été activés : réunions CCODES, révision des PCD, activation des FDE/MAE, renforcement des équipes avec du personnel qualifié (ACDES), élaboration de plans Genre… Des MOU ont été signés pour mener des actions conjointes mais leur durée a été compressée à +/-1 an. Cela n’a pas permis de tout accomplir comme prévu et de sécuriser toutes les actions souhaitées comme : envisager une meilleure utilisation du 1% nutrition, consolider les FDE/MAE qui restent embryonnaires, appuyer les partenariat OSC qui débutent, soutenir la dynamique CCODES qui est fragile et inscrire les plans « genre » dans les budgets des communes. Read More...
Support for Service Delivery Integration- Services (SSDI-Services) Endline
SSDI-Services was the flagship project for USAID/Malawi’s health office. The project was implemented from November 8, 2011 to March 7, 2017 under a cooperative agreement, valued at USD 89 million. Active project implementation occurred over a 4.5-year period from April 2012 to December 2016, with the preceding and following months focused on startup and closeout activities respectively.
SSDI-Services provided financial and technical assistance to the Malawian Ministry of Health (MoH) to deliver, refine, and scale up high-impact interventions contained in the Essential Health Package (EHP). The EHP includes globally proven and cost-effective interventions to address key causes of illness and death in Malawi. SSDI-Services implemented interventions under the following program areas: maternal, newborn, and child health (MNCH); family planning (FP); malaria; nutrition; HIV/AIDS; and sanitation and hygiene.
SSDI-Services was implemented by a consortium comprising Jhpiego as lead, CARE, Plan International, and Save the Children. The project focused on increasing access to, and strengthening the delivery of, EHP services both at the health facility and in the community. It leveraged the work of both SSDI-Communication and SSDI-Systems to improve health-seeking behavior and the quality of health services by addressing the informational needs of both service providers and their clients. It also addressed systems issues that may hinder the provision of high-quality Read More...
SSDI-Services provided financial and technical assistance to the Malawian Ministry of Health (MoH) to deliver, refine, and scale up high-impact interventions contained in the Essential Health Package (EHP). The EHP includes globally proven and cost-effective interventions to address key causes of illness and death in Malawi. SSDI-Services implemented interventions under the following program areas: maternal, newborn, and child health (MNCH); family planning (FP); malaria; nutrition; HIV/AIDS; and sanitation and hygiene.
SSDI-Services was implemented by a consortium comprising Jhpiego as lead, CARE, Plan International, and Save the Children. The project focused on increasing access to, and strengthening the delivery of, EHP services both at the health facility and in the community. It leveraged the work of both SSDI-Communication and SSDI-Systems to improve health-seeking behavior and the quality of health services by addressing the informational needs of both service providers and their clients. It also addressed systems issues that may hinder the provision of high-quality Read More...
Gender Analysis: Prevention and Response to Ebola Virus Disease in the Democratic Republic of Congo
The latest epidemic of Ebola Virus Disease (EVD) in the Democratic Republic of Congo (DRC) has rapidly evolved into the second largest outbreak in history. Deployed in an operational environment characterised by ongoing volatility, EVD prevention, treatment and containment efforts have faced multiple difficulties. Mistrust of EVD responders by local communities, coupled with targeted attacks on healthcare workers and facilities, have proved to be serious operational challenges. Despite a gressive efforts to stamp out the disease across three provinces, the virus has continued to spread and is responsible for the deaths of 3,303 people to date (as of 24th November 2019) with an overall fatality rate of 67%.
However, these casualty numbers hide the underlying characteristics of the EVD crisis. The reality is that the majority of fatalities consist of women (56%), and children (28%). Adult men constitute just 11% of EVD deaths. Yet fatalities alone do not fully demonstrate the differential ways in which men, women, boys and girls are exposed and experience the immediate risks and longer-term consequences of the disease. Socially prescribed cultural norms, attitudes and practices in relation to gender and age dictate how individual women, men, girls and boys are differentially impacted by the EVD crisis. It is therefore critical to better understand the socio-behavioural underpinnings to EVD aetiology. In light of the gendered dimensions of the EVD crisis, CARE International in DRC commissioned a Gender Analysis of the EVD crisis in North Kivu in order to provide information about the different needs, capacities and coping strategies of women, men, girls and boys during the EVD crisis. Read More...
However, these casualty numbers hide the underlying characteristics of the EVD crisis. The reality is that the majority of fatalities consist of women (56%), and children (28%). Adult men constitute just 11% of EVD deaths. Yet fatalities alone do not fully demonstrate the differential ways in which men, women, boys and girls are exposed and experience the immediate risks and longer-term consequences of the disease. Socially prescribed cultural norms, attitudes and practices in relation to gender and age dictate how individual women, men, girls and boys are differentially impacted by the EVD crisis. It is therefore critical to better understand the socio-behavioural underpinnings to EVD aetiology. In light of the gendered dimensions of the EVD crisis, CARE International in DRC commissioned a Gender Analysis of the EVD crisis in North Kivu in order to provide information about the different needs, capacities and coping strategies of women, men, girls and boys during the EVD crisis. Read More...
FINAL PERFORMANCE EVALUATION REPORT OF THE PROJECT “ZIKA RESPONSE IN ECUADOR AND PERU”
This document is the final report of the performance evaluation of the binational project Zika Response in Ecuador and Peru, implemented in Ecuador and Peru by CARE from 2016 to 2019. The main objectives of the project were to strengthen community, local and national capacities to respond to the outbreak of Zika virus and other vector-borne diseases, as well as to improve regional and national efforts to reduce Zika transmission rates.
The evaluation of the project in Ecuador was carried out in the intervention zones of 10 cantons of the provinces of El Oro, Manabí and Esmeraldas, between August and September 2019; in Peru, in 20 districts of 10 provinces of the departments of Tumbes, Piura, Lambayeque, and Cajamarca. After the elaboration of the work proposal and the methodological design of the evaluation, secondary information was collected and primary information was collected at field through interviews, focus groups and social mapping (in Ecuador), and a Likert scale survey (in Peru). The evaluation was framed in five blocks: General Aspects, Community Mobilization, Community-Based Surveillance, Social and Behavioral Change, and Inter-Institutional Planning and Coordination.
The main findings of the evaluation determine that the project achieved, for the most part, the objectives of the project, having as its main achievement the facilitation of inter-institutional coordination of the different actors in the territory. In Peru, the experience of community-based vector control, supported by technological and communications innovations, stands out. In both countries, the project successfully mobilized the community to carry out prevention strategies against Zika and increase knowledge of the risks of this type of disease, as well as useful individual and collective strategies for its prevention. Read More...
The evaluation of the project in Ecuador was carried out in the intervention zones of 10 cantons of the provinces of El Oro, Manabí and Esmeraldas, between August and September 2019; in Peru, in 20 districts of 10 provinces of the departments of Tumbes, Piura, Lambayeque, and Cajamarca. After the elaboration of the work proposal and the methodological design of the evaluation, secondary information was collected and primary information was collected at field through interviews, focus groups and social mapping (in Ecuador), and a Likert scale survey (in Peru). The evaluation was framed in five blocks: General Aspects, Community Mobilization, Community-Based Surveillance, Social and Behavioral Change, and Inter-Institutional Planning and Coordination.
The main findings of the evaluation determine that the project achieved, for the most part, the objectives of the project, having as its main achievement the facilitation of inter-institutional coordination of the different actors in the territory. In Peru, the experience of community-based vector control, supported by technological and communications innovations, stands out. In both countries, the project successfully mobilized the community to carry out prevention strategies against Zika and increase knowledge of the risks of this type of disease, as well as useful individual and collective strategies for its prevention. Read More...