International Development Select Committee Inquiry into Humanitarian Crises Monitoring – COVID-19

Submission by CARE International UK

Introduction and summary

1. CARE International UK is part of the global CARE confederation which has been working to defend dignity, fight poverty and to provide lifesaving humanitarian assistance to people in need for over 75 years. CARE is responding to COVID-19 through new specific programming, or adaptations to our existing programmes, in 52 countries. This includes working in 23 countries to increase water and sanitation support; 14 country teams are scaling up health and reproductive health services, and a further 19 countries are working on needs such as income, shelter and education.
2. Informed by crises including: public health emergencies like the Ebola crisis in West Africa and the Democratic Republic of the Congo; grave humanitarian contexts like those of Syria and Yemen; and economic downturns like the Global Economic and Financial Crisis, CARE is deeply concerned about the implications of COVID-19  on women and girls in development and humanitarian settings. These include adverse effects on:  education; food security and nutrition;, health including sexual and reproductive health and rights (SRHR) livelihoods and protection including against gender-based violence (GBV). Even after the outbreak has been contained, women and girls may continue to suffer from ill-effects for years to come.
3. CARE welcomes the UK Government’s leadership on responding to COVID-19 globally including leading the search for a vaccine, and in making gender equality a priority. We stand ready with DFID and the humanitarian community to work collectively to build back better. However, we share concerns with other civil society organisations that a response funneled through multi-lateral institutions will be life-threateningly slow and unnecessarily costly. The Rapid Response Facility (RRF) is welcome, but funds allocated are inadequate against the time-bound need to save lives and contain the spread of the disease. Charities also face funding shortfalls in the next few months that will limit on our ability to help those most in need.

Recommendations:

DFID should:

• Provide immediate flexibility and additional funding for civil society to ensure that existing development and humanitarian aid can rapidly scale up and adapt to the risks posed by COVID-19, including increasing resources available for the RRF and greater support for essential core costs.
• Prioritise gender equality in the COVID-19 response both as a standalone and mainstreamed approach. Practically, this means rapid, robust gender analysis in all programming, and allocating specific funding to SRHR, GBV and women’s economic empowerment, and participation and leadership programmes, including those led by civil society.
• Recognise women as humanitarian leaders, especially first responders and frontline workers. Ensure that funding reaches women’s rights and women-led organisations, as well as women’s groups and community networks responding to the crisis.

Gender implications of COVID-19: lack of women’s leadership despite many at the frontlines; a silent GBV pandemic as countries go into lockdown; reduced access to healthcare

4. CARE’s Rapid Gender Analysis (RGA) of COVID-19 is based on secondary data analysis undertaken 12-20 March 2020, exploring the current and future gendered dimensions of COVID-19 and the ways in which women, girls and other marginalised people are likely to suffer from the pandemic. The RGA is a unique CARE method that allows us to quickly, efficiently respond in rapidly unfolding crises like COVID-19, especially in humanitarian emergencies already affected by war, climate change and economic fragility. The COVID-19 RGA learns from past public health emergencies, and data on changing gender roles and responsibilities and risks and opportunities to different communities.  The key findings are summarized for this submission. Further RGAs are being carried out at the regional and country level, and CARE will continue to share the results with DFID and the wider sector to help inform the response.
5. Access to health care; including Sexual and Reproductive Health and Rights (SRHR)
1. Already low resources are diverted from essential healthcare, including maternal and SRHR. Shortage of health professionals and fewer women in healthcare leadership, financial resources and medication will undoubtedly have a disproportionate impact on women and girls. The nature of lockdowns also presents challenges for accessing services as normal. Maternal health is already a critical issue for women around the world: 61% of maternal deaths worldwide occur in fragile states, many of them affected by conflict and reoccurring natural disasters.[1] Importantly, reductions in SRHR services will have a greater effect on patients who rely on free or subsidised care, most notably women, girls and/or other marginalised groups living in poverty or those already facing other barriers to SRHR health care.[2]
6. Gender-based violence (GBV)
1. Incidences of GBV increase substantially during humanitarian crises.[3] Important measures to prevent the spread of the virus such as mandatory lockdowns, quarantine and self-isolation mean that individuals, particularly women, are trapped with the perpetrator with no physical respite from the abusive relationship. Perpetrators may also use the virus to further isolate their victim from family, friends and social networks, as well as from the services that could support.[4] Evidence is already showing a dramatic increase in Domestic Violence and Intimate Partner Violence cases during quarantine.[5]
2. Access to GBV services: the potential loss of income due to self-isolation, potential lack of information regarding which GBV services remain available, and fears of contracting the virus at service points could create multiple barriers whereby survivors of GBV may find themselves in a near impossible situation: unable to seek support, unable to access services, and unable to leave their abusers.[6] Similarly, the diversion of limited resources away from GBV response and prevention services toward infection control and treatment, court closures that prevent or delay legal protection for survivors will all undoubtedly culminate in a rise in violence against women and girls.[7]
3. Sexual exploitation and abuse: the forecasted economic downturn will lead to a spike in sexual exploitation and abuse, most notably within at-risk groups such as adolescent, migrant, refugee and IDP women and girls who may be forced or coerced to provide sex in exchange for food. This was seen during the Ebola outbreak with female-headed households at additional risk. Emerging evidence also suggests that the COVID-19 pandemic has the potential to increase the risks of sexual exploitation and violence by state officials and armed guards.[8]
7. Decision-making and leadership
1. In a study by CARE, the multi-level impact of social norms and gender roles demonstrated the importance of incorporating women’s specific needs both during the response itself and later, during the design and implementation of economic relief packages, new services, or other support systems.[9]  Therefore, the importance of incorporating women’s voices and knowledge is critical at all stages of outbreak preparedness and response.
2. Women’s lack of decision-making power in health systems: although women constitute the majority of health and social care workers, more than 70% of CEOs in global organisations active in health are male and just 5% are women from low- and middle-income countries.[10] This disparity negatively affects health outcomes for women and children worldwide.[11]
3. Household power: women’s healthcare is not determined solely by the provision of healthcare treatments but also by whether women have free and safe access to such services.[12] In contexts where men hold the majority or all decision-making power in the household, this will limit women’s access to health and SRHR services, especially if their freedom of movement is restricted or if they have no control over household finances. Such unequal household power and its impact on women was noted during the Ebola crisis. [13]
4. Women’s participation in community decision-making: Women’s frontline interaction with communities and socially prescribed care roles place them in a prime position to identify outbreak trends at the local level, which is why it is concerning that women have not been fully incorporated into global health security surveillance, detection and prevention mechanisms.[14] In humanitarian crises, women and girls are often excluded from community-level decision-making processes and governance structures that shape the response strategies.[15] As late as 2018, only 56% of the monitored crisis contexts directly consulted with local women’s organisations in the humanitarian planning process.[16]
8. Access to information:
1. Literacy: Data on gendered access to information about COVID-19 is scarce and this is especially concerning given the nature of the pandemic.  At global and local levels, it is important that information reaches and is understood by everyone, most notably at-risk groups. However, around the world, literacy is highly gendered: young women account for 59% of the total illiterate youth population.[17] UNICEF’s statistics show that in one-third of countries illiterate women far outnumber their male counterparts.[18] Similarly, research conducted by Translators Without Borders highlighted the gender gap in comprehension of Ebola-related community messages, thereby proving the necessity for hyper-localised key messages, particularly in contexts with low literacy levels and linguistic diversity.[19]
2. Unequal access to mobile phones: as countries emplace movement restrictions and prevent women and girls from physically accessing safe spaces and services, it is important to understand how gender affects access to mobile phones. Women in low- and middle-income countries are 10% less likely than men to own a mobile phone. The Global System for Mobile Communications estimates that there are 443 million ‘unconnected’ women around the world. The data is even more stark in refugee populations. For example, in Tanzania’s Nyarugusu refugee camp, research showed a 42% gender gap in mobile phone ownership. [20]
9. Women's economic empowerment
1. COVID-19 has triggered a global economic crisis. Around the world, women are more likely to work jobs that are low-paid, informal, and lacking protection in terms of wages and contracts. In humanitarian settings, women are even more likely to be employed in informal, low-wage activities that are highly prone to disruption during public health emergencies.
1. Strict quarantine measures will mean no opportunities to earn and less access to social protection.
2. Many women will be forced to put safety at risk to seek alternative income sources.
3. Preventative measures such as lockdowns will hit informal workers first, a sector dominated mainly by women especially migrant women.
4. Female migrant workers, particularly those engaged in care and domestic work, are likely to experience grave economic consequences.[21] Travel restrictions associated with the outbreak may keep women from reaching or leaving their jobs, while unequal power dynamics between workers and employers may expose female migrant workers to additional risks.[22]
2. Coupled with a potential loss of income due to the mortality of other household income earners, the economic impact of COVID-19 outbreaks on women and girls could be long-term and widespread.
1. During the Ebola crisis, the restrictions on the movement of goods and people hampered women’s trading activities, both cross-border and between communities as well as their ability to cultivate their land and engage in other agricultural activities.[23] Consequently, women were unable to pay back loans from village savings and loan associations, which reduced the capital of the associations and affected women’s longer-term economic prospects.
3. The gender pay gap will also widen as women are more likely to be in lower paid jobs and therefore more likely to sacrifice work for dependents which in turn will have a lasting impact on earnings and career.

The impact of COVID-19 in ongoing humanitarian contexts

10. COVID-19 outbreaks are devastating in any context. However, the dangers of such outbreaks will be magnified for the nearly 168 million vulnerable people around the world who need humanitarian assistance and protection.[24] At particular risk are the more than 70 million people—half of whom are women—who have been forced to flee their homes due to persecution, conflict, violence, and human rights violations. Many of the displaced are sheltering in countries with weak WASH infrastructure[25] and lack access to health services.[26]
11. Refugee and IDP populations in camps and informal settlements are acutely vulnerable, as overcrowding or exposure can exacerbate infection rates.[27] Restrictions on entry, travel, and freedom of movement can also have adverse effects on populations on the move, restricting their access to safety and protection.[28] Those who remain in conflict-affected areas also face dire circumstances. Conflict often interrupts health services, results in damaged health infrastructure, and impedes the ability of health care workers to conduct disease surveillance.[29] Below we discuss the particular challenges faced in two humanitarian crisis CARE is supporting, as an illustration of the types of analysis and needs that are being presented in ongoing humanitarian contexts.

Syria

12. After nine years of conflict, the health infrastructure in Syria has been decimated and is grossly unequipped to monitor, test, or prevent a public health emergency. CARE is particularly concerned about the extremely vulnerable population of Northwest Syria, due to the offensive that began in mid-December 2019 and has displaced nearly one million people, the vast majority being women and children. It is critical that aid workers focus on prevention measures together with response planning. There is an urgent need to scale up the health response and increase health supplies as well as continuing the ongoing humanitarian response to address the growing need to access to clean water, latrines, safe spaces, access to food and other basic items. It is vital that humanitarian border crossings remain open.

Yemen

13. Adding complexity to the world’s worst humanitarian crisis, the first COVID-19 case was confirmed in Yemen on 13 April, following reported cases in all neighbouring countries. CARE’s analysis of INFORM risk management data finds that the world’s ‘highest risk’ countries including Yemen, are three times as likely to be exposed to epidemics like COVID-19, and six times less likely to have access to healthcare as the world’s lowest risk countries .[30] Yemen, considered ‘very high risk’ by INFORM, is already suffering from a cholera epidemic, years of war, economic deprivation and frequent natural disasters, and only 51% of its health centres are fully functional with little medicine, equipment and PPE available. With only two sites in Sana’a and Aden able to conduct a few hundred tests, the likelihood of in-country infections is high. Both limited medical and testing capacities, and fear of reporting, are behind the initial lack of information on COVID19 in Yemen. With more than 3.6 million people displaced since the start of the war, one-third of whom live in overcrowded camps and informal settlements, and escalating conflicts in fragile areas, the outbreak of COVID-19 in Yemen will be catastrophic.[31]

Rohingya refugee crisis in Bangladesh

14. Overcrowding, unsanitary living conditions, poor basic health infrastructures, could have disastrous consequences for the 859,161 Rohingya refugees living in camps in Cox’s Bazaar, Bangladesh.  The camps have a 40,000 person per km[32] density, almost four times that of New York city and ten times that of Wuhan. Overcrowding of the camps renders social distancing practically impossible.  In August-September 2019, 17% of the households reported not having enough water for personal hygiene purposes, and 33% not having soap.[33] The WASH facilities in the camps are public and often overcrowded, which increases the risk of COVID-19 transmission. 46% of the population in the camps have poor to borderline food consumption score[34], which increases the risks of contracting the virus. Without access to livelihood opportunities, the Rohingyas refugees heavily rely on the assistance provided by humanitarian organisations.

The UK Government's response to COVID-19 as a humanitarian crisis

15. CARE welcomes the UK Government’s leadership on responding to COVID-19 globally including leading the search for a vaccine, and in making gender equality a priority.  We stand ready with DFID and the humanitarian community to work collectively to build back better and bring unique gender expertise and deep partnerships with local NGOs and women leaders. However, we share concerns with other civil society organisations that a response funnelled through multi-lateral institutions will be life-threateningly slow and unnecessarily costly (given higher overheads at the UN, as well as the roughly 90-day turnaround to disburse funds to local actors versus 48 hours for INGOs as learned from the Ebola response). INGOs also have less bureaucracy and trusted local partnerships with communities, versus multilateral institutions, as well as the capacity to be accountable.
16. The activation of the Rapid Response Facility (RRF) component of DFID’s response is timely, but we are concerned that the current RRF allocation is insufficient for this stage of the response to be as effective as we all need it to be. DFID has asked INGOs to respond in up to 15 countries through the RRF and allocated £20m. Along with BOND and 11 other INGOs, we have called on this allocation to increase, suggesting on previous experience that £100m would be appropriate. We have called on DFID to ensure proposals for the first round of funding could be considered for new funding, and to work with country offices to find resources while ensuring existing humanitarian programmes can continue. 
17. Charities also face funding shortfalls from voluntary donations in the next few months that will limit our ability to help those most in need. According to BOND, the international development sector stands to lose £1.28bn.[35] 37 percent of UK development charities do not believe they will last beyond the next six months without additional funding.[36]

Recommendations:

18. DFID should:

• Provide immediate flexibility and additional funding for civil society to ensure that existing development and humanitarian aid can rapidly scale up and adapt to the risks posed by COVID-19, including increasing resources available for the RRF and greater support for essential core costs.
• Prioritise gender equality in the COVID-19 response both as a standalone and mainstreamed approach. Practically, this means rapid, robust gender analysis in all programming, and allocating specific funding to SRHR, GBV and women’s economic empowerment, and participation and leadership programmes, including those led by civil society.
• Recognise women as humanitarian leaders, especially first responders and frontline workers. Ensure that funding reaches women’s rights and women-led organisations, as well as women’s groups and community networks responding to the crisis.