Report No. 44427-GW Republic of Guinea-Bissau Social Sector Review January 15, 2009 Human Development II Africa Region Document of the World Bank GER Gross Enrollment Rate GFATM Global Fundto Fight AIDS, Tuberculosis and Malaria GIPASE Gabinete de Estatistica e Planeamento do Sistema Educativo GIR Gross Intake Rate HDI Human Development Indicator HIS Health Information System HR Human Resources HRH Human Resources inHealth IDA International Development Agency IEC Information, Education and Communication I L A P LightHouseholdSurvey ILO InternationalLabor Organization Instituto Nacional para o Desenvolvimento da Educaqio (National Institute for INDE Education Development) INEP Instituto Nacional de Estudos ePesquisa (National Institute for Studies and Research) INPS Instituto Nacional dePrevidsncia Social (National Institute o f Social Security) IPSA Integrated Poverty and Social Assessment JSAN Joint Staff Advisory Note M&E Monitoring and Evaluation Mandinga Muslimethnic group livingmainly inthe northand east of the country Mandjuandade Social club providingbenefits to its members MBB Marginal Budgeting for Bottleneck MDG Millennium Development Goals MICS Multiple Indicators Cluster Survey M o E Ministry o f Education M o H Ministry o f Health Mutualidade de Sa6de Community-based informal health insurance N A S National Aids Secretariat NGO Non-Governmental Organization N S H National School of Health PER Public Expenditure Review PNDS National Health Development Plan PRSP Poverty Reduction Strategy Plan PSB Project0 de Salide de Bandim (Bandim HealthProject) U A C Universidade Arnilcar Cabral (University Amilcar Cabral) UN UnitedNations Vice President: Obiageli Ezekwesili (AFRVP) Country Director: Habib M.Fetini (AFCF1) Sector Director: Y a w Ansu (AFTHD) Sector Manager: Eva Jarawan (AFTH2) Task Team Leader: Gerald0 Martins (AFTH2) 111 .I, TABLE OFCONTENTS ACKNOWLEDGEMENTS ............................................................................................................ 1 EXECUTIVE SUMMARY ............................................................................................................ 2 MATRIX o f POLICY PRIORITIES FORTHE SOCIAL SECTOR............................................. 9 1. INTRODUCTION ................................................................................................................ 13 2. SOCIOECONOMIC CONTEXT OF SOCIAL SERVICEDELIVERY ............................. 15 2.1. DEMOGRAPHICS, MACROECONOMIC PERFORMANCE AND POVERTY ..... 15 2.2. POPULATION VULNERABILITY AND RISKS ...................................................... 18 2.2.1. 18 Idiosyncratic risks................................................................................................. Main Sources ofRisk ............................................................................................ 2.2.2. 18 2.2.3. CovariateRisks ..................................................................................................... 19 2.2.4. 20 3. OUTCOMES INSOCIAL SECTORS: OVERVIEW AND CHALLENGES..................... Vulnerable Groups................................................................................................ 28 3.1. THEHUMANDEVELOPMENT OUTLOOK............................................................ 28 3.2. THE EDUCATION SECTOR...................................................................................... 29 3.2.1. Access to Education .............................................................................................. 29 3.2.2. Internal EfJiciency ................................................................................................. 33 3.2.3. 35 Management of the Education Sector................................................................... Relevance and Quality .......................................................................................... 3.2.4. 37 3.2.5. Institutional Capacity............................................................................................ 39 3.2.6. Cost and Financing ofEducation Services........................................................... 40 3.2.7. 42 3.3. THE HEALTH SECTOR ............................................................................................. Assessment ofRecent Policy Reforms ................................................................... 44 3.3.1. Access to Basic Health Care................................................................................. 44 3.3.2. Critical Challengesfor Public Health .................................................................. 46 3.3.3. Management of the Health Sector......................................................................... 50 3.3.4. Health Financing .................................................................................................. 55 Institutional Capacity............................................................................................ 54 3.3.5. 3.4. THE SOCIAL PROTECTION SECTOR..................................................................... 60 3.4.1. 61 4. SUMMARY OF FINDINGS AND RECOMMENDATIONS............................................. Formal Safety Nets.,.............................................................................................. 65 4.1. GENERAL FINDINGSAND RECOMMENDATIONS............................................. 65 4.2. SERVICES................................................................................................................................ SPECIFICRECOMMENDATIONS TO IMPROVE DELIVERY OF SOCIAL 67 4.2.1. TheEducation Sector ............................................................................................ 67 4.2.2. TheHealth Sector ................................................................................................. 72 BACKGROUND DOCUMENTS ................................................................................................ 4.2.3. The Social Protection Sector ................................................................................ 74 76 iv Fiaures Figure 1. GER in Primary and Secondary Education .................................................................. 30 Figure 2. GER and Completion Rate in Primary Education ........................................................ 35 Tables Table 1: Government Recurrent Expenditures and Public Investmentby Sector in2005 ..........16 Table 2: Main Sources o fRisk inGuinea-Bissau........................................................................ 18 Table 3: LivingArrangements and Orphan Status o f Children under 17 years o f age Table 4 Unemployment Rate Among Adult Population (%) . ................22 ...................................................... Table 5: CondomUse Duringthe Last HighRisk Sexual Encounter........................................... 24 Table 6: Percentage of Women aged 15-49 having undergone FGC.......................................... 25 27 Table 8: Number of Schools and Students inPrimary Education in2006 .................................. Table 7: Education and Health MDGs inGuinea-Bissau ............................................................ 29 Table 9: Progress inSchool Enrollment and GER inPrimary and Secondary Education ...........29 31 Table 10: Guinea-Bissau andthe EFA-FTI Benchmarks ............................................................ 41 Table 11: Progress Towards Achievement o f the HealthMDGs ................................................ Table 12: HIV/AIDS Prevention Knowledge, Women aged 15-49............................................ 45 49 Table 13: Estimated Needs o f Key Staff inthe Health Sector in2006 Table 14: Government Recurrent Budget for the Health Sector (2002-2007) ............................ ........................................ 51 56 Table 15: HealthExpenditure by Source in2006........................................................................ Table 16: Social Protection Mechanisms inGuinea-Bissau........................................................ 57 60 Boxes Box 1. Legal Protection o f Children ;...................................................... 23 Box 2. The Case of Higher Education in Guinea-Bissau .................................................................................................. 32 Box 3. Sexuality and HIV/AIDS in Guinea-Bissau ...................................................................... Box 4. TheBurden of Medical Evacuations .................................................................. ...,............48 ................................................................................... 57 58 Box 6. Health Mutual Faith-Based Organization in Varela Box 5. Cost Recovery (Bamako Initiative) ........................................................ 64 Box 7. Key Policy Optionsfor Guinea-Bissau to Reach Universal Primary Education .............70 V ACKNOWLEDGEMENTS This study is a joint effort between the Government o f Guinea-Bissau and the World Bank to provide an accurate account o f the current status o f the provision o f key social services inGuinea-Bissau, with a focus on education, health, and social protection. The aim o f the study i s to update critical information regarding these three sectors in order to promote sound and credible dialogue betweenthe country and the Bank, as well as with other development partners inthecontext ofimplementationofthePovertyReductionStrategyPlan(PRSP). . The World Bank team consisted o f Gerald0 Martins (Senior Education Specialist and T T L of the study), Stephane Legros (Senior Health Specialist), and Gerold Vollmer (Consultant, Social Protection). Contributions to the study were received from peer reviewers Helene Grandvoinnet (AFTP4), Sigrun Aasland (AFTS3) and Valerie Kozel (HDNSP). Boubacar-Sid Barry (AFTP4), Dirk Prevoo (AFTEN), Barbara Weber (AFCSN), Joelle Dehasse (AFCC l), William Experton (AFTH2), Setareh Razmara (AFTH2), and Vincent Turbat (AFTH2) provided valuable contributions and suggestions. Administrative support was provided by Adriana Cunha Costa (AFTH2). The team carried out two field visits in February and May 2007, primarily to perform data collection. To ensure country ownership and a broad participatory approach, the Government created a multi-sector working group composed o f high-level staff from different Ministries interested in the exercise. The group was lead by Paula Pereira (Ministry o f Economy) and composed o f Alfred0 Gomes (MinistryofEducation), Alfa Umaro Djalo andAugust0 Paulo Silva (Ministryof Health), Romiio Varela (Ministry of Finance), and Inacia Gomes (Ministry o f Solidarity and Poverty Reduction). The study benefitedalso from the contributions o f several technicians from these Ministries. The team would like to thank all o f them for their collaboration and support. The team would also like to thank the staff o f development agencies in Bissau who provided support to the study, particularly the UNDP, UNICEF, and the AfDB. Our acknowledgements also go to Thierry Vincent, Adviser to the Minister o f Health, and Daniel Kertesz, WHO representative inGuinea-Bissau. 1 EXECUTIVE SUMMARY Afragile state with many challenges ahead 1. This review delivers one clear message: Despite the deep crisis in which the social sectors in Guinea-Bissau are immersed, achieving the goal o f better education, good quality health care and adequate social protection for the most vulnerable i s still possible, provided the country breaks out with the "business-as-usual" approach on social sectors. Robust reforms are needed to put the country back on track for the achievement o f the education and health Millennium Development Goals (MDGs). Clearly, some human development MDGs will not be reached by 2015, but a few are still affordable if substantial progress i s achieved inthe delivery o f social services. 2. Guinea-Bissauremains a fragile, post-conflictstate grapplingwith significant social changes. Despite attempts to rebuild the government's administration and address economic issues, following the politico-military conflict o f 1998-1999, continued political tensions, frequent changes in government, and lack o f ownership o f policies have contributed to worsen the economic outlook and the living conditions o f the population. An estimated 30 percent o f its 1.5 million inhabitants live in cities and urban areas, up from 18 percent in 1991, as a result o f rapid urbanization and migration. 3. The socioeconomic context of the period covered by the review was particularly difficult. While pressure was mounting on social services because of rapid urbanization and growing demand, delivery o f such services has been constrained by poor macroeconomic performance in recent years. GDP per capita was estimated at $ 180 in 2006. The economy still suffers from the consequences o f the 1998-1999 conflict, which contracted real GDP by 28 percent. Duringthe period 2000-2005, the real GDP growth rate averaged about 1 percent, with negative growths recorded in 2001 and 2003. The fiscal situation remains precarious with government fiscal revenues representingabout 14percent o f GDP. While spending on health and education remained lower than the regional average, external assistance dwindled at the same time, leading to mounting domestic arrears and huge fiscal imbalances. 4. Not surprisingly, poverty is widespread, particularly in rural areas. At the household level, 64.7 percent o f the population was living inpoverty in 2006, with 20.8 percent living in extreme poverty. Poverty also increases the vulnerability o f population to an array o f risks. As opportunities for non-farm wage labor have diminished considerably due to the post- war stagnation o f the economy, most o f the country's active population i s prone to employment 2 vulnerability. Adult unemployment rate stands at 12.4 percent, with youth unemployment exceeding adult unemployment considerably. Vulnerable groups include children, youth and women, whose exposure to a variety o f risks i s high. 5. Social indicators remain strikingly poor. Guinea-Bissau ranked 173rd out o f 177 countries inhuman development index in2006. Life expectancy at birth i s estimated at 47 years, and the illiteracy rate i s 63 percent. According to the MultipleIndicators Cluster Survey (MICS- 3) between2000 and 2006, the infant mortality rate increased from 124 per 1,000 live births to 138 per 1,000 live births, and the mortality rate o f children under age five has gone up to 223 per 1,000 live births from 203 per 1,000 livebirths (the lothhighestinthe world). Today, two out o f ten children die before they reach the age o f five, Maternal mortality i s estimated to be at 800 to 1,100 per 100,000 live births.Six out o f 10 children who enter the first grade do not complete the full cycle of primary education. Many of those who do complete primary education remain illiterate because o f the poor quality o f education they receive. Social protection mechanisms are almost non-existent and large segments o f the population rely on informal, community-based arrangements to cope with risks. The education coverage has improved, but inequitiespersist 6. The recent expansion of primary education coverage has been impressive,but it was not accompanied by improvementsin internalefficiencyand quality. Over the last ten.years Guinea-Bissau has substantially expanded its education system coverage, particularly in primary education. Today, there are twice as many students in primary education than there were ten years ago. Girls have particularly benefited from that expansion, as the gender gap has been closing steadily. However, internal inefficiencies persisted and even worsened. An inadequate structure and organization o f primary education sub-cycle, combined with high repetition and drop out rates and low quality o f education, has resulted in low completion rate in primary education, makingit hard for Guinea-Bissau to achieve universalprimary completion by 2015. 7. Demand for secondary education is growing steadily. As primary education enrollments increase, supported by an increase o f community-financed schools and private schools (both representingtogether 1/3 o f all primary schools) a growing demand for secondary education is emerging. Gross Enrollment Rate (GER) in secondary in 2006 was estimated at 35 percent, slightly above the 30 percent average for Sub-Saharan African countries. Private sector providers are playing a critical role in accommodating that demand. The expected expansion o f primary education will continue to put pressure on enrollment in secondary education. If the current investment trends in secondary education persist, it i s unlikely that private providers alone will be able to absorb the growing number o fnew enrollments. 8. Guinea-Bissau must dedicate efforts to increase the provision of technical and vocational training and strengthen the emerging higher education sector. Technical and vocational training i s important to build capacities for labor market and economic development, but its current marginal status in Guinea-Bissau is far from contributing to reach that goal. The 1998-99 conflict has contributed partially to disarticulate the sector, and progress in revamping the system has been slow to come. On the other hand, Guinea-Bissau has undertaken serious efforts to build tertiary education institutions. This effort has resulted in a new panorama o f higher education training in Guinea-Bissau with the opening o f two universities. But there are challenges. They include the institutional strengthening o f recent initiatives, quality o f learning, improved management, and the setting up o f a clear legal framework for the sector. A health system still unreachable by most of thepopulation 9. The current organization of the national health care system faces multiple constraintsin practice.The central Ministryoften fails to provide strategic planning, to monitor implementation o f the various healthprograms, and to ensure coordinationbetween stakeholders. The implementationo f healthprograms at regional and local levels is hampered by infrastructure and equipment shortages, as well as by weak management capacity. The management of the whole system i s also hindered by an inadequate monitoring and evaluation system, as the consolidation o f data at the central level results in low data reliability preventing appropriate decision making. Moreover, supervision o f health facilities, which i s essential to managing and maintaining the performance o f the health network, is not conducted on a regular basis, lacking funds, and appropriate coordinationandorganization. 10. As a result, the majority of the population of Guinea-Bissauhas limited access to healthcare of good quality, which results in their poor healthstatus.Access to quality health care i s limited and inequitable. On average, only 38 percent o f the population has access to health care, and the situation i s worse for the poor. Services are often o f very poor quality that there are little incentives for demand. Children immunization and malaria fighting are among the most important factors likely to improve health outcomes o f the population. Results achieved in these areas over the last years have beenmixed. With regard to children immunization, there are clear signs that effective interventions have not been sustainable, since the immunization coverage has fluctuated considerable over recent years. 11. Despite signs of reduced incidence, malaria remains the number one public health problemin Guinea-Bissau. It accounted in2005 for 35 percent of consultations inhospitals and health centers across the country and remains the first cause o f mortality among children under 5. But a recent 30 percent reduction o f new cases o f malaria remains encouraging. These positive results can be explained, in part, by the availability and extensive use o f impregnated bed nets, particularly by vulnerable groups. At present, about 60 percent o f both pregnant women and children under age five are sleeping under impregnated bed nets, and 46 percent o f households have at least one impregnated bednet. On the curative side, only 45.7 percent o f children with a fever received appropriate treatment in 2006, mainly because the shift towards the new therapeutic scheme o f artemesinin-based combination therapies (ACT) has been slow and consequently, drug shortages are recurrent. 12. There is mounting concern that the HIV/AIDS pandemic is spreading rapidly. Different estimates place the HIV prevalence in Guinea-Bissau's adult population inthe range o f 3 to 8 percent. The truth o f the matter i s that the prevalence has not decreased over recent years, despite all the programs that have been implemented to fight HIV/AIDS. In any case, that prevalence exceeds those for Guinea-Bissau's two neighbors, Senegal and Guinea-Conakry, where total prevalence is estimated to be between 0.4 percent and 0.7 percent, and 1.2 percent 4 and 1.8 percent, respectively. Access to HIV/AIDS treatment is very limited. Despite the availability o f generic anti-retro-viral drugs (ARV) from Brazil and funding from the Global Fundto FightAIDS, Tuberculosis and Malaria (GFATM), only 496 people receivedtreatment in the first quarter of 2007. Challenges inthis regard include the poor status of the health facilities and the poor capacity o f supply-chain management. Stock ruptures of pediatric ARV and o f testing supplies occurred in2007 and in early 2008. There are still several misconceptions about HIV/AIDS forms oftransmission and serious stigmas among seropositive persons. Afield of socialprotection still embryonic 13. The vast majority of the population of Guinea-Bissau does not benefit from any formal social protection support. Despite substantial need for support, there is no comprehensive social protection scheme inplace. Formal social protection arrangements, namely health insurance and pension schemes, are affordable to only a small segment o f the population in the formal sector. Government transfer programs (or safety net programs) have limitedscope and impact and receive limited government funding. Because o f these limitations, various segments o f the population rely on informal risk management strategies, including social networks, community mutual faith-based support and saving schemes. 14. The social protection institutionalframework is scattered and needs improvement. The Ministry o f Social Solidarity could play a key role in convening actors and in coordinating policy development fostering a better collaboration between the public and the non- governmental sector. Such a policy, however, needs to be evidence-based and has to prioritize interventions according to need and effectiveness. Cross-cutting issues in relation to education, health and socialprotection 15. Social sectors are in dire need of qualified staff. The country should significantly increase its numbers o f qualified teachers, general practitioners, midwives and nurses. In addition to lack o f personnel, HR policies and management system are ill-defined. They entail regional disparities, imbalances between the capital city and the most remote rural areas, and lack o f motivation o f personnel who do not see linkages between performance and their career path. 16. Poor governance and weak financing of social sectors are the main causes of low performance.As the review indicates, failures insocial services delivery inGuinea-Bissau have their root causes inthe low investment and the poor management of the social sectors. Current public spending in social sectors in 2005 represented about 20 percent o f the total government recurrent spending. In2006, per capita public spendinginthe health sector was estimated at US$ 6, and donors have contributed the same amount. Therefore, with US$ 12 total health expenditure per inhabitant, Guinea-Bissau i s not in a good position with regards to international benchmarks on health financing for developing countries. 17. A poor publicfinance management constitutes a common feature across the sectors. The budgeting process globally would require significant improvements as budget allocation procedures remains non transparent. The budget execution rate insocial sectors i s generally low. 5 The under-financing o f social sectors translates in the chronic problem o f delayed payment of salaries and allowances, which obviously affect performance. 18. Donor financing and coordination is insufficient.Donor assistance is still defined too often by donors and not by the government. The immediate consequence i s frequent overlaps of interventions and inefficiencies in the use of scarce resources. Political instability and the turnover rate at Ministries' level explain partly this situation. However, there are positive signs of better coordination among key actors with new institutional mechanismsput inplace recently (for example, the Country Coordination Mechanism for HIV/AIDS, and the EFA-FTI partnership). The prospect for external financing o f the health sector in the years to come i s disturbing. The Global Fund will likely remain the single significant donor in the sector. The World Bank support for the PNDS closed in December 2007. Similarly, the ADB and the EU, two major players inthe sector, have also withdrawn from the sector. But not all news is bad 19. The assessment indicates that, despite all the setbacks, some progress have recently been achieved in specific aspects o f education and health sectors. Inaddition to progress on education coverage and malaria, progress have also been registered in civil service reforms in both health and education, and in some cases, like the reform to rationalize the use o f teachers in the classroom, it i s impressive that the govemment was able to get the agreement to implement the reforms, amid social tensions and disputes with unions, Last but not least, non-state actors are increasingly playing a role in the delivery o f social services, sometimes with innovative approaches and good results. 20. More importantly, most of the efforts needed to improve delivery of social services are within reach of the country. As the review discusses, improving governance and financing o f social sectors can have a huge impact on outcomes. For example, it was estimated that more than 90 percent o f the relevant population would be able to complete a full cycle of primary education in a few years, if Guinea-Bissau increases the budget allocation to the education sector, improves intra-sectoral allocation and budget execution, and carry out key structural reforms. Inthe health sector, the low per capita public spending($ 12 in 2006), means that there i s enough leverage to increase public financing o f the sector with improved results. 21. In addition to specific recommendations to the education, health and social protection sectors (see Chapter 4); the review proposes the following agenda to move towards a better social services deliveryin Guinea-Bissau(see Matrix). 1. ImprovePublicFinancingof Social Sectors The share o f domestic budget effectively allocated to social sectors must be increased in order to be aligned with acceptable international and regional standards. The simple increase o f budget allocation to social sectors, however, i s not sufficient to improve outcomes. In order to positively impact service delivery, it i s important to improve budget execution insocial sectors; 6 rn Increased spending on education and health, however, i s not the sole answer. The quality and equity of spending are equally important. Improved governance, stronger accountability mechanisms, and sound expenditure management are essential to raisingthe quality o f social services. rn Donors' commitment i s important to support reform efforts in social sectors. That will require commitment o f more resources, including increasing donor support to key programs in education and health. Examples include the Fast Track Initiative in education, strengtheningo f health systems, and combating HIV/AIDS and malaria. 2. Accelerate and Scale Up PromisingReforms rn Despite their mixed results, some reforms undertaken in the recent past need to be pursued and achieved. In education, the adoption o f a six-year primary education cycle; the provision o f free primary-education; the development o f new curriculum; and the investment in teachers are among measures that are likely to have a positive impact on schooling. Inthe health sector, reforms must include measures to develop and implement a new infrastructure plan; improve the drug supply chain system; and reevaluate the whole evacuation process for patients. Non-state actors, including NGOs, are playing an increasingly important role in service delivery. In order to extend service delivery coverage -- particularly to the poor -- and to improve quality, it is important to forge partnerships with these non- state actors. This will improve and/or scale up various promising initiatives they are currently undertaking. rn Givenits limitedresources, highpoverty incidence and periodic external and internal shocks, an effective, coherent, sustainable and equitable social protection strategy i s essential for Guinea-Bissau. Such a strategy should include three key components: (i) improving the efficiency and scope o f existing social protection programs (including social insurance system and safety net programs); and (ii)promoting effective medium-term strategies and investments to improve the living standards o f the population (education and health). In this context, the social protection mechanisms must be geared towards safeguarding the well-being o f the population o f .Guinea- Bissau. It i s important for the Government to step up efforts to formalize the sector and to develop a coherent policy framework. Such framework should be designedin the context of development o f a broader social protection development agendawhich will be consistent with the country's overall strategy for growth and poverty reduction. rn The social protection development agenda must include efforts to (i)improve coverage, equity and financial sustainability o f the formal social insurance system (including health insurance and old age benefits) through either parametric or structural reforms; and increase administrative efficiency o f the system; (ii)develop 7 safety nets to protect poor and vulnerable people from falling deeper into poverty. Particularly the development o f an effective safety net programcould include steps to improve the efficiency o f existing government programs while ensuring their long- term financing (including donors commitment), and introduce new programs involving cash payments and conditional cash transfers (ie., linked to school attendance, and health service utilization for chi1dren);and (iii)support well-tested informal social protection mechanisms, which for the foreseeable future will continue to be the main mechanisms available to the vast majority o f Guinea-Bissau's populationto cope with risks. . 3. EnsureInstitutionalDevelopmentof SocialSectors Strengthening policy framework i s one important step towards a stronger institutional capacity in social sectors. Sector policies and programs must factor a strong link with the PRSP. While the health sector has a clear long-term strategic framework orientation (PNDS), the education sector and the social protection lack strategic orientation. Strategic and policy orientations in the health sector must be consolidated, through the subsequent phases o f PNDS, Developing an explicit long- term education policy and strategic framework i s a priority. The same i s true for social protection. Monitoring and evaluation information systems across the sectors must be developed. Successful design and implementation o f reforms cannot take place without reliable information. An action plan to develop monitoring and evaluation systems in social sectors would help to clearly identify priority needs in the short-term and medium- term. Government and development partners could come together with an harmonized schedule for priority household surveys covering key social sectors issues. Effective human resources management, including capacity development strategies and programs at all levels, is crucial for improved service delivery. Capacity development must take into account the kind o f capacity needed to implement reforms in these sectors. The new human resources strategy and action plan in the health sector should be effectively used to create linkages between planning, production and deployment o f personnel. In education, the newly developed but incomplete HRmanagement system needs to be consolidated. 8 *0 6 ea U aJ a M 1 e 1 Y C Ja !i 2 Y m a $1 1. INTRODUCTION 1. Since the last Poverty Assessment and Social Sectors Strategy Review for Guinea-Bissau was done in 1994, the political, macroeconomic, and social context o f the country have dramatically changed. Following the first multi-party and democratic elections in 1994, the country entered a period o f renewed hope for development; political stability, emerging democratic institutions, and relatively good economic governance have nurtured that hope. In 1998, unfortunately, an eleven-month-long military conflict plunged the country into a severe crisis, the consequences o f which persist today. In addition to the loss o f human lives and destruction to infrastructure, the conflict provoked severe brain drain, with the most qualified humanresources seekingrefuge and staying abroad. Butperhaps the most lastingconsequenceof the conflict is the political and institutional instability that it produced. Almost ten years after the end of the conflict, the returnto a normal life for the majority of the population is slow and the country continues to face institutional perturbations that have severe economic and social repercussions. 2. Social sectors have been particularly affected by the conflict. Human development indicators continue to be poor, and social sector development suffers from severe constraints. Prospects for sustainable progress are severely constrained by very low public investment inthe social sectors and, consequently, a high dependency on donor support. Over the last twenty years, the World Bank has been involved in active dialogue with Guinea-Bissau regarding the social sectors, particularly with respect to the education and health sectors. In recent years, the Bank has actively supported these sectors through major investment projects such as the Basic Education Support Project (1997-2005) and the implementation o f the National Health Development Plan (1997-2007). InMay 2008, The Bank approved a 10 million US$for the education sector, mainly for payment of teachers' salaries, as a measure to ensure continuity in the provision of education services. The Bank is also supporting the preparation of a Country Status Report (CSR) on education to help the country move towards the development o f a sound and credible education sector plan, as well as a the preparation of a Community-Driven development Project (CDD) that includes social sectors. 3. HOW, the context of state fragility and current social transition, Guinea-Bissau can in effectively restore the delivery o f basic social services? The main purpose o f this review i s to assist the Government o f Guinea-Bissau in its efforts to improve the efficiency and efficacy o f basic social service delivery. It was agreed with the Government that the review would cover the sectors o f education, health, and social protection - the latter including vulnerable groups, the pension scheme, and social assistance programs. Therefore, the review seeks to: (a) analyze current outcomes on education, health, and social protection in Guinea-Bissau; and (ii) identify challenges and opportunities towards the expansion and improvement o f social service delivery. It is expected that the recommendations o fthe review will helpthe Government identify strategic 13 paths toward strengthening the social sectors in the medium term by ensuring an appropriate transition from a post-conflict environment to long-term development, through policy considerations, and institutional .development. I t i s also expected that this review will help inform the work on the ISN,CSR and CDD project, as well as the implementation o fthe recently approved grant by the Global Fundfor the health sector. 4. The methodology o f the review relied mostly on desk review o f available literature and data. These include recent assessment work such as the 2005 Integrated Poverty and Social Assessment (IPSA), the 2007 Joint Staff Assessment Note (JSAN) on the Poverty Reduction Strategy Paper, and the 2004 Public Expenditure Review (PER). Quantitative and qualitative data are usedto assess the status o f delivery o f social services in each sector. Whenever possible, the team used the most recent data available. In some cases, primary sources o f information (including non-treated administrative data) were usedto compile and/or cross-check information. It is worth mentioning that while the education and health sectors have a set of data and information produced mainly in the context o f investment and donor support projects, data on social protectionare scarce. To overcome this constraint, duringthe fieldwork, the team met with government officials, UN staff, NGO representatives, and other key people in Bissau, and held focus groups with vulnerable population groups across the country. The research was complemented by a scan o f available documents and literature. Part o f the analysis on social protection i s based on data from the 2002 Light Household Survey (ILAP), preliminary results o f the 2006 Multiple Indicator Cluster Survey (MICS), and the 2005 Light Household Survey. 5. The report i s divided into four sections. After a brief introduction in Section I,Section I1 provides the country context, including demographic and socio-economic status of the population. Section I11presents an overview o f current outcomes in social sectors, including a background description o f the education, health and social protection sectors. Section IV discusses the main findings o f the review and presents recommendations to improve delivery o f basic social services. 14 2. SOCIOECONOMIC CONTEXT OF SOCIALSERVICE DELIVERY 6. This chapter is an attempt to put Guinea-Bissau's basic social service delivery into context. The first section presents demographics, poverty and socioeconomic data, since they are important dimensions o f social service delivery, Demographic factors may have direct and indirect effect on the demand for social services. It determines, for example, the number of school-age children, the size o f the labor force, and the number o f elderly people. Poverty profile i s an important predictor o f the level o f demand for basic social services, and the macroeconomic perfonnance indicates the capacity and limits of the public sector to finance social sectors in a sustainable way. Section two discusses population vulnerability and risks, which in part may trigger special social protections needs. It presents an overview o f vulnerable groups and the main risksthey face intheir day-to-day live. 2.1. DEMOGRAPHICS, MACROECONOMIC PERFORMANCEAND POVERTY 7. Guinea-Bissau is a small, fragile state in West Africa grappling with significant social transition. The country i s home to 1,500,000 inhabitants, most o f whom are young. An estimated 41.7 percent (0.58 million people) i s under 14 years o f age.' The population has been growing at an average rate of 3.1 percent in recent years - from about 900,000 inhabitants in 1991. The large share o f young population presents an enormous challenge for the education sector, which is supposed to accommodate an increasingly important number o f newcomers to schools. 8. The urban populationhas been growing steadily as a result of rapid urbanization and migration. Today, an estimated 30 percent o f the population lives inurban areas compared to 18 percent in 1991. The average population density i s about 30 inhabitants per km2, but the population is unevenly distributedacross different geographical areas, with major concentrations in the coastal areas. Bissau, the capital city, concentrates about 30 percent of the country's population, and it i s overwhelmingly registering significant pressure on demand for basic social services. 9. The economy of Guinea-Bissau relies mainly on agricultural production, which accounts for 60 percent o f GDP and 90 percent o f exports. About 80 percent o f the population live in rural areas and rely on agriculture as the main source o f employment. Apart from cashew nuts, which represent the main source of income for rural households, agricultural production includes 1 USBureauofCensus estimates the totalpopulation to be 1.38 million. 15 rice and other cereals, fruits, fishing, livestock, and forestry products. The economy as a whole i s predominantly informal. The unemployment rate among people aged 15 and plus was estimated at 12.4 percent nationwide in 2006, with a rate of 19.3 percent in the capital city of Bissau and 10.2percent inthe other regions. 10. Macroeconomic performance has been poor in recent years. GDP per capita was estimated at $ 180 in 2006. The economy still suffers from the consequences of the 1998-1999 conflict, which contracted real GDP by 28 percent. Since then, economic growth has been sluggish. During the period 2000-2005,the real GDP growthrate averaged about 1percent, with negative growths recorded in 2001 and 2003. Fiscal situation remains precarious with government fiscal revenues representing about 14 percent of GDP. Government efforts since 2000 to restore economic stability have showed mixed results. The road towards economic recoveryhasbeenhamperedbythe slow pace of policy reforms andinsufficientdonor support. Table 1: GovernmentRecurrentExDendituresand PublicInvestmentbv Sector in 2005 Current primary expenditure Public Investment Socio-educative sectors 5.6 1.6 Health 1.7 0.9 Education 3.7 0.7 Economic Sectors 3.6 Agriculture 0.3 0.3 Sources: Ministry of Finance and Ministry of Economy. 11. Social sectors have suffered from the sluggish economic progress of recent years. The security sector has been absorbing a huge part of the recurrent budget. 80 percent of the government recurrent primary spending goes to wage bill. The 7,000 security sector personnel represent 60 percent of all civil servants in Guinea-Bissau, and they absorb nearly half o f the wage bill. Public investment in education and health has not been robust. In 2005, public investmentinboth sectorsrepresented1.6percentof GDP (Table 1). 12. Poverty is widespread with higher incidence in rural areas. At the household level, 64.7 percent of the populationwas living inpoverty in2006, with 20.8 percent living inextreme 16 poverty.2 The impact o f the 1998 conflict, political instability and poor economic performance over the last few years have contributed to highrates o f poverty in Guinea-Bissau. An important feature o f poverty in Guinea-Bissau i s the high incidence o f poverty for men compared to women, which i s partly explained by the fact that unlike men, women in Guinea-Bissau generally engage in various income-generating activities. Poverty on an aggregate level remains lower in urban than in rural areas, but urban households are becoming more vulnerable to particular shocks thanrural populationsbecause they cannot survive on subsistence agriculture. 13. The incidence of poverty is uneven among gender and age groups. A breakdownby gender and age group reveals that the incidence o f poverty i s higher for women below 31 years o f age and above age 65 compared to men (up to 3 percentagepoints o f difference inthe poverty headcount measures). By contrast, women tend to be better off compared to men within the 31- 65 age cohort (2 to 10percentage points o f difference inthe poverty headcount measure^).^ This relative wealth in comparison to men may be attributed to that fact that women traders dominate the informal market while men mostly seek salaried employment, which i s hard to find given the bleak situation o f a large part o f the private sector. Regression analysis undertaken for the IPSA indicated that inrural areas, female heads o f households were 23 percent more likely to meet the food needs for the household than male heads o f household. Additionally, female-headed households in rural areas were found to have consumption levels 20 percent higher on average thanhouseholdsheadedbymales. 14. Widows and divorced women are particularly prone to poverty. Indeed, in rural areas, the level o f consumption by heads o f household that are widowed or divorced was found to be significantly lower compared to households headed by those who are single or married (19 percent and 15 percent (monogamous), and 16 percent (polygamous) respectively. In urban areas, single households' consumption level was 35 percent higher than that o f the divorced and widowedS4The relatively high incidence o f poverty among widowed and divorced women may relate to some discriminatory social practices against this category o f population. For many traditional communities, in the event o f the husband's death, the surviving widow and her descendents are "inherited" by a male relative o f the deceased, often the oldest brother. The rationale o f these practices i s to guarantee family cohesion and to provide a safety net for the widow and her offspring, as she will move in with the relatives o f her deceased husband. A woman that for one reason or another decides to or i s forced to live on her own does not have a place in the traditional family structure and i s subject to ostracism. With the ongoing erosion o f traditional values, many widows find themselves on their own and having to fend for themselves. 2 The incidence of poverty was measured by the headcount poverty index. The poor represent the share of the population with levels of consumptionper equivalent adult below apurchasingpower parity adjustedat $ 2 per day. All figures in this paragraphare fromthe IPSA Povertyanalysisbasedonthe 2002 ILAP. World Bank 2006. 17 2.2. POPULATIONVULNERABILITY AND RISKS 2.2.1. Main Sources of Risk 15. The majority of Guinea-Bissau's population is not only chronically poor but also vulnerableto an array of risks.A household can be considered vulnerable when it is likelyto be exposed to income insecurity due to shocks; it is chronically poor whenit has a very low level of assets and i s expected to remain that way, Households that are bothvulnerable and chronically poor are most likely not to recover from shocks should they occur since they have only limited access to risk management instruments. It i s these households that are in special need o f social protection. Household Level MesoMacro Level Health Risks Death IllnessDisability Harmful practices (excision, abandonment o f twins) HIV/AIDS Buildingsafety Social Risks Lack of social network, Gender discrimination Orphanhood Economic Risks Unemployment Degradation o f rice paddies Cyclical harvest losses IPolitical Risks I 1IConflict Political instability I 2.2.2. Idiosyncraticrisks 16. Vulnerability to idiosyncratic (household) risk factors i s mainly determined by the household's socioeconomic characteristics (assets, income, dependency ratio, household break- down etc.). Exposure to risk i s also often the result o f culturally ascribed attributes, defining, for example, the status o f women or childrenwithin the ho~sehold.~ Tovo and Bendokat 2006. 18 17. Death and illness.The death of the breadwinner of the family creates significant costs for the family, as tradition often requires expensive funerah6 Inaddition, inmost cases, death of the main breadwinner does not only translate into a significant loss of income for the household, but also yields a weakened support network and diminished social ~apital.~Inheritance rights and the status o f the surviving partner still depend to a large extent on customary laws. Widows and their descendants pass under the guardianship o f a brother o f the deceasedhusband, who, in turnfor taking care ofthe widow, also inherits all assets 18. But these traditional systems are under strain as a result of loosened family ties, basic poverty of the successor leading to his incapacity to provide for the widow, as well as the economic empowerment o f many women who are not willing to subordinate themselves to another man's household, preferring to live on their own, often at the expense o f their social position. Similarly, negative health shocks, such as acute or chronic illness o f family members, put households under considerable strain. Medical services, in most cases, need to be paid for upfront, although the cost o f treating an illness or injury i s significantly less than the income lost as a result o f it.* 19. Building safety is a critical issue. Many houses, especially in rural and peri-urban areas, have thatched roofs (and these are always the houses o f the poorest). As a consequence, homes often bum down because o f hearth fires that get out o f control. Affected families lose everything and have only informal coping mechanisms at their disposal, aside from punctual assistanceby non-governmentalactors such as Caritas. 2.2.3. CovariateRisks 20. Most of the country's active population is prone to employment vulaerability. About 80 percent o f the population i s employed in the primary sector, with most engaging in labor-intensive subsistence agriculture. A low level o f agricultural diversification, relative isolation o f many communities, and the low level o f monetization of the economy inrural areas provide farmers with very little room for investing in capital goods or building up savings as a buffer against external shocks. Degradation o f rice paddies and substandard cashew husbandry andharvesting practices reflect a low level of farming capacity. This vulnerability i s exacerbated by cyclical harvest losses due to insufficient rainfall, intrusiono f salty water into rice paddies (in the case o fmangroverice cultivations), andplagues o finsect andother pestsSg 21. Opportunities for non-farm wage labor have diminished considerably due to the post-war stagnation of the economy. This is reflected in the adult unemployment rate in the percent consider themselves unemployed.I Youth unemployment is, in accordance with a capital, where the formal sector i s most imfortant, o f 14.36 percent. In rural areas, only 7.91 pattern found throughout sub-Saharan Africa, much higher than adult unemployment. 6For example amongthe Papel it i s customary to bury a large number of objects(textiles etc.) with the deceased as a symbol ofhis wealth during his lifetime. * Gertler Lourenco-Lindell2005. and Gruber 1997. WFP 2006. loILAP2002 19 22. Cashew dependency is a potential source of food insecurity. A large majority of the population working in agriculture also own cashew plantations, currently covering 180,000 hectares (or 5 percent o f the country's land area, the largest percentage globally)," with cashew amounting to 98 percent o f total exports. Small farms account for 80 percent o f cashew plantations averaging between 2 and 3 hectares in size. According to the Ministryo f Agriculture, cashew farming employs 82 percent o f the rural workforce.12 The cashew sector continues to grow rapidly, as large areas o f the country are being turned into plantations. This poses several risks for the population. First, plantations are usually unprotected monocultures, in which the introduction o f pests mightbe potentially devastating. Inaddition, the lack o f crop diversification exposes small farmers to the risk o f fluctuations in the price o f cashews on the world market. Usually, farmers exchange their harvest directly for imported rice at the farm gate instead of being paid in cash. The 2006 and 2007 cashew seasons, however, were characterized by a steep drop inprices, switching from a ratio o f two sacks o f rice per sack o f cashews to two to two-and- a-half sacks o f cashews per sack o f rice. The situation was exacerbated by unrealistic price fixing, reportedly leadingto widespread hunger. 2.2.4. VulnerableGroups 23. While the majority o f the population o f Guinea-Bissau i s exposed to structural vulnerability due to poverty and a low level of assets, some population groups are especially vulnerable to one or several risks either because they are more likely to experience a shock or because they do not possess the adequate assets to manage these risks. Among the vulnerable groups, one can cite children, youth and the elderly. The paragraphs below provide an overview o f the main risks that may affect these different categories o fpopulation. Children 24. Children are vulnerable to a variety of risks. While the early years are critical in terms o f child survival, a large number o f children aged 5-14 are vulnerable to exploitation, negligence, and abuse, which stunt their development and bar them from building much needed human capital. This i s especially true for working children, children living away from home, orphans and twins, and child beggars. Despite considerable efforts to register all children, only 38.9 percent o f all infants aged 0-59 months have beenregistered.While there i s no significant variation with regard to gender, the percentage o f registered children i s especially low in the south o f the country (Quinara, Tombali, and Bolama-Bijagos) where only 20 percent have been registered by their parents, compared to 57 percent in the Autonomous Sector o f Bissau. When asked about reasons for not registeringtheir children, 34.2 percent o f parents attribute, it to the excessive cost o f doing so, 25.7 percent say that registration offices are too far away, while 18.9 percent do not know where to register their ~hi1dren.l~ `IChasse 2006. l2World Bank2006. l3MICS 2006. 20 25. As elsewhere in West Africa, child labor is widespread in Guinea-Bissau. O f all children aged 5-14, 39.2 percent are believed to be engaged in some form o f child 1ab0r.l~This figure is very much in line with the estimated average for West and Central Africa, which is 42 percent-the highest o f any sub-region inthe ~ o r l d .Most o f the activity involves work in the ' ~ family enterprise and i s therefore predominantly farm work. Children start helpingon the family farm from a very early age by, for example, harvesting cashew nuts, which i s traditionally an activity undertaken by women and children. Only 2.1 percent of all children in the 5-14 age bracket have a paidjob outside their homes. Many children, however, work and attend school at the same time. O f all child workers, 53.7 percent say that they also attend school and o f all students, 37 percent say they also work.16 26. Orphans are in particular need of increased protection. 11.3 percent (about 11,000 children in absolute terms) o f Guinean children are single or double orphans, and their percentage increases with age. Among 15-1 7-year-old adolescents, 22.8 percent are orphans. In terms o f school enrollment, the ratio o f orphans to non-orphans i s 0.97, putting orphans only at a slight di~advantage.'~Also, their sexual debut tends to be slightly earlier than that o f non- orphans: 23.67 percent of non-orphan girls aged 15-17 report sexual activity before turning 15. Among the orphaned girls, this proportion increases to 25.12 percent, corresponding to a ratio o f 1.06.'* 27. Many children do not live with their biologicalparents, even if they are still alive. This can largely be attributed to the custom o f placing children o f both genders, but more frequently girls, in the custody o f relatives [meninus ou meninos dudus/os pura criaqi%io]. Frequently, the receiving household i s in an urban area where the relative covers lodging of the child and other costs and sometimes hidher school fees as well. Inreturn, the child i s expected to do household chores. Data also shows that most o f the children get placed with families in the city-among the MICS sample, less than half o f the children sampled in Bissau actually lived with their parents and the richest quintile o f families had the highest percentage o f children living with neitherparent, though bothwere still alive (20.1 percent). Also, this practice starts at an early age; in fact, between ages 5-9, 15.4 percent o f children already live with neither parent, although both biological parents are in fact alive. Not all children are placed with their extended family as some live with strangers. Regardless o f whether they live with kinor not, living away fiom their immediate family from an early age puts children at risk-es female children-of falling victim to mistreatment, neglect, and abuse as child servants. 8ecially l4 This is based on the MICS definition: A child is consideredto be involved in child labor under the following classification: (a) children aged 5-1 1 who completed at least one hour of economic activity or at least 28 hours of domestic work during the week preceding the survey, and (b) children aged 12-14 who completed at least 14 hours of economic activity or at least 28 hours domestic work during the week preceding the survey. Source: childinfo.org. I swww.childinfo.org. l6 MICS 2006. '*MICS2006. l7 2006. MICS l 9Kiellandand Tovo 2005. 21 15-17 44.8 2.5 5.5 17.5 4.6 30.2 22.8 Income quintiles Poorest 61.3 1.1 2.6 14.4 1.3 19.3 11.4 I Poor 64.4 1.1 2.0 12.4 1.3 16.9 10 I Mid-income I 65.2 .9 2.0 I 10.0 I 1.1 14 I 10.6 Rich 60.8 1.2 2.1 1 12.6 1 1.4 II 17.2 I 10.4 Richest 46.1 2.3 3.9 20.1 2.1 28.3 14.4 Language of head of household Balanta 53.2 1.3 4.0 21.4 1.4 28.0 11.6 FuldMandincla 72.6 .8 1.3 8.0 1.4 11.5 8.8 Brames 49.6 1.5 2.1 13.0 1.6 18.2 14.7 Other 51.5 2.4 3.7 18.0 1.2 25.2 12.4 Total 59.9 1.3 2.5 13.7 1.4 18.9 11.3 28. As in all of sub-Saharan Africa, orphans are usually cared for within the wider family network and are almost never placed in institutional care. This family-based solidarity i s put under increased strain because o f HIV/AIDS. According to Caritas, the Catholic charity, there are an estimated 6,000 AIDS orphans inthe country at this time. With the looming AIDS crisis, their numbersare likelyto grow over the next decade andprovisions will have to be made to support their caregivers. 29. Trafficked child beggars, known as tafibes, are a group that deserves special attention.It is an accepted practice among the Muslimethnicities to provide their male children with a religious education, which traditionally not only comprises teaching o f the Holy Scriptures, but also strict discipline and begging for alms by the students. Traditional schools are very common inFula and Mandinga communities; according to a recent study commissioned by UNICEF the total number o f students attending Coranic schools inthe East, South, and Bissau i s estimated to be over 22,000.20These children are potentially at risk of being sent to Senegal by their Coranic masters, where they will live in abject poverty, have no access to health care and 2o INEP, 2006. 22 formal schooling, tend to be malnourished and in poor health, and often be victims o f violence. A recent survey found that 28 percent o f the children begging inDakar (30 percent o f the talibes and 12 percent o f the street children) originated from Guinea-Bissaun2'Parents often claim to be aware o f their children's fate abroad, though in most cases the children have lost contact with them. While far from being endemic like in the cities of neighboring Senegal, increasing urbanization i s leading to a noticeable increase in this phenomenon in the capital o f Guinea- Bissau. Box 1. Legal Protection of Children The government o f Guinea-Bissau has ratified a number o f pertinent international treaties aimed at ensuringthe legal protection o f children, such as the Conventionon the Rights o f the Child, the Optional Protocol to the Convention on the Rights o f the Child on the Sale o f children, Child prostitution and Child Pornography, and the Optional Protocol to the Convention regarding children affected by armed conflicts. Inaddition, the Convention o f Ottawa, concerning the banning o f all anti-personnel landmines, was ratified in2000. The harmonizationo f domestic laws, however, which would be necessary inorder to ensure compliance with these international agreements, has not yet beenconcluded. There i s no comprehensive child policy inthe country. There is, however, some pertinent legislation, the "Estatuto Jurisdicional de Menores" (1971), which offers the basic legal framework for child protection. Guinea-Bissau, however, has not ratified ILO conventions 138 and 182 determining the minimumage for child labor andthe worst forms ofchildlabor. The General Labor Law sets 14 as the minimumworking age and makes school attendance obligatory, Furthermore, it forbids the employment o f children under 18 years o f age inheavy or dangerous work. However, these provisions are not enforced. Several groups o f vulnerable children fall through the legislative cracks. These are notably child beggars, as there i s no law forbidding this practice, and mostly female child servants, whose status are not regulated either. Source: Instituto da Mulher e Criaqa. Youth 30. Youth in Guinea-Bissau face enormous difficulties in their transition to economic independence. Not being able to attain the roles that are socially ascribed to them, that is, getting married and starting their own households, youth are stuck in a "social moratorium," extending the period o f youth well into the This stands in stark contrast to developed countries, where young people are seen as the locus o f cultural production, often prompting adults to try to extend their youth. In Guinea-Bissau, asymmetric control over resources causes 2'UnderstandingChildren's Work, 2007. 22This paragraphis basedonHenrikVigh's anthropological field work. See Vigh 2006. 23 young people to be highly dependent on patrilineal or matrilineal family support. As observed elsewhere in the region, the economic and social marginalization o f large numbers of young people adds to smoldering inter-generational tensions. 31. Youth unemployment exceeds adult unemployment considerably. An analysis of available unemployment data by age cohort reveals that the percentage o f unemployed individuals aged 15-24 i s consistently higher than that o f adults, regardless o f milieu or gender. The magnitude o f the phenomenon however differs considerably when these variables are taken into account, ranging from 12.03 percent unemployment among girls residing outside the capital to 46.87 percent among Bissau's male youth population. The elevated unemployment rate among male urban youth can be attributedinpart to the differinggender roles inthe labor market. While women dominate the informal market, young men aspire and are expected to enter the formal labor market. Despite the very limited job opportunities in the formal sector, young men often choose not to engage inlabor that is seen as traditionally female, and thus rest idle. Table 4. UnemploymentRateAmong Adult Population(YO) I I 15-24 age cohort 25-60 age cohort Bissau 40.15 14.36 BissauMale 46.87 16.31 BissauFemale 29.29 11.61 Restof Country 15.74 7.91 Rest of CountrvMale 19.34 8.30 Rest of CountryFemale 12.03 7.53 32. In order to break free from this situation of dependence, young people frequently seek access to patrimonialnetworks. Association with a homi grandi, a man o f status, brings the prospect o f employment and social advancement; access to such a network i s often based on family and ethnic ties. As pointed out by Vigh, the practice o f enlisting in pro-government paramilitary militias in the 1998 war by more than 1,000 young men in Bissau, was to a large part drivenbythe expectation o f socioeconomic advancement. 33. Urbanyouth are in a precarioussituation as they do not inherit land, havingto rely on the "economy of affection," which is supported by relatives.23Nevertheless, Bissau and the bigger regional capitals attract many migrants. According to a study by the WFP,24 population growth in Bissau i s estimated at 6 percent annually, versus more modest growth in regional capitals, which for the two southern provinces, Quinara and Tombali, was estimated at 1.5 percent and 2 percent respectively. While data on the composition o f the stock o f migrants is not available, it can be assumed that most o f these internal migrants are in fact young people. Duringfieldwork, almost all women inthe tabancas visitedaffirmed the absence o f one or more o f their sons. Young women usually stay behind helping inthe household and taking care of the children, which creates a rupture in the family and leads to estrangement. This trend i s likely to 23Vigh 2006. 24World FoodProgram2006. 24 continue and accelerate inthe coming years, bringing with it the typical problems of urban youth indeveloping countries: increased so,cialtensions, riskysocial behaviors, and delinquency. 34. Increased internal and external migration is reported. Many young men dream of moving to Europe as a solution to hardship; illegal migration, however, i s as costly as it is dangerous. A place on a fishing boat from Senegal to the Canary Islands i s reported to cost a minimumof CFAF 600,000. The share of Guineans amongthe 31,000 illegaLmigrantsthat made it to Europe from West Africa on this maritime route in 2007 is unknown, but repatriations are reported to be common.25 35. Youth is also a period of sexual experimentation and risk-taking.26 In Guinea- Bissau, sexual relations with non-cohabiting partners are reported to be frequent (60.6 percent), especially in the capital (82.5 percent). While only 6 percent o f all young women report more than one sexual partner within the last 12 months, no more than 38.8 percent have used a condom with their last non-cohabiting partner. Condom use, however, i s much higher in urban areas such as Bissau (48.5 percent) and i s correlated with education level and income. Additionally, traditional practices may increase vulnerability to infection, especially among young girls (Box 3). Table 5: CondomUse Duringthe LastHighRisk SexualEncounter percentageof women aged 15-24 Non-formal 44 4 23,4 Income qumtiles Poorest 35 5 12,l Poor 40 3 14,7 Middle income 51 8 26,O Rich 64 3 39 2 Richest 83 I 53 5 Total 60.6 38.8 36. However, new forms of social organization among young people can be observed. Youth clubs and community-based youth associations have multiplied both in urban and rural Guinea-Bissau. There exists a plethora o f youth organizations; some have legal personality, but 2*Reuters. 26Zewdie 2006. 25 most do not. Often, they are neighborhood initiatives that are formed to respond to a number of needs that are perceived as urgent-water and sanitation problems, health issues, and employment opportunities (or the lack thereof) are the main concerns. Several national youth platforms have emerged to represent young people's interests. Women 37. The situation of women in Bissau Guinean society is undergoing considerable changes. Traditional gender roles increasingly cease to make sense when faced with a contracting formal sector and increased internal migration. Especially inthe urban environment, it is now often the women who are the households' providers through their activities in the informal market, while their husbands are unable to secure long-term employment. Traditionally, however, almost all ethnic groups, regardless o f their religion, are organized into patriarchal structures. Women and children are subordinate to and under the guardianship o f the (male) head o f the household, the chefe defamilia. Inthis position, the husband enjoys a monopoly on power, so that, for example, 51.6 percent of all women deem it justified for their husbands to beat them for any reason.27 38. The incidence of polygamy is high and early marriageis common in Guinea-Bissau. Around half o f all marriages (48.8 percent) are estimated to bepolygamous.28This practice i s not only common among the Fula and Mandinga Muslim ethnic groups, but also among the mainly animist Balanta, and it i s more widespread inrural than inurban areas. While the legal minimum age for marriage i s 14 for girls and 16 for boys, 7.3 percent o f all girls marry before turning 15 and 27.3 percent are married before their 18`h birthday. Among wives aged 15-19, 51.2 percent have a husband that i s 10 years their senior; in the capital region, this proportion reaches more than two-thirds o f married women in this age group. Early marriage is clearly linked to income, as among the poorest quintile, 8.5 percent are already married by age 15; this number drops to 4.5 percent inthe richest q~intile.~' 39. Femalegenitalcutting(FGC), called"fanado" in Creole,is very common in Guinea- Bissau. Apart from greatly diminishing a woman's capacity to experience sexual pleasure, this practice puts women at heightened risk for reproductive and urinary tract infections, various forms o f scarring, and infertility, as well as infection with HN/AIDS and other communicable diseases. According to the latest MICS data (Table 6), around 44.5 percent o f women in the country have been subjected to this procedure, which i s usually performed during adulthood. Female genital cutting i s almost exclusively practiced among Muslim ethnic groups; in fact among the Fula and Mandinga, the two major Muslim groups in Guinea-Bissau, more than 95 percent o f women have undergone the procedure. While there i s a burgeoning public discourse about the practice inthe country, with a draft law being discussed by parliament and some NGOs campaigning against tfie practice, there are still many women who themselves believe that the practice o ffanado should, in fact, continue. This i s related to the socio-cultural significance o f the ritual. "MICS2000. ''MICS 28MICS 2006. 2006. 26 Table 6: Percentage of Women aged 15-49 havingundergoneFGC and their opinionabout the practice r I Percentageofwomenthat believe Percentageof cut women the practiceshould continue discontinue Region SAB 32.1 10,8 81.3 East 92.7 64.5 28.7 North 28.7 18.8 63.1 South 36.3 31.8 46.1 Milieu Urban 39.0 14.9 76.1 Rural 48.2 37.1 47.5 Education None 54.4 40.3 44.4 Primary 34.5 14.5 74.2 Secondarv+ 21.3 3.6 90.8 Non-formal 91.8 62.0 17.6 Languageof headof household Balanta 6.2 4.3 79.7 FuldMandinga 95.2 59.5 30.0 Brames 6.5 3.5 82.9 Other 38.5 19.3 68.4 Total 44.5 27.9 59.3 Source: MICS 2006. TheElderly 40. The elderly, age 65 and over, make up only a very small percentageof the population. This i s not surprisingina country like Guinea-Bissau where the current life expectancy at birthis 47 years. However, the highest incidence of poverty occurs among heads o f households over age 66, with 75.6 percent living in poverty, almost ten percentage points above the national average of 64.7 percent.30This elevated figure may be explained by the fact that the old and ailing are usually cared for by their children. The elderly only head their own households in circumstances where they do not have such a social safety net at their disposal. 30ILAP 2002. 27 3. OUTCOMES IN SOCIAL SECTORS: OVERVIEWAND CHALLENGES 3.1. THE HUMANDEVELOPMENT OUTLOOK 41. This chapter presents the current outcomes in education, health and social protection. It begins by providing an overview o f where Guinea-Bissau stands with regard to critical human development indicators, particularly those expressed by the Millennium Development Goals (MDGs). It then goes on to offer in more details the main challenges in education, health and social protection, respectively insections two, three, and four. 42. The human development outlook is weak. In 2006, Guinea-Bissau ranks 173'd out o f 177 countries in human development index. Most social indicators have stagnated or even declined over the last few years. Life expectancy at birth i s estimated at 47 years, and the illiteracy rate i s 63 percent. Population growth, including the sizeable growth o f the urban population in recent years, poses a complex challenge to the country to improve its economic performance, while reinforcing effectiveness and efficiency in the provision o f basic social services. 43. Guinea-Bissau is off track regarding the achievement of most of the education and health MDGs. According to the Multiple Indicators Cluster Survey (MICS-3) between 2000 and 2006, the infant mortality rate increased from 124 per 1,000 live births to 138 per 1,000 live births, and the mortality rate o f children under age five has gone up to 223 per 1,000 live births from 203 per 1,000 live births (the lothhighest inthe world). Today, two out o f ten children die before they reach the age o f five. Maternal mortality i s estimated to be at 800 to 1,100 per 100,000 live births. Social protection mechanisms are almost non-existent and large segments o f population rely on informal, community-based arrangements to cope with risks. 44. In the education sector, despite considerable progress in coverage in recentyears, the country is far from reachinguniversalprimary completion. Six out of 10 childrenwho enter the first grade do not complete the full cycle o f primary education. Many o f those who do complete primary education remain illiterate because o f the poor quality o f education they receive. Gender gap in primary education has been gradually closing, but bias still remains betweensocio-economic groups. 28 MDG Benchmark Current Situation (2015) (2006) Universal Primary Education Completion 100 % 42% Gender Parity inPrimary Education (ration girls to boys) 1:l 0.9 Infant Mortality (per 1,000 births) 47 138 UnderFive Mortality (per 1,000 births) 80 223 Maternal Mortality (per 100,000 births) 229 800 Estimated HIV/AIDSPrevalence 5.9 8.7 3.2. THE EDUCATIONSECTOR 3.2.1. Access to Education 45. The most visible sign of progress in education in Guinea-Bissau is the large increase in coverage in recent years. With nearly 300,000 students enrolled inprimary and secondary education in 2005, the education system holds today twice as many students as in 1995. In primary education, the number o f students more than doubled over the same period, from 105,430 to 252,479. This increase in coverage, particularly in recent years, i s a result o f the unprecedentedpublic effort to increase the supply o fnew classrooms and to stimulate demand. It i s also associated with the growing involvement o f private providers and local communities in the provision o fprimary education service.31 Table 8: Number of Schools and Students in PrimaryEducationin 2006 Bafatd Number o f primary education schools (1-6) 211 Number of classrooms 539 Students 35605 Pupil/classroom ratio I 66 Percentageof private primary schools 18.2 64.6 2.2 11.1 3.O 1.4 5.6 6.1 12 Classroomsin 41.4 41.3 31.0 55.4 55.6 55.4 33.3 46.1 3' The number of primary schools grew from 650 to 1,334 over the same period (an increase of about 100percent). Today, community and private schools represent 20 and 12 percent of all primary schools in the country respectively. 29 Percentage of community primary schools 27.4 1.8 1.6 2.2 14.9 16.8 29.7 23.6 35.6 19.4 46. Gross Enrollment Rate (GER) in primary education has steadily increased. GER rose from 53 percent in 1995 to 102 percent in 2005, reflecting the growing accommodation capacity of the system (Figure 1). However, the net enrollment rate inprimary educationis at 45 percent. Gross and net enrollment rates are highly divergent because o f widespread delayed enrollment. While the theoretical age group for children inthe primary cycle i s 7 to 12years old, the actualage group of studentsinthis cycleranges from 6 to about 18 years. 47. Gross Intake Rate (GIR) has been high over the recent years. Consistent with the increase in participation in primary education, as expressed by the raising levels of enrollment across the primary educationsub-cycle, the intake rate in the first grade has beenhigh in recent years. It was estimated at an average of 120 percent during the period 2002-2005.32This high value reflects the presence inthe group of new entrants into the first grade ofover-agedchildren. Keeping the GIR at 100 percent or more is important to achieve in the medium term the objectiveofuniversalprimary completion. Figure 1. GER in Primary and Secondary Education 1994-95 1995-96 1997-98 1999-00 2000-01 2001-2002 2004-05 Source: Ministry of Education. 48. Secondary education has followed a similar pattern. The number of students enrolled in this level of education more than tripled between 1995 and 2005, rising from 15,000 to 32GIR for the school year 2004-05, the last year for which data are available, is estimated at 137.4 percent. 30 50,000. The private sector, with 12.4 percent o f enrollments in 2005, played a catalytic role in this expansion, as the government investment in the sector remained very modest.33 Private schools, however, are unevenly distributed across the country, with most o f the schools concentrated inthe capital and its outskirts. 49. Further development o f secondary education seems to be constrained by a limited supply of schools. This expansion in enrollment has contributed to increase the GER in secondary education to 35 percent, a value slightly higher than the average 30 percent for sub-Saharan African countries in 2005. In2005, the transition rate from primary to secondary education was 75 percent. From 2002 to 2005, the GIR in the first year o f the secondary cycle averaged 36 percent. A limited intake capacity, the high opportunity costs, and the low external efficiency o f secondary education may explain families' decision not to enroll their children in this level o f education. School Year 1991-92 1995-96 1997-98 1999-00 2000-01 2001-2002 2004-05 EBE(1-4) 67054 86305 99337 123307 149640 176886 209871 EBC (5-6) 13964 19125 19386 27712 32015 37955 42608 ESG(7-9) 5854 12580 13167 20004 25424 30509 38273 ESC (10-11) 852 2177 2754 5030 7541 9049 12234 EBE 59.8 1 65.2 76.8 I 90.7 104.4 I 114.4 EBC 1 28.6 I 34.5 I 33.1 44.9 I 50.5 58.3 1 60.4 EBE+EBC 46.3 52.8 56.3 67.9 79.6 91.6 99.4 ESG 9.3 17.4 17.3 24.9 30.8 36.0 41.7 ESC 2.3 5.1 6.1 10.6 15.5 18.2 22.7 ESG+ESC 6.7 12.9 13.2 19.6 25.2 29.4 34.6 50. Tertiary education has been growing. An important feature in the development o f the education system in Guinea-Bissau in recent years i s the increasing supply o f tertiary education as a result o f a surge in demand. Two universities were opened recently: the University Colinas do Bok, a private university created in 2003, and the University Amilcar Cabral, a public university established in 2004. These two universities accounted for 3,000 students enrolled in higher education in2005 (excluding students who benefit from scholarships abroad). Despite this 33The growth o f private schools providing secondary education has been remarkable. In 2000, private schools accounted for 6 percent of enrollments. 31 surge in the availability of higher education, the tertiary education GER is at a mere 3 percent, well behind the average o f 6 percent for sub-Saharan African countries. 51 I Early childhood education and technical and vocational education remain two marginal sub-sectors. Early childhood education is supplied mostly by private providers. Most schools are concentrated inurban areas. In2005, these schools enrolled about 7,500 children and employed 250 teachers (40 percent unqualified). Coverage i s only 2 to 3 percent o f the population o f relevant age group. Technical and vocational training i s still suffering from the effects o f the conflict o f 1998-99 that contributed decisively to disarticulate the sub-sector. Three out o f the four schools that were publicly runbefore the conflict are currently closed34.There are a few emerging private sector initiatives enrolling several hundreds o f students in different specialties, most o fwhich are located inthe capital city. 'ox2. TheCase of Higher Education in Guinea-Bissau Guinea-Bissau has long lived without any higher education institution. In the late 70s, the government started progressively to create higher education schools in order to respond to the critical needs o f the country. In 1979, a teacher training school (Escola Tchico Tk) was opened inBissau to train secondary education teachers. Followed then the creation o f the law school (1979), the school o f physical education and sports, and the faculty o f medicine (1986). The law school was transformed into a faculty o f law in 1990. Despite the emergence o f these schools, most o f higher education training continued to be provided abroad (mostly inPortugal, Cuba and the former Soviet Union). Some of these schools were supported by bilateral cooperation. For example, the Faculty o f Law was supported by the Portuguese Cooperation, and the Faculty o f Medicine, by the Republic o f Cuba. By the late 9Os, the crisis inthe former communist block led to a significant decrease o f the number o f scholarships offered to young students o f Guinea-Bissau. At the same time, the increasing number o f graduates from secondary education put an enormous pressure on tertiary education. Not only existing higher education institutions were unable to absorb the increasing demand, but also the variety o f proposed courses was insufficient to meet the demand of the labor market. Discussions about setting up a national university became more intense. The important question to answer on that regard was how to create a university without diverting the scarce resources from the other levels o f education. As the experience o f some Sub-Saharan African countries shows, higher education institutions are often a serious competitor for funds with primary and secondary education (and often with big advantages), but at the same time may be a source o f disturbances related to students' andor teachers' demands. The answer found was to create a public university with a private management. Created in 2004, the University Amilcar Cabral (UAC) is managed by a private foundation composed of the government o f Guinea-Bissau and a private Portuguese university (Universidade Luscjjiona). Students pay enrollment and tuition fees and teachers are paid usingprimarily these collected resources. Enrollment fee is approximately US$ 20 and tuition fee is US$ 300 per year per student. The government usually does not transfer resources to the university, but has helped with investment costs (improvement o f infrastructure, equipment, etc.). In 2005/06, there were about 2,000 students enrolled in 13 different courses, and the university functioned normally. This model i s still at its early stage, but seems to be a promising solution to the recurrent problem of financial sustainability o f many African Universities. Of course, muchneeds still to be done, particularly to ensure the quality o f training in order to meet the demand o f the labor market. The main challenges o f higher education today include: (i) institutional strengthening o f recent initiatives; (ii)assuring quality o f learning; (iii) assuring equity (for example by offering scholarship to the poorest students); (iv) setting up a legal framework for tertiary education; and (v) promoting a democratic and transparent management o f these institutions. 34CENFI(the industrial school located inBissau) was destroyed during the conflict and CEFAGand CEFC (two agricultural schools located in the countryside) ceased their activities after the conflict. CENFA (the administrative school in Bissau) is the only center that was able to gradually restart its activities. 32 52. Enrollmentin primary education is influenced by location of the school. .According to the Integrated Poverty and Social Assessment (IPSA) 2005, while 96 percent o f households in Bissau are located 30 minutes or less from a primary school, only 79 percent o f households on average for the rest o f the country are located at that same distance. In other words, primary schools are accessible to more households inBissau than in other regions. School access remains geographically uneven across the country, with various communities, particularly in the south and the islands, being the most disadvantaged. 53. The gender gap in primary education has been closing, but disparitiesstill remain. Increased enrollment in primary education was favored by an overall positive trend in girls' enrollment. The gender gap has been gradually closing, to a ratio o f 0.9 girls per enrolled boy. In 2005, girls represented about 47 percent o f enrollments inprimary education. Compared to1995, this represents a 6 percent increase in the share o f girls to boys. This average, however, hides disparities across regions. Inthe capital, 52 percent o f primary education students are girls. Gabu and Bafath, with nearly 50 percent o f girls' enrollment, are two other regions where equity was achieved. Inall other regions, girls' enrollment stands below 50 percent, rangingfrom 40 percent inOio, to 43 percent inCacheu, 45 percent inQuinara and Biombo, and 46 percent inTombali and BolamdBijagos. The impressive achievement o f girls' enrollment in Gabu and Bafata (two predominantly Muslim regions) seems to be the result o f the sustained joint effort by the Government, several development partners, and NGOs through targeted interventions in girls' education. 54. Girls' enrollment drops off at higher levels of the education system. In secondary education, girls are underrepresented. They account for only 39 percent o f enrollments nationwide, with great disparities between regions. Their share in enrollment ranges from 25 percent inOio to 42 percent inBissau. Intertiary education, girls are highly underrepresented. 55. The previous brief overview suggests that while there has been substantial progress in coverage, enormous challenges remain to improving the performance o f the education system, and the prospects for Guinea-Bissau to achieve the MDG o f universal primary completion and gender equity by 2015 are still bleak. While enrollment has substantially increased and the gender gap in enrollment has gradually been diminishing in recent years, most children o f the relevant age group do not complete a full primary education cycle. 3.2.2. InternalEfficiency A system with multiple inefficiencies 56. Despite the positive trends in coverage, the education system presents several inefficiencies, the most important o f which are: 57. The current structure and organization of the primary education, which was inheritedfrom the former colonialsystem, raises serious problems of efficiency and equity. The primary education cycle i s divided into two sub-cycles: elementary primary education o f four years, and complementary primary education o f two years. Most schools offering the elementary sub-cycle do not offer the complementary sub-cycle. Because schools offering 33 primary complementary education are mainly located in urban areas, children from rural areas can hardly complete a full six-grade primary education. This structural inefficiency i s a huge source of waste because children who do not complete a six-year education are more likely to remain illiterate.35This picture has started to change as the reform to integrate the two sub-cycles into one single cycle was initiated in 2002, but much still remains to be done. While most primary schools now offer the full six grades o f education, in many schools education still ends at the fourth grade or less. On the pedagogical side, the curriculum content o f the new unified system is yet to be finalized. Consequently, the reform is still an incomplete endeavor with inherent implications for the performance o f the education system. 58. Repetitionand dropoutrates are high. Although the repetition rate has been declining,36 it is still relatively high across the system. In primary education, the average repetition rate is 15.2 percent. Insecondary education, 13 percent o f all enrolled students in 2005 were repeaters. Repetition i s high at all grades o f primary education, even inthose where it should have been an exception.37 In2005, 17.2 percent o f studentsingrade one and 13 percent o f those ingrade three were repeaters. The high repetition rate imposes a significant cost on the education system because scarce public resources are wasted. If one considers the overall budget allocated to primary education in 2005, the cost o f repetition is CFAF 264 million (approximately US$ 525,000). To make things worse, the system i s also hit by frequent dropping out o f students across different levels. In 2005, the dropout rate in primary education was estimated to be 7 percent. The dropout rate i s mainly associated with students' and parents' dissatisfaction with the quality of education, as well as with changes in perceptions by parents about the value o f the school. 59. More striking, however,is the low completionrate in primary education,estimated at 42 percentin 2005. Figure 2 below shows the discrepancy between enrollment and completion inprimary education. While the GER has steadily increased inrecent years, the completionrate has increased only modestly. The low completion rate i s a result o f a low survival rate across the primary education system. In 2005, only 58 percent o f the cohort o f children who had entered primary school four years earlier was retained through grade four. Not surprisingly, education attainment inGuinea-Bissau, measured as the average years o f schooling, is only five years. 35Analysis shows that inGuinea-Bissau, while 78.7 percentof peoplehaving completed six grades o f schoolingcan read, only 54.2 percent of those with up to a 4" grade educationcan read.(Mingat, A. et al., 2001). 36In1995, the repetitionratewas estimatedat 31percentinprimary educationand the dropoutratewas 35 percent. 37The rule inprimary education stipulates that students in grades one, three, and five must benefit from automatic promotion to the following grade. This rule, however, is not respectedby many teachers. 34 Figure 2. GER and Completion Rate in Primary Education 120 100 BO 60 40 20 0 1999/00 2001/02 2003/04 2004/05 Source: Ministry of Education. 3.2.3. Relevanceand Quality 60. The quality of education is low. Guinea-Bissau does not apply a student learning assessment system to track learning achievements o f its students, nor does it participate in any regional or international learning assessment process; hence, there i s no objective way to measure learning achievement o f students. The common perception, however, i s that learning achievement i s very low. The poor learning environment and the insufficient teacher training and motivation are perceived as the main factors that affect students' learning outcomes. The language o f instruction i s also an issue. While the official language o f instruction i s Portuguese, in many classrooms programs are taught in part in creole (the national language), as many teachers have not mastered the official language. 61. The learning environment is poor. Despite considerable efforts made in recent years to provide low-cost classrooms to a growing number o f primary school students, 32 percent o f classrooms at the primary level are still considered to be in bad shape. Many classrooms are categorized as barracas (shacks made o f palm leaves or bamboo) that flood when the rains come. Textbooks are sorely lacking as they have not been distributed to students since 2004, when the World Bank-financedBasic Education Support Project (BESP) closed. The ratio of one textbook per student inthe principal subjects that had beenachieved inthe 2002-2003 academic 35 year has vanisheda3*In secondary education, the curriculum has not been revised for decades and there i s no harmonized curriculum throughout the system. Each school chooses and implements its own curriculum, some o f which are of questionable relevance. Textbooks are practically non-existent and most o f the time students are forced to use texts prepared by their teachers [apontamentos] inlieuo f textbooks. 62. Teachers' qualificationsand performance levels need to be improved. Teachers are at the center of any education system. In Guinea-Bissau, the substantial increase in enrollment in recent years has put enormous pressure on the recruitment o f new teachers. The number of teachers in primary education has increased from 3,269 in 2001 to 4,327 in 2005. Teacher training programs have not kept up with the demand because o f the low capacity o f the two teacher training colleges (423 students enrolled in 2005). As a result, contractual teachers have been hired. In 2005, contractual teachers represented 20 percent o f active primary education teachers. While this responded to the quantitative needs o f teachers inthe system, there remained great concerns regarding the qualifications o f these teachers. About 63 percent o f teachers did not have the appropriate pedagogical training. Most o f them were recruited locally and did not hold adequate academic training. The same i s true for secondary education, where the only existing teacher training college [Escola Tchico Ti] trained an average o f 80 teachers annually between 2001 and 2005, against an estimated demand o f 120. 63. Inefficient organizationof the learningprocess has resultedin a shortage of teachers in public schools. In primary education, teachers used to work only four hours a day. Many teachers usedtheir remaining free time to teach in private schools as a strategy to increase their revenues, while public schools often suffered from a shortage o f teachers. In 2006 the government launched a reform whereby teacher's hours in the classroom were extended from four to eight hours a day. This was supported by a 50 percent increase in salaries but also resulted in a reduction o f 40 percent of primary education teachers in public schools and 35 percent insecondary schools, The measure seems promising, but it i s still too early to evaluate its full impact. 64. Teachers' motivation needs to be improved.The systematic arrears in salary payments appear to discourage some teachers. Although there i s no consistent data to prove it, teachers' absenteeism is reported to be high.While the main causes o f absenteeism include participation in traditional ceremonies, travel to the capital o f the region to receive salaries, and engaging in agriculture and farming activities, which serve as complementary sources o f revenue, teachers' strikes and other perturbations o f the system disrupted 20 percent of the officially planned number o f school days in 2005. As a result o f these disruptions, curriculum coverage is often incomplete and, consequently, students' learning i s negatively affected. 65. The issue of quality in tertiary education has hardly been discussed. The development o f higher education will surely put on the agenda the issue o f its quality and relevance. While the oldest national tertiary education institutions such as the law school and the ~ 38During the life of the BESP, textbook printing was supportedby the project. After the project closed in2004, the governmentwas unable to pay the costs of reprinting and therefore textbooks were no longer printed for distribution to students. 36 teacher training school for secondary education are reputedly o f good quality and rele~ance,~' it i s still too early to draw any conclusions in that regard for the two new universities. The first group o f trained young people will only leave these universities in 2008. Some concerns have, however, been expressed about the relevance o f some proposed training courses as well the quality o f the faculty. 3.2.4. Managementof the EducationSector 66. To put the main features o f the management o f the education system in context, a brief account o f the administrative arrangements in Guinea-Bissau's education system i s important. The system i s managed by one central Ministry in charge o f all levels o f education (from preschool to higher education). The central Ministry has several departments, some of which possess a degree o f administrative and financial autonomy, mainly attributable to their nature or mission. The National Institute for Education Development (INDE) and the School Printing House [Editora Escolar] are two examples o f departments that enjoy some autonomy. The system consists o f eight peripheral levels that coincide with the administrative division of the country. There are eight regional directorates o f education (plus the directorate o f the capital city). Each directorate i s responsible for the local management o f the education system; including: (i)the supervision o f schools; (ii)the collection o f education statistics; (iii)the recruitment o f contractual teachers, if necessary; and (iv) the provision and distribution of pedagogical inputsto schools. 67. The management of the system in recent years has been tumultuous. There is no recent memory o f a school year that has begun on time (e.g. in respect o f the school calendar approved by the MoE); has gone without sometimes relatively long paralysis due to teachers' strikes; and has closed on time, This turbulent picture i s in large part due to the country's financial crisis, which hinders the capacity o f the government to pay teachers' salaries on time. Although all civil servants are affected by this constraint, the education system i s perhaps the area where the crisis is most visible. A very influential teachers' union in the sector and the relatively high sensitivity o f education issues has made the sector a permanent battlefield between teachers and the various governments, and the management o f the system suffers as a result. 68. A long-termstrategic education plan is still lacking.It is clear that without anationally developed and endorsed education plan the sector will fail to implement sound education and training policies. Many attempts have been made in the recent past to develop such a plan. In 2000, a Letter o f Education Policy was developed, setting the vision and the objectives for the development o f the education sector, The letter, however, was not translated into a sector plan with quantitative and qualitative targets because there was no coherent statistical data on which to base the plan. In 2003, efforts were undertaken to develop an Education For All (EFA) Plan, 39 Many civil servants and top officials from different Ministries with a recognized, solid background and performance are people who were trained inthese institutions. Trained teachers from Tchico Tk have been employed as secondary education teachers in Cape Verde, where many o f them have gone in search of better salaries, as well as by the private sector inGuinea-Bissau. 37 following the commitments o f the 2000 EFA Conference in Dakar. This plan, however, did not have a coherent financial framework and was never endorsed by the Government. The frequent turnover o fministersand top officials inthe sector did not favor the finalization o f the process. 69. More recently, in 2007, the Ministry o f Education, with support fiom development partners, embarked on a process o f development o f an Education Sector Plan. The process is underway and is expected to be completed bythe end o f2008. Having a strategic education plan i s now crucial for Guinea-Bissau to give clear orientation to its long-term education goals and objectives, but i s also one o f the eligibility criteria for the Education For All - Fast Track Initiative (EFA-FTI). In the current context o f heavy constraints to domestic and external financing o f the sector, this would be an opportunity to benefit from additional funds, such as the catalytic fund, to tackle supply and quality issues inthe education sector. 70. There is insufficient monitoring and evaluation information for policy decisions. Despite efforts made in the past to revamp the monitoring and evaluation system in the Ministry o f Education, the current situation i s still fragile. Availability o f relevant and pertinent data i s a major concern o f all education stakeholders. School surveys are now hardly organized and when they are, data are often fragmented or incomplete because many schools and/or directorates simply do not send data to the center, or they send them with substantial delays. By May 2007, part of the data from the 2005/06 school survey had not yet been received by GEPASE, the Ministry o f Education unit responsible for statistical work. Data collected are often treated with delays and, naturally, are seldom usedby policy decision makers. 71. The main causes of this weakness are: (i) financial difficulties in carrying out consistent data collection; (ii)organizational problems related to transmission and collection of questionnaires; and (iii)institutional weakness at the central level to treat questionnaires and conduct analysis. In 2002 and 2003, the Basic Education Support Project financed the school surveys that allowed the collection o f data from all regions on an ad hoc basis. Since then, school surveys have been carried out sporadically and are often incomplete. Without specific, well- targeted support, it i s unlikely that the M o E will be able to tackle the issue o f developing a sound monitoring and evaluation system inthe near future. 72. Financial management is a critical issue. As mentioned above, the financial management o f the sector i s problematic. First, the Government's inability to pay teachers' salaries in a timely manner often provokes disputes with teachers' unions and leads to losses in the calendar year. Second, contractual teachers are not paid regularly, partly because o fthe dense bureaucratic measures neededto develop their payroll, but also because these teachers are often neglected with regard to pay. Given the pressure to pay salaries to all civil servants and the insufficiency o f funds, the Government has, in the past, often opted to pay salaries to the so- called effective teachers (civil servants) to calm their spirits, while delaying payment for the contractual ones. In the long run, the mounting arrears o f contractual teachers' salaries will lead to a strike o f this group o f teachers, or in many cases, o f a larger group o f teachers as a sign o f solidarity with their peers. 73. Public funding to schools is limited. It is important to stress that the limited financial capacity o f the government associated, in some cases, with questionable priorities in terms of resource allocation through the sectors, makes it difficult to finance beyond salaries. As a result, 38 schools are underfunded.Because regional directorates are less able to compete for funds in the public treasury compared to their central-level peers, the more distant a school i s from Bissau, the less probable that it will receivepublic funds. 74. Human resource management remains deficient. Much still remains to be done to allow the Ministry to access and analyze the data necessary to make effective policy and planning decisions. With the support o f the BESP, some work was accomplished regarding the improvement o f the personnel management system. In2003, the MoE set up the Individual Staff Record [Pvocesso Individual do FuncionBvio] wherein data on personnel was collected and enteredinto a central database containing the academic qualifications, other training experiences, and professional career evolution o f every staff member. This data has allowed the Government to make more informed decisions when appointing new candidates to posts and in determining humanresources development needs across the sector. However, the system still needs to be put into an electronic format. Inaddition, the database at MoE needs to be harmonized with that o f the MinistryofFinance and the Ministryo fPublic Administration. 75. The Ministry of Education's payroll system needs to be improved. There is no harmonized database on personnel between the Ministry o f Education, the Ministry of Finance, and the Ministry o f Public Administration; hence, each o f these three Ministries often provides discordant figures about the correct number o f teachers to be paid. On the other hand, the payroll system is not entirely credible. When available, cash is gathered for the entire system in the Ministry of Education. Regional representatives then travel to Bissau to collect the payroll for their schools, gather the cash together, take public transportation back to their region and hand deliver payments to each o fthe schools. Often, one person will sign for the payment o f a number of people. Needless to say, inefficiencies and the possibility o f leakage are inherent in the system. 3.2.5. InstitutionalCapacity 76. Government effectiveness in the sector has been seriously affected by political and institutional instability in the country. With seven different ministers over the last seven years, the education sector never really had an opportunity to take root and time to develop and implement medium- and long-term policies. This resulted in decreased government capacity to effectively deliver education services, particularly in remote and underprivilegedareas. With a rising demand for education coming from families and communities, religious organizations (the Catholic Church, Muslim charities), NGOs, and community-based organizations (CBOs) have appeared to fill the gap o f education provision in these areas. Several NGOs are reported to be active in the education sector, but according to a capacity assessment undertaken recently by PLACON, only a few NGOshave the capacity to effectively deliver education services. 77. Communities are playing a greater role in service delivery.Community participation in school management and community ownership have been enhanced as the role o f the community increases inthe management o f schools and, inmany cases, in the process o f school building. Many community schools in recent years have been promoted by NGOs through a process that relies on community empowerment. In the region o f Bafati, for example, Plan International has backed a process through which community members take an active part inthe 39 * . construction o f classrooms and in the follow-up of the academic performance o f their children. Community members control teachers' presence in schools and incentives are provided to families to send girls to school. Inremote areas across the country, communities often contribute to the costs o f education, for example by paying part o f teachers' salaries and/or allowances. Of course, communities' voice and accountability in these schools are stronger than in publicly managed schools. 78. The institutional capacity in the Ministry of Education needs to be improved. In addition to the political volatility and high turnover rate at senior levels o f government that disrupt services delivery, visible signs of declining institutional capacity inthe ministryinclude: (i) verylowqualityofinfrastructure; (ii) scarcityofresourcestocovercurrentexpenses; the the (iii)frequent arrears in salary payments; and (iv) a pronounced brain drain phenomenon that impoverishes the humancapital available inthe sector. 79. In fact, the effectiveness of the institution as a whole is at stake. Some of its best departments inthe past are now sinking into a crisis. For example, inthe recent past, INDE was an example o f dynamism in the development o f education studies and research, the development o f curricula and school programs, and the planning and implementation o f in-service teacher training courses. Today, the erosion o f capacity almost limits its action to this latter activity. Another example i s Editora Escolar, which once was considered one o f the best institutions in the country. It autonomously conceived and developed school manuals o f acceptable quality and, at times, ensured their careful distribution among schools everywhere. It i s uncertain ifthese capacities still exist as many qualified staff has abandoned the house, mainly because o f a lack of financial sustainability inits operations. 80. The legal and regulatory framework in the sector needs to be strengthened. Frequent changes in the structure o f the ministry constitute a barrier to the development of a sound and coherent legal and regulatory framework. The rule o f law i s not always clear when it comes to the internal role o f the departments and units within the ministry. Organic law is often non-existent or does not keep pace with changes inthe structure and organization o f the ministry. By the same token, not every unit has its tasks clearly defined, with cases o f overlap and confksion o f roles and responsibilities. Needless to say, these conditions do not favor transparency and accountability in the process o f service delivery. Challenges also include the development o f a regulatory framework for the emerginghigher education sub-sector as well as the strengthening o f the internal capacity o f the ministry to perform oversight and exercise appropriate supervision duties with regard to non-state actors. 3.2.6. Cost and Financingof EducationServices 81. Budgetary provisionsfor the education sector continue to be below average for sub- Saharan African countries. Guinea-Bissau has not always prioritized education in its allocation o fpublic spending.Between 1996 and 2004, public spendingon education represented 2.8 percent o f GDP compared to the average 3.8 percent for sub-Saharan African countries. The education share o f the Government's budget fluctuated between 11percent and 17 percent over 40 the same period. It has even declined between 2003 and 2005, when average current public spending on education was only 10.7 percent o f the total recurrent government pend ding.^' 82. The execution rate of the education budget has been low. One reason for this underinvestment in the education sector i s the difference, at times very significant, between the assigned budget to the sector and the executed budget. In the context o f heavy resource constraints and competition between different government institutions for meager resources, the education sector i s often unable to get an adequate share. This tendency persists. Between 2003 and2005, for example, the average execution rate o f the education recurrent budget was only 62 percent.41 If the education budget had been executed at 100percent, average current spending in the sector would have been at 15 percent o f the total government current spending. Table 10: Guinea-Bissau and the EFA-FTI Benchmarks EFA-FTI Guinea-Bissau benchmarks Service Delivery Average annual teacher salary (as multiple of GDP per capita) 3.5 6.3 Pupil-teacherratio 4011 53 Spending on inputs rather than teachers (as % primary educ. spending) 33 20 Average repetition rate (%) 10 15 Systemfinancing Government revenues (as % of GDP) 14-18 18 Educationrecurrent spending(as % of governmentrevenues) 20 11 Primary education recurrent spending (as % education recurrent 50 37 spending) Privateenrollments(as % of total) 10 12 83. Current expenditure on inputs other than salaries and allowances is very limited. Between2003 and 2005, an average o f 80 percent o f the recurrent public spending on education went to salaries and other allowances for personnel; hence, very little is left for investment in quality. In the past, investment projects represented the primary source o f financing o f non- salary items. As these projects became rare in the sector, the financing o f quality dropped dramatically. Not surprisingly, the sector i s suffering from a lack o f basic resources for recurrent costs-textbooks, paper and toner for printers, gas for generators, maintenance o f facilities, or resources for inspectors to visit schools. 84. The intra-sector allocation of public resources does not favor primary education. The share o f recurrent expenditure on education that went to primary education was around 37 40Recurrenteducationexpenditure (excluding debt service and common expenditures) accountedfor 9.4 percent of the total governmentrecurrentbudget in2003. Itremainedat 9.9 percentin2004 androse to 13 percentin2005. 41The executionrate was 50 percentin2003 and 2004, and 86 in2005. 41 percent for the period 2003-2005. On average and for the same period, secondary education received 39 percent o f the recurrent education budget, while about 20 percent was allocated for tertiary education. This means that on average only 4 percent o f recurrent government spending went to primary education inthe course o f 2003-2005. Recurrent spending on primary education as a percentage o f total recurrent education spending i s well below the benchmark allocation of 50 percent recommended for low-income countries for primary education efficiency and quality. 85. Unit costs are low at all levels of the educationsystem. The unit costs across different levels o f the education system are low. In absolute terms, unit cost i s estimated to be CFAF 10,000 (US$ 22) in primary education and CFAF 27,000 (US$ 60) in secondary education. In higher education, the cost per student stands at about CFAF 37,000 (US$ 86). Unit cost in primary education i s low at any standard, and it cannot ensure universal primary education of quality. 86. Capital expenditure remains low. Investment expenditure in education remains low compared to regional and international standards, and depends essentially on external Investment expenditure in education was estimated at CFAF 1.7 billion (or 1.3 percent o f GDP) in 2003. It then rose to CFAF 2.7 billion (1.9 percent o f GDP) in2004, only to fall to CFAF 1 billion (0.7 percent o f GDP) in 2005. This decrease probably reflects the closing o f the World Bank-financed BESP in 2005, with no other large external investment in the sector under implementation. It i s noteworthy that capital expenditure in the sector in 2003 and 2004 was financed entirely by external sources, while in2005, probably because o f the shortage o f external resources, the Government financed 30 percent o f expenditure. 3.2.7. Assessment of RecentPolicyReforms 87. Policy reform efforts have been undertaken in recent years with encouraging results. Guinea-Bissau has undertaken various education policy reforms in recent years to address the many issues plaguing its education system. Among the key ones with direct impact on families and schools are the following: (i)the elimination o f school fees for primary education inacademic year 2001/02; (ii) the free provision o ftextbooks to primary school pupils, beginning in academic year 2000/01; (iii)the development o f an integrated basic education system o f six years beginningin academic year 2001/02; (iv) the adoption o f a low-cost model o f infrastructure development in primary education; and (v) the provision o f higher education to a growing number of young people. Some key features o f these reforms include: 88. Free primary education. In 2001, the government decided to eliminate enrollment and tuition fees in public primary education schools in line with the poverty reduction policies in social sectors, as expressed in the interim PRSP. The policy was simultaneously believed to remove barriers to schooling o f most children in rural areas, especially girls. Fees that had been imposed were not uniform across the country (they could go up to US$20 a year per student) and the very legal existence o f these fees led to misconduct and abuses in many schools. It i s believed that the rapid growth in enrollment registered in the subsequent years was a 42Capital expenditure on education between 1998 and 2005 was guaranteed by a few partners as follows (US$ million): World Bank(144, PlanInternational(6.0), World FoodProgram(1.9),andUNICEFFNUAP (4.0). 42 consequence o f this measure (it i s also likely that many dropouts returnedto school as a result of this dramatic change in policy), which was complemented by the provision of free meals in schools for many students invarious parts o f the country. 89. Free textbooks for primary education students. In tandem with free enrollment and no tuition fees, the government also decided to ensure free distribution o f textbooks to primary education students. The measure had a direct impact on families. The cost o f a kit o f three textbooks was about US$ 10 and transferring this cost from parents to the government was particularly welcomed by families with several children enrolled in schools. The measure seemed to benefit girls' schooling as some evidence suggests that when families are unable to support the schooling o f all their children, they will more likely decide to finance the education o f their male children. 90. The development of a single six-year basic education system. This i s an important policy measure, the objective o f which was to improve the efficiency o f the system (by making more effective use o f teachers) and to reduce inequities betweenrural and urban areas. Children from rural and remote areas would likely drop out after completing the fourth grade of primary education becausepursuingfurther studies would require them to "emigrate" to the nearest urban center, where complementary primary education i s provided. The reform required not only that primary elementary schools adapt to provide 5`h and 6`h grade schooling, but also that the curricula be adjusted and teachers trained to teach at all levels o f primary education. 91. Expansion of infrastructure. In the late 1990s,most primary education classrooms were constructed at a cost o f US$ 13,000 or more. This unit cost would have made it difficult to keep pace with the recent increase in the demand for primary education. As a result, the government decided to construct classrooms at half o f that cost. Community involvement in infrastructure development, which was carried out with support from NGOs and more recently inthe context of the implementation o f the BESP, has further facilitated the decrease inthe cost o f a classroom to an average o fUS$4,000. 92. A prudent tertiary education policy. While continuing to take advantage of the scholarships offered to its students by several countries to pursuepost-secondary training abroad, inthe beginningo fthe 2000s Guinea-Bissau movedtoward the creation of anational university. With more than 2,000 students graduating annually from secondary education, it was no longer possible to continue to rely only on training abroad to create the critical mass necessary for the development o f the country. The process o f creating the public university was founded on the idea that a public tertiary education institution should not place additional strain on already very limited government resources. This idea was realized through the creation o f a federation comprising the existing higher education institutions before the conception o f new courses, and the setting up o f a private management model. The universityi s managed by a private foundation and students pay enrollment and tuition fees, which cover a large portion of the university's recurrent costs. The financial burden o f tertiary education on the government did not increase, as demonstrated by the absolute values o f annual government transfers to higher education.43 With 43 In 2004 and 2005, the total government financial transfer for tertiary education was, respectively, CFAF 274 million and CFAF 305 million,' with more than 80 percent o f these amounts going toward the payment o f scholarships abroad. Of these totals, UAC received CFAF 52 millionand CFAF 28 million respectively. 43 its adopted cost-recovery model, tertiary education i s likely to develop without getting a larger share o fthe government budget inthe near future. 93. These policies, however, have not had the full expected impact on the development of the education sector. The main causes o f this counter performance are the very low level of public investment in the sector, which has severely constrained sustainable progress, and the persistent institutional instability, which has jeopardized the successful completion of. several measures. Free primary schooling led to a significant increase in enrollment, but raised the problem o f how to accommodate the additional number o f children given the scarcity o f resources. The construction o f hundreds o f classrooms in recent years by means o f external support helped in part to address the problem. In addition, for many schools, the collected fees were the only resources available to meet the needs o f a minimal set o f pedagogical inputs. By eliminating the fees and not being able to provide pedagogical inputs or transfer money to schools, the government has in practice contributed to the further degradation o f the learning environment o f most o f the schools. The same i s true regarding free textbook distribution, which, ultimately, has ledto a shortage o f textbooks inclassrooms. 3.3. THE HEALTHSECTOR 3.3.1. Access to Basic Health Care 94. The health status of the populationof Guinea-Bissau is among the worst in Africa. Infectious diseases like malaria, tuberculosis, HIV/AIDS, and diarrhea are among the main sources o f morbidity and mortality. The percentage of assisted deliveries by qualified personnel was estimated to be 39 percent in 2006. Cholera outbreak i s recurrent, causing many victims, particularly among the children and elderly. Poverty i s usually associated to the poor health status o f the population, but the country's failure to effectively respond to the needs o f the population through improvedhealth services i s a major factor. 95. Access to quality health care is limited and inequitable. Overall, access to quality health care for the population i s limited. Public healthcenters and hospitals are often inaccessible for a large proportion o f the population, either because they are distant from villages or their services are o f such poor quality that they do not stimulate demand. On the other hand, a discrepancy remains between access by the rich and poor to health care. In 2002, about 37 percent o f the poorest households had access to health services compared to 46 percent o f the wealthiest. Consequently, the rate o f usage o f medical services was only 9 percent for the poor, as opposed to 19 percent for the rich. Access was higher in Bissau than inthe rest o f the country (55 percent compared to 38 percent on average). 44 Health MDG 1990 2000 2006 2015 MICS2 MICS3 Target MDG4. Reduceunder 5 & infant mortality (under five mortality per 1,000 births) 240 203 223 80 (infant mortality per 1,000 births) 142 124 138 41 MDG5. Reduce maternalmortality (maternal mortality per 100,000 births) 914 822 800 229 MDG6. FigthHIV/AIDS, Malaria & TB (HIV/AIDS prevalence) 5.9 8 8.7 5.9 96. Access was seriously affected by the 1998-99 armed conflict. The conflict damaged part of the national health infrastructure in the capital city and in other parts of the country. It also contributed to disarticulation o f the structure and organization of the national health care system as many professionals left the country and did not return after the conflict. Although reconstruction efforts are much remains to be done to ensure appropriate access to quality health care for the population. Today, seven out of eleven regional hospitals are still closed or provide only limited health services, thereby limiting the access o f the population to health care.45 Immunization Coverage 97. Progress on immunizationcoverage has been mixed.Since 1995,vaccination coverage among relevant population groups has had its ups and downs. The immunization rate among the under-five age group decreased until 1999, increased significantly between 2000 and 2004, and then decreased again in 2005. It increased again in 2006, with particularly encouraging results for certain antibodies such as BCG, DTP3, and Polio3, with respectively 90 percent, 83 percent and 78 percent coverage. However, despite sustained national campaigns supported by some development agencies, particularly UNICEF and WHO, several indicators on immunization stand below PNDS targets. In 2006, the tetanus immunization rate (TT2) for pregnant women was estimated at 52 percent; the proportion of children below one year of age fully vaccinated stalled at 54 percent, against a target o f 78 percent; and the immunization rate for measles was at 65 percent, against a target o f 80 percent. 98. Several organizational constraints have hampered immunization efforts. Deficiencies in the organization o f immunization services are associated in large part with the unfavorable organizational context in which the health care system is evolving. Problems of 44 The EU, ADB, and World Bank have recently invested heavily in health infrastructure rehabilitation and construction. For instance, the national hospital is being fully revamped, and many health centers, health posts, and housing facilities are being renovated. There are no new foreign funds projected for 2008 to pursue and complete this effort. 45 In addition to the capital city, only four regions (Bafath, Cacheu, Gabu and Tombali) had a primary regional referral hospital operational in2006 (these hospitals represent the first level o f reference). 45 physical accessibility, lack o f resources for advanced strategies, poor maintenance o f the cold chain, and unmotivated personnel are among the factors that affect the current organization of the system, with direct impact on immunization coverage, To address the issue, an immunization plan (2005-2009) has been developed in collaboration with the international community. The plan i s realistic and viable and, if well implemented, i s likely to offer an opportunity to promote vaccination coverage to larger groups o fpopulation, 3.3.2. CriticalChallenges for PublicHealth Malaria 99. Malaria remainsthe number one public health problemin Guinea-Bissau. h2005, it accounted for 35 percent of consultations inhospitals and health centers across the country and remains the primary cause o f mortality among children under 5. But recent outcomes on malaria prevention are encouraging. From 2005 to 2006, there was a 30 percent reduction of new cases o fmalaria, (175.012 cases in2005 against 131.171cases in2006) even though access of children to malaria treatment has worsened, mainly because the shift towards the new therapeutic scheme o f artemesinin-based combination therapies (ACT) has been slow and consequently, drug shortages are recurrent. In2006, only 45.7 percent o f children with a fever received appropriate treatment. 100. These positiveresultscan be explained, in part, by the availabilityand extensive use of impregnatedbed nets, particularly by vulnerable groups, At present, about 60 percent of bothpregnant women and children under age five are sleeping under impregnatedbednets, and 46 percent o f households have at least one impregnatedbednet. The priority now i s to strengthen the network o f impregnating centers in order to increase access to impregnated bed nets by the poorest populations. 101. The country's application to the Global Fund was approved. Guinea-Bissau is expected to receive US$12 million in 2008 to implementthe malaria component o f its national policy over the next five years. These resources should help reduce the incidence o f malaria, to provide broader access to new treatment methods, and to reduce the economic burden of the disease. Activities will include the introduction o f ACT countrywide, staff training, distribution o f impregnated bed nets during vaccination campaigns, impregnation campaigns through appropriate centers, and strengtheningo f the system o fmonitoring and evaluation. HIV/AIDS 102. Despitethe lack of reliable epidemiologicaldata, there is mountingconcern that the HIV/AIDS pandemic is spreading rapidly. The country still lacks reliable data on HIV prevalence and AIDS-related deaths, but available information suggests rising HIV prevalence and AIDS-related mortality. According to WHO estimates in 2005, about 32,000 people in the 46 country were living with HIV/AIDS, o f which 3,200 were under 15.46It can be assumed that a large part of these do not know that they are infected. The National HIV/AIDS Secretariat has estimated HIV-1 prevalence in 2005 at 2.5 to 3 percent. UNAIDS estimate in 2005 put HIV prevalence among the adult population o f Guinea-Bissau inthe 2-6 percent range (with a median value o f 3.8 percent), and the MICS-3 led by UNICEF calculated a prevalence o f 8.7% in 2006. In any case, these rates exceed those for Guinea-Bissau's two neighbors, Senegal and Guinea- Conakry, where total prevalence i s estimated to bebetween0.4 percent and 0.7 percent (Senegal) and 1.2 percent and 1.8 percent (Guinea-Conakry) re~pectively.~' Among the factors contributing to HIV transmission are the early onset o f sexual relations (55 percent o f the population i s sexually active by age 15) and the high poverty incidence, which leads to prostitution o f younger girls; the relatively high incidence o f sexually transmitted diseases (STDs):* and the low use o f condoms. Information from a variety o f sources indicates that there i s a substantial urban bias in HIV infection (in particular in the main transportation axis from Bissau to Senegal) and that without a more intensiveprevention campaign, transmission rates are likely to increase dramatically. A sentinel study i s planned for 2008 to get better information on HIV infection rates and their distribution. 103. Access to HIV/AIDS treatment is very limited. AIDS-related mortality in 2006 was estimated at 3,600 (NAS) and 2,700 (UNAIDS). Mother-to-child transmission has also been increasing over the years. The 2006 transmission rate was 9 percent, up from less than 1 percent in2005. Recent data shows that no more than 8.6 percent of all pregnantwomen were tested for HIV during prenatal care and that only 7.1 percent of all women had actually received their results.49 Despite the availability of generic ARVs from Brazil and funding from the Global Fundto Fight AIDS, Tuberculosis and Malaria (GFATM), only 496 people received treatment in the first quarter o f 2007,50up from none in2004. The poor status of the health facilities and the poor capacity o f supply chain management are limiting factors. Stock ruptures o f pediatric ARV and o f testing supplies occurred inearly 2007. 104. Knowledge of HIV/AIDS forms of transmission is relatively low among the population.About 86 percent o f the population claims to have heardo f HIV/AIDS. However, the knowledge o f methods of transmission is weak. Eighty-sevenpercent o f 15 to 24 year olds claim to know how HIV i s transmitted, but only 7 percent are able to correctly identify two methods o f transmission (12.7 percent urban and 3.4 percent rural). Serious misconceptions on HIV transmission exist, with 32 percent of respondents declaring that HIV is spread through divine intervention, 51 percent declaring that it can be spread through sharing food bowls, playing or sleepingtogether, and 72 percent saying it can be transmitted by mosquito bites. Only 10 percent o f people interviewed knew that these three modes of transmission were incorrect (behavior study, 2006). 46 World Health Organization. 47 World Health Organization, UNAIDS/WHO Global HIV/AIDS online database. 48 Slightly less than 7 percent o f all respondents (age 15-49) reported an episode o f STDs in 2005. On average, each person contracts one STD during hisiher lifetime. Most cases o f STDs, especially for men, are not reported because they seek help through traditional healers. Health facilities have reported an average o f 9,000 cases per year over the last three years. 49 MICS 2006. This correspond to less than 40 percent o f people identifiedas needing access to ARV treatment and to less than 10 percent o f the estimated number o f people requiring treatment. 47 105 I Prevention knowledge among population groups differs widely. Knowledge of methods o f prevention is much lower inrural areas than it i s inurban areas. O f all women living in urban areas, 91.6 percent say that they have heard of HIV/AIDS, with almost half (47.2 percent) correctly identifying three modes o f prevention (abstinence, being faithful, consistent condom use). In rural Guinea-Bissau, more than half of the women have neither heard of HIVIAIDS nor know how to prevent it. At the regional level, there are also differences in prevention knowledge. The southern part o f the country (Quinara, Tombali, and Bolama- Bijagos) lags behind considerably, with 70 percent o f women being unaware o f even one mode of preventing the disease. Knowledge about prevention o f an HIV infection i s also positively correlated with income level. While only 12.4 percent o f the poorest women are able to correctly identify the ABC prevention methods, this figure increases to 51 percent among the top income quintile. BOX3. Sexuality and HIV/AIDS in Guinea-Bissau Several sociocultural attitudes toward sexuality and some sexual practices contribute to the vulnerability of a large part o f the populationto HIV/AIDS. Male circumcision and female excision, both referred to as fanado are widespread. While male circumcision i s the norm everywhere, female genital cutting i s mostly practiced among Muslim populations. Justified not only by claims of "hygienic" concerns, female excision i s widely regarded as a prerequisite for marriage. Both women and men are at great risk o f contagion as circumcision ceremonies are usually held for many young men and women concomitantly, usingthe same knife for the operations. Fanado i s a ceremony charged with symbolism, marking the transition from adolescence to adulthood. Among the Balanta, for example, the ritual o f fanado i s a feast characterized by heavy drinking and socially acceptable heightened sexual activities among the community, extending even to what has been described as rape. As observed elsewhere in sub-Saharan Africa, often young women engage in occasional sexual relations with older men in exchange for money and gifts. While their sexual encounters are clearly "contractual," the girls themselves do not see themselves as sex workers and are thus also not organized as such. Male promiscuity is socially acceptable among all ethnic groups. Female promiscuity, however, while severely punished among the Fula, i s reported to be tolerated among the Mandinga and animist ethnicities. Among the Balanta, it i s accepted practice for a married man to engage in sexual relations with any female guests staying under hisroof(Bnanhga). Resistance to condom use as an "alien" object is common in rural areas and increases with age. Even if more widespread among the young urban population, condom use i s reported to be low and irregular. Among Muslim populations, HIV is regarded as just punishment by God and condoms are seen as an open invitation to adultery. These traditional practices, in combination with a very low level o f knowledge about prevention and an expressed resistance to condom use, are nothing short o f a time bomb with regards to the spread o f HIVIAIDS. ISource: INEP (CESE) (2005). 106. Misconceptions about HIV contribute to risky behavior and serious discrimination against infectedpeople.Only 37 percent o f the 15 to 24 age group reported use of condoms in casual sexual relationships, but this seems to be an overestimated figure given the limited availability o f condoms in the country, which i s linked to a reported resistance to condom use in 48 the same age group for a variety o f rea~ons.~'The practice o f female genital mutilation that in the past has victimized an estimated 272,000 girls and women represents a serious risk o f spread of the disease. Misconceptions about HIV also lead to the end o f marital relationships in 50 percent o f cases when one partner informs the other about being contaminated, or to expulsion from families inabout 30 percent o f cases. 107. Nonetheless, a serious stigma against seropositive persons persists. According to recent MICS data, 75.2 percent-an overwhelming majority-of the population holds one or several discriminatory opinions against people living with HIV/AIDS. Of these, 41.8 percent think that an HiV-positive teacher should be banned from exercising her profession, 48 percent would not buy vegetables from an HIV-positive seller, and 20.6 percent would refuse to take care o f a person living with AIDS. Given these numbers, it i s not surprising that almost half of the people in the sample said that they would keep the seropositivity of a member of their household a secret.52 Source: MICS 2006 (preliminary report). 108. Information,Education, and Communications(IEC) are not effectivelyused as tools to influencebehavior.Available material is not widely distributedand very little use is made o f materials from other lusophone countries. The use o f billboards has not yet been piloted and ~~ ~ 5 1The number of condoms available in-country through public and private channels over the past three years has been low (2004: 140,000; 2005: 290,000; 2006: 350,000). This is inpart due to weak capacity o f national NGOs to ensure adequate distribution. A total of 5,799 were womenpolled for the MICS. 49 since 2006, a conflict between the National AIDS Secretariat and the journalists union has been jeopardizing the effectiveness o f part o f the national media in conveying HIV/AIDS messages. Some community radio stations convey messages on HIV/AIDS on a contractual basis, but these contracts are not always honored because o f poor management o f these stations. The more successful IEC activities are spearheadedby NGOs, such as Step Up and smaller national NGOs and CBOs. Their messages are more varied than radio programs (fidelity, abstinence, condom use). Their impact is, however, geographically limited and heavily dependent on donor funding. Limitedaccess to condoms also reduces the impact of their messages. It is worthmentioning that the school curriculum has been adapted to include information on HIV/AIDS, but implementation has not yet started because o f a lack o f funding. 3.3.3. Managementof the HealthSector 109. The current organization of the national health care system faces multiple constraints. The current health care system is three-tiered-central, regional, and local-with each level being entitled to offer different types o f care. At the central level, The Ministry of Health (MoH) i s responsible for defining policies and strategies, setting out regulations and technical orientation, and providing operational and logistical support for different programs and health activities. It also ensures supervision and monitoring and mobilization and coordination of external aid.53At the regional level, there are 11regional health directorates whose function i s to translate national policies into operations, and perform monitoring and evaluation. At the local level, the country i s divided into 37 sectors and i s organized into 114 health areas including type A, B and C health centers, depending on the level o f care provided. The basis at this level is a primary health care system through which a minimum package o f services covering immunization, malaria, reproductive health, nutrition, and HIV/AIDS i s offered. At the local level, communities [tabancas] are organized around the so-called Basic Health Units (BHUs) that make available to the population essential drugs for primary health care needs. Among the 697 existing BHUs, 466 are currently operational, ensuring basic care, prevention, and health care promotion. 110. This system is well organized in theory, but faces multiple constraints in practice. The center often fails to provide strategic planning, monitor implementation ofthe various health programs, or ensure coordination between stakeholders. The implementation o f health programs at regional and local levels i s hampered by infrastructure and equipment shortages, as well as by weak management capacity. 53 The M o H encompasses two General Directorates (Public Health and Health Infrastructure); twelve sub- Directorates (including Finance and Administration, Hospital Care, Primary Care, Drugs, Hygiene and Epidemiology, Human Resources, and HIVIAIDS); three inspections (General, Pharmacy, and Administrative and Financing), two National Institutes (Health and Blood), three Centers (Essential Drugs Purchasing, Mental Health, and Motor Rehabilitation); and one National Health School. It has one national referral hospital (Hospital SimSlo Mendes) and two Referral Centers (Pneumonology and Management o f Leprosy). 50 Human i-esoui-cesmanagement 111. A human resources strategy was recently produced. The lack o f a clear human resources strategy was perceived as the main obstacle to health developments. Developing a new national HR strategy (the previous one was developed in 1997) i s therefore a key element in improving the performance o f the health sector. Efforts were developed in that direction under the guidance o f the World Bank through a Bill Gates Trust Fund. The new strategy addresses the fundamental questions necessary to ensure strengthening o f the whole health system through improved performance (e.g. planning, production, deployment, performance management, and regulation and administration). The challenge is now for the M o H to translate this brand new strategy into comprehensive actionplans. 112. The sector is in dire need of qualified staff. The ratio o f one physician per 10,000 inhabitants is extremely low, as i s the ratio o f two nurses per physician. Lack o f personnel remains an issue. Estimated needs require that the country double its number o f general physicians, and increase by one-third the number o f nurses and midwives currently working. In addition to the lack o f personnel, placement o f health personnel is biased in favor o f urban areas. In addition, the HR deployment policy and promotion system is not transparent; it entails regional disparities, imbalances between the capital city and the poorest regions, and lack of motivation ofpersonnel who do not see linkages betweenperformance and their career paths. Table 13: EstimatedNeedsof Key Staffin the HealthSector in 2006 HRHGuinea-Bissau In Place EstimatedNeeds Lacking Physicians/GPs 30 56 26 IForeignspecialist physicians I30 I30 I Nurses 261 368 107 Midwives 162 528 96 Healthtechnicians 40 82 42 113. The Government is considering new incentive schemes for health personnel. The Government intends to introduce monetary and other incentives, including the construction o f staff housing in a few regions, in order to encourage staff placement in remote areas. A new salary grid i s about to be implemented, aimed at motivating personnel through a significant salary increase for health workers. The proposed salary increase would range from 25 percent for technicians to 100 percent for specialists. Other monetary incentives such as overtime pay for night duty, premiums for isolated areas, and times when personnel are "on call" are also being 51 updated. It i s not clear if all 12,000 civil servants54would be affected by this wage adjustment policy. 114. Training institutions have limited capacity. The National School o f Health (NSH) is responsible for training all nurses, midwives and health technicians in Guinea Bissau. The school was totally destroyed during the 1998-1999 conflict and since then has not been rebuilt. The Amilcar Cabral University's campus i s hostingthe school, but it offers very limited facilities for students, administrative personnel, and faculty. There are 12 full-time faculty and over 200 studentscurrently enrolled inthree- to four-year programs. The NSHhas no library, no reference or teaching materials, and no textbooks or learning materials for students. The lack o f equipment is prevalent throughout the system and the need for a curriculum update i s crucial. The training plan currently in place will not be able to fill the gaps for several years yet. Pairing with Northern institutions may be an option to provide opportunities for staff to acquire andor improve their pedagogical skills and to help the school to stay on track with modem capacity- buildingstrategies and programs. A school o fmedicine with 90 students at present is fbnctioning with support from the Cuban government, which brought 34 physicians to Guinea-Bissau in 2005 (mostly general practitioners) to ensure training inthe school. Monitoring and Evaluation ('&E) 115. Management of the health system is hindered by an inadequate monitoring and evaluation system. In fact, most of the relevant data are collected in the regions, but their consolidation at the central level remains weak, resulting in low data r e l i a b i l i t ~ .The ~ ~ Department o f Hygiene and Epidemiology (DHE), responsible for Health Information System (HIS), lacks the capacity to analyze data and to use it for decision-making purposes. With the support o f a few donors, including the World Bank, the French Cooperation and the Global Fund, efforts are under way to enhance the health M&E system by allowing a regular flow of information from health facilities to the center and vice versa. In2006, the IDA-financed project in particular signed a contract with the Bandim Health Project [Projecto de Satide de Bandim PSB], an autonomous health organization funded by DANIDA, to support data collection and treatment. The French Cooperation i s providing technical assistance to the DHEwith the support o f an epidemiologist. However, the DHEwill still require few years o f technical support and an intense training program for its staff to be fully operational. Technical leadership o f the department also has to be strengthened to improve the quality o f work and ensure better management o fthe whole technical team. 116. Supervision of health activities is not conducted on a regular basis. Supervision is essential to managing and maintaining the performance o f the health network, but it i s a rare event in Guinea-Bissau. The last supervision mission occurred in October 2006, financed by the PNDS, and another one has been planned for 2007; an adequate supervision system should include six teams visiting two regions at least twice a year. A supervision manual was revised in 2005. Each team produces a report based on established guidelines. Unfortunately many problems identified during the 2006 supervision, in particular a lack o f drugs and supplies and difficulties with fleet maintenance, remained unattended. Moreover, the supervision system 54The security sector is not included. 55IDA signed a contract with DANIDA in2006 to help strengthen data collection andtreatment. 52 suffers from a lack o f coordination and organization. Many vertical programs supervise their activities on their own, and the concept o f integrated supervision i s not yet fully implemented. Integration would bringwith it several benefits, among them achievement o f economies o f scale and higher efficiency. Such a supervision scheme would also motivate staff and improve the efficiency and quality o f care by facilitating prompt feedback aimed at correcting wrong practices and at responding to logistical needs. 117. A reliable analytical and patrimonial accounting system is missing. This system is crucial to the sound management o f health-related public finances, facilities, and vehicle fleets, along with maintenance activities. At present, the lack o f control from the central to the regional level i s striking. There is no organized supervision to control expenditure at decentralized levels; consequently, there is a lack o f transparency and efficiency in the use o f scarce resources. Auditing of public expenditures remains a rare event, the last one having been carried out in 2006 with the support o f the AfDB. In that context, a Public Expenditure Review would be highly useful as it would provide key information to decision makers on the technical efficiency of resource allocation and management. 118. Decentralizationis not yet being considered, A common aim of decentralization is to bring government nearer the people and to encourage community participation. At the moment, no decentralization process i s envisioned for the health sector in Guinea-Bissau. The administrative link with the regions and districts remains very hierarchical and highly centralized. An internal debate about a policy aimed at decentralizing power and distributingkey tasks to the regions should be initiated without delay. Many points could be discussed from a medium term perspective, such as legal status, appropriate mix o f decentralization types, financial flow efficiency, level o f control and regulation from the central level, level of empowerment o f regional directorates/committees, governance rules, and matching the scale o f the local needs with the scale o f decentralized organization. At any rate, such a reform would require technical assistance to prepare the regions and local units for planning, monitoring, and management capacity. Drug management logistics 119. The logistics of drug management needs to be improved.Along with human resource management and supervision activities, equitable access to drugs i s the other requirement for good performance o f the health care system. Most regional deposits/warehouses are facing a serious financial situation. Some o f them are unable to continue to buy drugs because they are highly indebted, which has a negative impact on the distribution o f drugs. For example, in 2005, the hospital of Mansoa in the North could only purchase approximately 10 percent of the necessary drugs through the existing system and had to buy the remainder outside o f the system. There are also some cases o f mismanagement, whereby working capital disappeared in some places. The absence o f reference documents for the list o f drugs and therapeutic protocols at various levels does not offer a favorable context for improvement o f the situation in the short term. 53 3.3.4. InstitutionalCapacity 120. The country's health priorities are reflected in the National Health Development Plan (PNDS 2003-2007). The plan outlines clear strategies for improving populationhealth. It i s both a crucial strategic document and an operational tool that encompasses four major national strategies: (i)the accessibility and quality o f the minimum package o f activities and standard care; (ii) institutional capacity building; (iii) resource development inthe management o f human programs and service delivery; and (iv) promotion o f inter-sector collaboration in disease prevention. The PNDS was financed largely by international aid sources. As the current PNDS comes to a close inDecember 2007, the government has launched the process o f developing the next plan (PNDS II), will cover the period 2008-2012. which The process i s being led by the Ministry of Health, with technical and financial support from development partners, other government ministries, and civil society. It would take six to nine months. Three UN agencies (WHO, UNICEF, and UNFPA) and the World Bank have jointly committed to providing technical and financial support to the entire process. 121. A roadmap (2007-2009) to reduce maternal and neonatal mortality has been approved. The roadmap was approved in November 2006 with the support of development partners. Its general objective i s to reduce maternal mortality from 818 per 100,000 live births to 205 per 100,000 live births and neonatal mortality from 55 per 1,000 live births to 20 per 1,000 live births before 2015. Specifically, the "roadmap" plans to increase the availability o f emergency obstetric and neonatal services and to strengthenthe utilization and quality o f such services. Intervention strategies will focus on strengthening the resolution capacity of the facilities offering Essential Obstetrical care (EOC) at different levels, improving the financing system to sustain EOC, and building partnerships with NGOs and communities to promote maternal and neonatal health. The main activities o f the roadmap will include supervision, physical rehabilitation, equipment vehicles and drug purchasing, training, and communication. This excellent detailed plan requires US$ 3 million over the next three years, but it remains unfunded as no external donors have yet expressed an intention to finance part o f the planned interventions. 122. Capacitybuildingis critical. The M o Hlacks a capacity-building program for its staff at the central and regional levels. The directorates o f the M o H require intensive, ongoing training aimed at strengthening the skills and knowledge o f their personnel in order to achieve better outcomes. The main fields identified that require capacity building are planning, monitoring, computer science, and program management. Specific training on the Marginal Budgeting for Bottlenecks (MBB) technique is envisioned inpartnership with UNICEF.56The MBB i s among those approaches and tools that have beenusedto overcome the issue o f health service coverage by assessing the impediments to faster progress in the health sector in the country, identifying ways to remove such obstacles, and estimating both the costs o f removing them and the likely impacts o f their removal on MDG outcomes. 56 MBB tool recently developed by UNICEF, the World Bank and WHO, and tested in several countries is a response to this demand. The tool focuses on those interventions that the literature has found effective for the improvement o f health MDG outcomes and that can be implemented in a development context. The MBB approach i s a country-specific designed to help manage and plan specific health systems and programs. 54 123. Donor coordinationneedsto be improved.The M o His not yet inthe driver seat to take the lead in donor coordination. Donor assistance is still defined too often by donors and not by the MoH, which causes overlaps and inefficiencies in the use o f limited resources. Political instability and the turnover rate inthe Ministrydo not help. However, there are positive signs o f better coordination among key actors. Two institutional mechanisms put in place recently are worth mentioning: the Inter-Agencies Coordination Committee on Immunization and Surveillance, and the Multi Sectoral Coordination Committee (CCM) for the Global Fund. The former has beenperformingwell. Last year, it received from GAVI an award o f US$ 135,000 for good performance. The C C M for the Global Fundi s composed o f 16 representatives o f different organizations, including society, government, NGOs, faith-based organizations, the private sector, academia, and PLWHIV/AIDS. It now meets frequently to discuss relevant issues and propose solutions. 3.3.5. HealthFinancing 124. Total public spending on the health sector is very low. In 2006, per capita public spending in the health sector was estimated at US$ 6 and donors have contributed the same amount. Therefore, with US$ 12 total health expenditure per inhabitant, Guinea-Bissau i s not in a good position regarding international benchmarks on health financing for developing countries and i s a long way from reaching international commitments on public financing o f the sector.57 Household expenditures on health are estimated at an average o f US$ 1.5 to US$ 2.0 per capita per year, corresponding to a total amount o f US$2 to US$3 million. 125. The share of the governmentbudget allocatedto the sector has been declining.It has decreased (Table 4) from 11.8 percent in 2002 to 7.9 percent in 2006 (2.18 percent to 1.84 percent o f GDP during the same period). This i s partly explained by the country's macroeconomic constraints, which i s linked to the low priority accorded to the sector by the government. The annual budget preparation i s a cumbersome process that requires tough negotiations with the regions. Budget execution i s affected by poor dialogue between the M o H and the Ministry o f Finance, which has tendedto occur mainly inthe context o f problem solving. Delays in paying health personnel's salaries are chronic; two- to three-month salary arrears are recurrent. The problem can be explained in part by the weak capacity o f the Direction o f Administration and Finance (DAF) o f the MoH; the recent creation by the health authorities o f the Direction of Computer and Finance management is part of the Government's efforts to overcome this weakness. 57According to the Abuja Agreementper capita healthpublic spendingindeveloping countries shouldreach at least US$25. 55 Year Allocation YO Yo GDP Execution Execution (xCFAF 1,000) Gov. budget (actually paid) rate 2002 3,509,200* 11.8 2.2 1,126,453 36.2 2003 3,509,200 11.8 2.2 888,076 25.3 2004 2,333,300 8.2 1.6 1,110,651 47.6 2005 2,618,500 7.1 1.7 1,398,279 53.4 2006 3,197,112 7.9 1.8 1,374,364 43 2007 3,782,481 9 2 126. Budget execution rate is low. Public health investment i s also aggravated by the low budget executionrate. Table 4 above shows that the Government has allocatedan average of 9.3 percent of the recurrentbudget to the health sector over the period 2002-2006, but the real share of the healthbudgetis less significant because o f the low budget executionrate. In2006, from an allocated budget of CFAF 3.2 billion (US$ 6 million), the MoH spent only CFAF 1.4 billion (US$ 2.6 million), which represents a 43 percent budget execution rate. To make things worse, salaries and allowances for personnelaccountedfor more than 80 percent ofthe executedbudget. In 2006, they represented83.5 percent of all expenditures; thus, little is left for non-personnel expenditures, including oil for vehicles, food, clothes, drugs, and office materials. On the other hand, non-personnel expenditures are unevenly distributed across different budgetary lines. While expendituresrelatedto medical evacuations, mainly to Senegaland Portugal, amountedto four times as much of the budget as originally planned, reaching CFAF 489 million (US$ 1 million),58drug expenditures continued to fall short of annual needs. Of an estimated need o f CFAF 353 million (US$660,000) in 2006, the Government spent only CFAF 25 million (US$ 47,000), despite calls from most international donors urging the government to dramatically increase its spendingon drugpurchases. In2006, 590 patients, mostly with chronic diseases such as cancers, renal and hearth failures, were evacuated to Portugal and Senegal. 56 ox 4. TheBurden of Medical Evacuations Medical evacuations continue to capture a high share o f non-personnel health expenditures. Many patients, especially with cardiological, neurological, and nephrological conditions, are sent over to Portugal under the umbrella o f a collaboration protocol signed between the two countries offering care for a maximum o f 300 patients in2006. The bilateral agreement offers free hospital care, including complimentary diagnosis and therapy, as long as these functions are performed inpublic hospitals, as well as transportation between the airport and the hospital in an ambulance, whenever the situation justifies it. The financial responsibility associated with the treatment o f evacuated patients is also shared by both countries: air transportation is paid by the government o f Guinea-Bissau through the health current budget, and the costs for the entire medical assistance are paid by the Portuguese government. Some money i s also made available by the Embassy o f Guinea-Bissau in Lisbon in the form o f allowances for patients with chronic conditions that are forced to stay permanently or for a long time in the Portuguese territory. Similar arrangement also exists with the government o f Senegal with a growing number of evacuations being made over the last years. 127. Health expenditures are mainly funded by contributions from development partners, representing nearly 86 percent of total health expenditure in 2006. Main multilateral contributors include the AfDB, the World Bank, and UNICEF. Twelve percent o f sector financing i s provided by GAVI and the Global Fund.Bilateral partners, mainly Portugal, but also China, Sweden, Denmark, France, and Brazil, contributed23 percent o f foreign aid in2006. Table 15: HealthEx?enditureby Source in 2006 Source of Financing Amount (Euros) Yo Government 2,095,000 13.9 IDA 1,430,154 9.5 AfDB 2,693,000 17.8 WHO 616,930 4.1 UNICEF 1,817,599 12 U N F P N U E 11,317 0.7 Global Fund 1,839,932 12.2 GAVI 68,000 0.5 Chinese Cooperation 560,000* 3.7 French Cooperation 186,247 1.2 Portuguese Cooperation 1,797,935 11.9 Brazilian Cooperation 80,000* 0.5 128. Guinea-Bissau is still one of the most under-aided countries in the world. Most major donor agencies and bilateral cooperation (US, Swedish, Dutch, British, Germany) are either absent or not resident in Guinea-Bissau, in part because o f chronic political instability since the 1998 conflict. As a result, the prospects for external health financing in the years to come i s bleak. The World Bank's support o f the PNDS came to a close in December 2007; similarly, the AfDB and the EU, two key players in the sector, are also withdrawing. FurtherEU support to the health sector i s not expected before the ninthEuropean Development Fund(FED). 57 iox 5. Cost Recovery (Bamako Initiative) In Guinea-Bissau, the cost recovery system is in disarray. Since 2003 when the Bamako Initiative was introduced as a strategy to co-finance the health sector, several bottlenecks have been identified. Among those are ineffective management o f funds, high mobility o f the population, lack o f capacity of the management committees, and inadequate supervision from the central level. The ineffective management o f funds i s explained mainly by the weak participation in the process by members o f the management committees [Cornitis de GestEo, CG], who are elected representatives o f the communities. The task is undertaken on a volunteer basis and is not remunerated. It is in fact quite demanding, as a member o f the CG i s supposed to regularly commute to other villages other than his own, covering distances that vary from 10 to 40 kilometers. Having to cover such distances is obviously not a motivating factor in the context o f a voluntary activity. Some elected representatives in the CG were clearly expecting some sort o f material andor financial benefits; when these expectations were not hlfilled, they gave way to feelings o f frustration, absenteeism, and a lack o f zeal and devotion to the community cause. It was also noted that the head o f the Health Center i s incharge o f funds management, carrying through expenditures that he judges necessary and convenient. As an immediate consequence, cases o f misuse o f funds for other ends not defined in the procedures o f communitarian co-management are frequently noticed. Examples o f these wrong practices are numerous in various health centers across the country. Drug sales funds are most commonly used for personal needs o f the health staff, particularly to compensate for salary payment delays, or to support the cost o f running facilities that normally would have been financed by the government budget. Besides law motivation, members o f CG, particularly the young ones, frequently abandon the task as a result o f migration, and the vacant positions are not promptly filled. Lack o f capacity o f CGs to appropriately manage hnds recovered is also another impediment to their effectiveness. Capacity strengthening remains an issue. Central level supervision i s errant and often necessary corrective measures have not been taken. Most recently, the government has been taking steps to address the problem. Corrective measures include training sessions for members o f the CG. Accounting and financial management tools have been distributed as well folders with administrative documents and forms, including receipts and statement o f expenditures to encourage transparent management o f funds. The health regional teams have been reinforced with technicians in charge o f managing treasury in the regions, reducing therefore the work load o f the regional financial administrators. It is thus expected that these administrators will be able to devote more time to follow up the management work o f the CG. At the central level, efforts envisage an increasing role o f monitoring and supervision. The government seems to be aware o f the importance o f allocating some money to finance supervision and monitoring activities. Some material incentives (e.g. bicycles) to encourage and reward the work o f relevant members o f the CG are also being considered. The potential impact o f these measures on the effectiveness and efficiency o f cost recovery i s yet to be determined. 129. Cost recovery has been modest.User fees have beenadopted by the Government since 2003 in order to recover part o f the cost o f health services. The total cost recovered in 2006 represented about 4 percent o f the health sector budget. Resources were primarily used to pay incentives to medical staff (20 to 30 percent), and to pay for drugs and maintenance costs (30 to 60 percent). Evidence from focus groups conducted in 2005 suggests that the poorest members of the population have difficulties even paying for basic costs o f adult or children consultation services, or for essential drugs. Inpractice, community leaders in villages determine who should be exempt from payment, based on their knowledge o fvillages' households. A waiver/exemption policy targeting the indigent and vulnerable groups, such as pregnant women and children under age five, has never beenenvisioned by the authorities. 58 130. Health insurance is only available for workers in the formal private sector. Mandated by law, the insurance fund is managed by the Instituto Nacional da Previdincia Social (INPS). The system covers only 6,400 individuals employed in 1,622 firms, which i s far below the pre-war level and can be partially explainedby the weakness ofthe private sector. The INPS i s constituted as a financially and administratively independentorganization, but stands falls the oversight o f the Ministry o f Labor. Its main characteristics are defined by the legislator, including the conditions o f affiliation, contributions, and benefits. Althoughthe country's 12,500 civil servants and their dependants are guaranteed medical assistanceby law5' and contribute 18 percent o f their salaries, they do not have any functioning insurance coverage. Medical assistance is provided to these civil servants on a selective basis. 131. The insurancesystem is financed by earmarkedpayrollcontributions.The employee component amounts to 8 percent o f the gross salary, the employer pays 14 percent. On top o f that, employers pay a premiumo f 2 to10 percent o f accident insurance dependingon the type o f work. Benefits currently provided by the INPS include the following: (i)sickness benefits (medical, remedies) foresee a 25 percent co-payment by the insured (50 percent for dependents); (ii)salarycompensation duringtimeofidlenessdueto sickness; (iii)evacuations abroad; (iv) family coverage (up to three children); (v) invalidity benefits (upon official declaration o f invalidity); (vi) pension benefits (minimum o f 10 years o f enrollment, state minimumpension i s CFAF 20,000 per month-currently 979 enrollees); and (vii) widow(er) benefits. Furthermore, there are plans to offer social housing and to construct a private clinic. 132. Informal sources, however, confirmthat services are often not available. Changes in management are frequent, often more than once a year, and preference i s usually given to political appointees over technicians. Non-compliance and arrears by companies are the norm. In fact, only 2.5 percent o f the eligible companies actually comply inpaying their contributions; in absolute numbers, this means only 40 companies. When funds are available, disbursement i s reported to be excruciatingly slow, which translates into low levels o f confidence in the institution among employers and employees. Currently, INPS i s in the process o f introducing electronic data management with the support o f the Portuguese Cooperation. 133. There are no private commercial insurance companies in Guinea-Bissau to date. INPS has made no attempt to insure workers in the informal sector, who are estimated to represent about 80 percent o f the country's workforce. According to the director, a prerequisite o f their enrollment would be to build up their trust inthe structure. 134. Community-basedhealth insurancefunds have been growing exponentially in West Africa over the last decade.60Guinea-Bissau, lagging behindinthis area, has only recently had its first pilot experiences with informal community-based insurance under the guidance o f non- governmental actors.61Each member o f the community participating in the insurance scheme pledges to contribute a certain amount annually, which i s then administered by a community- based organization. Fees are adjusted to the annual income cycle as payment comes due in the harvest season. The funds are exclusively devoted to covering medical assistance o f the 59 Decree-Law no. 30-N92, article 645. 6o Gottret 2006. 6' AD -Mutualidade de Satide de Varela,Cacheuprovince. 59 members.According to the experience o f one such community-based health insurance scheme, there must be a minimum o f 150-200 members, each contributing a minimum of CFAF 1,000 annually. No co-funding from external sources i s sought and, given the small scale o f operations, risk-pooling effects are low. While potential demand for such community-based insurance schemes i s estimated to be high, the main stepping stone in the Guinean context i s the poor quality on the supply side. The insured depend on basic public health services as community- based schemes have only limited means to provide these services themselves. In 2001, only 99 out o f the 639 health posts were considered operational and had sufficient stocks o fmedication.62 3.4. THE SOCIAL PROTECTIONSECTOR 135. The following table gives an overview of existing social protection mechan.,ms in Guinea-Bissau. Risk management strategies are grouped according to whether they focus on prevention, mitigation, or coping with risk. Preventivemeasures aim to reduce the probability of a negative shock, while mitigation measures decrease the potential negative impact of a manifested shock, and coping strategies try to relieve the impact of the shock once it has occurred.63 Table 16: Social ProtectionMechanisms inGuinea-Bissad4 Formal Public FormalPrivate Informal Prevention Informationcampaigns (HIV, vaccinations etc.) Regulatory framework Education MissionSchools Community schools Mitigation HealthInsurance (private sector employees) Community-based healthinsurance Pensions(civil servants) Family-basedcare of elders Microfinance Abotas (savings groups) Privatebanking, Informal loans moneylenders MigratiodRemittances Coping Transfer programs Dissaving \Subsidizeddrugs Foodaid Charities Restriction of consumption Begging 62 JosC Antonio MendesPereira: Power Point Presentation11/2006. 63 H o l z m a andJorgensen(2000). ~ 64 The table is modeledonBendokatand Tovo 1999. 60 3.4.1. FormalSafety Nets 136. Formal social protection refers to public or contractual, market-based arrangements.The public sector contributes to risk prevention efforts by providing information and regulation and basic social services (see the detailed analysis in the education and health chapters, respectively). In terms o f risk mitigation, the government offers limited but obligatory health insurance coverage for workers inthe private sector and a pension fund for civil servants. There i s also a transfer program for the handicapped, still in its early stages o f development, which can be classified as a risk coping program, in addition to food aid provided by the WFP in targeted communities throughout the country. Pensions 137. The formal pension system covers only a small part of the population. Beneficiaries are civil servants, including teachers and retired members o f the government, as well as ex- combatants o f the 1974 independence war, numbering 2,817 individuals at present. In order to qualify for pension benefits, the eligible individual has to either reach the legal retirement age of 60 years, combinedwith 40 years o f service as a civil servant or, alternatively, be 40 years of age and demonstrate 15 years o f service if judged unfit for work. Surviving direct ascendants can request a lump sum payment equaling six months o f the pension with no possibility o f an extension beyond that period. Designed as a pay-as-you-go system, based on a 6 percent payroll contribution, tax i s applied to the salaries o f roughly 12,250 civil servants (including 5,135 teachers).65 Pension deductions go into the general budget, which leads to frequent disbursement problems. The Ministry o f Labor and Civil Service would like to introduce an autonomous pensionfund for civil servants. 138. Benefits are unevenly distributed among eligible groups. Monthly average disbursements o f benefits amount to CFAF 196 million. However, 31percent o f these payments go towards 192 ex-members o f the government and ex-deputies, who are guaranteed 80 percent of their last base salary as a pension. Arrears o f several months are frequent. INPS offers retirement benefits for retired workers in the private sector after a minimum o f 10 years o f enrollment. These benefits are extended to the surviving partner along with a one-time payment o f CFAF 100,000 to cover funeral-related expenses. 139. A governmenttransfer programaims to provide assistance to a range of vulnerable groups. The program, managed by the Ministry o f Social Solidarity, currently covers around 2,500 beneficiaries. The funds stem exclusively from the sale o f official stamps. Targeting criteria, however, do not seem very clear; the Ministry does not possess any data collection mechanisms to that end. Individuals are expected to apply directly to the Ministry, which checks their background and decides whether or not to enroll them. Out o f the 2,500 beneficiaries, 1,500 are people living with a disability and another 1,000 are categorized as "others." Beneficiaries are eligible to receive CFAF 10,000 quarterly. Given the amounts allocated and the frequent payment delays, none o f the beneficiaries can rely exclusively on this form o f assistance. The 65MFPTISewiGode GestEodeBase de Dados 03/05/2006. 61 government does not dispose o f any emergency funds that would permit it to intervene in cases of man-made or natural disasters. The ministry currently plans to support a program o f social pharmacies varmcicias sociais] that provide drugs at a subsidized rate for pre-qualifiedpatients. 140. Given the weak capacityof the government,non-stateactors fill an importantgap in terms of providing health and education services, especially in rural areas. The Catholic Church entertains a dense network o f mission schools and health posts, often runincollaboration with the government. Evangelical churches originating from Brazil are increasingly present, especially in the capital, often attracting the poor in part because they provide food and other support. Only a few international NGOs are present in Guinea-Bissau. Several, however, focus on vulnerable groups, most prominent among them being PLAN International which provides 16,000 children in the region o f Bafata with a basket o f social services financed by sponsors from Europe and North America. SOS Children Villages currently hosts more than 300 orphaned and/or destitute children intheir three facilities. 141. Social assistance for orphans and vulnerable children (OVC) is very limited. Recent data from the MICS shows that only 7.5 percent o f all children classified as orphaned and vulnerable have in fact received some sort o f social assistance, o f which 4.4 percent received medical support and 4.8 percent education support. Coverage rates for the east are the highest with 11.6 percent, which canbe attributedto PLAN'Sactivities inBafatS andparts o f Gab6. Informal Risk Management Strategies 142. Bissau Guineans rely mainly on informal arrangements to manage as formal social safety nets reach only a very small and relatively well-off segment o f society. Informal risk management instruments,however, tend to be ineffective. Riskpooling takes place on a very low level as informal instruments usually involve only a very limited number of individuals. Obligations between parties are often based on mutual trust and customary law and may be difficult to enforce when necessary. 143. Most informalarrangements focus on mitigation and coping measures for negative shocks that have already occurred. Rarely do the poor have the capacity to take preventive measures to avoid negative outcomes. Community schooling, however, i s an example o f a preventive measure, as it would build human capital and generate income. As a response to the ongoing crisis in the education sector, communities have built schools and raised funds for their operation. 144. Social assistance networks are criticalto determiningpeople's fate in times of need. These networks, however, are not always resilient when faced with acute idiosyncratic shocks like medical emergencies, but they are even less able to cushion covariate shocks, be they natural disasters such as lack o f precipitation, or man-made ones such as prolonged conflict or macroeconomic downturns. Social capital cannot function as a direct substitute for missing economic capital in times o f need as the two are in fact mutually reinforcing. Not everyone benefits equally from such social networks o f assistance, which makes it crucial to unpack them to be able to identifythe most vulnerable groups inthe population. 62 145. Many Bissau Guineanscan expect to rely first and primarily on their immediatekin for assistance. While there are differences according to ethnic group with regard to the division of responsibilities, usually parents (matrilineal or patrilineal), uncles, and cousins provide a safety net by, for example, "joining stoves," i.e. merging households in times o f need or providing ad hoc assistance in kind or in cash. In a small household survey undertaken among urban households in the neighborhood o f Bandim in Bissau, reliance on receiving gifts several times a month or regularly was reported by over 50 percent o f households. Households led by women captured in the sample were relatively more reliant on gift giving than male-headed households.66 146. A variety of informal risk mitigation strategies are utilized by the poor. These strategies can be horizontal or vertical, rooted in traditions or "modern," and entail different levels o f reciprocity. Patrimonial networks, often leading upstream via several intermediate steps to a homem grandi, i.e. a "wealthy man", are often based on kin and ethnicity. They may be based on obligations to traditional chiefs, although this allegiance i s increasingly disappearing in urban areas. Individuals with a regular income usually have a large number o f direct dependents and an even larger number o f friends, family, and acquaintances that ask them for support on a regular basis. In times o f economic contraction, however, such vertical networks may dry up; when a firm lays off an employee this may easily throw a whole chain o f dependents into poverty. Horizontal networks, on the other hand, involve contacts with a similar socioeconomic standingand encompass a variety o frelatives - family and non-family alike. 147. Informal measures may include risk sharing over time (informal loans) as well as across space remittance^).^^ Kin-based support frequently involves exchanges between urban and rural relatives with transfers going both ways, depending on need. For example, it i s quite common for women and youth to seasonally migrate to "their" village during the cashew harvest season (May-July) inorder to improve their income, while relatives from the countryside expect to be hosted by their relatives in the city when they come to market or send their children to be fostered by family intown duringthe school year. 148. Participationin informalrotatingsaving schemes [abotas] is a widespread practice, especially among women engaged in the informal economy. Usually members are from the same socioeconomic strata and also the same age group. Due to the low and often irregular contributions o f the members, these funds are often minimal. In addition, management o f the funds is generally quite weak because o f the limited competence of the members and the prohibitive cost o f professional services. While abotas are mostly used as a source o f credit to members, sometimes these savings schemes have a clear protective dedication. Some women, however, are too destitute to participate in an abota due to their limitedand/or irregular income. Other informal safety nets take the form o f organized wage-sharing groups among (male) day workers [surni] and social clubs [mandjuandades], providing not only recreational but also limitedincome opportunities for its members.68 66Lourenqo 2005. 67Alderman 2001. World Bank 2006. 63 149. Mutual faith-based support networks are a complementary safety net for some. Adherence to evangelical churches o f Brazilian or American origin has been on the rise among the urban poor, providing for a tighter community than the more institutionalized Catholic Church. However, conversion to an evangelical church may also lead to marginalization in the community o f origin and disruption o f social networks. 150. Risk coping, however, frequently leads to dissaving, both in financial and human capital, and may lead to a reduction in consumption (for example eating only one meal a day) and the sale o f investment goods. It may also lead to children dropping out o f school due to the inability of their families to cover the direct or indirect costs of schooling. In the worst cases, families are forced to live on the streets and beg for subsistence. BOX6. Health Mutual Faith-Based Organization in Varela With the support o fthe ILO, in2003, the nationalNGOAcqdo para o Desenvolvimento -AD set up a mutual health organization inthe area o f Varela, situated inthe Northern region o f Guinea-Bissau, not far from the Senegalese border. Following a feasibility study and door-to-door informationwork, each family inthe community that decided to enroll was asked for an initial contribution o f CFA 500 and agreed to annual fees o f CFA 1100 per enrolled family member up to a maximum o f six persons per household. Upon enrollment, each registered member received an insurance card from AD. In2005, the organization counted 120 members. The Mutualidade de Salide covered urgent care, small surgeries, pre-natal care, obstetric care, hospitalization and evacuation services to Ziguinchor, Senegal and a lump sum for hospitalized patients. The organization's aims as a community-based organization went beyond service provision inthat it offered sensitization and training on the prevention o f illnesses and activities to strengthen community cohesion. Although not rigorously evaluated, the experience so far can be described as mixed. While potential demand for such community-based insurance schemes is estimated to be high, enrollment actually turned out to be sluggish. AD attributes this to the poor quality o f services on the supply side. Due to the limited funds o fthe community- based insurance the beneficiaries depend on services by public health posts and the public Sao Domingos hospital. An additional reasonmight be that insurance the flat rate askedper insuredpresents a prohibitively highcost to the local population. This i s confirmed by experience elsewhere that has shown that community-based insurances may not reach the poorest. According to an evaluation by the STEP in2005, the organization was faced with several difficulties: sluggish demand by the population, lack o f health professionals inthe area's public healthposts, l o w managerial capacity o f staff, lack o f information about the organization among the community and an "assistentialist" mentality. Source: Interview with AD, Statutes of the Mutualidade de Sazidede Varela. 64 4. SUMMARY OF FINDINGSAND RECOMMENDATIONS 4.1. GENERAL FINDINGS AND RECOMMENDATIONS 151. The central message o f this review is that Guinea-Bissau cannot afford to continue with its "business-as-usuaYYapproach ifit i s to achieve the goal o f better education, quality health care and adequate social protection for its population. Robust reforms are neededto put the country back on track for the achievement o f the education and health MDGs. From the review, it i s clear that while some human development MDGs will not be reached by 2015, a few are still attainable ifsubstantial progress is achieved inthe delivery o f social services. 152. The review shows that social indicators in Guinea-Bissauremain alarmingly poor. Illiteracy i s high and life expectancy i s low. Six out o f 10 children who enter the first grade do not complete the full cycle of primary education. Many o f those who do complete primary education remain illiterate because o f the poor quality o f education they receive. On average, only 38 percent o f the population has access to health care; the situation is much worse for the poor. Maternal mortality and under-fivemortality are still very high - two out o f ten children die before they reach the age o f five. It i s highly unlikely that Guinea-Bissau will achieve the MDG targets on maternal mortality and under-five mortality by 2015. Social protection mechanisms are almost non-existent and large segments o f population rely on informal, community-based arrangements to cope with risks. 153. But not all news is bad. The assessment indicates that, despite all the setbacks, some progress has recently been made in specific aspects o f education and health sectors. Education coverage at all levels has dramatically increased inrecent years. Today, there are twice as many students in primary education than there were ten years ago, while the gender gap in primary education has almost beenclosed. Secondary education i s expanding considerably, with a Gross Enrollment Rate (GER) in 2006 estimated at 35 percent, slightly above the 30 percent average for Sub-Saharan African countries. Guinea-Bissau has also undertaken serious efforts to build tertiary education institutions, and has established a national university based on a promising public-private partnership model. Inthe health sector, the immunization coverage has presented mixed results and progress inthe fight against malaria, although fragile, i s encouraging. 154. More importantly, most of the efforts needed to improve the delivery of social services are within reach of the country, As the review discusses, improving governance and financing o f social sectors can have a huge impact on outcomes. For example, it was estimated that by simply increasing the budgetary allocation to the education sector from the current 11 percent to 20 percent, and by allocating 50 percent o f that to primary education, the Government would be able to raise the completion rate from 42 percent to 96 percent. Inthe health sector, the 65 low per capita public spending ($ 12 in 2006), means that there i s enough leverage to increase public financing o f the sector with improved results. 155. The review proposes a four-point agenda to move towards improved delivery of social services in Guinea-Bissau,Beyond the specific recommendations made for each sector, looking across all the social sectors, there i s a set of pillars that emerge as common points, and that deserve to be tackled ina broader way: . 1. ImprovePublicFinancingof Social Sectors The share o f domestic budget effectively allocated to social sectors must be increased in order to be aligned with acceptable international and regional standards. The simple increase o f budget allocation to social sectors may have a huge impact on service . delivery, particularly inthe achievement o f universalprimary education; Increased spending on education and health, however, i s not the sole answer. The quality and equity of spending are equally important. Improved governance, stronger accountability mechanisms,' and sound expenditure management are essential to raising . the quality o fsocial services. Donors' commitment i s important to support reform efforts in social sectors. That will require commitment of more resources, including increasing donor support to key programs in education and health, Examples include the Fast Track Initiative in education, strengthening o f health systems, and combating HIV/AIDS and Malaria. Equally essential, therefore, i s the renewal o f fundingby development partners. . 2. Accelerateand Scale Up PromisingReforms Despite their mixed results, some reforms undertaken in recent past need to be pursued and achieved. In education, the adoption of a six-year primary education cycle; the provision o f free primary-education; the development of new curriculum; and the investment in teachers are among measures that are likely to have a positive impact on schooling. Inthe health sector, reforms must include measure to: develop and implement a new infrastructure plan; improve the drug supply chain system; and reevaluate the . whole evacuation process for patients. Non-state actors, including NGOs, are playing an increasingly important role in service delivery. Inorder to extend service delivery coverage -- particularly to the poor -- and to improve quality, it i s important to forge partnership with these non-state actors This will . improve and/or scale up various promising initiatives they are undertaking It i s time to develop coherent, sustainable and equitable social protection mechanisms geared towards safeguarding the well-being o f the population o f Guinea-Bissau. It is 66 important for the Government to step up efforts to formalize the sector and to develop a coherent policy framework. Such framework should be designed in the context o f development o f a broader social protection development agenda The social protection development agendamust include efforts to support the well-tested informal social protection mechanisms, which for the foreseeable future will continue to be the main mechanisms available to the vast majority o f Guinea-Bissau's population to cope with risks. . 3. EnsureInstitutionalDevelopmentof Social Sectors Strengthening policy framework i s one important step towards a stronger institutional capacity in social sectors. Sector policies and programs must factor a strong link with the PRSP. While the health sector has a clear long-term strategic framework orientation (PNDS), the education sector and the social protectionlack strategic orientation. Strategic and policy orientations inthe health sector must be consolidated, through the subsequent phases o f PNDS. Developing an explicit long-term education policy and strategic . framework i s a priority. The same i s true for social protection. Monitoring and evaluation information systems across the sectors must be developed. Successful design and implementation o f reforms cannot take place without reliable information. An action plan to develop monitoring and evaluation system in social sectors would help to clearly identify visualize priority needs in the short-term and medium-term. Effective human resources management, including capacity development strategies and programs at all levels, i s crucial for improved service delivery. Capacity development must take into account the kindo f capacity needed to implement reforms inthese sectors. The new human resources strategy and action plan in the health sector should be effectively use to create linkages between planning, production and deployment o f personnel. In education, the newly developed but incomplete HR management system needs to be consolidated. 4.2. SPECIFIC RECOMMENDATIONSTO IMPROVEDELIVERY OF SOCIAL SERVICES 4.2.1. The EducationSector Access and Quality Improvement 156. The recent expansion of primaryeducationcoverage has been impressive,but it was not accompanied by improvementsin internalefficiency and quality. Over the last ten years Guinea-Bissau has substantially expanded its education system coverage, particularly inprimary 67 education. Girls have particularly benefited from that expansion, as the gender gap has been closing steadily. However, internal inefficiencies persisted and even worsened. An inadequate structure and organization o f primary education sub-cycle, combined with high repetition and drop out rates and low quality o f education, has resulted in low completion rate in primary education, making it hard for Guinea-Bissau to achieve universal primary completion by 2015. 157. Demand for secondary education is growing steadily. As primary education enrollments increase, supported by an increase o f community-financed schools and private schools (both representing together 1/3 o f all primary schools) a growing demand for secondary education i s emerging. Private sector providers are playing a critical role in accommodating that demand. The expected continuing expansion of primary education will continue to put pressure on enrollment in secondary education, If the current investment trends in secondary education persist, it i s unlikely that private providers alone will be able to absorb the growing number of new enrollments. 158. Implementing short-term reforms. Adopting a six-year primary education cycle is critical to ensure that a growing number o f children complete a six-year basic education and that the basic skills are mastered by all children. A new curriculum for the six-year model o f primary education has been drafted under a pilot program. The process now needs to be scaled up and quickly rolled. Restructuring the primary education architecture; providing free primary education o f six classes to children; addressing the issue o f repetition; investing on teachers and making a more rationalized use o f them; and introducing some measurement o f learning achievements are among measures that are likely to have positive impact on schooling. 159. Making more rationaluse,ofteachers in the classroom. Doubling the timing teachers spend inclassrooms from four to eight hours should be consolidated and improved. The measure will help to accommodate additional students without the need to increase, in the short run, the number o f graduates o f teacher training colleges. The setting up o f an integrated basic education system will also reduce the number of teachers needed at this level (the current complementary primary sub-cycle curriculum i s taught by six teachers; the new integrated curriculum will require no more than three teachers for all subjects). 160. Mitigating the impact of the HIV/AIDS epidemic.Reform o f the use o f teachers' time i s also important to mitigate the potential impact o f the HIV/AIDS epidemic. HIV/AIDS has a negative impact on the education system and i s an important element to consider in efforts to achieve universal primary education. Assuming that teachers are affected inthe same proportion as adults in general, approximately 280 primary education teachers are likely to be infected with HIV/AIDS. With absent or sick teachers, substitutes will be needed to avoid disruptions to schooling. 161. Rethinkingteacher training.The current model ofprimary education teacher training is inadequate, costly, and lengthy.69 More effective initial teacher training could be achieved by developing a combination o f pre-service training, in-service support and training, and continuous professional development, limiting therefore the initial training time. In this way, it would be 69 Teachers graduate from teachers training college after a full three years training course. The entrance requirement to these colleges is the completion of gthgrade of secondary education. 68 possible to reduce the cost to the system if teachers leave the profession (Lewin, 2000) and also increase teacher supply by placing teachers in the classroom quickly. This i s consistent with an international trend toward greater training o f teachers in schools, drivenby the desire to improve the relationshipbetweentraining and classroom practice. 162. Revamping technical and vocational training. Technical and vocational training is important to build capacities for labor market and economic development, but its current marginal status inGuinea-Bissau i s far from contributing to reach that goal. The destruction and subsequent crisis o f the technical and vocational education sub-sector represents an opportunity for the country to revamp the system, by setting up an appropriate legal and regulatory framework and by transforming the current supply-driven vocational training system into a demand-driven system (thereby increasing its relevance), focusing mainly on public-private partnership. This includes the establishment o f vocational courses for young people that meet the demands o f the labor market, and the creation o f opportunities for rural dwellers to get technical qualifications for employment. Improving the capacity o f the country's human resources i s crucial for economic growth. In the process o f rebuilding the sector, the government should clearly define its policy with respect to vocational training, including the role o f the public sector, and ensure that vocational training institutions are financially sustainable. 163. Guinea-Bissaumust dedicateefforts to strengtheningthe emerginghigher education sectors. The country has witnessed over the last years a wide effort to structure and expand the supply o f higher education. This effort has resulted in a new panorama o f higher education training in Guinea-Bissau with the opening o f two universities. But there are challenges. They include the institutional strengthening o f recent initiatives, quality o f learning, improved management, and the setting up o f a clear legal framework for the sector. Institutional Development 164. Prioritizing actions for better results. As discussed above, the weak performance of Guinea-Bissau's education system is mainly due to a combination o f three interconnected and mutually reinforcing factors: (i)low investment in the sector; (ii) the deficient structure and organization o f the education system; and (iii) sector management. Acting on these three poor factors is important in order to ensure better education service delivery, but this will require that policy priorities be defined. An important first step in that direction i s to develop an explicit long-term strategic education plan that defines the vision, establishes objectives and priorities, and sets a clear timetable for implementation. The PRSP addresses these topics in a general way but cannot serve as a reference policy document for the sector. For example, while the PRSP highlights the importance of increasing access to education, it does not include key actions for achieving this objective. Various actions are listed in its education component, but lack prioritization and costing. 165. Strengtheningthe education management informationsystem. Successful design and implementation o f reforms cannot take place without reliable information. Also, information i s the key to improving internal management and reinforcing the planning function of the Ministry o f Education. Strengthening o f the information system will require a specific action plan that includes training and training support, as well as provision o f materials (equipment and other 69 inputs) to strengthenthe institutional capacity o f the Ministry o f Education to produce statistical information on a regular basis. 166. Improving school-based management. Incentives may involve capitation grants to schools, increased participation o f parents and communities in school management, and the generation o f information about inputs, outputs, and outcomes, as well as dissemination o f this information to local stakeholders. These measures are likely to create accountability mechanisms and improve transparency at the school level, by enabling parents and students to use information to lobby for school performance. The capitation grant incentive might also be used as a pro-girl policy in order to stimulate girls' enrollment and attendance inbasic and secondary education. Financing 167. Improving inter- and intra-sectoral allocation to meet universalprimary education. Progress toward this goal will require more resources and betterpolicies. One first important step might be to mobilize adequate domestic financial resources to the sector. A recent estimate indicates that Guinea-Bissau would be able to considerably increase the completion rate in primary education by increasing the by increasing budget allocation to the education sector from the current 11percent to 20 percent, and by allocating 50 percent o f that allocation to primary education. If this measure i s kept in parallel with high budget execution and key structural reforms to ensure greater internal efficiency o f the system, including less repetition and dropout and an integrated primary education cycle, more than 90 percent o f the relevant population would be able to complete a full cycle o fprimary education ina few years.70 Box 7. Key Policy Optionsfor Guinea-Bissau to Reach Universal Primary Education Goal Policy choices Expand supply and ensure retention Better intra-sectoral allocation o f the recurrent budget More cost-effective use o f teachers Alternative models o f pre-service teacher training Equitable funding across schools (per student allocations) Appropriate education management information system Planning for HIV/AIDS impact Improve quality Control o f teacher absenteeism Increased hours and days o f training Free distribution o f textbooks to schools and students Curriculum revision to improve relevance Teacher network and resource centers (in-service teacher training) Simple school monitoring and reporting system 70Brossard, Mathieu, Eltments d'Analyse du Secteur de I'Education en Guinte-Bissau, P61e de Dakar (BREDA), M a i 2003, 70 Periodic assessment of student learningoutcomes Schoolhealth andnutritionprogram Parents involved inschool councils with decision-makingpower. 71 4.2.2. The HealthSector Access and Quality Improvement 168. The majority of the population of Guinea-Bissauhas limited access to healthcare of good quality, which resultsin their poor health status. Services are often o f very poor quality that there are little incentives for demand, Children immunization and malaria fighting are among the most important factors likely to improve health outcomes o f the population. Results achieved inthese areas over the last years have beenmixed. On the malaria front, there are signs of reduced incidence o f the disease, particularly among children, but new, most effective treatments are not yet accessible to large parts o f the population. With regard to children immunization, there are clear signs that effective interventions have not been sustainable, since the immunization coverage has fluctuated considerable over recent years. 169. The HIV/AIDS epidemic is a big concern. There are indications that the disease i s spreading. The increase in prevalence rate over the last years suggests that strategies used so far to fight the disease have not been effective. Low knowledge and misconception of HIV/AIDS forms o f transmission, serious stigmas against seropositive persons, and limited access to treatment are among factors that hinders progress on this front. 170. Preparea new infrastructureplan aimed at completing what was initiated underPNDS 1and the ninth FED. Seven regional hospitals (out of 11) and four health areas (out of 114) are still not operational. New housing for health personnel has to be planned in a few remote regions. 171. Reevaluatethe whole evacuation process for complicatedpatients, suffering mainly from non-communicable diseases. Many patients are evacuated under vague criteria; others wait for months and eventually die. Clear and transparent rules on the decision-making process of the Medical Board [Junta Me'dica] are urgently needed. A mid-term strategy aimed at increasing the retention power o f health facilities has to be prepared. At time same, it i s urgent to promote public-private partnerships to increase the power o fretention o f the health systemand in so doing, reduce the number of evacuations abroad and improve the drug distribution network. 172. Invigorate the drug purchasing and supply chain system. Currently, most of the regional warehouses are bearing huge financial burdens. The system requires significant investmentininfrastructure as access to drugs for the population and particularly the vulnerable groups i s limited. Institutional Development 173. Review the M o H organizationalstructure and strengthen key MoHdirectoratesand departments.Leadership within the Administrative and Financial, Hygiene, and Epidemiology Directorates has to be reinforced, allowing closer dialogue with other entities and facilitating achievement o f better outcomes. The MoH could reduce its current total number o f twelve directions through an appropriate merging policy aiming at reducing operational costs at the 72 central level. It could also engage in a decentralization process combining devolution and decentralization with a view to increasing the efficiency and equity o fthe whole health system. 174. Use the new national HRH strategy and action plan to create linkages between HR planning, production, and deployment.Demand for health personnel responding to national norms has to be clearly documented and communicated. Innovative ways o f taking advantage of the diaspora settled in Portugal should be considered. Promote close collaboration betweenthe public sector and FBOs and NGOs, seeking areas where complementarities exist and coherence of interventions through information sharing and cross-fertilization. Financing 175. Increase the execution rate of the MoH budget. Public spending has been low in recent years, demonstrating a declining trend. Mechanisms for cost recovery are not effective, and donor contributions amount to only US$ 6 per capita. Further financial efforts from the government and development partners are necessary if Guinea-Bissau i s to meet the MDGs. In terms o f public finance management, a unique budget should be produced yearly. Linkages betweenbudget and treasury directorates have to be strengthened with the goal o f eliminating the existing gap between the executed and paid budget. In addition, there i s a need to improve coordination in the PNDS/PRSP process so as to ensure that limited budgetary resources are targeted to the poor. 176. Performa PER for the healthsector. The study would examine the flow of funds with a focus on public policy, and the performance o f the system in ensuring and financing public provision o fhealth care. Financing and provision are either highly regulated or managed outright by the State, but the rationale for state involvement infinancing and provision must be explicitly justified, and its consequences explicitly acknowledged. Public involvement in finance and provision i s often defended by reference to theoretical abstractions such as economies o f scale and market imperfections. These conditions may hold, but they must be supported by evidence rather than based on mere assumptions. 177. Ensuresustainability of healthfinancing. The multiplicity of sources of funding care, including donor contributions, raises the question o f sustainability-the availability o f funding over the medium and long term. This issue grows particularly acute when certain types o f care depend on funding (such as from donors) that might not be sustained. The study would also focus on efforts to be developed toward strengthening health systems with regard to the health- related MDGs and specific diseases, such as malaria, AIDS, TB, conditions affecting mothers and children, and nutrition. 178. Strengthen capacity of the INPS. The INPS has a great potential for extending its coverage and services. However, it should be'put under public-private oversight to assure good governance. Strengthening the capacity o f INPS could be done through technical assistance to create a better image and instill greater confidence, increase the contribution o f the private sector and o f public companies, reduce payment delays, and increase the number o f beneficiaries through the creation o f new regimes for the informal sector. INPS should seek external collaboration to review its business model aiming at strengthening its weak health insurance 73 scheme. By the same token, it would be important to launch multiple pilot initiatives to create community healthmutualities, taking advantage o frecent UNFPA supported initiatives. 4.2.3. The Social ProtectionSector 179. The vast majority of the population of Guinea-Bissau does not benefit from any formal social protection support. Formal social protection arrangements, namely health insurance and pension schemes, are affordable to only a small segment o f the population. Government transfer programs have limited scope and impact. Because o f these limitations, various segments o f the population rely on informal risk management strategies, including social networks, community mutual faith-based support and saving schemes. 180. The institutional framework is scattered and needs improvement. The Ministry of Social Solidarity could play a key role in convening actors and in coordinating policy development fostering a better collaboration and between the public and the non-governmental sector. In order to assume this role, the Ministry would benefit from an organizational analysis, identifying strengths and weaknesses o f its current configuration. Further, it needs to develop a coherent strategy with a focus on coordination and supervision o f interventions instead of attempting to act as a direct implementation body. Its transfer program needs to be reconfigured and endowed with the necessary means to function properly. Also, the Ministry's staff i s inneed to buildthe capacity o f its staff inorder to successfblly fulfill its obligations. 181. A multi-sectoralsocial protectionpolicy is needed. Guinea-Bissau would benefit from a multi-sectoral social protection policy based on the PRSP and the Lei do Enquadramento da ProtecqEo Social. Such a policy, however, needs to be evidence-based and has to prioritize interventions according to need and effectiveness. Policy development should include all stakeholders (government, NGO's, civil society and to some extent the private sector) inorder to create broad-based ownership. Untilnow, there has been no thorough analysis o f the efficiency of existing interventions in the social sectors. Inorder to identify the approaches with the biggest impact and the greatest cost effectiveness, such a review appears to be indispensable. 182. Interventionsneed to be prioritized. While the PRSP's focus on vulnerable groups is a step in the right direction, a prioritization o f interventions within the document i s necessary, adapting it to the resource-constrained environment. Instead o f creating new infrastructures for the different groups, synergies with existing structures, both governmental and non- governmental, should be sought to avoid duplication and assure best use o f existing resources. The lack o f reliable household-level data must be addressed expediently as an indispensable basis for informed, evidence-based programming as targeting interventions without data can only be based on assumption. 183. Measuresto improve child wellbeing and protection must focus on behavior change communication,legal reform and enforcementof legalnorms. Inthis regards, sequencing is e~sential.~'The population must be informed about harmful practices such as the worst forms o f 71KiellandandTovo 2005. 74 child labor and child begging. The education system must strive to accommodate working children. International commitments such as the CRC and its protocols as well as pertinent ILO conventions need to be transformed into directly applicable domestic law. Efforts to register all children must be stepped up, Child trafficking as practiced with talibe children needs to be prohibited and perpetrators prosecuted. Additionally, Guinea-Bissau has to be prepared to accommodate the expected rise in HIV/AIDS orphans, with a focus on strengthening affected households. Also, currently there are no halfway houses to assist women and children fleeing from domestic strife or otherwise inneed. 184. Young people need more employment opportunities. Giventhe enormous difficulties young people face in successfully transitioning into the labor market, priority should be given to active labor market interventions, comprising microfinance, traditional apprenticeships and insertion into the formal sector. Providing employment opportunities in the smaller regional towns could attenuate the rural exodus towards the capital. HIV/AIDS prevention efforts among young people need to be stepped up based on international evidence o f what successful approaches with this age group. Finally, youth civil society should be supported in its efforts to channel young people's energy towards constructive aims. 185. Provisions needto be made to assurewomen's access to landownership.Widows and divorced women in poverty needto be targeted inneeds-based social assistance programs. With regards to the nefarious practice o f female genital cutting, given the still large approval for it among the population and the ritualistic significance o f fanado, the emphasis should be on grassroots behavior change communication within communities. Only in sequence, the practice shouldbe forbidden. ' 186. Social assistance programs should target the elderly and disabled people. There i s currently no legislation ensuring equal treatment for people living with disabilities and there i s a need for information and education campaigns to raise awareness o f the rights o f the handicapped. Community-driven assistance programs to the disabled are in dire need o f assistance. 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