Guinea-Bissau Human Capital Review Guinea-Bissau Human Capital Review © 2024 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Direc- tors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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Editing and design: Nita Congress Contents Acknowledgments ...................................................v Box Abbreviations...........................................................vi 3.1 Fragmentation in decision-making highlighted during COVID-19 ............................45 Executive summary................................................ vii Figures 1 Introduction......................................... 1 1.1 Life-cycle lens: health, skills, and Country context........................................................ 1 productivity at each life stage............................. 3 Methodology and data: a life-cycle approach..... 2 2.1 Trends in child mortality rate, 2001–21.............. 6 2.2 Child mortality, 2021............................................. 6 2 Assessing human capital across 2.3 Top causes of death in children under age the life cycle in Guinea-Bissau.......... 5 five in Guinea-Bissau............................................ 6 Accumulation of human capital in early 2.4 Top causes of DALYs in children under childhood (ages 0–5) ............................................. 5 age five in Guinea-Bissau.................................... 6 Accumulation of human capital among 2.5 Global comparison of not stunted rates, school-age children and youth (ages 6–18) ......16 circa 2020.............................................................10 Utilization of human capital and productivity 2.6 Wealth inequalities in child stunting in (ages 19–60+)........................................................29 Guinea-Bissau, 2018–19.....................................10 2.7 Comparison of adjusted net attendance 3 Human development systems rates for year before primary school.................13 required to strengthen human 2.8 World Bank’s Investing in the Early Years capital..................................................44 Conceptual Framework 2016.............................14 Fragility and governance......................................44 2.9 Guinea-Bissau population structure, Financing for human capital ...............................46 1990–2043............................................................16 Human resources..................................................50 2.10 Out-of-school rates for children in Guinea- Bissau, by age and demographic......................17 Data for informed decision-making and planning...................................................................53 2.11 Contributing factors to out-of-school incidence and low educational attainment Climate change .....................................................54 in Guinea-Bissau..................................................18 2.12 Repetition rates in Guinea-Bissau.....................18 4 Key recommendations......................57 2.13 Expected years of school, circa 2020 ............20 2.14 Trends in gross enrollment rates and the References.................................................59 Gender Parity Index by level of education in Guinea-Bissau, 2014–18................................22 iii iv Guinea-Bissau Human Capital Review 2.15 Disparities in gross enrollment rates 3.1 Effects of COVID-19 on education and across Guinea-Bissau........................................23 health in Guinea-Bissau.....................................46 2.16 Leading causes of death in children ages 3.2 Shares of total government spending by 5–14 in Guinea-Bissau, 1990 and 2019..........26 function, 2020.....................................................46 2.17 Leading causes of DALYs in children ages 3.3 Social assistance packages in Guinea- 5–14 in Guinea-Bissau, 1990 and 2019..........26 Bissau, 2020–21................................................. 47 2.18 Leading causes of death in children ages 3.4 Donor funding for nutrition in Guinea- 5–14 in Guinea-Bissau disaggregated by Bissau, 2012–21..................................................48 sex, 1990 and 2019............................................ 27 3.5 Employment in Guinea-Bissau, 2017 and 2.19 Distribution of professions/employment in 2023......................................................................50 Guinea-Bissau (%)..............................................31 3.6 Human resources planning in the health 2.20 Distribution of Guinea-Bissau workers by and education sectors .......................................52 sector.....................................................................31 2.21 Per capita consumption by profession/ Tables employment category in Guinea-Bissau.........32 2.1 Priority health care strategies shown to 2.22 Unemployment rates in Guinea-Bissau by prevent most deaths among children sex and highest level of education attained...33 under age five........................................................ 9 2.23 Hours worked in Guinea-Bissau by level of 2.2 Preschool net enrollment rates in Guinea- education and worker location..........................34 Bissau (%)............................................................13 2.24 Main problems faced by enterprises in 2.3 Social assistance programs targeting Guinea-Bissau.....................................................35 early years in Guinea-Bissau, 2020–21...........15 2.25 Personal remittances received in Guinea- 2.4 Summary of key primary education Bissau...................................................................36 outcomes in Guinea-Bissau (%).......................19 2.26 Services and owned goods by welfare level...39 2.5 Interventions to improve teaching and 2.27 Social protection targeting and poverty in learning..................................................................21 Guinea-Bissau.....................................................40 2.6 Girls’ marital, childbearing, and 2.28 Social protection targeting by educational status, 2018–19.............................24 consumption in Guinea-Bissau.........................40 2.7 Adolescent birth rate by residence, 2.29 Survival rate of individuals age 15 years in region, mother’s education, and wealth Guinea-Bissau and its peers..............................41 quintile..................................................................28 2.30 Top 10 causes of DALYs among people 15 2.8 Examples of social assistance programs years and older in Guinea-Bissau.....................41 targeting school-age children and youth .......29 2.31 Maternal mortality ratio in Guinea-Bissau 2.9 Cash transfer programs in Guinea-Bissau, and its peers, 2000–17......................................42 2018–22...............................................................38 2.32 Life expectancy at birth in Guinea-Bissau 3.1 Flood risk associated with schools and and its peers, 2015–20......................................42 population count, by region 2021.....................55 2.33 Age-standardized mortality rate in Guinea-Bissau and its peers, 2000–19...........43 Acknowledgments The main authors of the report are Yemdaogo The report was developed under guidance provided Tougma (Task Team Leader and Senior Economist, by Keiko Miwa (Country Director), Gaston Sorgho Health), Opope Oyaka Tshivuila Matala (Co–Task (Practice Manager, Western and Central Africa Team Leader and Senior Health Specialist), Emily Region), Anne-Lucie Lefebvre (Resident Repre- E. Gardner (Co–Task Team Leader and Senior sentative for Guinea-Bissau), and Rebekka Grun Education Specialist), Teegwende Valerie Porgo (Human Development Practice Leader, Western (Health Specialist), and German Daniel Caruso and Central Africa Region). The World Bank team (Senior Economist, Human Capital Project). Other is indebted to the quality assurance teams, peer authors include Silvia Coni (Senior Social Protection reviewers, and other reviewers for their valuable Specialist), Djeniffer Zamy Lima Melo (Young Profes- feedback throughout the preparation of this report. sional), Yann Tapsoba (Consultant), Nuria Garriga Llavina (Consultant), Josep Vicent Puig Gomez The World Bank team would like to thank the (Consultant), Javier Lovelle Varela (Consultant), staff of the General Directorate of the Economy, Ndoh Ashken Sanogo (Extended Term Consultant), the National Institute of Health, and the Ministry Michelle Ashwin Mehta (Nutrition Specialist), Jona- of Education for their excellent collaboration. The than Kweku Akuoku (Nutrition Specialist), Yannis team would like to also thank the representatives Arvanitis (Senior Governance Specialist), Halimatou of the following nongovernmental organizations Hima Moussa Dioula (Extended Term Consultant), and development partners for their contributions: Paula Tavares (Senior Private Sector Development UNICEF, the World Health Organization, the World Specialist), Patrick John McCartney (Economist), Food Programme, the United Nations Development Sering Touray (Economist), Sylvestre Bea (Senior Programme, and the Instituto Marquês de Valle Flôr. Water Specialist), Birgit Embalo (Consultant), Yao Thibaut Kpegli (Consultant), Khadidja Malloum Boukar (Consultant), and Aboubacar Sidibe (Consultant). v Abbreviations CECOME Central Drug Purchasing Agency MICS Multiple Indicator Cluster Survey (Central de Compras de Medicamentos Essenciais) NGO nongovernmental organization DALY disability-adjusted life year PASEC Program for the Analysis of Education Systems (Programme d’analyse des EHCVM Harmonized Survey on Household Living systèmes éducatifs de la Confemen) Standards (Enquête Harmonisée sur le Conditions de Vie des Ménages) SAB Bissau autonomous sector (Sector Autó- nomo de Bissau) GDP gross domestic product TVET technical and vocational education and HCI Human Capital Index training HIV/AIDS human immunodeficiency virus/acquired UNICEF United Nations International Children’s immunodeficiency syndrome Emergency Fund IDA International Development Association WASH water, sanitation, and hygiene INSS National Social Security Institute (Insti- tuto Nacional de Segurança Social) MMFSS Ministry of Women, Family, and Social Solidarity (Ministério da Mulher Família e Solidariedade Social) All dollar amounts are US dollars unless otherwise indicated. vi Executive summary Human capital comprises the knowledge, skills, ■ Discussions with Guinea-Bissau authorities and health people accumulate over their lives, around the human capital agenda enabling them to realize their potential as produc- tive members of society. Human capital is a central ■ A workshop to identify government priorities for driver of sustainable growth and poverty reduc- the human capital review to ensure alignment tion. It is measured using the Human Capital Index with the government’s human capital vision and (HCI), which quantifies the contribution of health facilitate dissemination of the resulting report and education to the productivity of the next gener- ■ A desk review of the literature, existing analyt- ation of workers. The HCI quantitatively illustrates ical work, and data specific to Guinea-Bissau the key stages in a child’s human capital trajectory and the consequences for the productivity of the During the workshop, consultations with stake- next generation of workers. Measurement of the HCI holders conducting their own assessment of human involves three components: (1) survival from birth capital in Guinea-Bissau were made; these findings to school age, measured using under-five mortality were compared with the preliminary results of this rates; (2) expected years of learning-adjusted study. schooling, which combines information on the quan- tity and quality of education; and (3) overall health, The review was guided by the life-cycle approach. which is captured by two proxies: adult survival This is in line with the 2020 World Bank HCI update rates, defined as the fraction of 15-year-olds who and the International Development Association’s survive until age 60, and the rate of stunting for chil- IDA20 approach to and focus on human capital. dren under age five. The review examined HCI indicators across all stages of the life cycle, highlighting investments in This report presents the findings of a study to health, education, and social protection and their analyze Guinea-Bissau’s HCI indicators and its contribution to human capital accumulation, use, human capital policies across three sectors— and protection across age groups. This process is health, education, and social protection. The report useful in identifying necessary actions at each step highlights a deep analysis of sociodemographic vari- of the life cycle to build and develop human capital. ables such as age, sex, income, and geographical disparities, based on the available data. It identifies Investments in health, nutrition, and education are critical gaps and constraints in the development of key for the accumulation of human capital—a period human capital and provides policy recommenda- spanning ages 0 to 18 years—to enable individ- tions for improving human capital outcomes; these uals to reach their full potential as future workers. will inform upcoming World Bank operations in the The current metrics of the HCI in Guinea-Bissau country’s social sector. reveal irreversible losses to human capital, leading to reduced economic productivity. Early mortality The study entailed several activities and method- has improved, and the survival rate of children from ologies: birth to school age (five years old), as measured vii viii Guinea-Bissau Human Capital Review using under-five mortality rates, was 94.4 percent relatively small private sector that fails to support in 2018. The rate of live births has also improved capital-intensive labor (since firms face obstacles since 2001, dropping from 116 deaths per 1,000 live in terms of access to finance, informality, corrup- births to 56 deaths per 1,000 in 2018. However, tion, and lack of adequate infrastructure) and offers nearly 33 percent of children between the ages of limited employment opportunities. Even highly 6 and 11 have never attended school, and primary educated individuals struggle to find high-quality school completion rates are low (27 percent on employment opportunities in Guinea-Bissau. This average) mainly due to high repetition. While the pattern becomes more pronounced when taking rate of stunting for children under the age of five gender into account, and leads to the emigration is 27.7 percent overall, this masks important socio- of many educated individuals. Jobs created are economic and regional disparities. Both the survival predominantly of low quality, and offer low wages. rate of children under age five and school perfor- A significant portion of the labor force is engaged mance are directly affected by malnutrition, which in informal sector activities, which lack job security, also has a direct impact on labor productivity. stability, and access to essential benefits. Forty-three percent of the working-age population suffered from stunting before the age of five. The combination of low wages and limited job opportunities has led to a widespread poverty crisis, Although the mortality rate in Guinea-Bissau which is worse in rural areas and largely unmitigated decreased from 18.7 to 13.6 per 1,000 person-years by social protection. As of 2018, 21.7 percent of the between 2000 and 2019, the adult survival rate is Guinea-Bissau population lives in extreme poverty, a low 83 percent and maternal mortality is high. which limits investment in human capital for chil- The adult survival rate is higher among women dren and leads to intergenerational impacts. In (86 percent) than men (79 percent). In 2019, the addition, there are significant disparities between most significant health burdens among individuals urban and rural areas. Regardless of labor market age 15 years and older were HIV/AIDS, followed by status, poverty rates are higher in rural areas than tuberculosis and road injuries. A particular area of urban. The poverty rate among workers in rural concern among women is the maternal mortality areas is 60.0 percent, compared with 23.5 percent rate, which was estimated at 667 per 100,000 live in urban areas in 2018. A substantial disparity also births in 2017. This rate is closely linked to female exists in educational attainment between urban genital mutilation; 52 percent of girls and women and rural areas. Social protection mechanisms in ages 15 to 49 years and 29.7 percent of girls under Guinea-Bissau have limited coverage relative to the age 14 have been subjected to the practice. The size of the population groups they aim to assist. The high adolescent birth rate—84 births per 1,000 coverage of contributory social protection devices women between ages 15 and 19—is also thought to is extremely low, mainly due to the small size of be associated with early marriage. Thirty percent of the formal sector in the economy. Social assistance girls marry before they turn 18, which drags down programs are extremely limited—complementary school completion rates. donor financing is essential—causing low coverage, fragmentation, and the potential for duplication. The Guinea-Bissau’s economy relies heavily on agri- availability of state social assistance is constrained, culture as the primary economic sector and on and it struggles to reach the poorest households in self-employment. The former makes the country rural areas, where the incidence of poverty is higher. susceptible to shocks and external factors; the latter is highly informal and labor intensive. The coun- Cross-cutting constraints such as climate chal- try’s unfavorable business environment results in a lenges, gender, fragility, and governance hinder the Executive summary ix strengthening and preservation of human capital. and children under the age of five to prevent The effects of climate change are already visible in negative effects on their physical and cognitive Guinea-Bissau, with notable impacts including sea development; (3) expanded integrated early child- level rise, temperature increase, changing precipita- hood development programs to increase children’s tion patterns, shorter cool seasons, longer drought readiness for elementary school; (4) greater access spells, and heat waves. These changes have to quality basic education through improved teacher negative consequences for human capital across performance and the availability of teaching and multiple dimensions all over the country, particu- learning materials; (5) income support to vulner- larly in vulnerable communities. Climate change able households through cash transfers, along with dramatically affects areas such as food security, accompanying measures to increase households’ clean water and sanitation, health, and education. ability to invest in health and education and to cope Gender inequality is pervasive in Guinea-Bissau, with shocks; and (6) economic inclusion measures with major implications for women’s and girls’ health, to support unemployed educated youth to promote education, and economic opportunities. Factors self-employment and for poor households in rural contributing to fragility and governance challenges areas to foster diversification by promoting off-farm include an ongoing political transformation driven income-generating activities, through a package of by elite fragmentation and noninclusive institutions training, cash start-up grants, and coaching. and poor public administration; an endemic lack of governance and dysfunctional institutions, leading Government leadership and institutional alignment to fragmentation in decision-making and weak plan- and coordination, as well as targeted mechanisms ning and coordination; and lack of human resources. to reach priority groups, are essential. These efforts are interconnected and involve multisectoral inter- To improve human capital and accelerate economic ventions, raising the risk of duplication and wasted growth and development, Guinea-Bissau must resources. To achieve these objectives, the govern- prioritize efforts to ensure children’s health and ment should (1) reactivate the National Council for education. A strategy to achieve this goal involves Social Protection (CNPS) to facilitate strong coordi- the following actions: (1) sustained efforts to nation among stakeholders; (2) increase local and improve access to quality health care and enhance community participation in service delivery; and the quality of care in order to decrease the high (3) establish a national social registry. maternal and neonatal mortality rates; (2) further progress in improving nutrition for pregnant women 1 Introduction   Country context potential productivity, versus 70 percent for a child born in a high-income country (World Bank 2021b). Human capital accounts for two-thirds of total wealth Guinea-Bissau’s political and socioeconomic globally and remains a central driver of inclusive context since independence in 1974 has not been economic growth (Lange, Wodon, and Carey 2018). conducive to building, protecting, and utilizing Human capital is the knowledge, skills, and health human capital. The small West African state with people accumulate over their lives, enabling them a population of approximately 1.9 million continues to realize their potential as productive members to grapple with low economic growth, high levels of of society. Countries like Singapore have demon- poverty, and long-standing political instability and strated that economic growth can be accelerated, fragility. Since independence, pervasive fragility— equity enhanced, and poverty alleviated by building driven mostly by conflicts and political turmoil—has human capital through robust investments in educa- been conducive to neither stability nor growth, with tion, health, and social safety net systems—utilizing devastating consequences for the economy and human capital in concert with other types of capital human development. Per capita income remains investments (World Bank 2021c). low, with a gross domestic product (GDP) per capita Healthy, well-educated people free of poverty of $832.70 in 2022, showing only marginal growth promote positive social externalities such as social over a span of 40 years; the 1981 GDP per capita cohesion and environmental protection (World Bank was $606. 2021b). The World Bank Human Capital Index (HCI) Poverty continues to be widespread in Guin- captures the impact of human capital on future ea-Bissau, increasing by 2.8 percentage points growth prospects and is a useful starting point for between 2018 and 2021. Data from the 2018–19 considering human capital challenges. The 2020 and 2021–22 Harmonized Surveys on House- HCI shows that, worldwide, before the COVID-19 hold Living Standards (EHCVM) show that pandemic, a child could expect to attain an average poverty increased from 47.7  percent in 2018 to of 56 percent of his or her potential productivity 50.5 percent in 2021—the equivalent of more than as a future worker (World Bank 2021b). Serious 80,000 additional poor. The surveys indicate that disparities in human capital outcomes exists across other measures of poverty also increased in Guin- high- and low-income countries and are largely ea-Bissau over the 2018–21 period. The poverty gap driven by gaps in access to quality social services. (which measures the extent to which individuals on Consequently, a child born in a low-income country average fall below the poverty line) increased from can expect to attain only 37 percent of his or her 1 2 Guinea-Bissau Human Capital Review 13.7 percent in 2018 to 15.2 percent in 2021. Simi- Methodology and data: a larly, the poverty severity index (which puts more weight on the poorest households, measured by life-cycle approach squaring the poverty gap) also increased, from 5.2 This report analyzes human capital outcomes in to 6.2 over the same period. The rise in these indica- Guinea-Bissau using a life-cycle approach. As shown tors illustrates an increasing intensity of poverty in in figure 1.1, it looks at key challenges and outcomes Guinea-Bissau during the period. Recovery from the at different points in human capital development and COVID-19 pandemic has been constrained by addi- utilization. Both quantitative and qualitative methods tional shocks—notably spillover effects from the war were used to assess human capital challenges and in Ukraine, resulting in disruptions in global supply solutions in Guinea-Bissau and to compare them chains and rising food prices. to the country’s regional peers, structural peers (fragile and nonfragile countries with similar struc- Despite a volatile political situation, Guinea-Bissau tural characteristics; i.e., Burundi, the Central demonstrated a willingness for strategic reforms African Republic, The Gambia, and Sierra Leone), and investments to drive economic recovery and aspirational peers (countries setting a good following the pandemic and to build resilience development precedent; i.e., Lao People’s Demo- against future shocks. Given its central role in cratic Republic, Rwanda, and Tajikistan).1 fostering sustained economic growth, improving human capital outcomes has emerged as a core The work was co-shaped by stakeholders. Several pillar of the government’s post-COVID development strategic discussions were held with Guinea-Bissau strategy. authorities regarding the country’s human capital agenda. At the study’s launch, a World Bank team This Guinea-Bissau human capital review was devel- engaged with key stakeholders to present the oped to inform the human development priorities of human capital review concept, including the HCI, the World Bank’s engagement in the country under and its objectives in Guinea-Bissau. A workshop the new Country Partnership Framework FY2024– was held to identify the government’s human capital 28. The study has two main objectives: priorities. During this session, a national focal point ■ To conduct a diagnostic of human capital for human capital was identified to facilitate coor- outcomes in Guinea-Bissau across the health, dination across sectors, aid in data collection, and education, and social protection sectors, and ensure the study’s alignment with the government’s identify existing gaps and constraints in human human capital vision. Sectoral focal points were capital development, protection, and utilization. identified to assist the World Bank team in obtaining sector-specific data. The study’s preliminary results ■ To propose policy recommendations to the were presented to experts from the government and government of Guinea-Bissau that will enable donor organizations at a May 2023 workshop, with the country to achieve the human capital aspi- the aim of reaching consensus on key findings and rations set out in its National Development Plan recommendations. 2020–2030. The desk review conducted involved a compre- hensive examination of existing literature, studies, See World Bank (2020) for a fuller discussion of these 1  three peer groups. 1 Introduction 3 Figure 1.1  Life-cycle lens: health, skills, and productivity at each life stage School presence, duration, and quality; technical and vocational education and training (TVET) and further education Labor force participation, gainful opportunities Preschool Adult survival Nutrition, parental rate presence, home environment; natal care and vaccinations Healthy, safe, and educated Aging with dignity Early and lifelong advantage Skilled, empowered, productive, and resilient I M PA C T S O N H U M A N C A P I TA L A C R O S S T H E L I F E C YC L E S o u r c e : Adapted from World Bank Human Capital Project. and data sources to evaluate the status of human violence; gender; and jobs and economic trans- capital in Guinea-Bissau. Key sources used in the formation. According to IDA20, investments must review include national and regional reports. Addi- be made in people as well as in systems, with the tionally, collaboration with United Nations agencies goal of ensuring universal access to quality social including the World Food Programme, the World services including health care, basic education, Health Organization, the United Nations Develop- and social protection. In addition, investments are ment Programme, and UNICEF was instrumental in needed to make service delivery systems more gaining a comprehensive understanding of the local resilient and inclusive in building, protecting, and challenges and needs. It is important to note that utilizing human capital. the findings and conclusions presented here are subject to the limitations of the available data and Investments across the life cycle have cumulative the reliability of the sources utilized. and complementary effects on enhancing produc- tivity and building resilience to shocks. Figure 1.1 Framing the review through a life-cycle lens aligns illustrates HCI metrics across every stage of the with the orientation of both the 2020 World Bank HCI life cycle to indicate human capital accumula- report and the IDA20 approach of the International tion across age groups. It also shows the different Development Association (IDA). This approach investments in health, education, and social protec- links human capital to the special themes of IDA19, tion across the life cycle and depicts outcomes which include climate change; fragility, conflict, and as potential consequences of shocks—which can 4 Guinea-Bissau Human Capital Review quickly reverse gains made in human capital. The capital and helping men and women access produc- prioritization of investments includes (1) expanding tive work); and (3) building resilience (e.g., providing access to primary health care and to reproductive, insurance against, and building the capacity to maternal, and neonatal health and nutrition; (2) manage, shocks). making early-years investments beginning in utero, including promoting health, nutrition, early stimula- The following section of the report uses the life-cycle tion, and early learning; (3) achieving better learning approach to review the status of human capital in outcomes in primary education; (4) expanding Guinea-Bissau; this is followed by an analysis of access to and completion of secondary education; cross-cutting constraints that impede the building, and (5) improving access, quality, and relevance of utilization, and maintenance of human capital in tertiary education, technical and vocational educa- Guinea-Bissau. Both sections present data and tion and training (TVET), and adult learning. findings as well as highlight recommendations for future actions. Key recommendations to enhance Using the life-cycle approach helps identify actions human capital in Guinea-Bissau, as substantiated needed at different stages to build and develop and suggested in sections 2 and 3, are captured in human capital by (1) promoting equity (e.g., reducing the final section. poverty and inequality, improving equality of oppor- tunities, and addressing exclusion); (2) ensuring opportunity (e.g., promoting investments in human 2 Assessing human capital across the life cycle in Guinea-Bissau   Accumulation of human the child’s health status and the attention and cogni- tive stimulation provided during the first two years of capital in early childhood life (the first 1,000 days), are critical to child growth (ages 0–5) and development (Likhar and Patil 2022). During a child’s first five years of life, the brain is highly The accumulation of human capital starts before a malleable and matures faster than at any other time. child is born and during the first stages of life, when Positive or negative development during this period investments in health, nutrition, and education play has implications for well-being, school readiness, a crucial role in enabling individuals to realize their and later success in life. In addition to brain develop- full potential. This section takes an in-depth look at ment, the child’s first 1,000 days are crucial for the factors that are strongly associated with child devel- development of the body, the immune system, and opment and at the opportunities available for young the metabolism. Consequences can play out years children in Guinea-Bissau to develop as healthy and or decades later; numerous epidemiological and strong individuals. First, it analyzes health outcomes clinical data indicate that poor maternal health and relevant for young children, including survival, nutrition increase susceptibility to chronic diseases immunization rates, and pre- and postnatal care. in adulthood (Gluckman et al. 2008). It then takes a closer look at nutritional outcomes, including stunting and malnutrition. This is followed Children under age five in Guinea-Bissau experi- with an examination of early learning opportunities, ence high morbidity and mortality, with more than as well as access to and participation in preschool 73  percent of deaths attributed to five prevent- programs, and the challenges related to language able conditions.1 By expanding access to essential of instruction. Lastly, it covers social protection maternal and child health services, the country programs targeting early years that can help chil- reduced the rate of child mortality by half between dren access what they need to survive and thrive, 2011 and 2021—from 169.1 to 74.3 deaths per 1,000 despite financial limitations. live births (figure 2.1). This rate is still high, however, compared to the average for low-income countries (67.4 deaths per 1,000 live births), and it is almost Child health double the rates reported by Guinea-Bissau’s aspi- Child health plays a pivotal role in driving economic rational peers (figure 2.2). Neonatal conditions development, as it directly affects human capital formation and long-term productivity. Maternal The data in this paragraph are from the World Bank, 1  health before and during pregnancy, coupled with World Development Indicators. 5 6 Guinea-Bissau Human Capital Review 35+14+117627z Figure 2.1  Trends in child mortality rate, 2001–21 Figure 2.3  Top causes of death in children under age five in Guinea-Bissau 200 Guinea-Bissau 150 ■ Neonatal conditions Western and Central Africa 27% 35% ■ Diarrheal diseases 100 Low income ■ Measles ■ Malaria 6% ■ Lower respiratory 50 Lower middle income   infections Sub-Saharan Africa 7% ■ Other 11% 14% 0 2001 2005 2009 2013 2017 2021 S o u r c e s : World Health Organization, Institute for S o u r c e s : World Health Organization, Institute for Health Metrics and Evaluation, and World Development Health Metrics and Evaluation, and World Development Indicators. Indicators. Figure 2.2  Child mortality, 2021 Figure 2.4  Top causes of DALYs in children under age five in Guinea-Bissau Aspirational peers Structural peers Regional comparators Guinea-Bissau 74.3 Neonatal conditions 182.2 Sierra Leone 104.7 Lower respiratory infections 54.9 Central African Republic 99.9 Diarrheal diseases 34 Burundi 52.6 Malaria 19 Gambia, The 47.9 HIV/AIDS 17.9 Lao PDR 42.5 Whooping cough 17.6 Rwanda 39.4 Tajikistan 31.4 Nutritional deficiencies 13 Cabo Verde 13.5 Tuberculosis 12.9 Western & Central Africa 94.4 Measles 11.3 Sub-Saharan Africa 73 Neural tube defects 10.3 Low income 67.4 0 50 100 150 200 Lower middle income 43.7 S o u r c e s : World Health Organization, Institute for 0 50 100 150 Health Metrics and Evaluation, and World Development Deaths per 1,000 live births Indicators. S o u r c e s : World Health Organization, Institute for Health Metrics and Evaluation, and World Development Indicators. include diarrheal diseases (14 percent), measles (11 percent), malaria (7 percent), and lower respira- account for the largest share of child deaths tory infections (6 percent); together with neonatal (35  percent; figure 2.3) and disabilities (182 causes, these four account for more than 73 percent disability-adjusted life years [DALYs]; figure 2.4) of all child deaths in Guinea-Bissau. in Guinea-Bissau.2 Other leading causes of death In Guinea-Bissau, child survival does not appear to be influenced by socioeconomic or geographic Source: World Health Organization, Global Health 2  factors. According to UNICEF’s Multiple Indicator Observatory. 2  Assessing human capital across the life cycle in Guinea-Bissau 7 Cluster Survey (MICS) conducted in Guinea-Bissau (100 percent of those who had completed tertiary for 2018–19, similar child mortality rates were education, 90 percent of those who had completed observed across wealth quintiles (the richest and secondary education, and 92 percent of those in the poorest quintiles registered 59 and 60 deaths per richest quintile), compared to their less educated 1,000 live births, respectively) and among urban and poorer counterparts (35 percent of those who and rural households (55 and 57 deaths per 1,000 had only completed preschool or had no education, live births, respectively). There is regional variation, and 35 percent of those in the poorest quintile). however: the highest number of child deaths occur Moreover, compared to those in urban areas, in Gabú (106 deaths per 1,000 live births), followed women in rural communities were more likely to give by Biombo (73), Quinará (72), and the Bissau auton- birth at home, with up to 60 percent of women in omous sector (59). The lowest rate occurs in Bafatá rural areas giving birth at home in 2019. Distance (28). to facilities also plays a part, as almost 70 percent of the population lives more than an hour’s walk Neonatal deaths are largely driven by limited access from the nearest health center. Adding in the poor to quality prenatal and intrapartum care for preg- road quality—further degraded during the rainy nant women. While 81 percent of pregnant women season—pregnant mothers are hard pressed to in Guinea-Bissau attend at least four prenatal visits, access services when needed.3 Cultural practices less than half (43 percent) attend their first visit have also been shown to block access to life-saving during the first trimester, according the 2018–19 care. Most women need their partner’s permission MICS. Moreover, according to the 2018 Service to give birth in a clinic; such permission can be Delivery Indicator survey, the quality of prenatal difficult to obtain because of taboos surrounding services remains a challenge, with only 23 percent women’s treatment by male doctors (TNH 2008). of health care workers attending to pregnant women adhering to prenatal guidelines (World Bank 2019a). Less than one in every five children (19 percent) Regarding the intrapartum period, almost half of all under the age of 2 in Guinea-Bissau is fully pregnant women in Guinea-Bissau (49 percent) give vaccinated. This low incidence contributes to birth at home; only 50 percent give birth in health the high rate of under age five deaths linked to facilities under the care of a skilled birth attendant. vaccine-preventable diseases such as diarrhea, Moreover, according to the MICS 2018–19, only pneumonia, and measles.4 In 2019, only 4 percent 52 percent of newborns receive a postnatal health of 12-month-olds had received all their required checkup before being discharged. The Service vaccinations. Because 65 percent of unvaccinated Delivery Indicator survey also confirmed significant children in Guinea-Bissau live in urban areas,5 the gaps in the quality of intrapartum and postpartum community is exposed to the risk of disease and care, with only 24 percent of health care workers death from vaccine-preventable diseases. Since having knowledge of how to manage maternal and 2019, immunization services have further deterio- neonatal complications during the perinatal period. rated amid disruptions in essential health services due to the COVID-19 pandemic, vaccine stockouts, The high rate of home-based deliveries observed among pregnant mothers is largely driven by socio- economic and cultural factors, as well as supply-side Source: UNICEF, Child Survival and Development 3  webpage. barriers. The 2018–19 MICS found that women with Source: MICS 2018–19, based on children’s vaccination 4  higher educational attainment and from wealthier cards. households were more likely to give birth at a health Source: UNICEF, Child Survival and Development 5  facility under the care of a skilled birth attendant webpage. 8 Guinea-Bissau Human Capital Review health worker strikes, and inadequate planning and Asia, that could prevent the most deaths in chil- financing of outreach services by the World Health dren under age five (Madewell et al. 2022). Table 2.1 Organization’s Expanded Program on Immunization. summarizes these interventions. Given that five Consequently, the country experienced polio and conditions contribute to more than 70 percent of measles outbreaks in 2021 and 2022—placing addi- under-five deaths in Guinea-Bissau (figure 2.3), tional pressure on an already fragile health system a minimum essential package of interventions and claiming the lives of 12 children. aimed at improving prenatal and obstetrics care, health-seeking behavior, health education, and the Most families have limited access to water, sani- use of existing vaccinations could yield significant tation, and hygiene (WASH) services. Almost results. While most of these interventions have 90 percent of diarrhea-related deaths globally are been prioritized in the government’s National Health attributable to unsafe drinking water and to poor Development Plan (2018–2022), they remain poorly hygiene and sanitation (CDC 2012). Rotavirus is the implemented because of weaknesses in the health leading cause of acute diarrhea globally and contrib- system (e.g., human resources, health financing, utes to around 40 percent of hospitalizations for governance, and other factors). diarrhea in children under five years old (CDC 2012). In Guinea-Bissau, only 67 percent of the population has access to an improved water source: 87 percent Nutrition and stunting in urban areas and 55 percent in rural areas. Water Malnutrition—particularly in very young children—, quality remains a serious problem. According to leads to increased mortality, higher risk of illness, the MICS 2018–19, an estimated 55.4 percent of and weaker cognitive development. These conse- water sources are contaminated with fecal mate- quences bring irreversible damage to human rial (Escherichia coli), with Tombali (82.5 percent) capital and contribute to reduced productivity. and Bolama/Bijagos (78.6 percent) being the most Undernutrition is an underlying cause of about half affected. Around 75 percent of the population does of all under age five child mortality and one-fifth not have access to improved sanitation, including of maternal mortality in developing countries. Chil- 43 percent in urban and 93 percent in rural areas. dren who are malnourished early in life are more Only 26 percent of the population has access to likely to experience cognitive deficiencies and poor hygiene facilities for hand washing (soap and water). schooling outcomes. In the long term, stunting can These factors contribute to the high prevalence lead to a loss of up to 20 percent of potential life- of WASH-related deaths and disability (especially time earnings (Kakietek et al. 2017). Furthermore, associated with diarrheal conditions) observed in because of the increased risk of child illnesses asso- children in Guinea-Bissau. ciated with chronic malnutrition, households incur To accelerate the decline in preventable child additional health care expenses in the short term. deaths, the government should roll out a priori- The results of a study led by the World Food tized benefit package of high-impact, cost-effective Programme highlight the significant socioeconomic public health interventions at scale, and increase impacts of hunger compounded by malnutrition in demand for these services, particularly among Guinea-Bissau (WFP 2022). Malnutrition accounted pregnant women and mothers. A study conducted for 23.5 percent of deaths among children under in 2022 by the Child Health and Mortality Preven- age five between 2008 and 2013. Additionally, tion Surveillance (CHAMPS) identified 10 health 93.2  percent of children who repeated a year and public health improvements, tailored to health of primary school had experienced some form system challenges in Sub-Saharan Africa and South 2  Assessing human capital across the life cycle in Guinea-Bissau 9 Table 2.1  Priority health care strategies shown to prevent most deaths among children under age five Health system improvement Example of public health action Improved clinical management and Advanced respiratory support, improvements in medical records, properly quality of care trained staff for parturition and health care Improved prenatal and obstetric care Ultrasonography, timely cesarean delivery, management of pre-eclampsia and management Regular antenatal checkups, early recognition of illness, early referral for Improved health-seeking behavior treatment at a health care facility Improved infection prevention and Personal hygiene, environmental sanitation, appropriate use of antibiotics control Improved health education Immunizations, malnutrition prevention, bed nets to prevent malaria Improved nutritional support Management of malnutrition Maternal access to testing and antiretroviral therapy, therapy for neonatal Improved HIV prevention and control infections Improved family planning Prevention of unwanted pregnancies Improved use of existing vaccinations Pneumococcal conjugate vaccine, Haemophilus influenzae type b vaccine Road infrastructure, availability of public transportation, availability of Improved transport system resources (e.g., oxygen on ambulances) S o u r c e : Madewell et al. 2022. of malnutrition. Given that 43  percent of the Socioeconomic and regional disparities in child working-age population suffered from stunting stunting continue. Stunting rates in the poorest before the age of five, it was estimated that child households are more than twice those in the malnutrition caused a loss equivalent to nearly richest households: 30.4  percent compared to 10 percent of gross domestic product (GDP) in 2014. 13.2 percent (figure 2.6). Although stunting rates Halving the prevalence of child malnutrition by 2025 are high across the three lowest wealth quintiles, could result in annual savings of $148.5 million. stunting is prevalent even in the wealthiest house- holds. In other words, while stunting is associated Disparities in child undernutrition across wealth with poverty, other factors also put children at risk quintiles are pronounced in Guinea-Bissau. While of chronic malnutrition. These factors include the the prevalence of wasting globally has remained high prevalence and incidence of disease, in partic- relatively stable at around 7 percent since 2010,6 ular diarrhea, as well as inappropriate feeding and many countries have seen an increase in wasting caregiving practices (Black et al. 2013). due to the food security crisis and the impacts of the COVID-19 pandemic. In Guinea-Bissau, stunting The national prevalence of stunting at 27.7 percent, prevalence has declined gradually from 32 percent as per the latest MICS, masks dramatic geographic in 2010 to 27.7 percent in 2019, according to the differences within the country. The Gabú, Bafatá, MICS 2018–19. When compared to other countries and Oio regions, for example, have a stunting with similar income levels, Guinea-Bissau performs prevalence above 30 percent, whereas the Bissau moderately well in terms of not stunted rates, as autonomous sector and the Bolama/Bijagós shown in figure 2.5. regions have much lower rates—14.3 percent and 17.1 percent, respectively. On average, southern regions have fewer cases of stunting than the Source: UNICEF–World Health Organization–World 6  northern and eastern regions. Bank: Joint Child Malnutrition Estimates, 2023. 10 Guinea-Bissau Human Capital Review Figure 2.5  Global comparison of not stunted rates, circa 2020 Guinea-Bissau S o u r c e : Adapted from World Bank 2021b. Figure 2.6  Wealth inequalities in child stunting in nut production. According to the World Food Guinea-Bissau, 2018–19 Programme’s Fill the Nutrient Gap study, only 28 percent of the country’s population can afford Richest a diet that meets minimum energy requirements, Wealth quintile Fourth which is estimated to cost about $2.35 per day for Middle an average household of seven people (WFP 2022). More than two-thirds of the population (68 percent) Second cannot afford a healthy and nutritious diet, which is Poorest estimated to cost about $4 per household per day. 0 10 20 30 40 50 The limited affordability, availability, and accessi- % stunting among children under age 5 bility of key nutritious foods are barriers to achieving healthy diets. S o u r c e : UNICEF Multiple Indicator Cluster Survey 2018–19. Improving nutrition and addressing the drivers of malnutrition require a multisectoral approach. Poverty and malnutrition in Guinea-Bissau are Central to achieving success in multisectoral nutri- compounded by chronic food insecurity. Rice is the tion programs is a strong governance system that main staple food, and many families in Guinea-Bissau focuses on advocacy, leadership, institutional struggle to complement their diet with other more support, management capacity, financing, results nutritious foods. Food security is reduced by irreg- measurement, monitoring, and accountability ular rainfall, volatile prices of imported rice, and (Subandoro, Holschneider, and Ruel-Bergeron an economy based on undiversified local cashew 2021). Many countries have successfully coordi- nated efforts across sectors to improve nutrition. In 2  Assessing human capital across the life cycle in Guinea-Bissau 11 Rwanda, for example, existing social protection plat- diets, and micronutrient-rich food production. Based forms are used to target cash transfers to pregnant on each of these strategies, a set of interventions/ women who attend prenatal care, thereby driving activities were planned for implementation during demand for quality health and nutrition services. the 2016–20 period. These interventions/activi- Inputs and performance-based financing from the ties included educational programs on infant and health sector have also contributed to improved young child feeding, provision of locally sourced coverage and quality of nutrition services. Indo- complementary food baskets for vulnerable children nesia has adopted a strong advocacy, governance, at health centers, supplements of vitamin A and and convergence approach at all levels, from the deworming for children age 6–59 months, provision highest levels of government to grassroots nutri- of zinc for diarrhea treatment, early diagnosis and tion programming (Subandoro, Holschneider, and treatment of acute malnutrition and common infec- Ruel-Bergeron 2021). tions associated with malnutrition, iron and folic acid supplements for pregnant and lactating women, free The Guinea-Bissau government, together with its distribution of long-lasting insecticide-treated bed national and international partners, revised the nets, intermittent preventive treatment for malaria country’s 2011 nutrition policy in 2014 using a in pregnant women, and iron and folic acid supple- multisectoral approach. The aim is to ensure more ments for preschool and schoolchildren as per productive human capital to contribute to the devel- national guidelines. opment of the country by 2025. The main objective of the nutrition policy is to improve the nutritional Data on key nutrition interventions suggests that status of the population, with a particular focus on current coverage falls short of that required to vulnerable people. It addresses reduction of low significantly reduce malnutrition, particularly birthweights, stunting, wasting, and anemia in chil- among infants and women. There is near-universal dren, the reduction of overweight and anemia in coverage of vitamin A supplements for children 6–59 women of reproductive age, and the elimination of months old—an important intervention to reduce vitamin A and iodine deficiencies. Establishment of a child mortality and the risk of adverse nutritional national nutrition multisectoral committee is planned impacts. This high coverage is likely due to intense, to ensure effective coordination and effective moni- semiannual community-level mass campaigns. toring and evaluation of the national nutrition policy. Similarly, community campaigns supported by the Global Fund and the United Nations Development Guinea-Bissau developed a National Nutrition Programme to distribute insecticide-treated bed Strategic Plan for the period 2016–20 to oper- nets has resulted in high coverage of this interven- ationalize the national nutrition policy. A set of tion—which is key to malaria prevention and the nutrition-specific and nutrition-sensitive strate- reduction of the associated risk for anemia in women gies were outlined in the plan targeting several and children. However, there are notable gaps in population categories (children 0–23 months and the coverage of other important interventions. 24–59 months, adolescents, pregnant and lactating Only about one-quarter (24 percent) of pregnant women, women of reproductive age, general popu- women receive intermittent preventive treatment for lation, and households). These strategies included malaria. Furthermore, only 14 percent of pregnant the promotion of adequate nutrition for women of women and caregivers of children under 24 months reproductive age, optimal feeding and nutrition of age received counseling on proper infant and for young infants and school-age children, inter- young child feeding practices, and only 22 percent ventions to address micronutrient deficiencies, of children with diarrhea are treated with both zinc community-based nutrition, balanced and diversified 12 Guinea-Bissau Human Capital Review and oral rehydration salts. While there is substan- A significant body of research confirms that proper tial coverage for women to receive iron and folic early childhood development leads to better acid supplementation during prenatal care services learning, health, and socioemotional outcomes. at health facilities, the lack of a community-based Investing in the earlier years of education has been program impedes reaching pregnant women whose shown to have high returns that often materialize in attendance at prenatal care services may be inad- the future after the completion of higher levels of equate. education. In Guinea-Bissau, results from a modified learning assessment—the Program for the Analysis Prioritizing the most impactful interventions could of Education Systems (Programme d’analyse des result in significant gains in nutrition outcomes in systèmes éducatifs de la Confemen—PASEC)—in Guinea-Bissau. Over a modeled five-year period, 2014 showed that children in grades 2 and 5 who prioritizing and scaling up these interventions could had attended early childhood education scored 4 result in up to 1,100 fewer child deaths, 5,100 fewer and 11 percent higher, respectively, than their peers stunted children, and 4,100 fewer wasted children who had not had any preprimary education (Ministry when compared with the current level and allocation of Education and Pôle de Dakar 2015). of funding for nutrition interventions.7 Additionally, there would be significant reductions in maternal According to the MICS 2018–19, a growing anemia, with an estimated 16,000 fewer cases over percentage of children in Guinea-Bissau are the five-year period. acquiring some level of early learning at home. Participation of adults in their children’s learning and early cognitive stimulation at home (i.e., Early learning reading children’s books with them, singing, taking them for a walk outside the home, drawing, etc.) During the first 1,000 days of life, nutrition and health increased from 2014 to 2019, although such partic- are necessary for survival, but to thrive, children also ipation remains relatively low. Support from fathers need stimulation. This early stimulation is as simple increased from 3 percent to 7 percent, that from as parents and caregivers playing with and talking, mothers increased from 3 to 24  percent, and singing, and reading to infants and toddlers. While support from any household members increased stunting is associated with deficits in cognition and from 34 percent to 43 percent. The study also noted school attainment, early stimulation improves chil- that only 1 in every 100 children under the age of dren’s development and strengthens mother-child five in Guinea-Bissau has three or more children’s bonding. It also leads to improved feeding practices books in the household. and dietary intake of infants and young children and is associated with improved nutritional status (Atta- Similar to the improvements in early cognitive nasio et al. 2022). Children vulnerable to multiple stimulation at home, enrollment in preschool has risk factors for stunting are the same children most increased, but remains low. According to the MICS at risk for long-term disadvantages in learning and 2018–19, the adjusted net attendance rate is around human capital associated with poor early childhood 14  percent for ages 36–59 months; the rate is development, which further contributes to the inter- higher in urban areas (40 percent) (table 2.2). Net generational transmission of poverty. attendance increases to 45 percent for the year before primary school, but remains lower than the Sub-Saharan Africa average of 59 percent and the least developed country average of 54  percent 7  The modeled estimates assume that the priority interven- tions would be scaled up to 95 percent coverage. (figure 2.7). Two-thirds of preschools are in the 2  Assessing human capital across the life cycle in Guinea-Bissau 13 Table 2.2  Preschool net enrollment rates in Guinea-Bissau (%) Attendance National Urban Rural Male Female  Preschool net attendance (36–59 months) 14 40 5 12 17 Year before primary school 45 77 31 45 44 S o u r c e : UNICEF Multiple Indicator Cluster Survey 2018–19. Figure 2.7  Comparison of adjusted net attendance and main language of instruction—which hampers rates for year before primary school their ability to learn. Linguistic diversity is a major Guinea-Bissau barrier to learning in Guinea-Bissau, as many chil- Latin America & Caribbean dren cannot speak or understand Portuguese. In South Asia fact, only an estimated 5 percent of the population Eastern & Southern Africa speaks Portuguese as their mother tongue (UNICEF Middle East & North Africa 2018). The majority of the population speaks Creole, Sub-Saharan Africa either as their mother tongue (15 percent) or as a Least developed countries second language (30–40 percent), while there are West & Central Africa more than 20 other indigenous languages. Among 0 20 40 60 80 100 these, the main languages spoken are Balanta S o u r c e : UNICEF global database on adjusted net (27  percent); Fula (23  percent); and Mandinca, attendance rates. Manjaco, and Papel (10–12 percent each) (Benson 2010). Research shows that children learn better in their first language than in a second language, Bissau autonomous sector, Cacheu, and Oio. and those who learn in their first language are more Most are privately managed (about 55 percent), likely to become proficient in their second language followed by community schools (26 percent) and over time (World Bank 2022b). They are also more public schools (17 percent). There is a gender gap likely to remain in school. Although language of of about 5 percent, with 17 percent of girls attending instruction policy reforms may not be possible in preschool compared to 12 percent of boys. Dispar- primary and secondary education, countries similar ities also exist in terms of household income and to Guinea-Bissau have successfully used preschool education level of parents. Of the children who education to help children transition from Creole to attend preschool, about 66 percent have mothers Portuguese to ensure children enter school ready who obtained at least a secondary-level education, to learn. and 73 percent come from the highest two income quintiles. Because of this low level of preschool The World Bank’s Investing in the Early Years attendance, children in Guinea-Bissau enter primary Conceptual Framework outlines possible inter- school unprepared, which pushes them into a cycle ventions that can help both individual children and of underperformance, grade repetition, and dropout Guinea-Bissau as a whole. Figure 2.8 highlights (Bendini and Devercelli 2022). (1) the interventions children need to reach their full potential, and (2) how improved development Language of instruction continues to be a signif- in the early years can contribute to countries’ pros- icant barrier to improving learning outcomes in perity. Guinea-Bissau has yet to develop a national Guinea-Bissau. Many children arrive at school strategy around the early years. This framework not able to speak any Portuguese—the official could provide a starting point to consider the 14 Guinea-Bissau Human Capital Review Figure 2.8  World Bank’s Investing in the Early Years Conceptual Framework 2016 TO END EXTREME POVERTY AND BOOST SHARED PROSPERITY CHILDREN ARE HEALTHY AND WELL NOURISHED, ESPECIALLY IN THE FIRST 1,000 DAYS DELIVERING ON THESE GOALS REQUIRES EFFORTS ACROSS SECTORS S o u r c e : World Bank n.d. cross-sectoral landscape that influences children’s three out of every four children worldwide not bene- development in their early years. It is grounded in fiting from any form of social protection.8 three pillars to help children reach their full potential: In Guinea-Bissau, government financing for social ■ Children are well nourished and healthy, espe- assistance programs is extremely limited, making cially during the first 1,000 days. complementary donor financing essential. A review of the general state budget’s public investment ■ Children receive early stimulation and learning programs for 2020 and 2021, and other programs opportunities from birth onwards. supported by international partners and nongov- ernmental organizations (NGOs), confirms the ■ Children are nurtured and protected from stress. existence of social assistance programs specifically targeting the early years—including food transfers, Social protection in-kind transfers, fee waivers, and targeted subsi- dies (table 2.3). Regular cash transfer programs also Social protection programs can improve children’s provide income support to some households. These access to good nutrition, health care, and education transfers increase household consumption, leading services, and reduce the lifelong consequences of to enhanced food security and better nutrition for poverty. Global coverage of these programs remains low, mostly due to a lack of financing, with almost 8  Source: UNICEF, Social Protection webpage. 2  Assessing human capital across the life cycle in Guinea-Bissau 15 Table 2.3  Social assistance programs targeting early years in Guinea-Bissau, 2020–21 Ministry Category Project Description responsible Fund Government Program to treat Provides nutritional support to children of Japan moderate acute under age 5 and pregnant and lactating MSP (implementing malnutrition women Food partner: WFP) transfers Sweden Program supporting Provides super cereal food complements and Norway complementary food MSP to children in Oio, Bafatá, and Gabú (implementing supplies for children partner: WFP) Food + Provides housing, food, education, and Netherlands/ Support to Aldeias in-kind health services to orphans in Bissau, MMFSS government of Infantis SOS transfers Canchungo, and Gabú Guinea-Bissau Target: children under age 5/pregnant women Integrated Program Benefits: doctor consultation fees; cost European Union for the Reduction of of basic medicines and medical analyses; (implementing technical assistance and equipment to MSP Maternal and Infant partners: UNICEF/ Mortality (PIMI) improve maternal and neonatal care; NGOs) and creation of a national network of community health workers to promote health awareness and good practices Fee GAVI/UNICEF waivers + Minimum immunization package for (implementing targeted Vaccine Supply children under 9 months; pentavalent MSP partners: UNICEF/ subsidies Support Program vaccine for children under 1 year; polio Expanded Program vaccination for children under age 5 on Immunization) Essential health, nutrition, and population services to 73,000 beneficiaries; allows World Bank 65,000 children under 1 year to be fully (implementing Project to Strengthen vaccinated; finances basic nutrition partners: Maternal Infant MSP services for 10,000 women and children; government of Health Services and provides health care consultations to Guinea-Bissau, 150,000 children between ages 1 and 5 UNICEF/NGOs) years S o u r c e : World Bank. N o t e : MMFSS = Ministry of Social Action, Family, and Women’s Promotion (Ministério da Acção Social, Família e Promoção da Mulher); MSP = Ministry of Public Health (Ministério da Saúde Pública); WFP = World Food Programme. children. These measures are especially impactful programs are highly fragmented and implemented when cash transfers are combined with accompa- by different ministries, with no clear leadership to nying measures that help households acquire the coordinate all the efforts, which affects the effec- tools and knowledge needed to invest in the health tiveness and efficiency of these programs. and education of their children. However, these 16 Guinea-Bissau Human Capital Review Accumulation of human digital/tech education, gender-sensitive learning environment, and other measures). capital among school-age children and youth (ages Health-related investments during the school years 6–18) are equally critical, given the effects of ongoing demographic and epidemiological transitions. As This section takes an in-depth look at human capital shown in figure 2.9, Guinea-Bissau’s population of outcomes during childhood and adolescence and approximately 1.9 million is forecast to increase to associated challenges during this phase of life. It is 3.2 million by 2043 (Aikins 2023). The population is organized into four subsections covering primary young, with a median age of 18.7 years as of 2019; education and foundational skills; secondary educa- and 42.2 percent of the population is below the tion, technical and vocational education and training age of 15 years. If current rising trends in the adop- (TVET), and job-relevant skills; adolescent and tion of birth control methods are maintained, the reproductive health; and social protection. fertility rate is expected to decline from 4.6 births per woman in 2019 to 3.0 births in 2043, and the Investments in the school years are needed to proportion of people below age 15 is projected to support learning and future productivity. Opportuni- decline to 34 percent by 2043. The large cohort ties to acquire skills and access to jobs are primary of children under the age of 15, coupled with the pathways out of poverty. Extensive evidence has limited proportion of skilled working-age adults established that in the primary years, the quality of (16–65 years) and low life expectancy (58 years, education is critical for providing students with the 2020),9 constrains materialization of a demographic foundational literacy and numeracy skills necessary dividend. Given the significant youth bulge in for lifelong learning. Offering learning opportunities Guinea-Bissau, ignoring the health and well-being of that enhance students’ potential to work and thrive in a world that is becoming increasingly more digital is especially important for young girls and women (e.g., 9  Source: World Bank, World Development Indicators. Figure 2.9  Guinea-Bissau population structure, 1990–2043 100 3% 3% 4% Popula on aged over 65 Popula on aged 15 to 30 Popula on aged 31 to 65 Popula on below 15 90 3M 26% 27% 80 34% 70 Percentage of total popula on (%) 2M 60 25% Number of people 28% 50 28% 40 1M 30 46% 42% 20 34% 10 0M 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037 2039 2041 2043 1990 2019 2043 S o u r c e : Adapted from Aikins 2023. 2  Assessing human capital across the life cycle in Guinea-Bissau 17 this large segment of the population and the demo- figure 2.10, about 43 percent of 6- to 11-year-olds graphic dividend it can contribute to the country’s from households in the poorest quintile have never future welfare, could lead to serious adverse societal attended school, compared to only 11 percent of and economic consequences for Guinea-Bissau in children from the wealthiest quintile (World Bank the immediate and long term. 2020). School dropout rates are also higher among children from the poorest quintile for both ages 6–11 and ages 12–14. The gap is also large between Primary education and urban and rural areas: 36 percent of rural 6- to foundational skills 11-year-olds have never attended school, compared Low educational attainment remains a major obstacle to 11 percent in urban areas. to improving human capital in Guinea-Bissau. The high incidence of out-of-school children and Despite improvements in access to primary educa- low educational attainment is largely driven by tion in recent decades, a considerable percentage interlinked sociocultural, economic, and geographic of the population remains underserved. Today, barriers (UNICEF 2018). Key sociocultural barriers nearly one-third (21 percent) of children between include low parental education level and aware- the ages of 6 and 11 have never attended school, ness, teen pregnancy, violence against girls, and and universal primary education is still far from safety concerns. The most pressing economic becoming a reality (World Bank 2020). Primary demand-side barriers are school affordability, oppor- school completion rates remain low: 27 percent on tunity costs of schooling, and loss of income of a average. parent. Serious supply-side barriers include inade- Out-of-school children are disproportionately from quate infrastructure, school distance, insufficient rural areas and from poor households. As shown in teacher supply, teacher strike/absenteeism, and Figure 2.10  Out-of-school rates for children in Guinea-Bissau, by age and demographic 50 Dropped out 5 Never attended school 40 6 Out of school rate (%) 30 4 5 5 5 4 20 43 36 3 3 4 27 3 4 28 26 10 21 21 14 15 2 2 11 13 11 5 5 0 National Male Female Urban Rural Poorest Richest National Male Female Urban Rural Poorest Richest Ages 6–11 Ages 12–14 S o u r c e : World Bank 2020. 18 Guinea-Bissau Human Capital Review lack of learning materials. Some of these barriers 2, exacerbate primary school net enrollments. are summarized in figure 2.11. As shown in table 2.4, net enrollment is around 69 percent at the national level, with higher rates The prevalence of out-of-school children is also due in urban areas (84 percent) compared to rural areas to children entering school underprepared, which (61 percent). pushes them into a cycle of grade repetition that affects all levels of education. About one-third of The underperformance in grade progression reflects students repeat grade 1, as shown in figure 2.12. various challenges around quality of education in The repetition rates remain around 10 percent for all the country and demonstrates significant ineffi- subsequent grades (World Bank 2023). Persistently ciencies within the system, with many late-age high repetition rates, particularly in grades 1 and entries. Factors likely influencing late entry into Figure 2.11  Contributing factors to out-of-school incidence and low educational attainment in Guinea-Bissau Sociocultural barriers Demand-side barriers Supply-side barriers Political, financial, and governance barriers ■ Negative values ■ Affordability ■ Distance to an toward education ■ Opportunity cost of adequate school ■ Lack of power of ■ Negative attitudes schooling for family ■ Inadequate school school management toward girls’ education infrastructure committees ■ Child hunger in the (early marriage) classroom ■ Teacher’s strike/ ■ Weak involvement of ■ Teenage pregnancy absenteeism parents and communi- ■ Negative image of ties in the school ■ Violence and safety public schooling ■ Competencies of concerns teachers ■ Lack of accountability at all levels ■ Lack of teaching and learning materials ■ Weak monitoring and evaluation capacity ■ Language age of instruction ■ Lack of communica- tion at all levels ■ Insufficient teacher supply, allocation and ■ Inequitable and insuf- deployment ficient resource allocation S o u r c e : UNICEF 2018. Figure 2.12  Repetition rates in Guinea-Bissau 40 34% 32% Male Female 30 Repetition rate (%) 20 17% 16% 14% 13% 12% 11% 11% 11% 11% 11% 10% 10% 9% 9% 9% 9% 10 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 S o u r c e : World Bank 2023. 2  Assessing human capital across the life cycle in Guinea-Bissau 19 Table 2.4  Summary of key primary education outcomes in Guinea-Bissau (%)  Outcome National Urban Rural Male Female Primary school net enrollment  rate 69 84 61 68 70 Primary school completion rate  27 47 14 29 25 Grade 1 repetition rate 33 24 41 34 32 Grade 2 repetition rate 16 15 17 17 16 Basic skills in reading 12 24 6 12 13 Basic skills in numeracy  8 8 7 8 7 S o u r c e s : UNICEF Multiple Indicator Cluster Survey 2018–19; World Bank 2023. school are a cultural belief that young children are at the top of the distribution, and low-income econ- unable to learn and the instability of the education omies are at the bottom (World Bank 2021b). The sector in recent years (Ministry of Education and number of years a child can expect to complete Pôle de Dakar 2015). Late enrollment in primary in Guinea-Bissau is comparable to that of other schools leads to a higher likelihood of dropping out low-income countries ranked at the bottom of the in adolescence. Guinea-Bissau’s Ministry of Educa- World Bank’s 2020 Human Capital Index (HCI). tion has estimated that, due to internal inefficiencies, Guinea-Bissau is 171 out of 174, with only South nearly 47 percent of the resources allocated to the Sudan, the Central African Republic, and Liberia education sector is lost (Ministry of Education and registering lower scores. Pôle de Dakar 2015). Additionally, poor learning outcomes keep students from advancing through Children in Guinea-Bissau are failing to master the system. basic literacy and numeracy skills, underscoring the urgency of increasing access to quality basic Guinea-Bissau’s expected years of schooling are education. Acquiring these foundational skills is crit- among the lowest in the world, and significantly ical to improving Guinea-Bissau’s human capital. lower than the average for Sub-Saharan Africa. 10 Guinea-Bissau has not yet been included in the A child in Guinea-Bissau who enters the educa- World Bank’s HCI due to a lack of reliable, inter- tional system at the age 4 can expect to complete nationally comparable, data on learning outcomes. only 4.94 years of schooling by his or her 18th However, evidence from the MICS 2018–19 on a birthday, which is even less than the full primary learning assessment conducted among children school cycle. The Sub-Saharan average is 8.3 years. ages 7–14 shows that only 17 percent of children Figure 2.13, which shows country-level averages can correctly read 90 percent of a basic text in for years of expected schooling against GDP per Portuguese, and less than 1 out of every 10 chil- capita in purchasing power parity (PPP), illustrates dren have basic numeracy skills. how length of schooling increases as economies become richer. High-income economies are bundled When adjusted for learning outcomes, expected years of schooling drop even further.11 For example, The expected years of schooling (EYS) component of 10  the Human Capital Index captures the number of years of school a child born today can expect to obtain by age 18, 11  Learning-adjusted years of schooling is a metric used by given the prevailing pattern of enrollment rates in his or the World Bank that combines information on the quan- her economy. Conceptually, the EYS is the sum of enroll- tity and quality of schooling in a single metric of progress ment rates by age from ages 4 to 17 (World Bank 2021b). (World Bank 2021b). 20 Guinea-Bissau Human Capital Review Figure 2.13  Expected years of school, circa 2020 Guinea-Bissau S o u r c e : Adapted from World Bank 2021b. in Angola, the number of expected years of schooling perform any better than those taught by teachers is 8.1; when adjusted for learning, it is only 4.2; in with no preservice training at all. National-level Ghana, the gap is even wider—from 12.1 to 6.0 years estimates mask regressive regional disparities. (World Bank 2021b). Although not internationally The poorest regions have significantly higher benchmarked, the learning outcome data avail- student-teacher ratios and fewer trained teachers. able for Guinea-Bissau indicate that, once years of The capital and Biombo have the highest percent- schooling are adjusted for quality, the actual years of ages of teachers who have attended university or learning would make the current situation even more teacher training schools, while up to 50 percent of severe—and even less than four years overall. Only teachers in Gabú and Oio have no formal qualifi- 7 out of 174 countries have learning-adjusted years cations or have only attended a technical course. of school this low: Liberia, South Sudan, Mali, Niger, the Central African Republic, Chad, and Rwanda. Guinea-Bissau recently adopted a new school curriculum for grades 1–4 with the aim of improving In Guinea-Bissau, poor learning outcomes are learning outcomes in the early grades. The previous directly related to the capacity of the teaching work- school curriculum was from 1984; the new curric- force. Nearly 70 percent of full-time teachers in ulum integrates subject areas and encourages Guinea-Bissau have benefited from some previous more active teaching pedagogies. While the training and are considered qualified. However, only student textbooks and teacher guides have been a small portion of teachers possess the requisite prepared, just over half of grade 1–4 teachers have content knowledge and pedagogical skills needed been trained on how to effectively teach the new to teach effectively. According to the 2014 PASEC, curriculum. To ensure the new curriculum results in students taught by teachers considered qualified better learning outcomes, there is a serious need and who have attended preservice training did not to train teachers on the new curriculum and provide 2  Assessing human capital across the life cycle in Guinea-Bissau 21 additional support during its implementation. Given and Central Africa Education Strategy 2022–25 the limited capacity of teachers in Guinea-Bissau, (World Bank 2022b) delineates five interventions the resources provided to teachers should not only to address teacher quality, children’s readiness include manuals but additional aids like scripted to learn, and the effectiveness of pedagogy in teaching lessons and step-by-step teachers’ guides. basic, primary, and secondary education. Some cost-effective interventions include structured Limited access to learning materials negatively pedagogy combined with teacher training and affects student learning outcomes. The last time learning resources, programs to teach children the country purchased any learning materials was at the right skill level, and preprimary education. in 2016, with UNICEF support. While donor-financed Other interventions, such as providing early stimu- initiatives have aimed to provide textbooks to lation to young children and involving communities schools, dissemination is weak. During previous in school management, also offer promising results distributions, many textbooks never reached their (table 2.5). intended classrooms. Instead, they were sold on the black market, remained in central-level warehouses due to poor planning, or remained in unopened S e c o n d a r y e d u c a t i o n , T V E T, boxes in school administrators’ offices. and job-relevant skills Gross enrollment rates at the secondary and tertiary Various urgent measures are needed to improve levels remain low, despite improvements in access teaching and learning. The World Bank’s Western Table 2.5  Interventions to improve teaching and learning Intervention (what) Reason (why) Activity (how) ■ Improve the quality of new teachers in the pipeline Transform Students of skillful teachers learn ■ Attract more women to teaching the teaching more and attain more years of ■ Recruit teachers based on merit, deploy based on profession schooling needs, strengthen career management ■ Support teachers with structured pedagogy ■ Invest in nutrition, health, early stimulation, and Students without proper early nutri- other cross-sectoral areas Enhance students’ tion and stimulation are not well ■ Encourage reading at home readiness to learn prepared to learn ■ Involve nonstate actors, including those in community-based early childhood development Provide learning Shortage of learning materials is ■ Provide a set of core learning resources/minimum resources and pervasive, and students cannot learn package of learning materials (textbooks, readers, EdTech tools without them and scripted lesson plans) Learning in a first language promotes ■ Instruct in local languages in first few years of Teach at the right schooling and transition to second language in later better learning outcomes and devel- level and in a years opment of other cognitive abilities, language children and targeting instruction to a child’s ■ Target instruction to children’s level, focusing on understand learning level provides quick results foundational reading and mathematics skills Regular assessments keep the focus ■ Institutionalize periodic, rigorous, large-scale Foster a culture of on learning, provide timely informa- assessments (national or international) regular learning tion on student performance, and assessments allow for adjustments to improve ■ Support frequent in-class formative assessments student learning using technology S o u r c e : World Bank 2022b. 22 Guinea-Bissau Human Capital Review to basic education in recent years.12 As shown in the tertiary level registered a 3 percentage point figure 2.14, gross enrollment rates increased across increase—from 1 percent to 4 percent—over the all levels of education between 2014 and 2018. The same period. largest gains were registered at the first cycle of the basic education level (EB1), where the gross enroll- Access to secondary education differs significantly ment rate increased from 132 percent in 2014 to across regions as well as between urban and rural 156 percent in 2018 (World Bank 2020). Access at areas. Although regional basic gross enrollment the secondary level also increased from 45 percent rates are relatively high, three regions (Gabú, Bafatá, to 66 percent over the same period but remains low, and Oio) registered gross attendance rates below indicating that gains at the primary level have not the national level in 2018 (World Bank 2020). In yet spilled over into the secondary level. Access at terms of disparity in access to secondary education, the same three regions have gross attendance rates below 25 percent, whereas the Bissau autonomous The gross enrollment rate is defined as the number of 12  sector recorded a ratio of 142 percent (figure 2.15). students enrolled in a given level of education, regard- less of age, expressed as a percentage of the official Furthermore, gross basic education attendance school-age population corresponding to the same level of in rural areas is 46 percentage points lower than education (see e.g., UNESCO glossary). The gross enroll- ment rate can exceed 100 percent due to the inclusion of in urban areas. This gap further increases to 88 overage and underage students because of early or late percentage points in secondary education. entrants, and grade repetition. Figure 2.14  Trends in gross enrollment rates and the Gender Parity Index by level of education in Guinea- Bissau, 2014–18 160 156 2014 2018 140 120 132% Gros enrollment (%) 97 100 91 77 90 76 84 80 59 66 82% 100% 85% 83% 76% 97% 60 40 45% 57% 4 20 1% 0 EB1 EB2 EB3 Secondary Tertiary EB1 EB2 EB3 Secondary Tertiary Gross enrollment rate Gender Parity Index S o u r c e : World Bank based on data from UNICEF Multiple Indicator Cluster Survey 2014 and Harmonized Survey on Household Living Standards (EHCVM) 2018–2019. N o t e : Basic education is broken into three cycles: EB1, EB2, and EB3. The gross enrollment rate is the ratio between all students enrolled in primary education, regardless of age, and the population of the official primary education age. The Gender Parity Index indicates parity between girls and boys. A GPI of less than 1 suggests girls are more disadvantaged than boys in learning. 2  Assessing human capital across the life cycle in Guinea-Bissau 23 Figure 2.15  Disparities in gross enrollment rates across Guinea-Bissau Basic education Secondary education 77% Gab 17% 85% Bafatá 27% 91% Oio 23% 104% Tombali 29% 111% Cacheu 55% 127% Bolama-Bijagós 64% 129% Quinará 29% 136% Biombo 59% 141% Autonomous 142% Sector of Bissau 109% National 66% 113% Male 70% 106% Female 63% 137% Urban 113% 91% Rural 25% 150 100 50 0 0 50 100 150 Gross enrollment rate (%) Gross enrollment rate (%) S o u r c e : World Bank based on data from UNICEF Multiple Indicator Cluster Survey 2014 and Harmonized Survey on Household Living Standards (EHCVM) 2018–2019. N o t e : The gross enrollment rate is the ratio between all students enrolled in primary education, regardless of age, and the population of the official primary education age. The dropout rate is significant at the secondary boys (68 percent) in the MICS 2018–19, suggesting level. According to the MICS 2018–19, the comple- relative gender parity. Net enrollment drops consid- tion rate for children who attend secondary school erably for both boys and girls (both 9 percent) in is only around 42 percent. Among other factors, lower secondary school and decreases further to the high repetition rates from earlier grades and 7 percent for girls and 6 percent for boys in upper late-entry enrollments—which affect students’ ability secondary school. The gap widens, however, in to complete their education cycle on time—increase terms of completion rates at the secondary level, the likelihood of dropping out and delay students’ with 14  percent of boys completing secondary ability to join the labor market. This in turn reduces school compared to 8 percent of girls. Significant their lifetime potential earnings. differences in learning outcomes are also evident when analyzing the adult literacy rate, which Despite progress in closing gender gaps at the was only 32.6 percent for females compared to primary level (figure 2.14), significant differences 52.3 percent for males in 2019, according to the in gender are apparent at the secondary level. 2018–19 MICS. Guinea-Bissau continues to have some of the lowest secondary education enrollment and completion While some constraints to stay in school are rates in the region, with females particularly disad- common to both boys and girls, girls face diffi- vantaged. At the primary level, the net enrollment cult odds due to entrenched patterns of gender of girls (70  percent) was slightly higher than of inequality. In Guinea-Bissau, girls face social 24 Guinea-Bissau Human Capital Review pressures to marry early and are at risk of early which not only affects them but also their children. pregnancy. Girls also have more responsibilities at For example, children of young mothers are often home than boys—including cooking and taking care at higher risk of dying by age five due to malnutri- of siblings—reducing the time available for study. tion, and of doing poorly in school. Simply going to school may not be safe for girls, given the high levels of gender-based violence; Guinea-Bissau’s Basic Law of the Educational moreover, families often may not support their System and the Education Sector Plan (2017– continued education. All these factors lead girls 2025) include strategies aimed at addressing to drop out of school early. About 8.4 percent of gender disparities. Some of the strategies include women of all ages marry before the age of 15, and raising awareness among community members and 30 percent of women between the ages of 20 and school directors to identify and mitigate obstacles 49 had married before the age of 18, according to girls’ school attendance; strengthening reporting to the 2018–2019 MICS. Child marriage is closely on gender-based violence; and reducing late entry related to low educational attainment for girls, as it and age-related school abandonment by sensitizing increases the likelihood of dropping out, which limits parents and improving school facilities to foster a education and employment opportunities. Table 2.6 better learning environment. Operationalizing these suggests that after a certain age, many girls may gender strategies, however, is often limited by tech- have to choose between marriage and schooling. nical and human resource constraints. The percentage of girls ages 15–19 who are both Beyond gender inequities, the learning crisis in married and in school is less than 1 percent. Guinea-Bissau means that people are entering Delaying marriage and childbearing and improving the labor market without adequate skills, which educational attainment for girls would have is worsened by limited access to training oppor- numerous benefits. Girls who marry or drop out tunities. According to a report produced by the of school early are more likely to have poor health European Union (EC 2022), Guinea-Bissau has outcomes and to earn less in adulthood, which 22 TVET centers, concentrated primarily in the makes it more likely that their households will capital and with a wide gender gap among partici- be poor. They are also at risk of intimate partner pants. About 63 percent of the training centers are violence and lack decision-making power within the in Bissau. Overall, they tend to attract more males household. Fundamentally, girls who marry, have (63 percent) than females (37 percent). Sixteen of children, or drop out of school early are disempow- the 22 centers are operated by private providers, ered in ways that deprive them of their basic rights, five are public led, and one is community led. The courses offered are mainly in traditional areas such Table 2.6  Girls’ marital, childbearing, and as civil construction, electrical installation, welding, educational status, 2018–19 car mechanics, carpentry, and areas related to small urban trades (e.g., refrigeration and air conditioning, Percentage of girls Status ages 15–19 plumbing, hairdressing/aesthetics, secretarial skills, In school, not married 52.6 and project management). Centers in rural areas Out of school, not married 31.2 offer courses in agriculture and agribusiness. Out of school, married 15.5 The absence of either a central TVET strategy or a In school, married 0.7 system of standards and accreditation undermines Total 100.0 the credibility and quality of existing centers. The S o u r c e : World Bank based on data from UNICEF TVET sector in Guinea-Bissau is characterized by Multiple Indicator Cluster Survey 2018–19. 2  Assessing human capital across the life cycle in Guinea-Bissau 25 training programs that are disconnected from labor In Guinea-Bissau, communicable diseases and market demands. The lack of a regulatory and insti- road accidents have consistently been ranked as tutional framework calls into question the legal value the leading causes of death and disability in chil- of trainee certifications and qualifications; the same dren ages 5–14 since the early 1990s (figure 2.16 reasoning applies to internships and apprentice- and figure 2.17). Like children under age five, young ships (EC 2022). Moreover, a small private sector children, preteens, and adolescents ages 5–14 die and political instability disincentivize prolonged from vaccine-preventable diseases (e.g., measles private sector investment in TVET, leading to a were responsible for 14 percent of all deaths in mismatch between skills training offerings and labor 2019, making it the leading cause of death for this market needs. age group); diseases associated with poor WASH services (e.g., diarrhea, accounting for 10 percent The Education Sector Plan identifies several strat- of all deaths among this age group), and conditions egies to help diversify and improve the supply of that either can be managed (HIV infection, 8 percent quality TVET programs in the country. These strat- of age group deaths) or treated with modern medi- egies include implementing a qualifications and cine (lower respiratory infection, 7 percent of age certification framework for TVET; developing new group deaths). The burden of deaths related to road courses that align with the demands of the labor traffic accidents has remained consistent since market; upgrading equipment and other pedagogical the early 1990s, accounting for 9–10 percent of all resources needed for practical training; strength- deaths in this age group between 1990 and 2019. ening the use of apprenticeships, including for the Conditions related to poor nutrition, measles, and informal sector; and developing quality preservice WASH constitute the leading causes of disability and in-service training programs for trainers. among adolescents. The burden of HIV infection among adolescents Adolescent and reproductive in particular is a serious problem. The burden of health HIV has increased significantly among adolescents Adolescence is a critical transitional phase in which since the early 1990s. HIV rose between 1990 and youth are expected to gain the physical, cognitive, 2019 as the 65th to the 4th leading cause of death social, and emotional capacities needed to ensure among the 5- to 14-year-old age group (UNAIDS well-being in adulthood. This includes skills to 2022). In 2019, HIV infection ranked as the third engage effectively in work, leisure, family life, and leading cause of death among girls ages 5–14 in the community. Failure to acquire these skills can Guinea-Bissau, after measles and diarrheal condi- have long-term detrimental effects. To this point, tions (figure 2.18). Several countries, including Sheehan et al. (2017) identify seven specific factors Guinea-Bissau, cite HIV risk factors as including affecting the health and social development and women’s social dependence and submission, diffi- capabilities of adolescents: physical, mental, and culties in negotiating condom use, cultural and/or sexual health; secondary school education; child traditional practices, prostitution, and male refusal marriage; violence against women; and road acci- to take tests and/or disclose their HIV status to part- dents. These factors—except for secondary school ners. education and associated gender-related consider- According to the 2018–19 MICS, the adolescent ations, which are discussed above—are examined birth rate is high in Guinea-Bissau (84 births per further in the next paragraphs. 1,000 women between the ages of 15 and 19), which contributes to the high maternal mortality rate. Births 26 Guinea-Bissau Human Capital Review Figure 2.16  Leading causes of death in children ages 5–14 in Guinea-Bissau, 1990 and 2019 1990 2019 1. Measles 1. Measles 2. Diarrheal diseases 2. Diarrheal diseases 3. Road injuries 3. Road injuries 4. Lower respiratory infection 4. HIV/AIDS 5. Meningitis 5. Lower respiratory infection 6. Hemoglobinopathies 6. Hemoglobinopathies 7. Malaria 7. Meningitis 8. Tuberculosis 8. Malaria 9. Protein-energy malnutrition 9. Congenital defects 10. Drowning 10. Drowning 11. INTS 11. INTS 12. Congenital defects 12. Tuberculosis 13. Whooping cough 13. Interpersonal violence 14. Yellow fever 14. Whooping cough 15. Chronic kidney disease 15. Chronic kidney disease 16. Stroke 16. Stroke 17. Cirrhosis 17. Cirrhosis 18. Tetanus 18. Leukemia 19. Acute hepatitis 19. Falls 20. Falls 20. Animal contact 21. Interpersonal violence 23. Protein-energy malnutrition 22. Animal contact 35. Yellow fever 25. Leukemia 42. Acute hepatitis 65. HIV/AIDS 44. Tetanus S o u r c e : World Bank based on data from Institute for Health Metrics and Evaluation. L e g e n d : ■ communicable, maternal, neonatal, and nutritional diseases; ■ noncommunicable diseases; ■ injuries. Figure 2.17  Leading causes of DALYs in children ages 5–14 in Guinea-Bissau, 1990 and 2019 1990 2019 1. Measles 1. Dietary iron deficiency 2. Diarrheal diseases 2. Measles 3. Road injuries 3. Diarrheal diseases 4. Lower respiratory infection 4. Road injuries 5. Malaria 5. HIV/AIDS 6. Meningitis 6. Hemoglobinopathies 7. Hemoglobinopathies 7. Lower respiratory infection 8. Dietary iron deficiency 8. Meningitis 9. Tuberculosis 9. Malaria 10. Congenital defects 10. Congenital defects 11. Protein-energy malnutrition 11. Neonatal disorders 12. Drowning 12.Headache disorders 13. INTS 13.Conduct disorder 14. Intestinal nematode 14. Anxiety disorders 15. Vitamin A deficiency 15. Idiopathic epilepsy 16. Asthma 16. Drowning 17. Headache disorders 17. Asthma 18. Idiopathic epilepsy 18. Other NTDs 19. Conduct disorder 19. INTS 20. Whooping cough 20. Intestinal nematode 22 Anxiety disorders 23. Tuberculosis 25. Other NTDs 25. Vitamin A deficiency 61. Neonatal disorders 28. Whooping cough 94. HIV/AIDS 45. Protein-energy malnutrition S o u r c e : World Bank based on data from Institute for Health Metrics and Evaluation. L e g e n d : ■ communicable, maternal, neonatal, and nutritional diseases; ■ noncommunicable diseases; ■ injuries. 2  Assessing human capital across the life cycle in Guinea-Bissau 27 Figure 2.18  Leading causes of death in children ages 5–14 in Guinea-Bissau disaggregated by sex, 1990 and 2019 Females 1990 2019 1. Measles 1. Measles 2. Diarrheal diseases 2. Diarrheal diseases 3. Road injuries 3. HIV/AIDS 4. Lower respiratory infection 4. Road injuries 5. Meningitis 5. Lower respiratory infection 6. Malaria 6. Hemoglobinopathies 7. Hemoglobinopathies 7. Meningitis 8. Protein-energy malnutrition 8. Malaria 61. HIV/AIDS 19. Protein-energy malnutrition Males 1990 2019 1. Measles 1. Measles 2. Road injuries 2. Road injuries 3. Diarrheal diseases 3. Diarrheal diseases 4. Lower respiratory infection 4. HIV/AIDS 5. Meningitis 5. Lower respiratory infection 6. Hemoglobinopathies 6. Hemoglobinopathies 7. Malaria 7. Meningitis 8. Drowning 8. Malaria 67. HIV/AIDS 9. Drowning S o u r c e : World Bank based on data from Institute for Health Metrics and Evaluation. L e g e n d : ■ communicable, maternal, neonatal, and nutritional diseases; ■ noncommunicable diseases; ■ injuries. among 15- to 19-year-olds accounted for 16 percent Globally, road traffic injury, suicide, and other of all births over the period 2015–20 (table 2.7). The noncommunicable diseases as a cause of death main causes of the high adolescent fertility rate in in adolescents is increasing; Guinea-Bissau is no Guinea-Bissau are thought to be associated with exception. While the burden of infectious diseases early marriage (30 percent of girls marry before they is declining globally, adolescent morbidity remains turn 18), early sexual intercourse, limited access of high and has barely declined since 1990. A study young people to adequate sexual and reproductive published by the Lancet in 2017 showed that health and rights services, and low utilization of improving the physical, mental, and sexual health contraceptive methods by couples in general (see, of adolescents by scaling 66 low-cost, high-impact e.g., May 2017; Djoufelkit, Rabier, and Koba 2019; health interventions—including sexual and repro- and Zoetyande, Yameogo, and Kenkou 2020). Very ductive health care; HIV prevention and treatment; few young people are reported to be adequately improved nutrition; and care for depression, prepared for sexual life, due to deeply rooted tradi- anxiety, and alcohol dependence—could avert tional norms and the lack of inclusion of women and up to 12.5 million adolescent deaths and prevent girls in the decision-making process—both of which 30 million unintended pregnancies in low- and factors limit access to adequate information and middle-income countries at a cost of $4.60 per services. Contraceptive prevalence (both traditional person per year. Tens of millions of young people and modern methods) and the prevalence of women would be able to contribute to their communities with unmet needs for contraceptive methods were and economies, producing a tenfold-plus return on both estimated to be 21 percent in 2019, according investments. Moreover, investing in adolescents to the MICS. 28 Guinea-Bissau Human Capital Review Table 2.7  Adolescent birth rate by residence, region, major obstacles to promoting human capital devel- mother’s education, and wealth quintile opment, particularly for women and girls. While Adolescent some progress has been made—particularly with the Sociodemographic birth ratea P-value adoption of laws, policies, and programs that aim Total 84 - to promote human capital development—there has Place of residence - been limited improvement in overall outcomes and Urban 42 0.0561 in closing significant and persisting gender gaps. Rural 119 - Region - A key objective of the National Policy on Gender and Tombali 123 0.8568 Equality 2016–2025 (PNIEG) is to adopt an agenda on gender equality in social sectors. The Reproduc- Quinará 87 - tive Health and Family Planning Law (L 11/2010) Oio 118 - guarantees the right to reproductive health and Biombo 88 - family planning without discrimination, as well as Boloma 69 - women’s access to health services toward safe Bafatá 102 - pregnancy, delivery, and pre- and postnatal care. Gabú 113 - Cacheu 100 - Violence against women and girls is widespread in SAB 35 - Guinea-Bissau, with compounding impacts on their Mother’s level of education - health. Recently published data from UNICEF on Preschool or none 164 0.0838 female genital mutilation indicates that 52 percent of Basic 77 - girls and women between the ages of 15 and 49 have Secondary 18 - been subjected to this practice before the age of five Wealth index quintile - (Silva 2022). Prevalence is highest in the regions 1st quintile (poorest) 121 0.07 of Gabú and Bafatá. These girls and women are at 2nd quintile 115 - risk of both short- and long-term negative health 3rd quintile 110 - consequences including gynecological, obstetric, 4th quintile 70 - urological, mental, and sexual complications. Addi- 5th quintile (richest) 34 - tionally, they may experience immediate health S o u r c e : World Bank, based on data from UNICEF complications arising from the procedure itself and Multiple Indicator Cluster Survey 2018–19. encounter challenges during future childbirths. N o t e : SAB = autonomous sector of Bissau. For vari- ables with 2 categories, a t-test was performed. For variables with more than 2 categories, an ANOVA was Social protection performed (one-way and two-way). a. per 1,000 live births to women ages 15–19). In Guinea-Bissau, various social assistance programs have been implemented to cater to school-age children and youth. These programs yields numerous benefits that can significantly offer support in the form of food transfers, in-kind enhance human capital development. transfers, fee waivers, and targeted subsidies; examples are provided in table 2.8. Through regular Guinea-Bissau’s pervasive gender inequality has cash transfer initiatives, households receive income major implications for women’s and girls’ health, support, which enhances household consumption education, and economic opportunities. Low educa- and enables investments in the health and education tional achievement and poor health outcomes are 2  Assessing human capital across the life cycle in Guinea-Bissau 29 Table 2.8  Examples of social assistance programs targeting school-age children and youth Ministry Category Project Brief description responsible Fund Ministry of US Department of Agri- Provides agricultural commodities and School Feeding Education/ culture (implemented by financial and technical assistance to Program Ministry of CRS; Plan International Food support school feeding Public Health and Caritas) transfers Project to Support Provides daily meals at schools to Japan and China (imple- Ministry of School Canteens encourage school enrollment and mented by World Food Education and Nutrition attendance Programme) Establishes national school stan- dards, the rehabilitation and Child-Friendly construction of primary schools Schools/Inclu- (including latrines), teacher training, Ministry of Other sive Schools and and basic school materials; iden- UNICEF Education Out-of-School tifies children with disabilities and Children Programs provides them with education; provides life skills and vocational training to out-of-school adolescents S o u r c e : Bahiaoui, Auffret, and López 2022. of their children. Notably, the short- and long-term their long-term prospects. The consequences of impacts of cash transfers on the urban population child labor extend beyond immediate implications, in Guinea-Bissau presents compelling evidence of perpetuating the cycle of poverty and impeding the the positive effects achieved by combining cash country’s overall development. When children are transfers with complementary measures aimed deprived of education and forced into labor, they at equipping households with the necessary tools miss out on acquiring the essential skills and knowl- and knowledge to invest in their children’s human edge necessary for a better future. capital (Bahiaoui, Auffret, Rúa López 2022). More- over, cash transfer programs can be customized to establish specific targeting criteria or utilize condi- tional cash transfers to promote children’s health Utilization of human and education. capital and productivity (ages 19–60+) It should also be noted that the prevalence of child labor disrupts investments in early childhood and the This section examines the utilization of human school years that are crucial for learning and future capital and productivity among Guinea-Bissau’s productivity. Over half of Guinea-Bissau’s children working-age population. It is organized into three between the ages of 5 and 17 are engaged in some subsections covering work, employment, and form of work, according to MICS6. These children 13 productivity; adult survival rates and overall health; often face hazardous and exploitative work condi- and social protection programs for working-age and tions, compromising their well-being and hindering elderly populations. Human capital utilization takes place from ages Results from Guinea-Bissau’s sixth MICS, released 13  19–65, when individuals use their accumulated October 2020, report on data collected in 2018–19 on over 250 250 indicators for a sample of more than 7,000 knowledge and skills to participate in the labor families. 30 Guinea-Bissau Human Capital Review market, while still developing their human capital via country’s per capita GDP is among the lowest glob- education and on-the-job experience. This stage is ally, and its economic performance has remained particularly critical, given the macroeconomic situ- poor over the past two decades, with an average ation and labor market conditions in Guinea-Bissau. growth rate of only 0.46 percent.15 Fragile political The country faces significant economic challenges, institutions and low investment have contributed characterized by prolonged stagnation and a fragile to the economic challenges. Guinea-Bissau has a economy. With a per capita GDP below $800 in history of political instability and weak governance, 2021, Guinea-Bissau ranks among the poorest 14 leading to a lack of confidence among investors nations globally. The labor market is constrained and limited private investment opportunities. The by a small private sector, and job opportunities are country’s institutions are concentrated among the limited—leading to high unemployment rates, espe- elites, resulting in widening inequalities. Further- cially among the youth. In this context, the effective more, Guinea-Bissau relies heavily on agriculture utilization of human capital, which is crucial for as a primary economic sector, with more than personal income generation and contributes to 45 percent of its GDP coming from the agri-food breaking the cycle of poverty, remains restricted. By sector.16 The high dependence on agriculture aligning investments in human capital with market makes the economy vulnerable to climate change, dynamics and the potential returns of different pests, disease, and natural disasters, which reduce professions, individuals are incentivized to acquire agricultural production and farmers’ income. Fluc- the necessary skills that are in demand, creating tuations in international prices further contribute to an intergenerational dependence on the utiliza- the country’s economic volatility. The combination tion of human capital and paving the way for the of economic stagnation, political instability, weak development of future human capital stock. This institutions, and heavy reliance on agriculture poses cyclical process of investing in human capital and significant challenges to Guinea-Bissau’s overall reaping its benefits generates positive feedback, economic stability and labor market conditions. leading to important intergenerational effects. Given the current economic challenges and limited labor The country’s weak business environment leads to market opportunities in Guinea-Bissau, it is crucial a relatively small private sector with limited employ- to address the structural constraints to enhance the ment opportunities. Figure 2.19 highlights the degree utilization of human capital and create sustainable to which opportunities in the private sector are economic growth and development. limited. A little more than half of employed individ- uals ages 18–64 are self-employed, and another 20  percent are family workers. This means that Human capital utilization: almost 75 percent of those employed do not work work, employment, and as wage earners in the private sector, probably due productivity to nonexistent opportunities or unattractive wages. An additional 13 percent are nonqualified salaried Guinea-Bissau, one of the poorest nations in the workers, meaning that most of those working in the world, has faced prolonged economic stagnation private sector are nonqualified (i.e., without special- characterized by sluggish growth that worsens ized training or skills). Only a small percentage of labor market conditions for youth and adults. The 15  Source: World Bank, World Development Indicators. 14  Sources: World Bank national accounts data; Organisa- tion for Economic Co-operation and Development national Sources: World Bank, World Development Indicators; 16  accounts data. World Bank (2020). 2  Assessing human capital across the life cycle in Guinea-Bissau 31 Figure 2.19  Distribution of professions/ Figure 2.20  Distribution of Guinea-Bissau workers employment in Guinea-Bissau (%) by sector Self-employed 51.8% 1.2% 1.8% Agriculture, fishing, 0.6% forestry 2.9% Family worker 21.1% 3.2% Wholesale & 3.7% retail trade Nonqualified worker 13.1% Manufacturing Qualified worker 4.8% 8.2% Other services Health & social Midlevel supervisor 2.7% services 10.6% Construction Nonpaid trainee 1.9% Extractive Paid trainee 1.8% Water, electricity 67.8% & gas Senior executive 1.1% Education Servant/domestic service 1.1% Manager 0.7% S o u r c e : Harmonized Survey on Household Living Standards (EHCVM) 2018–2019. 0 10 30 50 Share of employed individuals (%) and Katz 2007; Gregory, Salomons, and Zierahn S o u r c e : Harmonized Survey on Household Living 2016; World Bank 2019b). Standards (EHCVM) 2018–2019. Most jobs do not guarantee good living standards. Figure 2.21 shows that the most widespread forms of the working-age population is employed in qualified employment—self-employment and family work—yield work—for instance, as skilled labor, supervisors, the lowest levels of per capita consumption. Almost senior executives, and managers. In sum, most 75 percent of all employed individuals (self-employed people are self- or family-employed, and the private plus family workers) have jobs that result in low levels sector offers few employment opportunities. of per capita consumption. Nonqualified workers have similarly low levels of per capita consumption. On the The jobs available in Guinea-Bissau are predomi- other hand, certain types of employment are asso- nantly characterized by low quality and low wages. ciated with higher levels of per capita consumption, Many individuals in the labor force are engaged such as qualified workers, supervisors, managers, in informal sector activities, which often lack job and senior executives. However, less than 10 percent security, stability, and access to essential benefits. of all employed individuals can access these kinds of These jobs are primarily found in the agricultural jobs (World Bank 2020). sector, encompassing activities such as crop culti- vation, livestock rearing, and fishing (figure 2.20). Enterprises in Guinea-Bissau are typically charac- Subsistence agriculture remains a prevalent form of terized by their small size, with an average age of work for many individuals. Labor-intensive sectors around 10 years, and are predominantly privately including fishing, construction, and small-scale owned.17 On average, firms have 10.6 workers, most manufacturing also contribute to the labor market. of whom are permanent workers (95.8 percent). The These industries often offer limited job security, low 10.4 year average age for firms is younger than both wages, and poor working conditions. The absence of significant investments in technology, skills devel- 17  The data on enterprises discussed here are from opment, and modernization further perpetuates the Guinea-Bissau’s Enterprise Survey; the data are from prevalence of low-quality jobs in the country (Goldin 2006. 32 Guinea-Bissau Human Capital Review Figure 2.21  Per capita consumption by profession/employment category in Guinea-Bissau 700,000 60 Share of employed individuals (%) Per capita consumption (LCU) 600,000 50 500,000 40 400,000 30 300,000 20 200,000 100,000 10 0 0 Manager Helper or Senior Paid Nonpaid Midlevel Qualified Non- Family Self- domestic executive trainee trainee supervisor worker qualified worker employed service worker S o u r c e : Harmonized Survey on Household Living Standards (EHCVM) 2018–2019. Expenditure consumption was used as a proxy for income due to a high nonresponse rate on income questions in the survey. the Sub-Saharan Africa average (15.1 years) and the differentiation by firm size—2.1 percent of small global average (19 years). Most firms are privately 18 firms, and 7.8 percent of medium firms. However, owned (91 percent); however, 9.2 percent of firms only 6 percent of all firms claim not to need a loan, have a minimum of 10  percent foreign owner- suggesting they need banks but have difficulties in ship, and 1.2 percent of firms have a minimum of obtaining bank loans or lines of credit. 10 percent government or state ownership. Owner- ship is generally male, as only 19 percent of firms Firms in Guinea-Bissau face multiple obstacles have female participation in ownership. including access to finance, informality, corruption, and lack of adequate infrastructure. These defi- Constrained access to credit limits growth oppor- cits hinder businesses from acquiring the modern tunities and capital-intensive production. The machinery, technology, and equipment necessary for percentage of firms in Guinea-Bissau identi- capital-intensive operations, stifling their productivity fying access to finance as a major constraint is and competitiveness. The prevalence of informality— 71.6 percent—much higher than the Sub-Saharan often due to the absence of formal regulations and Africa average (38.3 percent)—because firms can weak enforcement—further exacerbates these almost never finance their investments through issues, limiting firms’ access to formal credit and banks. The proportion of investments financed impeding their growth. Corruption acts as a signifi- internally is 85.3 percent; the proportion financed cant deterrent to investment, introducing uncertainty, by banks is only 0.8 percent. Just 2.7 percent of all distorting fair competition, and undermining the rule firms have a bank loan or line of credit, with some of law, which discourages both domestic and foreign investors. Furthermore, the lack of adequate infra- structure, such as reliable electricity, transportation 18  Regional and all country averages of indicators are computed by taking a simple average of country-level networks, and telecommunications systems, poses point estimates. For each economy, only the latest avail- significant hurdles to businesses in Guinea-Bissau, able year of survey data are used in the computation. Only surveys posted during the years 2013–23 and adhering impeding their ability to operate efficiently and to the Enterprise Surveys Global Methodology were used engage in value-added activities. in computing these averages. 2  Assessing human capital across the life cycle in Guinea-Bissau 33 Addressing these obstacles through targeted poli- to the previously mentioned factors of limited job cies and reforms is crucial for creating an enabling opportunities; a lack of industry diversification; and environment that promotes capital-intensive insufficient investments, especially in sectors that labor and fosters sustainable economic growth in require higher skills. Guinea-Bissau. Enhancing the availability of finan- cial resources is particularly critical to bolster private The pattern becomes more pronounced when sector investment and improve public infrastructure. considering gender differences. The unemployment The current financial constraints limit the capacity rate for women with higher education attainment of businesses to make the advancements crucial to is 15  percent—significantly higher than that of increasing productivity and maintaining a competi- men (5 percent; figure 2.22). Similar trends are tive stance. For instance, addressing frequent power observed for tertiary education, with women facing outages is a significant operational challenge that an 8  percent unemployment rate compared to needs to be tackled. With the right policy actions 5 percent for men; and for secondary education, with and reforms, Guinea-Bissau’s business climate can women experiencing a 10 percent unemployment be reformed to support robust industrial activity and rate versus 7 percent for men. When comparing promote long-term economic growth. individuals with no education—particularly those residing in rural areas—women conversely have The labor force participation rate for individuals ages lower unemployment rates than men. These dispar- 15–64 has been declining consistently for the last ities in unemployment rates, which are influenced 25 years. Data from 2018 on the characteristics of 19 by gender and educational attainment, highlight the working-age population show that 42 percent the challenges faced by highly educated women had less than a basic education level (no primary in accessing suitable employment opportunities.21 school), while only 3 percent had an advanced level (higher than upper-secondary education). More than Note that the labor force participation rate for women is 21  half of this population (52 percent) resided in rural lower than that of men—51.8 percent versus 66.6 percent. Women also tend to have lower educational attainment areas. When analyzing labor force participation rates by education level, it becomes evident that individuals with less than basic education levels exhibit higher Figure 2.22  Unemployment rates in Guinea-Bissau participation rates than those with basic and inter- by sex and highest level of education attained mediate levels of education. Moreover, the data show that labor participation for individuals ages 15–64 is Higher 15% education 5% higher in rural than urban areas. Tertiary 8% Highly educated individuals struggle to find education 5% high-quality employment opportunities. Unemploy- Secondary 10% ment rates tend to be higher among individuals with education 7% higher levels of education (i.e., those completing Primary 3% upper secondary education and above) than those education 2% with primary education: 9  percent compared to 1% Women No education 3 percent.20 This phenomenon can be attributed 3% Men 0 5 10 15 Unemployment rate (%) 19  Source: International Labour Organization, ILOSTAT. S o u r c e : Harmonized Survey on Household Living 20  Source: International Labour Organization, ILOSTAT. Standards (EHCVM) 2018–2019. 34 Guinea-Bissau Human Capital Review Most high-skilled workers find themselves working Another challenge is the scarcity of quality educa- longer hours compared to their unskilled coun- tion and skills development opportunities. The lack terparts (figure 2.23). Data from the 2018–19 of access to quality education, vocational training, Harmonized Survey on Household Living Stan- and technical skills hinders the workforce’s ability dards (EHCVM) indicate that, due to the scarcity to participate in more advanced and skill-intensive of high-quality employment opportunities, highly sectors. The most recent assessment of learning educated individuals are compelled to work more outcomes shows poor performance and a declining hours to compensate for the limited availability of level between grades 2 and 5 (Ministry of Education well-paying jobs rather than rely on the creation of 2015; World Bank 2017), indicating that education new job opportunities. This reliance on the intensive quality is worsening at higher levels. The low level margin of work, involving longer work hours, rather of education and skills among the workforce exac- than the extensive margin of hiring more workers erbates the problem of low-quality jobs, as limited highlights the challenges faced by educated indi- access to quality education and training programs viduals in accessing suitable employment. It also hinders the ability of individuals to acquire the suggests that the traditional notion of higher educa- skills needed for higher-paying and more produc- tion leading to better job prospects and shorter tive employment opportunities. The mismatch working hours may not hold true in Guinea-Bissau between the skills available in the labor market and due to the lack of employment opportunities. the requirements of emerging industries limits the country’s ability to attract investments and promote economic diversification. levels: approximately 28 percent of men have completed secondary education, compared to only 16 percent of women; and 4.6 percent of men have achieved higher Employment in Guinea-Bissau follows a clear education compared to 2.5 percent of women. sectoral distribution. The 2018–19 EHCVM found that individuals with secondary education and below are mainly employed in the agricultural sector; those Figure 2.23  Hours worked in Guinea-Bissau by with higher educational attainment tend to work level of education and worker location in education, health, and other service sectors. For instance, among all employed individuals, 68 percent of those with no education are employed in the agricultural sector. This trend reflects a higher labor demand in agriculture and lower educational requirements for agricultural jobs—potentially leading to reduced incentives for pursuing higher education. Most household businesses rely heavily on labor-intensive operations rather than capital-intensive investment. This characteristic of the country’s economic landscape has significant implications for its productivity and growth potential. Most household-owned businesses tend to be small S o u r c e : Harmonized Survey on Household Living Standards (EHCVM) 2018–2019. in scale and primarily managed by families. Approx- imately 64 percent of households own at least one N o t e : The dotted red line indicates the national median of worked hours. nonagricultural enterprise, according to the 2018–19 2  Assessing human capital across the life cycle in Guinea-Bissau 35 EHCVM. On average, these businesses do not have Figure 2.24  Main problems faced by enterprises in salaried workers; 89 percent do not demand wage Guinea-Bissau employment. Instead, they are mainly managed by Excessive competition 65 family members (94 percent), with an average of 1.3 family members engaged in the business. Lack of clients 48 Lack of access 40 Self-employment is highly informal and labor to credit Lack of adequate intensive. Informality among household-owned busi- facilities 30 nesses is striking, as 96 percent of them lack formal Scarce supply of 29 raw materials records or accounting practices, and 97 percent Lack of access to 23 operate without being officially registered. Addi- electricity Lack of access to tionally, 99 percent of workers are not registered equipment 22 as formal workers. Only 6 percent of businesses Power outages 21 own machinery, indicating their labor-intensive Lack of water, 14 nature. Over three-quarters (78 percent) of these telephone, or similar Excessive regulation businesses were initially funded using their own or taxes 11 resources, highlighting the extremely limited access Technical difficulties 8 (management) to credit, as discussed earlier. The widespread lack Technical difficulties of credit for firms hampers investment and the adop- 8 (production) tion of new technologies. Insecurity 8 Lack of qualified 4 Access to credit is one of the main constraints workers reported by businesses in Guinea-Bissau, together Lack of Internet 4 with excessive competition and a lack of clients. The 0 20 10 30 40 50 60 70 2018–19 EHCVM delved into the problems faced Share of firms facing problem (%) by enterprises during their operations (figure 2.24). The prevalence of responses citing excessive S o u r c e : Harmonized Survey on Household Living Standards (EHCVM) 2018–2019. competition (65  percent) and a lack of clients (48 percent) indicates that family workers struggle to provide products or services that are demanded Given this scenario, many educated individuals in the economy. These problems frequently lead are unable to secure quality employment, and thus to interruptions in business operations. Access to choose to emigrate. As noted earlier, unemployment credit was identified as a problem by 40 percent of is higher among the most educated (people with all surveyed enterprises. Only 9 percent of those upper secondary education and higher education). surveyed said they had a bank account, and only The lack of employment opportunities, inadequate 0.7 percent had sought credit from a financial insti- health systems, and limited access to quality educa- tution in the previous 12 years. Among those who did tion often drive young individuals to undertake not apply for credit because they claimed they did perilous migratory journeys in pursuit of improved not need it, the reasons cited included not meeting livelihoods (Black and Sward 2009; Browne 2017; the necessary conditions (47 percent), concerns Eggert, Krieger, and Meier 2010; Hermans and about being unable to repay loans (19 percent), and Garbe 2019; Kristensen and Birch-Thomsen 2013). not knowing how to apply (15 percent). Migration trends reflect predominantly econom- ically motivated movements, with a significant 36 Guinea-Bissau Human Capital Review impact on the country’s youth population, particu- the creation of ventures that cater to unmet needs. larly those between 18 and 28 years old. According Unemployed educated youth develop small busi- to estimates, 22 the number of migrants in 2021 was nesses with training (small business management, 117,478, which accounted for 5.7 percent of the financial education, and professional training), cash population. The brain-drain of qualified personnel, start-up grants, and coaching (to help them resolve especially in the health and education sectors, is a troubles in the start-up phase). persistent problem. Economic inclusion programs can support poor Personal remittances sent back to Guinea-Bissau households in building sustainable sources of have increased over the past 30 years. These remit- income and improving resilience, thereby benefiting tances represent a significant share of the country’s the human capital development of all household GDP (figure 2.25). In 2021, remittances accounted members. Economic inclusion programs can help for 12.6 percent of the GDP. create employment opportunities for educated but unemployed youth (people with upper secondary The potential for congestion within markets and education and higher education) and facilitate the sectors where household businesses operate is development of income-generating activities for significant. A thorough analysis of the existing busi- self-employed households operating in the primary ness landscape would help identify areas that are sector, which have very limited access to credit. already saturated with similar enterprises, allowing Self-employment can provide young educated for a more informed allocation of resources and individuals with a means to earn a living and support. Aspiring entrepreneurs also need help with avoid unemployment. This approach has its limits, market research. Equipping individuals with the tools however. Two-thirds of all self-employed individuals to assess market demand and identify opportunities identify excessive competition as a major constraint, will enable informed decisions about their business and half of the self-employed individuals identify a orientation, help prevent clustering of similar busi- lack of clients as a significant issue. nesses in already saturated markets, and encourage Economic inclusion programs can help foster diver- sification among households that mainly rely on 22  Source: KNOMAD. agriculture. Households involved in agriculture, particularly cashew production, are extremely Figure 2.25  Personal remittances received in vulnerable to market fluctuations and climate Guinea-Bissau change. Economic inclusion programs can focus on diversifying off-farm income-generating activi- 15 ties or on adding value to agricultural production. 12 The economic inclusion package should consist of Personal remittances received (% of GDP) building capacity, improving skills (training), cash 9 start-up grants, and coaching. Given the fragility of government institutions and the limited availability of 6 services from central ministries, the involvement of NGOs in economic inclusion interventions is essen- 3 tial. 0 1990 1995 2000 2005 2010 2015 2020 S o u r c e : World Bank, World Development Indicators. 2  Assessing human capital across the life cycle in Guinea-Bissau 37 Social protection for as they cover eight of the nine benefits outlined in working-age and elderly Convention 102 of the International Labour Organi- populations zation and are not limited to unemployment benefits. With a median age of 18.7 years in 2019, the compo- The population over age 60 represents 5 percent of sition of Guinea-Bissau’s population results in a high Guinea-Bissau’s total population; only 6 percent of dependency ratio. This ratio indicates that for every this group receives a contributory pension.24 Again, 100 active persons (ages 15–64 years), there are the large informal sector affects the outcome. This 80.5 inactive persons (under age 15 and 65 years pension covers only retirees from the civil service and older). Population projections for Guinea-Bissau and thus excludes most of the elderly, who worked indicate that the younger age groups will be larger in the informal sector and are therefore not included than the working-age adult population by 2050. 23 in the social insurance system. Relatedly, less than The country’s total population could reach 3.5 4  percent of disabled people receive disability million by 2050, accompanied by a decline in the pensions. proportion of youth under the age of 15. Less than 2 percent of the population ages 15–49 Contributory social protection (social security) is covered by health insurance. The MICS 2018–19 in Guinea-Bissau is almost nonexistent outside found that 1.8 percent of men, 1.0 percent of women, the public sector. Two contributory social protec- and 1.0 percent of children are covered by health tion schemes exist: one for civil servants, military insurance mechanisms. This includes INSS social personnel, and other state employees; and one for security (29.3 percent of insured women), commu- the rest of the workforce, including the private sector nity mutual health organizations (37.4  percent), and public enterprises (general regime). However, employer-provided insurance (26.2 percent), and less than 4 percent of the working-age population is private insurance (9.0 percent). enrolled in pension schemes and pays contributions (OPM 2023). The public administration regime only The main benefit funded by the general state budget, provides old-age pensions and disability benefits. a noncontributory program, is a social pension for There is no autonomous pension fund; revenues and former combatants managed by the Ministry of expenses are integrated in the general state budget. Defense. Although most veterans of the war of inde- pendence are dead, this benefit accrues to their The coverage of contributory social protection heirs, which places a significant financial burden on devices is extremely low, mainly due to the small the state budget, accounting for 12 percent of the size of the formal sector in the economy. The social protection expenses in 2023 (OPM 2023). general regime for employees is managed by the The Ministry of Women, Family, and Social Soli- National Social Security Institute (Instituto Nacional darity (Ministério da Mulher Família e Solidariedade de Segurança Social—INSS). Under this regime, the Social—MMFSS), which is responsible for assistance contribution rate for salaried employees is set at to families and people in need, receives resources 22 percent of gross pay, with 8 percent contributed from the state budget to support those who face by the employee and 14 percent by the employer. extreme need or who are victims of a disaster. The benefits provided are relatively comprehensive, There are no available data on the actual benefi- ciaries of this support. Aside from these pensions and benefits, the remaining noncontributory social Sources: United Nations, Department of Economic and 23  Social Affairs, World Population Prospects 2022; UNFPA (2021). 24  Pension Watch website, Guinea-Bissau country profile. 38 Guinea-Bissau Human Capital Review protection interventions are financed by external registration of potential beneficiaries, targeting of partners (96 percent) and include cash transfers, beneficiaries (using a combination of a new house- food distribution, and public works. hold survey and a special index to measure access to basic social services), and payment. External partners have been supporting targeted cash transfer programs since 2018 (table 2.9). Public works enable the provision of temporary Accompanying measures to support nutrition, employment and the development or maintenance health, and education have complemented the cash of labor-intensive infrastructural projects and social transfers. There is no national program for regular services. In Guinea-Bissau, public works programs cash transfers over the long term and at a suffi- focus on strengthening and rehabilitating agri- ciently large scale to effectively reduce poverty and cultural infrastructure, with a strong focus on strengthen resilience to shocks. Notably among environmental protection and improving access to these partner initiatives, the Social Safety Nets and basic social services for rural communities. Public Basic Services Project referenced in the table laid works can combine cash for work and food for work the groundwork for a future single social registry by components, paying wages via mobile money and/ preparing a unified social registry survey form jointly or vouchers. with the National Institute of Statistics; and devel- oping a management information system that allows Table 2.9  Cash transfer programs in Guinea-Bissau, 2018–22 Number of beneficiaries Implementing Program Year (households) Region Amount Duration institution Fund Rural Community CFAF 10,000 Development 2018–19 387 Bissau City monthly per 2 years Ministry of Project member Planning and World Bank Social Safety Gabú, ~CFAF Regional Inte- Nets and Basic 2019–22 5,000 Cacheu, 70,000 each 2 years gration Services Project Oio quarter July–Oct. Buba Govern- Civil Protection 851 2020 sector, CFAF 40,000 4 Ministry of ments of Project (shock June– Quinará monthly months Interior Japan and response) 59 Aug. 2021 region Italy Ministry of COVID-19 Rapid Gabú, Oio, Women, Oct.–Dec. CFAF 40,000 3 UNICEF, Response 1,587 Cacheu, Family, and 2020 monthly months WFP, UNDP Program Biombo Social Soli- darity Cash transfers Global Part- for vulnerable nership May–Oct. Gabú, CFAF 40,000 6 households with 1,400 UNICEF for Educa- 2021 Bafatá, Oio monthly months at least one child tion and enrolled in school Camões Food Security CFAF FAO/World 2022–23 3,000 1 payoff Project 85 million Bank S o u r c e : World Bank. N o t e : FAO = Food and Agriculture Organization of the United Nations; UNDP = United Nations Development Programme; WFP = World Food Programme. 2  Assessing human capital across the life cycle in Guinea-Bissau 39 Transfers of productive assets, along with additional Figure 2.26  Services and owned goods by welfare support, can also play an important role in enhancing level productivity and thus improving income in the long 25 Welfare indicator, Welfare indicator, run. The impact evaluation of the Social Safety Nets below median above median 21.7% Share of individuals (%) and Basic Services Project highlighted that regular 20 cash transfers not only increase consumption but 15 also stimulate investments and purchases of agri- cultural inputs and livestock (Bahiaoui, Auffret, and 10 8.6% López 2022). However, programs incorporating productive asset transfers (especially the distribu- 5 4.8% 2.9% tion of seeds, fertilizers, and tools to small farmers) 1.0% 1.3% 0.1% 0.7% accompanied by other forms of support (such as 0 Boiler Ceiling fan Water Electrical agricultural extension services and training) have network the potential not only to improve food security but S o u r c e : Harmonized Survey on Household Living also to enhance productivity and improve income Standards (EHCVM) 2018–2019. in the long run. The combination of low wages and limited job oppor- shows that only 4.8 percent of households below tunities in Guinea-Bissau has led to widespread the median welfare level have access to electricity, poverty. Rural areas have been particularly affected compared to a significantly higher percentage of by the country’s economic stagnation and fragility. households above the median (21.7 percent). Also, Poverty is especially pronounced in these regions, households below the median welfare level dedi- where more than half of the population is poor. The cate a relatively larger amount of time each week incidence of poverty increased by 5.7 percentage to activities such as collecting water and firewood points between 2018 and 2021 to reach 67 percent. compared to households above the median welfare In the capital city of Bissau and other urban areas, level. On average, low-welfare households spend poverty increased by 2.7 and 4.6 percentage points, approximately 1.8 hours per week looking for water; respectively, between 2018 and 2021, accounting high-welfare households spend an average of 1.7 for 21 and 42 percent of the respective popula- hours on this task. This pattern extends to the allo- tions (World Bank 2020). The rural economy relies cation of time for domestic tasks and childcare as heavily on agriculture, livestock rearing, and fishing, well. accounting for nearly 85 percent of economic activ- ities. Additionally, 55.7 percent of rural adults are State social assistance is limited and fails to effec- self-employed, 29.7 percent engage in family work, tively target the poorest households. The most and only 10.9 percent of adult workers are engaged impoverished rural areas receive nearly equiv- in wage-based employment. This vulnerability leaves alent levels of social protection as urban areas, rural families susceptible to climate fluctuations and where comparatively wealthier households live price shocks, further exacerbating their hardships. (figure 2.27). This disparity raises concerns about the equitable distribution of resources and suggests There are significant disparities in access to a significant gap in addressing the specific needs services and time allocation at different welfare and challenges faced by the rural population. levels. Households with higher welfare levels have more access to basic services, on average, than A similar pattern arises when considering social those below the median welfare level. Figure 2.26 protection across households with different levels 40 Guinea-Bissau Human Capital Review Figure 2.27  Social protection targeting and poverty consumption and regional poverty rates with social in Guinea-Bissau assistance highlights a significant disconnect 0.9 between government support and the needs and % of people in housholds with at least one social security program Rural Urban circumstances of vulnerable individuals. 0.8 Cash transfer programs can tackle constraints that 0.7 hamper socioeconomic inclusion and human capital enhancement of the poorest and most vulnerable. 0.6 Timely cash transfers provide household income 0.5 support, enabling smooth and increased consump- tion, improved food security, enhanced nutrition for 0.4 children, safeguarding of household assets, and 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 % of people living below the poverty line the building of resilience to shocks. Given the high poverty rates among agricultural sector workers and S o u r c e : Harmonized Survey on Household Living the lack of income for the unemployed, predictable Standards (EHCVM) 2018–2019. transfers allow households to maximize the use of their financial resources, and plan and invest for of consumption. Figure 2.28 shows that the rates of the future—particularly in resilient livelihoods and social protection among the wealthiest households the human capital of their children. are comparable to those of the poorest households. Among the poorest 20  percent of households, Receiving regular transfers with accompanying only 56 percent receive any form of social assis- measures over a period may help households tance from the government; among the wealthiest acquire the tools and knowledge needed to invest 20 percent, no less than 54 percent receive some in the health and education of their children. A form of support. This lack of correlation between good strategy to improve the effectiveness of the accompanying measures is to increase local and community participation in service delivery by selecting community health workers or teachers Figure 2.28  Social protection targeting by consumption in Guinea-Bissau from within the communities themselves. Such indi- viduals are more likely to be motivated, accountable, 60 % of people in housholds with at least one social security program and trusted by the communities they serve. Because nearly one-third of children between the ages of 40 6 and 11 have never attended school, cash trans- fers could be (partly) conditional upon children’s schooling to encourage on-time entry and primary 20 school enrollment. The consistent implementation of cash transfers and the integration of recipients into a social protection system is a potential game-changer 0 in the design of economic inclusion programs. 1 2 3 4 5 Per capita consumption expenditure quintile Targeting mechanisms that help reach vulner- S o u r c e : Harmonized Survey on Household Living able groups and households will help improve Standards (EHCVM) 2018–2019. cost-effectiveness and impact. Targeting is N o t e : Quintiles are ranked from lowest to highest, currently inadequate. The coverage of social indicating relative wealth. 2  Assessing human capital across the life cycle in Guinea-Bissau 41 protection programs is similar across all five quin- Figure 2.29  Survival rate of individuals age 15 tiles of per capita consumption and across all levels years in Guinea-Bissau and its peers of education. Three targeting mechanisms could Aspirational peers Structural peers be considered and implemented simultaneously: Guinea-Bissau 83% (1) self-targeting; (2) community-based targeting; Tajikistan 87% and (3) household survey-based targeting, using Rwanda 81% household survey data to determine eligibility, such Lao PDR 82% as proxy means testing. Sierra Leone 63% Gambia, The 75% All these options can be enhanced by establishing a national social registry. A national social registry Central African Rep. 59% would enable rapid and accurate identification and Burundi 72% targeting of potential beneficiaries for social assis- 0 20 40 60 80 100 tance programs; reduce opportunities for fraud, Percent benefit duplication, and access to benefits by illegiti- S o u r c e : World Bank 2021b. mate actors; and improve social assistance program monitoring and coordination. As noted earlier, the Social Safety Nets and Basic Services Project has Figure 2.30  Top 10 causes of DALYs among people established a registry for beneficiaries that includes 15 years and older in Guinea-Bissau a basic information system with modules to track HIV/AIDS 56.8 payments, prepare reports on cash payments, and Tuberculosis 50.9 monitor attendance at accompanying measures. It Road injuries 26.1 would be beneficial to continue and expand devel- Stroke 23.9 opment of this registry. To enable broader usage of Ischemic heart disease 23.1 Lower respiratory infections 20.9 the national social registry and enhance coordina- Diarrheal diseases 17.3 tion, it should be led at a high/central level. Malaria 15.7 Cirrhosis of the liver 13.7 Depressive disorders 10.5 Adult survival rates 0 20 40 60 DALYs Based on the latest data (World Bank 2021b), the survival rate of 15-year-olds to age 60 in S o u r c e : World Bank, using data from the World Guinea-Bissau is estimated to be 83 percent. This Health Organization, Global Health Observatory. percentage is higher among women (86 percent) than men (79 percent) and exceeds that of countries attributed, in part, to health system challenges with similar structural characteristics; it is similar related to children. to that of Lao People’s Democratic Republic (Lao PDR) and Rwanda, but lower than that of Tajikistan The maternal mortality ratio in Guinea-Bissau is very (87 percent; figure 2.29). In 2019, the most signif- high: 667 deaths per 100,000 live births in 2017. icant health burdens among individuals 15 years This ratio was higher than that of all aspirational and over were HIV/AIDS (with 56.8 DALYs per peer countries, which varied between 17 deaths 1,000 people), followed by tuberculosis (50.9 DALYs per 100,000 live births in Tajikistan, to 248 deaths per 1,000) and road injuries (34 DALYs per 1,000; per 100,000 live births in Rwanda (figure 2.31). The figure 2.30). These suboptimal indicators can be country’s mortality rate was also higher than that of 42 Guinea-Bissau Human Capital Review Figure 2.31  Maternal mortality ratio in Guinea-Bissau and its peers, 2000–17 3,000 2000 2017 % of decrease 0 Death rate per 100,000 live births −10 % of decrease in death rate 2,500 −20 2,480 2,000 —35 —36 −30 —45 —46 −40 1,500 —55 −50 1,000 —66 —68 −60 1,210 1,280 1,160 1,010 932 −70 500 1,120 667 —79 548 829 597 544 −80 248 53 17 185 0 −90 Guinea- Burundi Central Gambia, Sierra Lao PDR Rwanda Tajikistan Bissau African Republic The Leone Structural peers Aspirational peers S o u r c e : WHO et al. 2019. two of its structural peers: The Gambia (597 deaths Figure 2.32  Life expectancy at birth in Guinea- per 100,000 live births) and Burundi (548 deaths Bissau and its peers, 2015–20 per 100,000 live births). From 2000 to 2017, the Aspirational peers Structural peers maternal mortality rate in Guinea-Bissau decreased 58 Guinea-Bissau by 45 percent. However, this decrease was lower Tajikistan 71 than that of all its aspirational peers (Rwanda at Rwanda 68 79 percent, Tajikistan at 68 percent, and Lao PDR Lao PDR 67 at 66 percent) and one of its structural peers, Sierra Sierra Leone 54 Leone at 55 percent. The decrease was almost iden- Gambia, The 62 tical to that of Burundi (46 percent). Central African Rep. 53 Over the period 2015–20, Guinea-Bissau’s life Burundi 61 expectancy at birth was 58 years (figure 2.32).25 0 10 20 30 40 50 60 70 80 This life expectancy was lower than that of all Age its aspirational peer countries, which ranged S o u r c e : United Nations Department of Economic from 67 years (Lao PDR) to 71 years (Tajikistan). and Social Affairs, Population Division. Guinea-Bissau’s life expectancy was also lower than that of two of its structural peers: The Gambia (62 years) and Burundi (61 years). in 2019 was higher than that of all the aspirational From 2000 to 2019, the overall age-standardized peers, where it ranged from 9 to 10 deaths per 1,000 mortality rate decreased from 18.7 to 13.6 per 1,000 people (figure 2.33). Guinea-Bissau’s mortality rate person-years but remains high.26 This ratio of 13.6 was also higher than that of two of its structural peers: The Gambia (10.9) and Sierra Leone (12.1). It Source: United Nations Department of Economic and 25  was also higher than the average for the world (7.19) Social Affairs, Population Division. and for African countries (7.13). Source: World Health Organization, Global Health 26  Observatory. 2  Assessing human capital across the life cycle in Guinea-Bissau 43 Figure 2.33  Age-standardized mortality rate in Guinea-Bissau and its peers, 2000–19 a. Aspirational peers b. Structural peers 23 30 Rwanda 21 Per 1,000 inhabitants Per 1,000 inhabitants 19 25 Central African Republic 17 Guinea-Bissau 20 15 Lao PDR Guinea-Bissau Sierra Leone 13 15 Tajikistan Gambia, The 11 9 10 2000 2010 2015 2019 2000 2010 2015 2019 S o u r c e : World Bank, using data from the World Health Organization, Global Health Observatory. 3 Human development systems required to strengthen human capital   T his section complements and supplements the preceding one by evaluating the cross-cutting constraints that hinder the formation, utilization, and ■ Weak governance and dysfunctional institu- tions, fueled by political instability and low accountability in the use of public services maintenance of human capital in Guinea-Bissau. It focuses on five cross-cutting constraints that need ■ An urban-rural divide, evidenced by the lack of to be addressed in the context of Guinea-Bissau; infrastructure and access to basic services these relate to ■ A lack of investment in human development ■ The country’s fragility and governance; and capital, which has left a large proportion of youth unemployed ■ Financing for human capital; ■ An inherent vulnerability to the impacts of ■ Human resources; climate change due to the coastal geography, with frequent flooding in inland and coastal ■ Data pertaining to the human capital sector; and areas, which affects the livelihoods of vulner- able communities. ■ The negative effects of climate change on human capital in Guinea-Bissau. Fragility in Guinea-Bissau has resulted in weak institutions unable to fulfill their core functions and deliver services to the population. With most insti- Fragility and governance tutions and systems concentrated in the central government and the lack of political and fiscal Decades of political instability, military coups, and decentralization, public services outside of the armed conflicts have contributed to a shortage of capital city are extremely deficient, and standards investments in Guinea-Bissau’s social sectors. of living are much lower in rural areas. Frequent The absence of social and economic infrastruc- changes in government foster a climate of uncer- ture—including hospitals, schools, and roads—in tainty, and the cost of political instability has been the country has hindered access to health care and considerable on economic growth and development education, thereby exacerbating the human capital prospects. deficits. Several critical drivers of fragility hinder Lack of investment in human development is a major Guinea-Bissau’s development trajectory, including driver of fragility in Guinea-Bissau, and this inter- the following: sects with other factors to further marginalize a 44 3  Human development systems required to strengthen human capital 45 large proportion of the population. The country’s fragility affects the delivery of essential public goods Box 3.1  Fragmentation in decision-making and services and exacerbates the rural-urban divide. highlighted during COVID-19 Higher poverty rates are compounded by deprivation Weak coordination between the Ministry of of social services, human capital, and infrastructure. Health and the High Commission for COVID-19 hampered the country’s response to COVID-19. Where these services are present, nonstate actors According to data from the Ministry of Public are often the main providers, frequently operating Health, the average case fatality in Guinea-Bissau with donor funding. This high dependence on donor reached 20.3 deaths per 1,000 infected persons funds results in donor-driven interventions and frag- in April 2022—higher than for all regional peers, mentation across the social sectors. except The Gambia—with peak rates in Biombo, Bafatá, and Gabú. Multisectoral coordination was Addressing the critical drivers of fragility in limited, and frequent staff turnover hindered the Guinea-Bissau could have a significant impact on retention of institutional knowledge—affecting the coordination of government and donor-led human capital development. Improving financial activities, as well as continuity of services. Coor- management at the regional level in the three key dination between line ministries and the planning sectors focused on in this review—education, health, directorate of the Ministry of Economy was incon- and social protection—would help address the sistent. issue of weak public financial management, which creates opportunities for rent-seeking behavior and poor budgeting practices. In light of the limited to make decisions in a timely manner, leading to administrative decentralization and service decon- higher-than-average COVID-19-related deaths centration and the weak state presence at the compared to the country’s neighbors. local level, key measures to support the delivery of services for human capital development can include The COVID-19 pandemic disrupted learning, partic- (1) reinforcing the capacity of regional structures ularly in rural areas. Data collected through a phone to deliver services and better track the transfer survey implemented in October 2020 shows that of resources; and (2) improving the management overall, only 53 percent of households with children of public resources in social sectors (health and age three years old and above who were enrolled education) allocated to other regions outside the in school were able to engage in educational activ- capital city. This approach would strengthen the ities. Children in rural areas were more affected by state’s presence at the local level and build trust school closure, with only 39 percent of households through improvements in service delivery. with school-going children able to pursue educa- tional activities compared to 59 percent in other The social sectors have been unable to adequately urban areas and 73 percent in the Bissau autono- respond to shocks and crises. A recent example mous sector (figure 3.1). The inability to respond to is the inability of the health and education sectors crises like COVID-19 may further widen the educa- to effectively respond to the COVID-19 pandemic tional attainment gap between rural and urban areas (box 3.1). Schools were closed, and few programs in the medium to long term.  were implemented to ensure continued learning for children, especially outside of the capital. Access to health care in Guinea-Bissau worsened In the health sector, access to overall health during the pandemic, driven in part by a lack of funds care was further reduced, exacerbating other and an overstretched system. Overall, as of October non-COVID-related health issues. Weak coordina- 2020, 10.3 percent of households were unable to tion also negatively affected the country’s ability access health services (figure 3.1). Access was 46 Guinea-Bissau Human Capital Review Figure 3.1  Effects of COVID-19 on education and health in Guinea-Bissau a. Education b. Health—reasons for not accessing medical care 53% 84% Conduct 73% 67% Lack of educational 59% money 83% activities 39% 86% 15% 8% In contact 23% No medical with teachers personnel 21% available 16% 9% 7% Conduct 12% Overall 8% Overall educational Bissau Refused due Bissau 20% 33% activities and in to lack of contact 16% Other urban Other urban space with teachers 6% Rural 7% Rural 0 20 40 60 80 100 0 20 40 60 80 100 Percent Percent much lower in rural areas (15.3 percent) compared Figure 3.2  Shares of total government spending by 46+13+6111421z to other urban areas (8.4 percent) and the Bissau function, 2020 autonomous sector (3.0 percent). Lack of funds was 0.7% 1% 0.4% the most common reason cited by households for ■ Public administration not being able to access health care (84 percent), 6% ■ Economic affairs probably due to the contraction in household 14% ■ Defense income after labor market disruptions triggered by ■ Education 47% ■ Health the pandemic. In Bissau, 33.3 percent of house- 11% ■ Public security holds cited insufficient hospital capacity as a major ■ Social protection reason for not being able to access health care. In ■ Religion 6% other urban areas, 16.8 percent of households cited 13% ■ Environment the absence of medical personnel as a constraint. S o u r c e : World Bank 2022a. Financing for human spending improved by 1  percent between 2010 capital and 2020, driven by an increase in the number of teachers and higher remuneration—although it still Government expenditure across the social sectors is falls far behind global benchmarks. Health spending relatively low (figure 3.2) and negatively affects the increased by almost 2 percent. It should be noted, quality of services, especially because the resulting however, that over half of all social spending was dependence on donors leads to erratic policy and financed with external grants and loans, and nearly spending. Social protection spending increased all capital was donor funded. This high dependence from 3.5 percent of gross domestic product (GDP) on donor funds results in donor-driven interven- in 2010–13 to 5.7 percent in 2014–20. Education tions and fragmentation among the actors involved 3  Human development systems required to strengthen human capital 47 in managing noncontributory social protection between 2020 and 2021 across the different age programs, projects, and measures. This conse- groups throughout the life cycle. Social assistance quently hampers the government’s ability to exercise was provided as either cash transfers (including leadership and achieve institutional alignment in noncontributory social pensions), food transfers, social assistance interventions. Figure 3.3 presents in-kind transfers, public works, fee waivers and an at-a-glance summary of the various social assis- targeted subsidies, and other social assistance. tance interventions implemented in Guinea-Bissau Figure 3.3  Social assistance packages in Guinea-Bissau, 2020–21 H U M A N C A P I TA L D E V E L O P M E N T Building human capital Utilizing human capital Protecting human capital 0–5 years 6–18 years 18–65 years 65+ years Individual health outcomes Functional ability Intrinsic capacity Birth, neonatal Early and late childhood Youth and adulthood (prime Older adulthood period, and infancy and adolescence employment and reproductive years) Family Support Package Support to families: Cash transfer programs (regular and emergency to respond to COVID-19 or natural disasters)—despite cash transfer being unconditional, it prioritizes families with children enrolled in school and/or with disabilities (inclusive education); nutrition-related accompanying measures for cash transfer beneficiaries Health and nutrition: Testing, prevention, and treatment for HIV/AIDS and malaria; medical assistance and medicines for vulnerable families; vaccines for COVID-19; food, medicines, and hygiene kits Maternity Package School Package Productive Package Reform Package Nutritional and food In-kind transfers (school Public works (cash or Social pensions; medical support; vaccines and feeding programs); food); cash transfers assistance (including consultation fees; testing scholarships for girls and and economic medicine, surgical and treatment for HIV/ children of low-income inclusion (grants and operations, orthopedic AIDS; birth registration HIV/AIDS patients; microcredits to finance prosthesis, wheelchairs) inclusive education income-generating and funerals for former activities) to socially combatants and their Child Health and Development Package excluded groups and descendants; cash women victims of transfers for former Child care services; specific support (food, violence combatants or their education, health services) for street chil- dependents dren and children suffering abuse; cash and in-kind transfers for orphans and children with disabilities S o u r c e : World Bank. 48 Guinea-Bissau Human Capital Review The 2007 Social Protection Framework Law in other Scaling Up Nutrition (SUN) movement defines the overall framework for social protection countries, where donor and government resources in Guinea-Bissau. It divides social protection into account for $3.16 and $1.13 per child, respec- two categories: social insurance, which is contrib- tively (SUN 2019).2 Available data show significant utory and corresponds to the formal sector; and declines in donor funding for nutrition (figure 3.4). social assistance, which is not. It also establishes the National Council for Social Protection (CNPS) The social protection scheme is one of the main as a coordinating body, together with the prime pillars used to achieve universal health coverage in minister. The Ministry of Women, Family, and Social Guinea-Bissau. The scheme is implemented through Solidarity (Ministério da Mulher Família e Solidarie- a fund managed by the National Social Security Insti- dade Social—MMFSS) is responsible for providing tute (Instituto Nacional de Segurança Social—INSS) social assistance to civilians. The ministry’s stated under the Ministry of Public Administration, Work, objective is “to formulate, propose, coordinate, and Employment, and Social Security. This mechanism execute government policies to promote integration, allows for the reimbursement of medical assistance, solidarity, social cohesion, the protection of women hospitalization, medical evacuation abroad, and and families, and poverty reduction.”1 However, the drugs. The reimbursement of health care expen- ministry’s low level of human and financial resources ditures amounts to 75  percent of total cost for limits its leadership and influence. Consequently, recipients and 50 percent for household members. social assistance strategies and initiatives are Although deductions are made from civil service almost entirely driven by donors, outlined in broad payrolls, these are not always channeled to the INSS strategic documents, but not particularized by due to mismanagement, and reimbursements are sector. often very slow, affecting the number of subscrip- tions to the scheme. Even though enrollment to Donor partners continue to provide almost all financing for both social protection and nutrition 2  The SUN movement is a country-driven initiative led by programs. The government finances a very small 66 countries and 4 Indian states united in their mission share of total social assistance expenditures (only to end all forms of malnutrition by 2030. 3.0 percent in 2020 and 4.4 percent in 2021) relying on donor funds for the remainder (World Bank 2021a). The planned amount for social assistance Figure 3.4  Donor funding for nutrition in Guinea- in the 2023 general state budget is 1 percent of Bissau, 2012–21 GDP, which is just below the average for low-income Sub-Saharan African economies (1.1  percent of 14 13.43 GDP). In the area of nutrition, current financing is 12 insufficient (Kakietek et al. 2017). Donor partners, 10 which also provide most resources for nutrition, 9.21 spent $0.55 per child under five years of age for 8 Million $ nutrition-specific interventions (2015–17), compared 6 with $0.15 of government resources per child (2014). 4 3.51 These amounts are well below the median spending 2 0.09 0.07 0.3 0.005 0.44 0 Guinea-Bissau Decreto-Lei n. 3/2020 - Estrutura do 1  2012 2013 2014 2015 2016 2017 2019 2021 Governo. 2 3  Human development systems required to strengthen human capital 49 INSS is compulsory, no mechanisms are in place are retained at the school level, while 10 percent are for enforcing employers or employees to join the transferred to the regional directorates for educa- scheme. The security scheme concerns only a small tion; 40 percent is to go back to the central ministry. fringe of the population—namely state and collec- However, there is no financial reporting and a lack tive wage earners, public and private contractual of transparency as to what actually happens and wage earners, and pensioners. The small number how the funds are used. Most schools—especially of taxpayers enrolled in the scheme is economically those with only grades 1–6, where there are no related to the predominance of the informal sector. student fees—receive no operating budget and rely on community support to operate. The most signif- Household out-of-pocket costs for health care icant losses are due to frequently absent teachers is the largest source of financing, accounting for and weak systems to manage human resources. 65 percent of current expenditure in 2019, largely for medicine and user fees. This amount is well The absence of formal administrative and financial above the World Health Organization (WHO) bench- processes in the health sector allows for gaps in mark of 15–20 percent. The government and donors oversight and a lack of transparency in spending and are exploring alternative and more sustainable decision-making. Expenditure reporting is weak, health financing models to ensure equitable access with at least a delay of five years in the validation to quality services for the population, especially the of national health accounts, leaving little room for most vulnerable, without risk of financial hardship accountability. Although data are limited, evidence (i.e., universal coverage). shows that budget transfers to subnational health entities and to the regional directorates for health Although expenditures in the education sector have remain low or nonexistent. The regional direc- been increasing (World Bank 2018, 2022a), the torates are supposed to receive a percentage of sector continues to be underfunded. Total educa- monthly incomes from regional hospitals and health tion expenditure accounts for 2.2 percent of GDP centers to cover their operating costs, but here too and 11.1 percent of government spending—which is no control mechanisms are in place to monitor the lowest spending on education as a share of GDP such transfers properly. Apart from two hospitals within the eight West African Economic and Mone- in Bissau, no health centers or hospitals receive tary Union (WAEMU) countries. It is also lower than funding for operational expenses. Transfers planned the average for Sub-Saharan Africa countries, and in the budget—such as the allocation of 40 percent far below the standard recommended 4–6 percent of tax receipts from sales of cigarettes, alcohol, and of GDP or 20 percent of government spending. As sugary drinks (a “sin tax”) for the health sector—are a result, the sector continues to be heavily reliant not being executed. Similarly, the education sector on donor support for all nonrecurring expenditures; is not receiving its allocated 60 percent share of the lion’s share of the national budget (between the tax. 90 percent and 95 percent) goes toward salaries. Centralized tendencies and weak budgetary plan- A significant portion of the limited resources for ning lead to inefficiencies and bad outcomes, education are lost due to disruptions in service and particularly in the health sector. Geographically, poor financial controls. School fees collected from most health-related spending occurs in the Bissau grade 7 onwards are intended to be an important autonomous sector, where health outcomes are source of internal revenue, but there is little infor- better than for the rest of the country. With a little mation about the actual amounts collected and less than a third of the country’s population, the how they are used. In theory, 50 percent of fees autonomous sector receives 60  percent of the 50 Guinea-Bissau Human Capital Review national health expenditure. Except for Gabú and Human resources Cacheu, which receive an allocation in line with their population shares, the remaining regions—which Weak planning and management in both the educa- account for 46 percent of the population—receive tion and health sectors has had significant impacts less than 18 percent of the national health expen- on the overall wage bill. Over the past five years, diture. The diseases causing the most deaths are employment in both the education and health the least well funded. Expenditures favor curative sectors has grown rapidly. Between 2017 and 2023, over preventive health care, including a preference the civil service recruited 7,600 new workers— for hospitals over health centers. (Preventive health primarily in the education sector, which grew from care financing is generally more efficient, because around 8,700 to some 14,800 workers, accounting it is less costly and has more impact than curative for 71 percent of civil service sector growth. The care.) The absence of a reference model, along health sector grew at the same rate as the civil with the poor infrastructure and human resource sector (62 percent), but with much smaller abso- conditions of health centers, drives individuals to lute numbers (figure  3.5) While there is a need seek health care in hospitals at high costs, even for more trained and qualified health workers and when their needs could be met in health centers at teachers, poor planning, recruitment, deployment, reduced costs. and oversight raise doubts about the impact these investments will have on improving human capital Due to donor dependence and a lack of regular outcomes. financing, key inputs to improve outcomes in both health and education are often missing entirely. Two The ability to plan effectively is hampered by the lack examples of this are (1) the lack of learning mate- of basic statistics and weak institutional structures rials required to support learning and (2) the lack to oversee human resource management within the of medicines to prevent and treat diseases. The last ministries for education and health. For example, time any learning materials were purchased was in the Education Management Information System is 2016 with the support of UNICEF. As a result, nearly basically nonoperational due to the extremely low all students in most schools across the country lack submission rates of annual statistics by schools. access to learning materials. To tackle this issue, the Ministry of Education is developing a new textbook policy that addresses sustainable financing. In terms of health care, a recent Service Delivery Indicator Figure 3.5  Employment in Guinea-Bissau, 2017 and 2023 survey revealed that none of the health facilities had all essential medicines and vaccines in stock (World 20 19,858 2017 2023 Bank 2019a). The Central Drug Purchasing Agency (Central de Compras de Medicamentos Essenciais— 15 CECOME) had been entirely dependent on donor Thousands 12,258 financing and nongovernmental organizations and 10 had not been able to purchase any essential drugs 7,432 7,966 for the national health system since 2018. Due to 5 years of financial mismanagement, the agency was 2,735 1,686 775 848 dissolved in 2022, and a new structure with a new 0 Civil service Health Justice Defense legal status and access to regular financing is under (incl. education) sector sector sector   development. S o u r c e : World Bank based on SIGRHAP data. 3  Human development systems required to strengthen human capital 51 Even basic statistics such as the number of schools/ civil servants) and the Ministry of Finance (which is classrooms, teachers by grade level, and student responsible for payments); this will demand strong enrollment are unavailable for effective planning. coordination between these ministries. Strong institutional structures to oversee human resource management and incorporate technology Cumbersome recruitment processes, coupled and tools to improve planning within both ministries with the lack of a human resource planning frame- are essential. One option would be directorates for work, lead to high opportunity costs. Currently, the human resources within the central ministries and Ministry of Health and the Ministry of Education corresponding structures at the regional and sector propose a list of professionals to be hired to the levels, particularly for education. Ministry of Public Administration. The list includes the type of staff to be hired (teachers, nurses, Poor human resource management has led to doctors, specialists, etc.) and suggestions for their frequent strikes, severely undermining efforts to deployment. The Ministry of Public Administra- improve health and education systems. Teacher tion handles the administrative processing of new and health worker strikes have been a significant hires, verifies their credentials, and forwards the means to demand the payment of salary arrears information to the Court of Accounts for validation. and push for pay and benefit reforms. One of the Once validated, the data are sent to the Ministry of major complaints of the teachers union, which led Finance for inclusion in the payroll. This process to months-long strikes and potential cancellation is lengthy and relies on paper-based documenta- of entire school years, was nonimplementation tion, leading to delays and errors. For example, new of the Teacher Career Law. A full revision of the teacher contracts are seldom in place at the begin- law was approved by Parliament in October 2018. ning of a school year, resulting in students without The government has since been actively working teachers in their classrooms for several months. on implementing the reforms, which have had The lack of comprehensive data hampers discre- a notable impact in preventing teacher strikes. tionary decision-making at the local level, making The revised Teacher Career Law sets out a new it challenging to determine staffing needs based and more generous payment structure for public on student enrollments, number of classrooms, sector teachers, along with other policies. This and other factors. There are disparities between new payment structure assigns higher salaries to policy intentions and actual practices in planning teachers with more qualification and experience, and recruiting new staff in the health and educa- gives monetary incentives to accept positions in tion sectors (figure 3.6). Staff allocation often fails rural areas, includes a subsidy for teaching supplies, to align with actual needs, resulting in an inequi- and will eventually include teacher performance table distribution of personnel across health centers evaluations.  and schools. A centralized, fully integrated human resource An uneven distribution of the workforce in both the management information system—ideally covering health and education sectors favors the capital. both the health and education sectors—is critical. There are generally few health care professionals Such a system could, for example, ensure effec- across the country, averaging 1.7 physicians and 6.1 tive implementation of the Teacher Career Law nurses and midwives per 10,000 inhabitants (World and prevent strikes among health workers. This Bank 2022a). Regions such as Bolama and Bissau centralized system would need to be linked to the have a comparatively larger number of physicians information systems of the Ministry of Public Admin- (4.3 and 5.2 per 10,000 inhabitants) compared istration (which is responsible for contracting of all to regions like Farim (0.8 per 10,000 inhabitants). 52 Guinea-Bissau Human Capital Review Figure 3.6  Human resources planning in the health and education sectors  Policy  Health Health Health Practice School School facility facility facility ■ Feedback on staffing ■ Little systemic needs from health feedback facilities and schools  ■ Inconsistent staff ■ Staffing surveys from planning oversight regional directorates  Regional Regional Regional ■ Incomplete staffing ■ Regional staffing directorate directorate directorate needs forwarded to needs forwarded to the ministry central ministries  ■ Absence of ■ Ministries consolidate medium-term human information with resource plan leads to Ministry of medium-term staffing Ministry of Health simple tally of needs Education needs ■ Submission based on ■ Submission of needs incomplete picture  to the Ministry of ■ Discussions limited Public Administration  by lack of data and ■ Discussions with Ministry of Public incremental budgeting  Ministries of Administration ■ Discretion over hirings Education, Health, leads to decisions and Finance take made outside the place in line with the established process budget cycle, with estimates of impact Ministry of on wage bill Finance S o u r c e : World Bank elaboration. Similarly, the ratio of nurses in Bijagós and Bolama monitoring and oversight in the education and health is 10.7 and 13.5, respectively, per 5,000 inhabitants; sectors. in Oio and Bafatá, it is 2.8 and 2.9, respectively. This uneven distribution of health workers mirrors ■ A UNICEF study found that the percentage of allocative inefficiencies and inequities in access teachers absent once a week or more—even to services. Similarly, pupil-teacher ratios vary when schools are in session—is as high as significantly by region, which has implications for 28 percent (UNICEF 2021). Of those present, educational equity. A recent study revealed a large more than one in four are not in their classrooms, variation in student-teacher ratios among schools. and a majority of those in the classrooms are On average, there are 64.2 students per teacher, not fully engaged in teaching. The top reasons but the bottom 10 percent of schools have ratios for absences and for not being fully engaged in below 37, while the top 10  percent have ratios teaching are strikes, poor health, administrative exceeding 102 (World Bank 2023). The lack of a or official duties, and lack of teaching materials. recent school census, which would enable adequate While collecting payments used to be a signifi- estimation of demand and better planning, further cant factor for teacher absences, only 6 percent exacerbates the situation. of teachers gave this as a reason for being absent from school in the UNICEF study. In the High rates of absenteeism among teachers and past, public school teachers would receive sala- health workers demonstrate the need for better ries automatically, regardless of their presence 3  Human development systems required to strengthen human capital 53 or participation in strikes. A more decentralized outcomes suggest that few teachers possess the system would give local school officials greater requisite knowledge and skills to teach effectively. control to monitor and incentivize teacher atten- dance. ■ Absenteeism among health workers is a chronic Data for informed problem undermining delivery. Data from 2019 decision-making and suggest that absenteeism reached 34 percent planning across all health facilities in the country (World Bank 2019a). The highest rates of absen- A lack of reliable and timely data severely inhibits teeism were observed in Bissau (55 percent) planning, coordination, and resource management and Quinará (50 percent), and the lowest rate in across social sectors. The most recent education Gabú (19 percent). The main reported reasons data are from 2014–15. Even the most basic statis- for absenteeism were dissatisfaction with sala- tics, such as the numbers and locations of schools, ries; payment arrears, particularly regarding the teachers, students, are not available. While collec- nonpayment of various incentives and bonuses, tion instruments have been developed, the high including isolation allowances (for those living in turnover of school and regional directors has remote areas) and top-ups for long shifts; and hampered the government’s ability to collect reli- long commuting times. To reduce absenteeism able school-level data. Various donors are working within the two sectors, key stakeholders need to resolve bottlenecks by leveraging technology and to be engaged to monitor attendance. conducting rapid surveys to bridge existing gaps. Well-trained, equitably distributed, and motivated The national health data information system (DHIS2) health workers and teachers are essential for only captures partial data from the Ministry of improving human capital outcomes in Guinea-Bissau. Health. Although a real-time monitoring program, The country especially lacks doctors, both gener- supported by external donors including the World alists (290 total to cover the entire population) Bank and the Global Fund, has been introduced, the and specialists (28 in total) (World Bank 2022a). government is not using it. Data collection, notably More than 40 percent of all health care workers, for maternal and child health, is frequently under- including all specialist physicians, are concen- taken by implementing agencies (nongovernmental trated in the capital. Recurring payment arrears organizations, UN entities) associated with Ministry discourages staff from working in remote regions of Health primary financial partners. and compounds existing allocative inefficiencies. The Service Delivery Indicator survey also revealed Weaknesses plague the health information system significant gaps in provider knowledge; very few due to insufficient human and financial resources. health care workers could accurately diagnose The government has turned to nongovernmental the leading causes of child mortality (e.g., only organizations for help in collecting specific health 2 percent of health care workers could diagnose a data. Communication breakdowns between central, case of malaria with anemia), and less than a third of local, and regional levels result in missing or delayed health care workers could correctly manage cases information recording, preventing real-time health of postpartum hemorrhage, the leading cause of data availability. Additionally, key indicators like maternal death in Guinea-Bissau. In the education fertility rates, maternal and child mortality, and sector, opportunities for continuous professional immunization records are inadequately updated. development are limited. Extremely poor learning 54 Guinea-Bissau Human Capital Review The lack of data has significant implications for esti- African Republic, Chad, Nigeria, and neighboring mating public expenditures on social assistance, Guinea-Conakry. The occurrence of climate-related assessing the impact of interventions, and deter- extreme weather events like floods and droughts mining appropriate targeting. The lack of a standard has increased significantly in Guinea-Bissau since classification of the functions of government intro- 2000. Recently, inland cities including Bafatá have duces uncertainty regarding the actual levels of experienced a rise in the frequency of heavy storms expenditure on social assistance. Data from the 3 during the rainy season. Annual droughts have been two national surveys conducted in 2018–19—the affecting another 74,000 people in the eastern part Harmonized Survey on Household Living Stan- of the country, leading to severe impacts on health, dards (EHCVM) and the Multiple Indicator Cluster agriculture, and livestock. Survey (MICS)—do exist, but without comprehensive household-level data, effective targeting of social Approximately one-third of the population in programs relies on self-assessment, community Guinea-Bissau experiences insufficient food approaches, and proxy variables. consumption every year. Climate change further exacerbates the risk to the overall well-being and nutritional status of the population—especially chil- dren. It is projected that, by 2050, most child deaths Climate change resulting from climate change will be attributable to undernutrition (WFP 2021). The visible effects of climate change are already hindering human capital development in Floods and droughts are both highly detrimental to Guinea-Bissau. Most prominent are sea level rise, agricultural production and productivity. Drought increased temperature, changing precipitation is the number one cause of yield loss; and rice is patterns, shorter cool seasons, longer drought spells particularly vulnerable to droughts, since it has and heat waves, and frequent extreme weather a higher water requirement than other crops. In events—all of which are expected to increase in Guinea-Bissau, more than 100,000 households in severity and frequency. Currently, 70–80 percent coastal areas depend on the productivity of rice of the population lives in coastal zones and inland paddies for their livelihood. Increased flooding hydrographic basins. The rising sea level and risk and saltwater encroachment into rice paddies are of flooding continuously threaten access to essen- already affecting these communities, resulting in tial services including health care, education, and many subsistence farmers abandoning their fields. food security. Rising sea temperatures and changes in the oceans are gradually but adversely affecting fisheries. On its Children’s Climate Risk Index, UNICEF ranks Guinea-Bissau among 33 countries classified as Climate change worsens the already precarious situ- “at extremely high risk.”4 Globally, Guinea-Bissau ation in most African public health systems, including ranked fifth in 2021, following the Central that of Guinea-Bissau. Direct effects include injuries from extreme events; infectious diseases associated with water, vector biology, and food contamination; The Classification of the Functions of Government was 3  allergies; air pollution–related acute respiratory developed by the Organisation for Economic Co-operation and Development in 1999 and published by the United illnesses and cardiovascular diseases; and malnu- Nations Statistical Division as a standard classifying the trition due to food insecurity. The percentage of the purposes of government activities. population dying from communicable diseases— Source: UNICEF, Children’s Climate Risk Index Interactive 4  such as diarrheal diseases and lower respiratory Atlas webpage. 3  Human development systems required to strengthen human capital 55 tract infections—is only expected to increase due suggest that the majority of Guinea-Bissau’s schools to more frequent flooding. Rising temperatures and are in vulnerable areas. humidity will increase malaria transmission, flooding will facilitate the spread of waterborne diseases, Flooding could severely affect school infrastruc- and droughts will escalate the risk of meningitis. ture in vulnerable areas and increase the number Moreover, the likelihood of essential health services of out-of-school children and school dropouts. being disrupted by flooding is very high. Damage to Damaged school infrastructure has compounding poor infrastructure, equipment, and medicine due negative effects, as it exposes the educational to flooding will result in even less consistent health community to severe physical and mental stress, care—particularly in rural areas—leading to higher and interferes with school operations, teaching, disease and mortality rates, especially among chil- and learning (World Bank 2011). The potential for dren. disruption of education could have adverse effects on learning outcomes, particularly in nonresilient Schools are highly exposed to flood risk. Increasing or low-income communities. Climatic shocks also sea levels, higher temperatures, and erratic rainfall threaten livelihoods and force families to coping are expected to exacerbate the effects of recur- mechanisms—such as diverting household expen- ring natural hazards in the country such as flooding, diture away from education toward other basic especially in coastal regions. Table 3.1 presents a 5 needs—that reduce human capital. 6 Children, 2021 estimate of the flood risks for schools and especially girls, often leave school to engage in populations by region. Approximately 20 percent time-consuming subsistence farming activities and of schools are categorized as having a high risk other household chores due to flooding.7 of exposure to flooding; an additional 48 percent are considered as being at medium risk. The data Guinea-Bissau should adopt various measures in the short to medium term to mitigate the negative 6  World Bank Group AFW Education Strategy. World Bank, Climate Change Knowledge Portal. 5  Guinea-Bissau. 7  World Bank Group. Safer Schools Program. Table 3.1  Flood risk associated with schools and population count, by region 2021 Region Number of schools Population Autonomous Sector of Bissau (SAB) 229 523,387 Biombo 183 105,944 Cacheu 285 235,078 Oio 311 233,786 Quinará 153 82,658 Tombali 145 126,204 Bolama-Bijagós 81 38,873 Bafatá 318 299,613 Gabú 313 286,452 S o u r c e : Ministry of Education, High Commission of COVID-19. L e g e n d : ■ high risk; ■ medium risk; ■ low risk. 56 Guinea-Bissau Human Capital Review impact of climate change on education outcomes. opportunities to reach the most vulnerable indi- The Global Alliance for Disaster Risk Reduction and viduals, helping them withstand shocks and build Resilience in the Education Sector recommends the resilience. Despite the recent development of following measures, among others: (1) strengthening some social safety net programs in Guinea-Bissau, the capacities of teachers to deliver risk reduction coverage in general has been insufficient. and resilience education content and respond to the mental health and psychosocial needs of children; (2) Considering the increasing frequency and severity developing high-quality teaching and learning mate- of climate change hazards and other covariate rials for students and teachers that cover topics such shocks, it will be important for Guinea-Bissau to as risk reduction, safety, and climate change action; adopt an adaptive social protection approach. and (3) developing and promoting action-oriented Adaptive social protection strengthens social messages for households and schools to reduce protection systems and enhances their prepared- risks and prepare for and respond to the impacts of ness for significant shocks. The focus is on building hazard (GADRRRES 2022). As part of the primary the resilience of poor and vulnerable households school curricula, it would be beneficial to incor- before, during, and after such events. In line with the porate a basic module on flooding, droughts, and adaptive social protection approach, Guinea-Bissau storms. This module should provide clear guidance should consider, among other options, estab- to students on appropriate actions and behaviors, lishing a regular cash transfer program, creating such as preserving the supply of drinking water and a national registry that prioritizes the inclusion of understanding escape strategies. high-risk households residing in “hot-spot” areas, and establishing a climate change recuperation The extreme level of poverty in Guinea-Bissau, fund to ensure timely and accessible funding for particularly in rural areas, further exacerbates response programs. the impacts of climate change. Moreover, climate change hazards are likely to undermine poverty reduction and development gains, with enormous repercussions for human capital development; and drastically increase demand for social protection measures and support. Social safety nets provide 4 Key recommendations   Challenge Recommendation Early childhood (ages 0–5) ■ Access to health care limited, with high ■ Strengthen primary health care, especially for vaccinations, neonatal mortality rates and only 60 percent family planning, and reproductive health services  of children under 2 years fully immunized ■ Ensure food security and scale up nutrition interventions for ■ Almost 30 percent of children stunted, and young children and women by (1) increasing awareness about poor nutrition is prevalent malnutrition and its management; and (2) providing complemen- ■ Limited early stimulation and early learning tary foods and nutrient supplements for the most vulnerable opportunities, leading to deficits in cogni- ■ Expand access to early childhood development and preschool tive development, literacy and numeracy, and programs, including appropriate languages of instruction, to socioemotional skills increase children’s readiness for school, on-time entry, and ■ Geographic and financial barriers to early improved learning outcomes childhood development programs for children ■ Provide cash transfers with accompanying measures to from rural areas and the poorest households enhance food security, better nutrition, and access to early childhood development programs School-age children/youth (ages 6–18) ■ Extremely low expected years of schooling ■ Finalize curriculum reform (grades 1–6) and include scripted (4.9 years) with high numbers of out-of-school lessons and high-quality in-service teacher training to improve children and low completion rates learning outcomes in basic literacy and numeracy ■ Outdated curricula and poorly trained ■ Expand TVET and training opportunities relevant to the labor teachers, leading to poor learning outcomes in market and opportunities for employment early grades ■ Develop targeted programs for adolescent girls, including ■ Low enrollments in technical and vocational life skills and knowledge of reproductive health, to reduce education and training (TVET) programs child marriage and early childbearing, lower fertility rates, and limited training opportunities to gain and improve enrollments and completion rates in secondary job-relevant skills schools ■ Child marriage and early childbearing, limited ■ Provide support to households through cash transfers and knowledge of reproductive health leading to accompanying measures to enhance knowledge needed to maternal and child health issues invest in their children’s health and education and encourage ■ High adolescent mortality and morbidity rate, primary school enrollment specially linked to infectious disease and ■ Integrate a low-cost, high-impact focus on adolescents in noncommunicable disease essential primary care services, addressing adolescent sexual and reproductive health, HIV prevention and treatment, improved nutrition, and care for mental health conditions 57 58 Guinea-Bissau Human Capital Review Challenge Recommendation Adults (ages 19–60+) ■ Economy highly dependent on agriculture and ■ Promote economic inclusion for poor households and foster susceptible to shocks and external factors diversification by promoting off-farm income-generating activ- ■ Labor force primarily engaged in low-wage ities or adding value to agricultural production, including skills jobs and informal sector activities that lack training, cash start-up grants, and coaching job security, sufficient income, and access to ■ Promote self-employment for unemployed educated youth essential benefits including training, cash start-up grants, and coaching to ■ High unemployment rates among educated develop small businesses youth ■ Improve affordable access to essential health services, partic- ■ Low life expectancy compared to aspirational ularly at the community and primary levels, to increase life peer countries expectancy ■ Low health care worker productivity ■ Improve working conditions of health care workers to improve performance Human development systems ■ Low expenditures in social sectors lead to ■ Prioritize investments in human capital by increasing govern- poor system quality and high donor depen- ment expenditures in social sectors dency ■ Adopt national policies and financing mechanisms to ensure ■ Weak human resource management and poor medicines and basic equipment (in health) and teaching and planning worsen service delivery and lead to learning materials (in education) are available frequent teacher and health worker strikes ■ Accelerate the establishment of the human resource database ■ Limited supply of trained health workers to consolidate all data on civil servants, including teachers ■ Lack of data to guide investments in social and health professionals, and use information to improve sectors and planning, leading to inefficiencies management (i.e., recruitment, deployment, monitoring) and loss of limited critical resources needed to ■ Devise and implement an effective 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