Report No: xxx Guinea-Bissau: Building Resilience for Vulnerable Populations September 2021 Social Protection and Jobs Global Practice West Africa Region © 2021 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution— World Bank. 2021. Guinea-Bissau Building Resilience for Vulnerable Populations. © World Bank. All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. ii Contents Contents ............................................................................................................................................ iii List of Figure ..................................................................................................................................... v Abbreviations.................................................................................................................................... vi Acknowledgements .......................................................................................................................... vii Executive Summary ....................................................................................................................... viii Chapter 1 Risks and Vulnerabilities................................................................................................ 1 A. Covariate Risks ........................................................................................................................ 1 A.1 Political instability ..................................................................................................................... 2 A.2 Lack of economic diversification ............................................................................................ 3 A.3 Weak public service delivery ................................................................................................... 3 A.4 Climate change, natural disasters, and health hazards.......................................................... 4 B. Idiosyncratic (Individual) Risks............................................................................................... 4 B.1 Characteristics of the population ............................................................................................. 5 B.2 Housing conditions .................................................................................................................... 8 B.3 Assets ........................................................................................................................................... 9 B.4 Labor ............................................................................................................................................ 9 B.5 Education................................................................................................................................... 10 B.6 Nutrition and health ................................................................................................................. 11 C. Risks of Falling into Extreme Poverty ................................................................................... 13 Chapter 2 Social Protection: Institutions, Policies, and Financing............................................. 15 A. Social Protection: Policies and Institutions............................................................................ 16 B. Expenditures on Social Assistance ........................................................................................ 19 C. Analysis ................................................................................................................................. 20 Chapter 3 Social Assistance Programs Review ............................................................................ 23 A. Cash transfers......................................................................................................................... 24 B. Food transfers ........................................................................................................................ 26 C. In-kind transfers ..................................................................................................................... 27 D. Public works .......................................................................................................................... 28 E. Fee waivers and targeted subsidies ........................................................................................ 29 F. Other social assistance programs ........................................................................................... 31 iii Chapter 4 Recommendations for Improving Social Assistance .................................................. 35 A. Defining a social assistance strategy...................................................................................... 35 A.1 Prioritizing vulnerable groups ........................................................................................... 35 A.2 Evaluating and rationalizing social assistance programs ............................................... 36 A.3 Increasing local and community participation ................................................................ 38 A.4 Establishing a national registry of beneficiaries ............................................................. 39 A.5 Developing targeting mechanisms to reach priority groups .......................................... 39 B. Monitoring the implementation of the social assistance strategy and its impact on vulnerability ………………………………………………………………………………………………40 Annex ………………………………………………………………………………………………41 References ........................................................................................................................................ 48 iv List of Figure Figure 1.1: Political Instability and Economic Growth ....................................................................... 2 List of Tables Table 1.1 Household Indicators by Quintile ....................................................................................... 5 Table 1.2 Individual Indicators by Quintile ........................................................................................ 6 Table 1.3 Education Outcome Indicators, Women ............................................................................. 7 Table 1.4 Housing Conditions by Quintile.......................................................................................... 8 Table 1.5 Household Assets by Quintile ............................................................................................. 9 Table 1.6 Employment Indicators, Women....................................................................................... 10 Table 1.7 Education Indicators.......................................................................................................... 11 Table 1.8 Education Indicators by Quintile....................................................................................... 11 Table 1.9 Health Indicators by Quintile ............................................................................................ 12 Table 1.10 Determinants of Adjusted Expenditure Per Capita ......................................................... 14 Table 2.1 Household Transfers to Friends and Family in Previous 12 months, by Quintile ............ 16 Table 2.2 Expenditures on Social Assistance Programs ................................................................... 20 Table 2.3 Expenditures by the Ministry of Women, Family and Social Solidarity .......................... 20 Table 3.1 Social Assistance Programs by Program Classification, 2020–21 .................................... 24 Table 3.2 Social Assistance programs included in the 2020 and 2021 budgets ................................ 25 Table 4.1 Priority Groups for Social Assistance ............................................................................... 36 Table A.1 Expenditures on Social Assistance Programs included in the Public Investment Program of the 2021 State Budget ................................................................................................................... 41 Table A.2 Social Assistance Programs in Guinea-Bissau, 2021 ....................................................... 42 v Abbreviations AIDA Help, Exchange and Development (Ayuda, Intercambio y Desarrollo) ASPIRE Atlas of Social Protection Indicators of Resilience and Equity BCG Bacillus Calmette-Guérin CFAF Financial Community of West African Franc International Center for Environment Monitoring (Centro Internazionale in Monitoraggio CIMA Ambientale) COVID-19 Coronavirus Disease of 2019 CRS Catholic Relief Services CSB Corn-Soy Blend ECOWAS Economic Community of West African States EHCVM Harmonized Household Living Conditions Survey FAO Food and Agriculture Organization of the United Nations FEC Faith and Cooperation (Fé e Cooperação) FGM Female Genital Mutilation GAVI Global Alliance for Vaccines and Immunizations GDP Gross Domestic Product HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome IDA International Development Association ILAP Light Poverty Assessment Survey (Inquérito Ligeiro para a Avalição da Pobreza) ILO International Labour Organization IMF International Monetary Fund IMVF Institute Marquês de Vale-Flor INSS National Institute of Social Security (Instituto Nacional de Seguridade Social) LGBTI Lesbian, Gay, Bisexual, Transgender, and Intersex MAM Moderate Acute Malnutrition MICS Multiple Indicator Cluster Survey NGO Non-Governmental Organization Integrated Program for the Reduction of Maternal-Infant Mortality Program (Programa PIMI Integrada para a Redução da Mortalidade Materno-Infantil em Guinea-Bissau) PMT Proxy-Means Testing Operational Plan for National Scaling Up (Plano Operacional de Passagem à Escala POPEN Nacional) PRSP Poverty Reduction Strategy Paper Q1-5 Quintile 1 to 5 UN United Nations UN DESA United Nations, Department of Economic and Social Affairs UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNDRR United Nations Office for Disaster Risk Reduction UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WASH Water, Sanitation, and Hygiene WFP World Food Programme WHO World Health Organization vi Acknowledgements This report was prepared by the World Bank’s Social Protection and Jobs Global Practice. The team consisted of Philippe Auffret (Social Protection Specialist and main author), Marlon Francisco (Consultant), María Rúa López (Consultant) and John (Ioannis) Arzinos (Consultant). The report was edited by Bronwen Brown. Christian Bodewig (Practice Manager, Social Protection and Jobs Practice, West Africa Region, World Bank) supervised the production of the report. Peer-reviewers were Djibril Ndoye (Economist/Statistician) and Ahmed Bahiaoui (Consultant). The team is grateful to Anne-Lucie Lefebvre (Resident Representative) and Rebekka Grun (Practice Leader). We are especially thankful to Sonia Sanchez Moreno (Operations Officer) who conducted a thorough review of the report. The team is also grateful to the government of Guinea-Bissau, UN agencies, NGOs and other donors who provided information for this report. vii Executive Summary Guinea-Bissau is a country riddled with prolonged episodes of political instability—hampering economic and institutional development for many years. As a result, its population is highly vulnerable and faces myriad covariate and idiosyncratic risks. The main covariate risks are related to the persistent governance crises resulting from political instability, an agriculture-based economy that is highly dependent on cashew production, a poorly managed public sector with low-quality public service delivery, and climate change and natural disasters, including health hazards. Several household characteristics, poor living conditions, low levels of assets, malnutrition and poor health, and low education constitute the main idiosyncratic risks. In this environment, individuals are vulnerable to falling into extreme poverty, with dire consequences for intergenerational well-being and from which it is extremely difficult to rebound. Individuals demand mechanisms to reduce the impact of adverse effects on their welfare. However, traditional mechanisms do not offer an optimal degree of protection.1 Consequently, governments elaborate policies and implement programs to reduce the impacts of shocks and provide a level of protection beyond traditional mechanisms. In Guinea-Bissau, the principle of solidarity—the basis for social protection—is embodied in the 1984 Constitution. The 2007 Social Protection Framework Law defines the overall framework for social protection. It divides social protection into two categories: social insurance, which is contributory and corresponds to the formal sector, and social assistance, which is not. In Guinea- Bissau, the coverage of the social insurance programs is extremely low (about 3 percent of the population). In contrast to social insurance programs, social safety net (also called social assistance) programs are noncontributory interventions designed to help individuals and households cope with shocks. Because government social assistance financing is extremely limited in Guinea-Bissau, complementary financing from donors is essential to reduce the risks borne by the population and its vulnerability. The Ministry of Women, Family and Social Solidarity is tasked with providing social assistance to civilians. However, its low level of human and financial resources limits its influence. Moreover, the lack of effective government leadership and financing of social assistance leaves it almost entirely dependent on international aid. This complicates coordination efforts, impeding reform and the momentum of development activities. Developing a social assistance strategy in Guinea-Bissau will require an increase in government leadership and resources. The Ministry of Women, Family and Social Solidarity could lead the process in close coordination with other ministries and donors involved in social assistance. Under its leadership, the development forums (called “clusters�) could be strengthened and organized around specific objectives to reduce the vulnerabilities of the identified priority groups. However, the needed increase in government leadership can only occur with an overall increase in government expenditures on social assistance. The objective of the report is to analyze the risks and vulnerabilities faced by the population and the existing social assistance programs. It seeks to identify the residual risks born by the population and make recommendations to improve social assistance. The report represents a best effort to identify the social assistance programs included in the 2020 and 2021 General State Budget (Orçamento Geral do Estado) and classify them into cash transfers (including noncontributory social 1 Traditional risk-sharing arrangements are made within extended families, kinship or professional networks. These arrangements rely on reciprocal repeated relationships. For example, they include Rotating Savings and Credit Associations (ROSCAs) which are financial instruments in which members belong to a trusted social network. viii pensions), food and in-kind transfers, public works, fee waivers and targeted subsidies, and other social assistance. It reviews these programs and shows that total budgeted expenditures of the social assistance programs totaled US$35.1 million in 2020 and US$36.3 million in 2021, which are almost exclusively (over 95 percent) financed by donors. It also reviews programs not included in the budget and implemented by large nongovernmental organizations (NGOs). The report outlines the main principles of a social assistance strategy and provides recommendations to assist the government in improving its strategy and monitoring implementation. These principles include prioritizing vulnerable groups, evaluating and rationalizing existing social assistance programs, increasing local and community participation, establishing a national registry of beneficiaries, and developing targeting mechanisms to reach the priority groups. The strategy should also include resources to monitor the implementation of the strategy itself, and its impacts on the vulnerabilities of the population. The report shows that Guinea-Bissau’s social assistance strategy could prioritize pregnant women and young children to reduce nutritional deficiencies and morbidities. Medium priority could be assigned to at-risk children not registered at school, the poor affected by disability, the elderly poor, refugees and internally displaced persons. The strategy could give special attention to girls who face more pronounced risks, including early pregnancy. The strategy could also prioritize groups within geographic regions. For example, programs that target the rural destitute could receive top priority. Medium priority could be given to the poor living in areas affected by natural disasters, including the coastline, where climate change has the most significant impact. The strategy could adopt mitigation measures and prepare emergency plans to alleviate the immediate effects of natural disasters and health hazards. A thorough evaluation of existing social assistance programs could be a practical first step toward reducing vulnerability. Such a review could guide the rationalization of existing programs to reach priority groups. Developing consistent targeting mechanisms for program and service delivery plans could also help channel more resources to vulnerable groups. Guinea-Bissau’s cash transfer programs could be evaluated and harmonized, and a single list of beneficiaries could be compiled to avoid duplication. The government could also review, rationalize, and streamline social assistance programs to improve nutrition among children and pregnant women into a well-targeted nutrition program. The effectiveness of introducing public works in a small country like Guinea- Bissau—where cash transfer and community-based small infrastructure programs are already in place—could be evaluated. Also, the rehabilitation or construction of small basic infrastructure in rural areas (water pumps, feeder roads, schools, etc) including standards and norms, and maintenance mechanisms could be harmonized across programs in collaboration with national and local authorities. The authorities may want to start financing from domestic revenues the network of community health workers for the implementation of preventive and referral health care interventions in poor and rural areas, with an emphasis on maternal-infant health, vaccines, potable water, prevention and early detection of tuberculosis, malaria, family planning, and health education including HIV/AIDS awareness programs and review the existing procurement, storage, and distribution of medication by the public sector for higher efficiency. Several programs with considerable impacts on specific vulnerable groups could be pursued or scaled up. They include the birth registration program which provides identity documents to children under seven years of age. Following a community-driven development approach, the authorities could scale up the delivery of basic infrastructure in communities (tabancas or clusters of tabancas). Involving local authorities and communities in service delivery could improve the effectiveness of social assistance interventions. The social assistance strategy could emphasize the role of both the local administration and the deconcentrated services of central ministries in the implementation of social assistance programs. Doing so would improve accountability and the quality and sustainability of service delivery. The strategy could also highlight the importance of showing the ix state’s presence at the level of communities, which have mainly been disenfranchised from access to basic services. Expanding the beneficiary registry initiated under IDA’s Social Safety Nets and Basic Services Project would allow fast and accurate identification and targeting of potential beneficiaries for social assistance programs. A registry would reduce opportunities for fraud, benefit duplication, and access to benefits by illegitimate actors. It would also allow for improved social assistance program monitoring. A central ministry, such as the ministry responsible for social solidarity, could maintain and update the national registry. The provision of administration documents to identify beneficiaries could accompany the development of such a national registry. Establishing targeting mechanisms to channel social assistance benefits to priority groups is essential. Targeting improves cost-effectiveness and impact by concentrating resources on the neediest. The government could consider the following three main targeting mechanisms: (i) self- targeting, used in workfare programs where potential workers decide whether to participate in a public works program; (ii) community-based targeting, based on a subjective assessment by communities to identify the poor; and (iii) household survey-based targeting, using household survey data to determine eligibility. In particular, proxy-means testing (PMT) targeting, the most used household- based targeting method which predicts consumption per capita based on household variables—family size, education, and housing conditions—selected based on their correlation with consumption, could be considered. Eventually, monitoring social assistance strategy implementation and its impact on vulnerability will be critical and adequate resources should be made available for this task. x Chapter 1 Risks and Vulnerabilities Guinea-Bissau is a country riddled with prolonged episodes of political instability—hampering economic and institutional development for many years. As a result, its population is highly vulnerable and faces myriad covariate and idiosyncratic risks. The main covariate risks are related to the persistent governance crises resulting from political instability, an agriculture-based economy highly dependent on cashew production, a poorly managed public sector with low-quality public service delivery, and climate change and natural disasters, including health hazards. Investment in human capital limits the impacts of covariate shocks on households. Several household characteristics, poor living conditions, low levels of assets, malnutrition and poor health, and low education constitute the main idiosyncratic risks. In this environment, individuals are vulnerable to falling into extreme poverty, with dire consequences for intergenerational well-being and from which it is extremely difficult to rebound. This chapter analyzes these risks and their impact on the vulnerabilities of the population. The typology of risks and vulnerabilities presented provides elements to evaluate the relevance and effectiveness of Guinea-Bissau’s social assistance programs, which are analyzed in the following chapters. ______________________ 1. Guinea-Bissau is a fragile state characterized by political instability, weak institutions, low human development outcomes, and high poverty levels. With an estimated population of 1.9 million (UN DESA 2019a), it is a small country located between Senegal and Guinea on the West African coast. According to World Bank national accounts data, Guinea-Bissau was the 19th poorest country globally in 2019, with an estimated Gross National Income (GNI) per capita of $820. Roughly two-thirds (63 percent) of the population lived below the $1.90/day poverty line in 2018 (World Bank 2020). In addition, Guinea-Bissau ranked 175 out of 189 countries in the 2020 Human Development Index (United Nations Development Programme (UNDP) 2020) and had the 16th highest under-five mortality rate worldwide, at 82 per 1,000 live births, in 2019 (UN DESA 2019b). 2. Individuals in Guinea-Bissau are subject to risks and vulnerable to shocks that can negatively impact their livelihoods throughout their lives. Risks can affect the whole population (covariate risks) or specific individuals or households (idiosyncratic risks).2 Covariate risks arise from weak governance, a lack of economic diversification, climate change and natural disasters among others. Idiosyncratic risks impacting individuals’ livelihoods on the micro level include a greater risk of contracting diseases due to nutritional deficiencies, a lack of education eroding the basis for improved livelihoods, low ownership of assets, and greater exposure to the consequences of climate change. This chapter reviews the covariate and idiosyncratic risks faced by Guinea-Bissau’s population. It also provides an assessment of the risk of falling into extreme poverty, from which it is extremely difficult to rebound in the current socioeconomic environment. A. Covariate Risks 3. Covariate risks are risks that affect the whole population. As they affect everyone simultaneously, these risks cannot be diversified within the population. The main covariate risks faced by Guinea-Bissau’s population are related to the persistent governance crises resulting from 2Idiosyncratic shocks refer to household-specific shocks (e.g., injury, birth, death, or job loss of a household member) that are only weakly correlated across households within a community. Covariate shocks refer to shocks that are correlated across households within communities but only weakly correlated across communities (e.g., natural disasters or epidemics). 1 political instability, an agriculture-based economy that is highly dependent on cashew production, a poorly managed public sector with low-quality public service delivery, and climate change and natural disasters, including COVID-19. Importantly, household characteristics (education, assets, health, etc) are key drivers of households’ resilience to covariate shocks, so that investment in human capital is key to limit the impacts of covariate shocks on households. A.1 Political instability 4. Guinea-Bissau’s fragile and unstable political environment has been detrimental to development and economic growth.3 Military coups and frequent changes of government have plagued the country since its independence from Portugal in 1974. Guinea-Bissau was one of the lowest-ranked countries worldwide for political stability (142 out of 194 countries) in 2020.4 Given the depressing effect of political instability on overall economic activity, Guinea-Bissau relies heavily on international aid: over 95 percent of the public investment program are financed externally (IMF 2020). However, political instability can also disrupt global aid flows. For example, donor-funded capital expenditures collapsed in the aftermath of the 2012 military coup, falling by 80.4 percent (World Bank 2015, p.6), adversely affecting investments in health, education, water, and energy and leaving the population in a situation of extreme vulnerability. Episodes of political turmoil in Guinea- Bissau are associated with significant contractions in economic activity. The economy contracted by nearly 30 percent amid the 1998 civil war (Figure 1.1). Guinea-Bissau ranked among the last economies in the World Bank’s 2020 Doing Business ranking, implying very challenging conditions for entrepreneurship and business development in the country.5 Figure 1.1: Political Instability and Economic Growth Sources: World Bank staff based on World Development Indicators (http://data.worldbank.org/indicator). 5. Guinea-Bissau is also characterized by widespread corruption and drug trafficking, reflecting weak governance frameworks. The country ranked 172 out of 180 countries in Transparency International’s 2018 Corruption Perceptions Index and 198 out of 209 countries on the 2019 Worldwide Governance Indicators control of corruption indicator. For years, Guinea-Bissau has reportedly functioned as a hub for Latin American drugs passing through Africa to Europe 3 See also World Bank (2011) on conflict, security, and development; World Bank (2017a) on governance and the law (particularly chapters on the links between governance and growth and inclusion). 4 See https://www.theglobaleconomy.com/rankings/wb_political_stability/#Guinea-Bissau. 5 Available at https://documents1.worldbank.org/curated/en/688761571934946384/pdf/Doing-Business-2020-Comparing- Business-Regulation-in-190-Economies.pdf. 2 (Transparency International 2017). In addition to Guinea-Bissau’s lack of capacity to control its porous land, maritime, and air borders, and offshore territory, weak state structures, political instability, and widespread impunity make the country a potential haven for organized crime networks. 6. Years of political crisis and political stalemate have eased since early 2020. On February 27, 2020, Umaro Sissoko Embalo was sworn in as President. In April 2020, the Economic Community of West African States (ECOWAS) recognized the election results and the Supreme Court of Justice declared Mr. Embalo the winner on September 8, 2020. In December 2020, President Embalo created a commission to review the Constitution. This initiative, which all political parties do not support, could undermine the promising degree of current political stability. A.2 Lack of economic diversification 7. Guinea-Bissau is rich in natural resources (fisheries, forestry, and agriculture) and biodiversity with a terrain consisting primarily of low coastal plains with swamps and mangroves. The agriculture-based economy relies heavily on the production and export of raw cashew nuts,6 which account for roughly 90 percent of exports and 45 percent of Gross Domestic Product (GDP). More than two-thirds of households and virtually all small family farms rely on this crop for their income. Cashew production represents 75 percent of household income and 40 percent of rural employment (African Development Bank Group 2021). 8. Strong dependence on a single cash crop renders Guinea-Bissau vulnerable to market fluctuations. Losses of export earnings impact Bissau Guineans’ living standards and food security in both urban and rural areas. In 2018, cashew export earnings slumped, falling by 25 percent; this severely impacted household income, particularly in rural areas. More recently, disruptions in international trade and weak global demand for cashew nuts due to the COVID-19 pandemic drove down producer prices and production quantities. As a result, cashew producers experienced a 47 percent year-on-year decline in average revenue in 2020. Poor households in particular, who disproportionately depend on agricultural production, saw a considerable drop in their incomes. The restrictions to prevent the spread of the virus—imposed rapidly and unexpectedly—negatively impacted on households’ ability to switch to other agricultural products, which requires time. Despite Guinea-Bissau’s relatively low positive case rate, in a recent survey, households reported negative changes to family income, children’s education, and food intake due to the pandemic (Pereira and al, 2020). A.3 Weak public service delivery 9. Decades of instability have weakened institutional governance frameworks and undermined the quality and effectiveness of public service delivery. The World Bank’s Worldwide Governance Indicators rank Guinea-Bissau among the 10 worst performers worldwide for the quality of public service delivery, mainly due to widespread corruption and poor governance (World Bank 2016a).7 10. The limited supply and quality of public services magnify the risk faced by the population, particularly in rural areas, thus amplifying existing idiosyncratic risks. Access to potable water, electricity, education, and health services remain limited. In 2018, approximately 15 percent of households had access to potable water; most of the population gets drinking water from public fountains or wells. Also, public garbage disposal services are available to less than 10 percent of the 6 The cashew tree was introduced by the Portuguese in the 19th century, but cashew production was only effectively expanded in the mid-1980s. The nut is largely cultivated by small farmers around villages. It also plays a role in land ownership since land tenure practices are linked to the planting of trees. 7 See the World Bank’s Worldwide Governance Indicators at https://info.worldbank.org/governance/wgi/Home/Reports 3 population. Most households burn their garbage or salvage trash. Over 60 percent of the population uses either simple slab latrines or open pits for sanitation purposes. Less than 20 percent of the population has access to electricity. Guinea-Bissau’s road infrastructure is also underdeveloped. In 2019, there were 2,700 km of roads, of which only 800 kilometers were paved, limiting access to health and education services. In 2019, 3.9 percent of the population had internet access (World Bank, 2021a). A.4 Climate change, natural disasters, and health hazards 11. Guinea�Bissau is highly vulnerable to anthropogenic pressure, climate change, and natural disasters. Natural disasters—causing the physical destruction of basic infrastructure and threatening the viability of agricultural activity—pose considerable risks to the population. For example, the rainy season has become shorter due to climate change dynamics, heightening the risk of severe droughts. According to the United Nations Office for Disaster Risk Reduction (UNDRR) there will be a seven times higher probability of extreme drought by the end of the century, with considerable adverse impact on the economy (CIMA and UNDRR 2018). In addition, agricultural expansion, wood extraction (logging or wood harvest for domestic fuel or charcoal), and infrastructure development due to urbanization have accelerated deforestation and are adding to these dynamics. Whereas the climate-related risks of enhanced deforestation are not imminently visible, climate change is already causing irreparable damage to the country’s beaches, as evidenced along the coast in the northwest region of Varela. With heavier rainfalls and higher tides due to rising sea levels, climate change will exacerbate flooding, a recurring natural hazard along the coast, posing significant risks to residents’ livelihoods. Furthermore, increased salinization from the ocean has harmed rice production, caused coastal erosion, and inundated coastal aquifers. According to the World Bank, the rise in sea level threatens 70 percent of the population. 12. With a weak health system, Guinea-Bissau is particularly vulnerable to health hazards. In 2014, the government took measures to contain the spread of the Ebola virus from neighboring Guinea. However, the Ebola outbreak reduced GDP growth from over 4 percent to under 1 percent due to trade disruptions. In 2020, the COVID-19 pandemic negatively affected the economy. Although authorities projected a robust increase of 5 percent in GDP, the economy contracted by 2.4 percent. B. Idiosyncratic (Individual) Risks 13. Idiosyncratic risks affect individuals, households, or specific groups but do not affect the entire population. Policymakers can mitigate these risks through the design and implementation of risk diversification strategies within the population. The composition of households, poor living conditions, low levels of assets, malnutrition and poor health, and low education constitute the primary sources underlying the idiosyncratic risks facing the Bissau Guinean population. These factors hinder individuals’ ability to shield against adverse events, absorb negative socioeconomic shocks, and effectively protect their livelihoods. This section analyzes the relevant characteristics of Guinea-Bissau’s poor to determine a household idiosyncratic risk profile. The analysis incorporates data from the World Bank’s 2018 Harmonized Survey on Household Living Conditions (EHCVM, Enquête Harmonisée sur les Conditions de Vie des Ménages in French) and the 2002 and 2010 Poverty Evaluation Household Surveys (ILAP, Inquérito Ligeiro para a Avalição da Pobreza in Portuguese). These characteristics—particularly those impacting the lowest income quintile (Q1)— are essential to identifying the main sources of vulnerability to shocks. 4 B.1 Characteristics of the population 14. Guinea-Bissau has an estimated population of 1.9 million (UN DESA 2019a). It is home to a variety of ethnic groups, languages, and religions. Only 14 percent of the population speaks Portuguese, 44 percent speaks Crioulo (a Portuguese-based creole language), and the remainder speaks various African languages. According to the EHCVM, almost half of Guinea-Bissau’s population identifies as Muslim, 29 percent as Christian and 10 percent practice traditional African beliefs. More than one-third of the population (37.3 percent) resides in rural areas; 63.7 percent live in urban areas, 20 percent of which live in the capital, Bissau (World Bank 2019). The geographic distribution of households plays a vital role in variations in income and poverty outcomes. Poverty is mostly a rural phenomenon (Table 1.1). According to World Bank estimates, 85 percent of households in Q1 live in rural areas. Three regions (Bafata, Oio, and Quinara) account for almost half the households in Q1. In contrast, households in the wealthiest income quintile (Q5) are located disproportionally in Bissau (40 percent). 15. The poorest households are considerably larger (10.8 persons per household) than the wealthiest (5.2 persons), partly because poor households are more likely to include polygamous marriages than wealthy households. Nearly 40 percent of Q1 households report a polygamous marriage compared to just 10 percent of Q5 households. Table 1.1 Household Indicators by Quintile (% of households, unless indicated otherwise) Variable Total Quintile Quintile Quintile Quintile Quintile Population 1 2 3 4 5 (Poorest) (Wealthiest) Households (number) 5,351 1,071 1,070 1,070 1,070 1,070 Size (number of people) 8.01 10.80 9.23 7.91 6.93 5.16 Type of household 100 100 100 100 100 100 Urban 37.2 14.8 26.4 38.9 44.3 61.6 Rural 62.8 85.2 73.6 61.1 55.7 38.4 Region 100 100 100 100 100 100 Bissau (capital) 20.3 4.9 11.2 19.3 26.0 40.3 Bafata 11.2 19.3 10.4 9.6 8.6 7.9 Gabu 10.7 12.3 11.4 10.9 10.6 8.2 Oio 10.7 14.0 14.4 13.0 7.9 4.1 Cacheu 9.8 11.8 10.5 8.9 8.2 9.5 Bolama/Bijagós 9.4 10.1 11.9 8.3 9.5 7.1 Biombo 9.3 5.6 9.3 10.2 10.9 10.7 Tombali 9.3 9.5 8.7 11.0 11.0 6.4 Quinara 9.3 12.5 12.2 8.7 7.3 5.8 Head of household 100 100 100 100 100 100 matrimonial situation Monogamous marriage 51.7 45.2 50.9 53.6 56.5 52.1 Polygamous marriage 23.6 38.7 30.0 21.1 18.0 9.9 Nonregistered union 1.8 0.9 0.7 1.6 2.8 3.0 Not married 22.9 15.2 18.3 23.7 22.6 34.9 Source: World Bank staff calculations based on EHCVM 2018. 16. Households in Q1 account for 27 percent of the population due to the larger size of poorer households (Table 1.2). With an average age of just 22.6 years, the overall population is very young. Forty-two percent of the population is under age 15 years. Individuals in Q1 tend to be younger (21 5 years, compared to 25.7 years in Q5). Poverty increases as the number of children in the household increases. Based on the 2018 EHCVM, the poverty rate among households with 1–4 children is 15.1 percent, but this rises to 57 percent in households with 10–14 children. However, children below age 15 years represent 47.6 percent of the Q1 population, but just 32.0 percent of the Q5 population. The average age of individuals monotonically increases with income from 21 years in Q1 to 25.7 years in Q5. Individuals in Q1 also marry younger than those in Q5 (by 2.5 years); this holds for both men and women. Close to three-quarters (74.4 percent) of the population in Q1 belong to three ethnic groups (Fula, Balanta, and Mandinga), while these three ethnic groups represent 46.2 percent of households in Q5. Table 1.2 Individual Indicators by Quintile (% of individuals, unless indicated otherwise) Variables Total Quintile Quintile Quintile Quintile Quintile Population 1 2 3 4 5 (Poorest) (Wealthiest) Individuals (number) 42,839 11,568 9,873 8,459 7,418 5,521 Male 48.0 48.1 47.7 48.3 48.5 47.3 Female 52.0 51.9 52.3 51.7 51.5 52.7 Children below 15 years of age 41.9 47.6 44.7 40.7 38.1 32.0 Elderly above 60 years of age 4.7 4.6 4.7 4.9 4.4 5.1 Age (years) 22.6 21.0 21.8 23.0 23.6 25.7 Age married (years) 22.0 21.3 21.6 22.0 22.4 23.8 Male 25.7 25.0 25.0 25.8 26.0 27.6 Female 19.7 19.1 19.6 19.6 19.9 21.1 Ethnicity (% of nationals) 100 100 100 100 100 100 Fula 26.2 29.5 23.1 25.7 27.0 24.3 Balanta 24.1 29.1 27.5 23.7 20.6 13.3 Mandinga 12.8 15.8 12.5 12.6 11.7 8.6 Papel 9.8 5.3 9.3 10.9 12.0 15.5 Manjaco 6.7 4.0 5.2 6.8 8.4 12.6 Beafada 5.7 5.6 7.6 5.4 4.9 4.3 Bijagós 5.3 5.7 7.1 4.2 4.4 4.6 Mancanha 2.5 0.3 1.2 3.0 3.3 7.8 Felupe 1.2 1.6 1.1 1.2 1.0 1.0 Others and naturalized 5.5 3.1 5.4 6.5 6.7 8.0 Source: World Bank staff calculations based on EHCVM 2018. 17. The elderly population (over age 60 years) represents 4.7 percent of Guinea-Bissau’s population; income shares in this population group appear to be distributed evenly. Nevertheless, the combined absence of family or community support and income poses a significant risk to the elderly. In particular, pension scheme coverage is very limited. Civil servants—about 3 percent of the national workforce—benefit from a retirement pension, but only 0.3 percent of the working-age population is affiliated with the private pension system.8 18. Children in Guinea-Bissau face risks, including marginalization and exploitation. Fifty- seven percent of children under the age of five years live in poverty, and one-third of children aged under 15 years are at risk of marginalization. Some children practice begging, while others work as street vendors. There are also reported cases of child exploitation. Children orphaned or “entrusted� to other adults (they do not live with their biological parents) are at the highest risk of not attending school; they are engaged almost exclusively in household chores or income-generating activities. In 8 For more details, see Auffret and Guven 2016. 6 addition, more than three-quarters of newborns are not registered at birth, limiting their access to basic public services.9 19. Among children, girls face more pronounced risks. Girls attend school less than boys: 32 percent of urban females have never attended school compared to 16 percent of urban males. The gender gap is even more pronounced in rural areas, where 67 percent of the female population receives no formal education (Table 1.3). Family refusal and costs are the main reason why girls do not attend school. During the 2009/10 school year, 17 percent of students cited getting married or becoming pregnant as reasons for not completing their academic studies. Although the practice is legally banned, young girls face the risk of female genital mutilation (United Nations Children’s Fund – UNICEF estimates that 52 percent of girls and women aged 15–49 years have been subject to this practice, varying from 96 percent in Gabu to 8 percent in Biombo).10 Reflecting these deeply rooted gender biases, girls are also at risk of early pregnancy and marriage, exposing them to heightened reproductive health risks. Table 1.3 Education Outcome Indicators, Women Indicators Bissau Rural Total Literacy level (%): None 32.2 66.7 56.8 Primary and lower secondary levels 45.2 31.4 36.1 Upper Secondary level 15.8 1.7 5.3 Other studies 6.9 0.2 1.7 Reasons not to study (of women in the age group) (%): Cost 17.4 12.0 13.0 Distance to school 1.5 16.0 13.4 Have to work (at home or job) 7.6 1.8 3.1 Not worth it/not interested 6.2 4.0 4.7 Family refusal 35.3 38.3 37.9 Illness 6.3 1.6 2.3 Another reason 25.7 26.2 25.6 Source: World Bank staff calculations based on EHCVM 2018 20. Those living with a disability are also at risk. The National Institute of Studies and Research (Instituto Nacional de Estudos e Pesquisas in Portuguese) estimated that less than 1 percent of the population was living with disabilities in Guinea-Bissau in 2009.11 However, this figure may underestimate the actual prevalence of individuals affected by disabilities; the World Bank and World Health Organization (WHO) estimate that 15 percent of the global population has some form of disability.12 In Guinea-Bissau, those living with a disability are among the most vulnerable populations as they are often marginalized. 21. Although Guinea-Bissau is one of the more accepting countries in the region, even so LGBTI persons face some specific risks. Social attitudes are tolerant towards LGBTI persons, especially in Bissau (Shryok 2018). As a result, Guinea-Bissau attracts sexual and gender minorities from neighboring countries seeking to escape harsh conditions (Peyton 2019). Nonetheless, there are reported cases of violence against LGBTI persons (Anjos, 2018). 9 For more information, see the U.S. Department of Labor’s Child Labor and Forced Labor Report for Guinea-Bissau, available at https://www.dol.gov/sites/dolgov/files/ILAB/child_labor_reports/tda2018/Guinea-Bissau.pdf. 10 For more information, see https://data.unicef.org/resources/female-genital-mutilation-in-guinea-bissau/#. 11 For more information, see https://uniogbis.unmissions.org/pt/confedera%C3%A7%C3%A3o-de-pessoas-com- defici%C3%AAncia-exige-integra%C3%A7%C3%A3o-e-inclus%C3%A3o-de-pessoas-com-defici%C3%AAncia. 12 The World Bank (Disability Inclusion) and WHO (World Report on Disability 2011 ) estimate that 15 percent of the global population has some disability. 7 B.2 Housing conditions 22. Homes in Guinea-Bissau are vulnerable to adverse weather conditions. Almost four out of five houses have a roof made of corrugated zinc; the others are mainly thatch (Table 1.4). Walls are overwhelmingly made of clay (87.1 percent). Approximately half of the homes in Guinea-Bissau have earthen floors; others are cement (45 percent) or clay (2 percent). The structure of houses makes them particularly vulnerable to storms. Water damage can also penetrate the roof deck, eventually compromising the home’s structural integrity. Table 1.4 Housing Conditions by Quintile (% of households) Variable Total Quintile 1 Quintile Quintile Quintile Quintile 5 Population (Poorest) 2 3 4 (Wealthiest) Roof type 100 100 100 100 100 100 Corrugated zinc 78.9 73.4 76.3 80.4 79.8 84.8 Thatch 18.8 25.4 21.8 17.9 17.8 11.2 Tile or concrete 1.6 0.6 1.0 0.9 1.8 3.6 Others 0.7 0.7 0.9 0.8 0.7 0.5 Walls type 100 100 100 100 100 100 Clay materials 87.1 92.6 90.5 89.7 86.5 76.3 Cement 8.9 3.3 5.3 7.0 9.3 19.4 Stone 3.5 3.7 3.9 2.6 3.7 3.5 Others 0.5 0.4 0.3 0.7 0.5 0.8 Floor type 100 100 100 100 100 100 Earthen floor 52.0 74.5 62.8 51.6 42.5 28.7 Cement 45.4 24.2 35.8 47.5 55.0 64.3 Clay 2.0 0.3 0.7 0.6 1.7 6.8 Others 0.6 1.0 0.7 0.4 0.7 0.2 Sanitation type 100 100 100 100 100 100 Private bathroom or latrine 48.5 51.0 45.1 43.9 49.2 53.1 Shared bathroom or latrine 35.1 27.5 34.5 38.9 37.2 37.5 In the open 16.4 21.5 20.4 17.2 13.6 9.4 Drinking water source 100 100 100 100 100 100 Public or shared water 33.0 38.0 36.7 32.5 32.6 25.2 fountains Piped water 27.2 13.4 17.7 24.6 32.4 47.8 Wells 24.8 30.9 29.0 28.2 20.3 15.7 Boreholes 9.3 12.5 10.8 9.3 7.9 6.0 Surface water 3.5 3.8 4.3 3.3 3.9 2.4 Others 2.2 1.4 1.6 2.1 2.9 2.9 Illumination source 100 100 100 100 100 100 Electricity-based 49.7 44.3 44.8 46.7 50.1 62.6 Torch 38.9 43.9 42.6 40.7 38.4 28.6 Candles 3.9 3.6 3.2 5.0 4.3 3.3 Wood, oil, or gas 7.6 8.2 9.4 7.6 7.2 5.5 Cooking energy source 100 100 100 100 100 100 Wood 75.5 94.2 87.9 79.1 68.6 47.8 Charcoal 23.8 5.7 11.7 20.5 31.1 49.8 Gas 0.4 0.0 0.0 0.0 0.1 1.9 Others 0.3 0.1 0.4 0.5 0.2 0.6 Source: World Bank staff calculations based on EHCVM 2018. 8 23. In 2018, only 66.8 percent of the population had access to an improved water source and 55.4 percent of water sources remain contaminated with fecal coliforms (Escherichia Coli) (World Bank, 2021b). About one-quarter of the population relies on wells, which are often unprotected while 13 percent rely on boreholes and surface water. More than half of the rural population walk more than 30 minutes to fetch water, a task generally completed by women and girls. The development of sanitation is still embryonic. In 2018, the rate of access to improved sanitation was 25 percent at the national level (57 percent in urban areas and 7 percent in rural areas). Sixteen percent of the population defecates in the open because they lack proper sanitation. Open defecation and lack of sanitation and hygiene, in general, are important factors in disease transmission, most commonly diarrhea and intestinal worm infections but also typhoid, cholera, and hepatitis. The low level of sanitation makes diarrheal infections the main cause of neonatal and infant morbidity, covariate mortality, and growth stunting in children. 24. About half of households do not have access to electricity and must instead rely on torchlights or candles. Burning wood, the main energy source for cooking, has a considerable impact on household-level health outcomes and the environment. B.3 Assets 25. Households have very few assets, leaving them vulnerable to shocks. On average, there are 0.48 mattresses and 0.43 beds per person (Table 1.5). Just one household out of seven has a motorbike, and one out of four has a cooking stove. Households in Q1 have fewer assets when compared to those in higher-income quintiles. Table 1.5 Household Assets by Quintile (number of assets) Variables Total Quintile Quintile Quintile Quintile Quintile Population 1 2 3 4 5 (Poorest) (Wealthiest) Mattresses per person 0.48 0.37 0.40 0.46 0.50 0.67 Beds per person 0.43 0.33 0.37 0.40 0.43 0.59 Motorcycle per household 0.14 0.08 0.11 0.13 0.15 0.23 Cooking stove per household 0.22 0.09 0.09 0.14 0.15 0.26 Computer per household 0.21 0.07 0.10 0.11 0.15 0.28 Source: World Bank staff calculations based on EHCVM 2018. B.4 Labor 26. Labor employment is the primary means of generating household income, making households vulnerable to labor market fluctuations. The 2018 EHCVM estimated labor force participation at 71 percent for men and 60 percent for women. Women’s lower labor force participation is due to women bearing primary responsibility for daily household chores and childcare. The International Labour Organization (ILO) estimated unemployment at about 2.5 percent in 2020, which is low.13 The unemployment rate is higher in Bissau (estimated at 7.1 percent). Unemployment primarily affects the young without work experience, recent graduates, and young women. The average unemployment duration is 12.8 months—long spells of unemployment and long-term unemployment can result in chronic poverty and marginalization. 27. Unemployment is higher among the most educated (persons with senior secondary education and higher education). In 2019, the unemployment rates among the uneducated and those with a basic education were 1.1 percent and 1.6 percent, respectively. Unemployment reached 7.2 13 See https://data.worldbank.org/indicator/SL.UEM.TOTL.ZS?locations=GW&view=mapo. 9 percent and 8.2 percent for those with senior secondary education and higher education. The unemployment rate for women with higher education is even higher, estimated at 14.2 percent. Unemployment among the youth with higher education is 27.3 percent. 28. Women are at greater risk of underemployment or unemployment (Table 1.6). Women are not as economically active as men and are mostly engaged in the informal sector. About half of women are employed in agriculture to support the family. Despite a comparably low unemployment rate, roughly half of working-age women are outside the labor force. Table 1.6 Employment Indicators, Women Indicators Bissau Rural Total Women’s employment status (%): Employee 46.2 54.8 53.4 Unemployed 6.0 6.7 6.7 No activity 47.8 38.5 39.9 Among those who have a job (%): Public sector 3.1 3.9 3.8 Private sector or company 15.4 17.3 17.5 Self-employed/agriculture 27.1 31.8 30.5 Self-employed/outside agriculture 16.2 17.9 17.8 Family business support 38.2 29.1 30.3 Source: World Bank staff calculations based on EHCVM 2018. 29. Child labor is widespread in Guinea-Bissau. More than half of children between 5 and 17 years of age work. According to the sixth Multiple Indicator Cluster Survey (MICS6), the share of economically active children increases with age: 23 percent of children between age 5 and 11 years; 59 percent of children between age 12 and 14 years; and 67 percent of children between age 15 and 17 years (Guinea-Bissau 2020, p. 478).14 The prevalence of child labor varies by geographical area: 58 percent of children in rural areas participate in income-generating agricultural activities compared to 36 percent in urban areas. B.5 Education 30. A lack of education increases a person’s vulnerability. Higher educational attainment for a household head or their partner significantly reduces the probability of falling into destitution. Also, a mother’s education significantly affects a child’s nutritional status and can break the intergenerational poverty cycle. Although education is an important complement to labor —it enhances productivity and potential earnings—the literacy rate is just 55 percent, and 28 percent of the population has never attended school (Table 1.7). Illiteracy is higher among women. 14 In October 2020, the Government of Guinea-Bissau, through the Ministry of Economy, Plan and Regional Integration, and its partners, released the results of the sixth Multiple Indicator Cluster Survey (MICS6), which data collection took place in 2018-2019. The sixth round of the MICS survey at the national level was carried out by the State Secretariat for Plan and Regional Integration and the National Statistics Institute (Instituto Nacional de Estatística or INE), benefiting from the technical and financial support of the European Union, UNFPA, WFP, UNDP and UNICEF. MICS6 included over 250 indicators and involved a sample of more than 7,000 families. See Guinea-Bissau (2020). 10 Table 1.7 Education Indicators (2002, 2010, 2018) Indicators 2002 2010 2018 Literacy rate (%) 41.1 49.7 55.4 Population with no education (%) 58.5 47.2 28.4 Net primary school attendance rate (%) 24.6 33.5 35.1 Lower secondary school attendance rate 6.2 15.9 25.0 Upper secondary school net attendance rate 1.2 0.9 9.7 Percentage of repetition in primary education, all grades, both sexes (%) 21.2 14.1 16.9 Primary completion rate, total (% of relevant age group) 26.9 62.2 70.1 Government expenditure per student, primary (% of GDP per capita) - 4.95 - Sources: ILAP 2002; ILAP 2010; EHCVM 2018. 31. Children from poorer families tend to receive less education. The percentage of children between 6 and 15 years of age who are enrolled in school monotonically increases with income— from 61 percent in Q1 to 88 percent in Q5 (Table 1.8). Almost 4 out of 10 children between the ages of 6 and 15 years in households in Q1 are not enrolled at school. One-third of these children are not enrolled for financial reasons. Average education expenditure represents 0.9 percent of adjusted expenditures for households in Q1 versus 1.5 percent for those in Q5. Table 1.8 Education Indicators by Quintile Variable Total Quintile Quintile Quintile Quintile Quintile Population 1 2 3 4 5 (Poorest) (Wealthiest) Children 6–15 enrolled in school 73.5 61.4 72.9 78.5 80.6 87.5 (% of children 6–15) Children 6–15 not enrolled in school 26.5 38.6 27.1 21.5 19.4 12.5 (% of children 6–15) Of whom: for financial reasons 29.9 33.6 28.2 23.5 25.6 36.7 (% of children 6–15 not enrolled) Education expenditures per enrolled 27,480 15,448 20,673 28,377 35,597 57,055 child (CFAF) (1.0%) (0.9%) (1.0%) (1.2%) (1.2%) (1.5%) (% of adjusted expenditures) Source: World Bank staff calculations based on Guinea-Bissau EHCVM 2018. B.6 Nutrition and health 32. Even though it has improved over time, the risk of nutritional deficiency is very high in Guinea-Bissau. According to the World Food Programme (WFP), more than half the population currently suffers from undernourishment (calorie intake is below the minimum recommended amount), and one-quarter is chronically malnourished. Proper nutrition is a determining factor for children’s physical health and important for a child’s development. According to MICS6, in 2018, 28 percent of children under age five years suffered from chronic malnutrition as measured by the stunting rate (<-2 Standard Deviation height-for-age), and 16 percent were underweight (<-2 Standard Deviation weight-for-age) (Guinea-Bissau 2020, p. 388). Guinea-Bissau’s malnutrition situation has stabilized since 2014 when 28 percent of children under age five years were stunted, and 17 percent were underweight (Guinea-Bissau 2016b, p.58). According to MICS6, only 2.7 percent of children between 6 and 23 months received the minimum acceptable diet in 2018 (Guinea-Bissau 2020, p.381). 33. Guinea-Bissau’s population is exposed to various health risks, including infectious and parasitic diseases, particularly in children. Malaria, acute respiratory infections, acute diarrheal diseases, tuberculosis, and HIV/AIDS are the main causes of morbidity and mortality in Guinea- Bissau. Obstetric complications, malaria, respiratory infections, and acute diarrheal diseases are responsible for most deaths in children.15 They also have consequences on cognitive development, 15 See http://www.cohred.org/wp-content/uploads/2012/09/National-Health-Research-Priorities-in-Guinea-Bissau.pdf. 11 future well-being, and adult productivity. A common source of morbidity is also related to iron deficiency in pregnant women and nursing mothers. Through its impact on fetal growth and micronutrient stores, the nutrition of the pregnant woman contributes to infant morbidity and mortality. In addition, only one-third of households use salt with an adequate iodine level, which is critical to developing normal cell metabolism (Guinea-Bissau 2020, p. 393). Although there has been a significant reduction in under-five and infant mortality over the past few decades, under-five mortality remains high at 56 per 1,000 live births and infant mortality at 36 per 1,000 live births (Guinea-Bissau 2020, p.136). 34. The risks associated with childbirth are very high. Maternal mortality remains extremely high explained by the difficult access to and poor quality of health centers and hospitals, especially in emergency situations, in addition to economic, social, and cultural factors. The maternal mortality rate for the period 2007 to 2014 was estimated at 900 per 100,000 live births (Guinea-Bissau 2016b, p.184), much higher than the average of 495 among low-income countries (World Bank, 2016b). Also, it is estimated that maternal deaths account for nearly one-quarter of all deaths of women in the reproductive age (Maternal Mortality Estimation Inter-Agency Group, undated). In addition, the risk of contracting a disease is elevated. In 2018, 28 percent of individuals reported being sick during the previous month (Table 1.9). About half of them sought treatment; 39 percent did not seek treatment for financial reasons (46 percent in Q1). Transport is also an issue as only one-third of the population lives within 30 minutes of a healthcare facility. Table 1.9 Health Indicators by Quintile Variable Total Quintile Quintile Quintile Quintile Quintile Population 1 2 3 4 5 (Poorest) (Wealthiest) Individuals reporting that they were sick during the last 27.9 22.4 26.7 27.6 32.1 36.3 30 days (% of individuals) Of whom: was treated 53.3 47.9 49.7 54.3 55.2 61.6 (% of sick individuals) Individuals untreated because they deemed 19.2 16.8 15.6 20.4 21.0 25.2 unnecessary (% of untreated individuals) Individuals untreated for financial reasons 39.3 46.3 45.2 38.5 33.1 26.4 (% of untreated individuals) Health expenditures per sick 10,031 7,224 8,412 9,826 11,718 15,528 person (CFAF) (0.4%) (0.4%) (0.4%) (0.4%) (0.4%) (0.4%) (% of adjusted expenditures) Treatment type (% of 100 100 100 100 100 100 treated individuals) Health center 56.9 65.7 65.3 56.8 51.8 44.5 Public hospital 24.0 16.8 18.0 23.5 27.3 34.7 Private hospital/clinic 9.3 5.0 6.3 9.4 11.2 14.8 Rural health community 3.8 6.1 3.7 3.5 4.1 1.4 worker Traditional medicine 3.5 4.9 4.3 3.9 2.4 1.8 Pharmacy 1.4 0.9 1.5 1.4 2.1 1.3 Other 1.1 0.6 0.9 1.6 1.1 1.5 Source: World Bank staff calculations based on EHCVM 2018. 35. Immunization coverage is improving rapidly. The number of unvaccinated children aged 12– 23 months fell to 5.1 percent in 2018. The most widely used vaccine is the Bacillus Calmette-Guérin 12 (BCG) vaccine primarily used against tuberculosis, with 93.7 percent of children vaccinated, followed by the diphtheria, tetanus and pertussis (DTP) vaccines, with 92.3 percent vaccinated.16 36. The HIV/AIDS epidemic remains a concern. The risk of contracting HIV/AIDS is high, with an adult prevalence rate of 3.4 percent in 2019.17 In 2018, 1,614 children were tested in general pediatric services (of whom 16.2 percent were HIV positive) and 686 children were tested at malnutrition treatment sites (of whom 23.6 percent were positive).18 As in most African economies, the epidemic is becoming feminized, with a prevalence rate of 4.1 percent in women compared to 2.6 percent in men. Nongovernmental organizations operating in this field, like Ayuda, Intercambio y Desarrollo (AIDA), recognize that male partners often reject the use of condoms, especially in the marital context, even if they know they are HIV-positive. C. Risks of Falling into Extreme Poverty 37. This section analyzes extreme poverty, which is a state of extreme deprivation from which it is extremely difficult to rebound with dire consequences on future generations, especially in a context of a low level of human capital. Table 1.10 displays variables that were found to be statistically significant correlates of expenditure per capita (p<0.1) predictors for household expenditure per capita and a subsequently increased vulnerability to shocks. The adjusted R-squared is 0.50, which indicates that the model explains 50 percent of the variation in household expenditures. 38. Several conditions are associated with vulnerability, defined as a lower level of expenditure per capita and an increased vulnerability to shocks. Expenditure per capita is negatively correlated with household size (Table 1.10). Expenditure per capita falls by 35 percent when household size doubles. This finding is consistent across urban and rural settings. Expenditure per capita is also negatively correlated with the number of children: adding a child to a household decreases the household’s expenditure per capita. Access to potable water and grid electricity is also positively correlated with expenditure per capita, supporting the notion that public infrastructure is critical to reducing household vulnerabilities. Expenditure per capita also correlates with the ownership of house titles and several housing characteristics (for example, a corrugated zinc roof, cement floor, or private bathroom). The ownership of assets (for example, a stove or a motorcycle) is also correlated with expenditure per capita. This correlation is broadly similar for urban and rural households. Expenditure per capita is also correlated with remittances received. Surprisingly, the variables related to the household’s level of education are not significant (they are not included in table 1.10 for this reason). The effect of education may be already incorporated in other variables, including the ownership of assets. 16 See Guinea-Bissau’s MICS-6, available at https://mics.unicef.org/surveys. 17 For more information, see the Joint United Nations Programme on HIV/AIDS - UNAIDS Guinea-Bissau country factsheet, available at http://www.unaids.org/es/regionscountries/countries/guinea-bissau. 18 This test was conducted as part of the Children and AIDS Project (Projecto Crianças e SIDA) (see chapter 3). 13 Table 1.10 Determinants of Adjusted Per-Capita Expenditure (Log of) Variable group Variables Overall Urban Rural -0.50 *** -0.50 *** -0.49 *** Household size (log of) (0.02) (0.02) (0.02) Family structure -0.01 ** -0.02 *** -0.01 Children (number of) (0.00) (0.01) (0.00) Housing 0.05 *** 0.05 *** 0.04 * situation Homeowner with title (0.02) (0.02) (0.01) (ref: other) 0.17 *** 0.16 *** 0.24 Potable water Basic services (0.03) (0.03) (0.25) (ref: not having) 0.15 *** 0.15 *** 0.20 ** Electricity (0.02) (0.02) (0.08) Remittances 0.07 *** -0.02 0.12 *** From Guinea-Bissau received (0.02) (0.03) (0.03) (ref: not 0.10 *** 0.06 0.11 ** From abroad receiving) (0.03) (0.05) (0.04) 0.08 *** 0.00 0.09 *** Zinc roof (0.02) (0.04) (0.02) House -0.06*** -0.09 *** 0.01 Clay walls characteristics (0.02) (0.02) (0.03) (ref: other 0.12 *** 0.07 *** 0.16 *** Cement floor materials) (0.01) (0.02) (0.02) 0.03 *** 0.06 *** 0.01 Private bathroom (0.01) (0.02) (0.02) 0.41 *** 0.37 *** 0.50 *** Car (0.04) (0.04) (0.09) 0.17 *** 0.09 ** 0.19 *** Motorcycle (0.02) (0.04) (0.02) 0.16 *** 0.12 *** 0.34 *** Stove (gas/electric) (0.03) (0.03) (0.08) Assets (total in 0.18 *** 0.19 *** 0.14 ** household) Computer (0.03) (0.03) (0.06) 0.18 *** 0.18 *** 0.00 Refrigerator (0.03) (0.03) (0.10) 0.10 *** 0.15 *** -0.07 Decoder (0.03) (0.03) (0.06) 0.13 *** 0.11*** 0.19*** Television (0.02) (0.02) (0.03) 13.44*** 13.56 *** 13.36 *** Constant term Constant (0.06) (0.11) (0.08) R-squared 0.50 0.56 0.38 Adjusted R-squared 0.50 0.55 0.37 224*** 104*** 84*** F-statistic (0.00) (0.00) (0.00) Number of observations 5,337 1,989 3,348 *** p < 0.01; ** p < 0.05; * p < 0.1. Source: EHCVM 2018. 14 Chapter 2 Social Protection: Institutions, Policies, and Financing Individuals demand mechanisms to reduce the impact of adverse effects on their welfare. However, traditional mechanisms do not offer an optimal degree of protection. Consequently, governments elaborate policies and implement programs to reduce the impacts of shocks and provide a level of protection beyond traditional mechanisms. In Guinea-Bissau, the principle of solidarity—the basis for social protection—is embodied in the 1984 Constitution. The 2007 Social Protection Framework Law defines the overall framework for social protection. It divides social protection into two categories: social insurance, which is contributory, and social assistance, which is not. In Guinea-Bissau, the coverage of the social insurance programs is extremely low (about 3 percent of the population). In contrast to social insurance programs, social safety net (also called social assistance) programs are noncontributory interventions designed to help individuals and households cope with shocks. Because government social assistance financing is extremely limited in Guinea-Bissau, complementary financing from donors is essential to reduce the risks borne by the population and its vulnerability. The Ministry of Women, Family and Social Solidarity is tasked with providing social assistance to civilians. However, its low level of human and financial resources limits its influence. Moreover, the lack of effective government leadership and financing of social assistance leaves it almost entirely dependent on international aid. This complicates coordination efforts, impeding reform and the momentum of development activities. ______________________ 1. Individuals demand mechanisms to reduce the impact of adverse events on their welfare. Traditional societies diversify their activities while relying on highly integrated interpersonal, interfamily, secular, and religious networks. They also develop behavioral norms and reciprocity rules that provide implicit insurance mechanisms. This system of reciprocity generally depends on an established structure of power and authority, the internalization of social norms, or repeated interactions. 2. Traditional mechanisms, however, do not offer an optimal degree of protection . An estimated 25 percent of households in Guinea-Bissau make cash or in-kind transfers to others, and one-third receive transfers over 12 months. However, the share of households making and receiving transfers increases monotonically with expenditure per capita, suggesting that poorer households face constraints to risk-sharing (Table 2.1). For example, only 15 percent of households in Q1 make transfers. In comparison, 17 percent receive transfers, indicating higher constraints to risk-sharing for the poor, who consequently maintain a higher level of residual risk. Furthermore, the covariate risks described in Chapter 1 must be borne by all households, including the poor. 3. Governments elaborate policies and implement programs to reduce the impacts of shocks and provide a level of protection that goes beyond traditional mechanisms. Chapter 1 reviews the risks and vulnerabilities faced by Guinea-Bissau’s population. This chapter describes the institutions responsible for social protection, the policies under implementation, and the overall financing of the social assistance programs. Chapter 3 reviews the social assistance programs in greater detail. 15 Table 2.1 Household Transfers to Friends and Family in Previous 12 Months, by Quintile Variable Total Quintile Quintile Quintile Quintile Quintile Population 1 2 3 4 5 (Poorest) (Wealthiest) Households that made transfers 24.5 14.6 18.9 19.2 28.3 41.4 (% of households) Households that received transfers 33.1 17.3 21.9 31.1 39.3 55.8 (% of households) Transfers made to friends and family (% of expenditures) 7.1 6.8 4.6 4.8 5.6 7.6 Transfers received from friends and family (% of expenditures) 12.8 9.7 10.4 10.9 8.5 13.7 Net cash transfers (% of expenditures) 3.1 2.9 6.0 5.8 2.1 3.1 Source: Staff calculations based on EHCVM 2018. A. Social Protection: Policies and Institutions 4. The principle of solidarity—the basis for social protection—is embodied in Guinea-Bissau’s 1984 Constitution. The 2007 Social Protection Framework Law defines the overall framework for social protection. It divides social protection into two categories: social insurance, which is contributory, and social assistance, which is not. 5. Social insurance programs are contributory interventions designed to protect individuals in situations of illness, maternity, occupational accidents, disability, old age (pension), and death (survivors’ benefits). In Guinea-Bissau, beneficiaries are civil servants, the military, political office bearers, employees of the formal private sector, and employees of state-owned enterprises. Individuals contribute a percentage of their earnings to a mandatory pension and insurance scheme. The scheme for civil servants, the military, and political office bearers is implemented by the Ministry of Public Administration, Labor, Employment and Social Solidarity (Ministério da Administrativo Pública, Trabalho, Emprego e Solidariedade Social). At the same time, the National Institute of Social Security (Instituto Nacional de Seguridade Social, or INSS) administers the scheme for the formal private sector. In 2016, it was estimated that only 2.8 percent of the labor force participated in the social insurance schemes, while approximately 3.9 percent of the elderly, defined as persons above age 60, benefited from a pension.19 6. In contrast to social insurance programs, social safety net (also called social assistance) programs are noncontributory interventions designed to help individuals and households cope with shocks. The government’s financing of social assistance is extremely limited in Guinea-Bissau. Consequently, complementary donor financing is essential to reduce the risks and vulnerabilities borne 19In January 2016, the government employed 19,398 public servants accumulating rights to a public service pension; 2,335 additional persons contributed to the social security pension scheme managed by INSS. World Development Indicators (2014) data indicate a labor force of 780,016. At the same time, 7,843 persons benefited from the public sector pension schemes and 2,308 benefitted from the social security pension scheme managed by INSS. However, only 48 percent of the beneficiaries were over age 60, suggesting that 97,749 persons were over age 60 (World Development Indicators, 2014). For a further discussion, see Auffret and Guven (2016). 16 by the population. Donors and NGOs seek to mitigate residual risk by designing, financing, and implementing social programs in coordination with the government.20 7. The Ministry of Women, Family, and Social Solidarity (Ministério da Mulher, Família e Solidariedade Social) (also referred to as the Ministry in charge of Social Solidarity) is responsible for providing social assistance to civilians.21 The ministry’s stated objective is “to formulate, propose, coordinate, and execute government policies, to promote integration and solidarity and social cohesion, the protection of women and families, and poverty re duction.� However, the ministry’s low level of human and financial resources limits its leadership capacity and influence. Consequently, social assistance strategies and initiatives are driven by donors and outlined in broad strategic documents. 8. The government outlines its strategy in Poverty Reduction Strategy Papers (PRSPs), which include a social assistance dimension. The first PRSP, for the period 2005–08, focused on achieving the Millennium Development Goals and supporting Guinea-Bissau’s poorest and most vulnerable. The second PRSP for 2011–15 outlined the government’s objective to increase employment—among the youth, in particular—and vocational training. It provided multiannual action plans and identified specific programs, including programs to reach poor and vulnerable groups, particularly women and children, and people with special needs. 9. In 2015, the government published an ambitious document, Terra Ranka (A Fresh Start), seeking to transform Guinea-Bissau in the decade between 2015 and 2025 (World Bank 2015). A national development plan for 2020–23, which included a social protection component, provided the basis for the first three years of Terra Ranka implementation. In addition, in October 2017, a Roadmap to Strengthen Social Protection in Guinea-Bissau (Roteiro para el Fortalecimento da Protecção Social na Guiné Bissau) was prepared and a committee was created to formulate a social protection strategy. However, this strategy is not yet finalized. 10. Donor strategies include their proposed interventions to reduce social vulnerabilities . For example, the UN’s Partnership Framework for 2022–26 includes two strategic outcomes related to social assistance: (i) equitable and sustainable access to health services, nutrition, HIV/AIDS, water, sanitation and hygiene, education, and quality of protection; and (ii) the promotion of sustainable management of the environment and natural resources, risk management, and disaster prevention. 11. The June 2021 update to the World Bank Group’s Country Partnership Framework (which covers June 2018–June 2023) guides its engagement in Guinea-Bissau. This engagement contains multiple objectives related to social assistance, including (i) enhancing resilience through the provision of social services in health, education, and potable water (Objective 1); (ii) strengthening the resilience of targeted communities and ecosystems in coastal areas (Objective 2); (iii) increasing access to quality health services for COVID-19 and maternal and child health (Objective 5); and (iv) strengthening social safety nets (Objective 6). Objective 6 involves the provision of cash transfers to vulnerable households and accompanying measures in health, nutrition, and gender empowerment; community-based microprojects supporting activities like school rehabilitation, water points, and rural roads; and the development of a social registry and broader social safety net system. World Bank Group initiatives, which will be coordinated with WFP, UNICEF, UNDP, and the European Union, also include the development of a government-owned database/unique registry to identify poor and vulnerable populations. 12. In 2011, the Food and Agriculture Organization prepared the Disaster Risk Management Strategy in West Africa and the Sahel (2011–13) and a corresponding Risk and Disaster 20 These programs are the subject of Chapter 3, which reviews the social assistance programs included in the 2020 and 2021 budget documents as well as several off-budget programs. 21 The Ministry of Women, Family, and Social Solidarity is divided into the General Directorate for Women and the Family and the General Directorate for Social Solidarity. The ministry also supervises the Social Action Foundation, the Institute for Women and Children, and the National Committee for the Abandonment of Harmful Practices. 17 Management Action Plan for Guinea-Bissau (FAO 2011). In addition, the Sub-Regional Action Program to Combat Desertification in West Africa, which covers Guinea-Bissau, seeks to respond to natural disasters (ECOWAS et al. 2013). 13. Additional strategies and plans related to social assistance include: • The National Nutrition Policy (Política Nacional de Alimentação e Nutrição) dated May 2011 aims to improve the population’s nutritional status, particularly vulnerable people, by fostering synergies between institutions directly involved in nutrition. The Zero Hunger Strategic Plan (2018–30) presents a strategic review of the food and nutrition security situation in Guinea-Bissau and defines the country’s strategy through 2030. An operational plan, which supports vulnerable populations during food crises, is integrated into the public investment program. • The Third National Health Development Plan 2018–22 (Plano Nacional de Desenvolvimento Sanitário III) emphasizes basic health care for the poorest and most vulnerable. The national health strategy, which centers on primary health care development in communities, targets a reduction in maternal and child mortality, promotes reproductive health, and combats HIV/AIDS, among other priorities. • The Plan to Accelerate Child and Maternal Mortality Reduction (Plano Operacional de Passagem à Escala Nacional das Intervenções de Alto Impacto relativamente à Redução da Mortalidade Materna e Infantil na Guiné Bissau, or POPEN) is a strategic document included in the National Health Development Plan for 2008-17 to coordinate all maternal and child health actors, including those involved with preventive and curative care packages. • The Master Plan for Water Supply and Sanitation (Plano Diretor de Abastecimento de �gua e Saneamento) 2010–20 aims to increase access to drinking water and sanitation.22 • The Education Sector Policy Charter 2009–20 (Carta da Política do Sector Educativo) and the Education Development Plan 2016–25 (Plano Sectorial da Educação da Guiné�Bissau) seek to improve education access and equity and school completion rates by prioritizing social, gender, and geographical inequalities. The main aims of these policies are to increase preschool enrollment rates and ensure a complete primary education for all children. • The 2017 National Policy for the Promotion of Gender Equality and Equity II seeks to integrate a gender dynamic into all policies, strategies, programs, and projects and highlights priority actions to improve women’s education. 14. Guinea-Bissau’s national laws related to social assistance include: • The Law to Prevent, Fight, and Suppress Female Genital Mutilation (FGM),23 approved in 2011, makes FGM illegal in Guinea-Bissau. In addition, the supporting national strategy provides training and community outreach on the consequences of FGM, supports NGOs and community-based campaigns to combat and denounce the practice, and offers social assistance to the victims. • The Law on Domestic Violence,24 adopted in 2013, and the Law to Protect against Gender- based Violence,25 adopted in 2014, define measures to protect victims of domestic violence. • The 1999 Law to Protect At-Risk Children and Youth26 and the Code of Conduct Against Children Exploitation from Travels and Tourism,27 adopted in 2016, provides awareness, tools, and support to the tourism industry to prevent the sexual exploitation of children. 22 See https://pascal.iseg.utl.pt/~cesa/files/BriefPapers/BriefPaperCEsA1_2015.pdf. 23 Law n° 14/2011 (Lei que visa prevenir, combater e reprimir a excisão feminina). 24 Law nº 6/2014 (Lei da Violência Doméstica). 25 Decree-law nº 6/14 (Decreto que criminaliza a Violência Doméstica - Lei Sobre a Violência Com Base no Género). 26 Law nº 147/99 (Lei de protecção de crianças e jovens em perigo). 27 Código de Conduta Contra a Exploração de Menores nas Viagens de Turismo. 18 • The Law on the Host Family and the Authorization and Inspection Regime28 for foster homes for children and youth was approved in 2017. • Adopted in 2011, the Law to Prevent and Combat Human Trafficking29 prohibits all forms of trafficking in persons and imposes criminal penalties. • The Law to Prevent, Treat, and Control HIV/AIDS,30 adopted in 2007, aims to reconcile individual rights and public health imperatives for people infected or affected by HIV/AIDS. 15. Guinea-Bissau has ratified the following social assistance-related international conventions: • The Convention on the Rights of the Child (in 1990) • The Convention on the Elimination of All Forms of Discrimination against Women • The International Covenant on Economic, Social and Cultural Rights • The United Nations Convention on the Rights of Refugees and their Additional Protocols • The Convention on Marriage Consent (which specifies the minimum age for marriage) • The Convention on Women’s Political Rights • The Convention on the Elimination of all Forms of Racial Discrimination • The International Convention on the Rights of Persons with Disabilities and its Optional Protocol (in 2014) B. Expenditures on Social Assistance 16. Estimating public expenditures on social assistance in Guinea-Bissau is challenging. The authorities do not use the standard “classification of the functions of government,�31 which would readily permit the identification of social protection expenditures. Instead, this study identified the social assistance programs included in the General State Budgets for 2020 and 2021 and the Budget Execution for 2020.32 Note that the expenditures reported in this section may not be comprehensive as ministries often spend outside the budget using off-budget resources or make expenditures without a budget line title.33 Also, these estimates do not include domestic or foreign donations for social assistance to NGOs and religious entities as these are not included in the budget. 17. Expenditures on social assistance programs amounted to US$35.1 million in 2020 (2.5 percent of GDP) and US$36.3 million in 2021 (Table 2.2). At 2.4 percent of GDP in 2021, spending on social assistance is above the global average (1.9 percent), the global median (1.4 percent),34 and the average for low-income Sub-Saharan African economies (1.1 percent of GDP).35 However, expenditures in 2020 and 2021 may be biased upward due to the high level of external assistance to fight the COVID-19 pandemic. The government finances a very small share of total social assistance expenditures (just 3.0 percent in 2020 and 4.4 percent in 2021); donors fund the rest. 28 Lei sobre Casas de Acolhimento de Crianças e Jovens e o regime de autorização e inspeção. 29 Law nº 12/2011 (Lei de Prevenção e combate ao tráfico de pessoas). 30 Law nº 5/2007 (Lei de prevenção, tratamento e controlodo VIH/SIDA). 31 The Classification of the Functions of Government, abbreviated as COFOG, was developed by the Organisation for Economic Co-operation and Development (OECD) in 1999 and published by the United Nations Statistical Division as a standard classifying the purposes of government activities. For more information, see https://www.oecd.org/gov/48250728.pdf. 32 See Chapter 3 for a detailed discussion of these social assistance programs. 33 For more details, see World Bank (2015). 34 As derived by Weigand and Grosh (2008), who found average expenditures on safety nets of 1.9 percent of GDP (median expenditures of 1.4 percent) based on an analysis of 87 economies. 35 Data from the World Bank’s Atlas of Social Protection Indicators of Resilience and Equity (ASPIRE); see https://www.worldbank.org/en/data/datatopics/aspire. 19 Table 2.2 Expenditures on Social Assistance Programs (US$ million) 2020 2021 Government 1.05 1.61 Donors 34.01 34.65 Total 35.05 36.26 Total (as a percentage of GDP) 2.5% 2.4% Sources: General State Budget for 2020 and 2021, Ministry of Finance. 18. Budgeted expenditures for the Ministry of Women, Family, and Social Solidarity were US$6.7 million in 2019, US$8.9 million in 2020, and US$3.3 million in 2021 (Table 2.3). Because this ministry was not included in the 2019 governmental structure, it had no budget allocation for 2019; the ministry was reestablished in 2020. However, the 2020 execution rate was only 20.2 percent. As a result, expenditures for the Ministry of Women, Family, and Social Solidarity represent 0.5 percent of total realized expenditures in 2020. Expenditures are highly dependent on external financing. Current expenditures were higher in 2020 than in 2019 due to incremental transfers to families affected by COVID-19 and other natural disasters, all financed externally. Also, investment expenditures are funded by donors and driven by each program’s disbursement capacity. In 2020, donor assistance (mainly grants) financed the public investment program in social assistance in its entirety. Key donors include the World Bank Group, West African Development Bank, African Development Bank, United Nations (UN) agencies (including UNICEF, UNDP, ILO, WFP, WHO, United Nations Population Fund (UNFPA), UN Women), and the European Union. In addition, donors collaborate with NGOs to fill gaps in public services, particularly in areas outside Bissau. Table 2.3 Expenditures by the Ministry of Women, Family and Social Solidarity (US$ million) 2019 2020 2021 Budget Budget Realized Budget Budget Current Expenses, of which: 0.363 5.140 0.422 1.289 Salaries 0.183 0.220 0 0.220 Good and Services 0.083 0.083 0.011 0.083 Transfers 0.096 4.837 0.411 0.985 Public Investment Program, of which: 6.319 3.758 1.361 1.976 Internal Financing 0.296 0.065 0 0.213 External Financing 6.023 3.693 1.361 1.763 Total 6.682 8.898 1.783 3.264 Total (% of total expenditures) 2.0% 2.1% 0.5% 0.8% M emo: Total Budget Expenditures 336.565 414.054 361.683 384.424 Source: Budget Execution for 2020 and General State Budget for 2021, Ministry of Finance. C. Analysis 19. Guinea-Bissau’s adoption of social assistance strategies, laws, international conventions, and plans has not reduced the vulnerabilities of the population to the degree expected. Most plans set ambitious objectives that depend on donor financing, which depends on the political situation. Donor funding in the area of social assistance vacillates as donors pull back and re-engage amid sporadic political crises. For example, the 2012 military coup halted all external financing, resulting in the de facto suspension of all externally-financed social assistance programs. 20. Donors are leading the elaboration of a social protection strategy. In October 2017, in coordination with the Ministry in charge of Social Solidarity, UNICEF initiated the development of a social protection strategy by preparing a Roadmap to Strengthen Social Protection in Guinea-Bissau (Roteiro para el Fortalecimento da Protecção Social na Guiné Bissau) and organizing a national forum 20 on social protection. In November 2017, UNICEF and the Ministry in charge of Social Solidarity established a committee to formulate a social protection strategy with the International Development Association (IDA), ILO, WFP, and several local NGOs. Workshops were organized in early 2018 to introduce several elements of social protection, including a social registry and health insurance. In March 2019, consultants hired by UNICEF drafted a Social Protection Diagnosis Report (Relatório de Diagnóstico da Proteção Social na Guiné Bissau) as an input a social protection strategy. Staffing changes at UNICEF and the Ministry in charge of Social Solidarity have left this document unfinalized. 21. The preparation of responses to natural disasters is also heavily dependent on donor assistance. In 2011, the Food and Agriculture Organization prepared the Disaster Risk Management Strategy in West Africa and the Sahel (2011–13) and a corresponding Risk and Disaster Management Action Plan for Guinea-Bissau (FAO 2011). However, these documents have not been updated, and government ownership remains weak. Guinea-Bissau has not acted on national progress reports on the implementation of the Hyogo Framework for Action prepared for 2009–11 and 2013–15.36 Guinea-Bissau has not implemented the Sub-Regional Action Program to Combat Desertification in West Africa and still needs to incorporate climate change risks and strategies into national programs. Guinea-Bissau currently lacks a community early warning and emergency response plan or national contingency plan. 22. The lack of government leadership has led to the ad hoc creation of “clusters� by donors . The main objective of these fora is to ensure the exchange of information and coordination among government actors and donors, including NGOs, around specific interventions. For example, the Water and Sanitation Thematic Group, led by the General Director of Water Resources, acts as an informal coordinating body for all interventions related to water and sanitation. The Local Education Group, led by UNICEF, coordinates interventions to increase access to basic education and build classrooms. The Gender Thematic Group and a group created under the national gender project of the NGO Konkourona Alliance Foundation (KAFO) coordinate interventions related to gender. The Cash Transfer and Voucher Working Group seeks to develop a harmonized approach for cash transfers and vouchers. These clusters have helped define Guinea-Bissau’s priorities, but they cannot substitute for government leadership and action. 23. The subnational administration’s role in providing social assistance is limited, primarily due to a lack of financial resources. A 1997 law established Guinea-Bissau’s political and administrative organization by dividing the country into regions and sectors.37 Under this law, regions were supposed to receive resources from the central government (in block grants and transfers from domestic revenues), complemented by regional-level revenues. However, in practice, the central government has made only one transfer to the regions since 2012 (in 2015). Also, the regions do not receive decentralized service revenues from customs, mines, ports, fishing, forestry, and tourism. As a result, they must finance their operations entirely from local resources, including income from markets, rentals, and land sales of questionable legality. The financial management of regions and sectors remains extremely weak (Brunet 2017).38 36 The Hyogo Framework for Action was the global blueprint for disaster risk reduction efforts between 2005 and 2015. 37 The 1997 law established Guinea-Bissau’s political and administrative organization, dividing the country into nine regions, one of which is the autonomous city of Bissau. The remaining eight regions are divided into 37 sectors. A governor—nominated by the government—has authority over all decentralized services provided by ministries present in the region. Each sector is managed by an administrator who is under the governor’s authority. 38 Locally-collected revenues are supposed to be deposited into commercial bank accounts and then credited to the government account at the central bank. In the absence of local treasury departments, all transactions are made in cash. In practice, local government officials (governors for regions, administrators for sectors) keep these revenues for their own use. Empirical evidence suggests that subnational-level budgets are not prepared systematically or transmitted regularly to the central government. Also, the budget nomenclature differs from one region to the next or even from one period to another for the same region. The budget’s content is also variable: it can cover both the regiona l level and the sectors, or only the regional level, with the sectors expected to set their own budgets. Revenue collection lacks a legal basis and appears to depend on the local context and the initiative of the local authorities (governors, administrators, and secretaries, who typically perform the role of accountant). Funds are kept in cash with little oversight, and the authorities use revenues 21 24. Consequently, local authorities lack the financial resources to provide adequate services. For example, municipal solid waste collection in Bissau is deficient and limited to a few neighborhoods (World Bank 2021). The city of Bissau has only one functioning landfill in Safim (the Antula municipal dump having closed). The two other largest cities, Bafatá and Gabú, have uncontrolled or open dumps where residents deposit garbage collected by cart. The majority of the population burns or buries their waste. The lack of solid waste management contributes to air and water pollution and remains a considerable public health challenge. 25. Because the regions and sectors have limited resources, local initiatives—including those for social assistance—depend almost entirely on external donor or NGO assistance. Local administrations are left to play a coordinating role, including for the implementation of critical social assistance programs. to finance expenditures directly. Accounts are not always kept; even when they are, they provide few details and there is no financial supervision. Overall, there is an absence of a common understanding and application of financial management. For more, see Brunet (2017). 22 Chapter 3 Social Assistance Programs Review This chapter represents a best effort to identify the social assistance programs included in the 2020 and 2021 General State Budget (Orçamento Geral do Estado) and classify them into cash transfers (including noncontributory social pensions), food and in-kind transfers, public works, fee waivers and targeted subsidies, and other social assistance. It reviews these programs and shows that total budgeted expenditures of the social assistance programs totaled US$35.1 million in 2020 and US$36.3 million in 2021, which are almost exclusively (over 95 percent) financed by donors. It also reviews programs not included in the budget and implemented by large NGOs. ______________________ 1. The previous chapter describes the institutions responsible for social protection, the related policies, and the financing of Guinea-Bissau’s social assistance programs. However, without an overall aid coordination mechanism, it is challenging to determine the actual yearly disbursements of each program and the amount benefitting households directly. This chapter attempts to identify those social assistance programs included in the General State Budget public investment programs for 2020 and 2021 (Table 3.2). It shows that social assistance is rather fragmented across institutions and programs which reinforces the need for leadership and institutional alignments. 2. This review has limitations. First, as indicated in Chapter 2, Guinea-Bissau does not use the standard classification of the functions of government. As such, the review’s identification of social protection programs may be imperfect. Second, the expenditures reported in this section are not comprehensive—ministries often spend outside the budget or make expenditures without a budget line title. Third, some programs financed by donors may not appear in the budget as they are either initiated too late during the budget preparation process or completed in under a year (and miss the window for inclusion in the budget as a result). These initiatives are generally small and financed directly by donor resources, as in the case of UNICEF’s support for Kangaroo Mother Care centers (see below). Fourth, the review excludes many small initiatives financed outside the budget from direct donations from abroad to NGOs and religious organizations. There is no official record of these donations. Fifth, and importantly, Table 3.1 reports budgeted expenditures, which may differ from actual expenditures. For example, budget expenditure execution was just 53 percent in 2020 and 73 percent in 2021 (Guinea-Bissau, 2021, p.7). Furthermore, some programs are not implemented even with a budget allocation, as in the cases (discussed below) of the food security support programs “Komo battle� and the Special Food Security Program (Programa de Especial da Segurança Alimentar). 3. In the absence of budget documents showing actual program-level expenditures,39 determining the disbursements of each program and the amounts benefiting households is not feasible. Instead, using the World Bank’s Atlas of Social Protection Indicators of Resilience and Equity (ASPIRE) classification,40 we divide the programs into cash transfers (including noncontributory social pensions), food and in-kind transfers, public works, fee waivers and targeted subsidies, and other social assistance. When a program spans several categories, we classify it in the category that includes most of its activities. We recognize that this classification may be slightly arbitrary. 4. The total cost of social assistance programs in Guinea-Bissau was US$35.1 million in 2020 and US$36.3 million in 2021. Donors financed over 95 percent of these costs (Tables 3.1 and 3.2). 39 The 2020 realized budget provides aggregate data but does not provide disbursements at the program level. 40 See World Bank (2018). 23 The composition of spending varies across program categories from 2020 to 2021. For example, the share of in-kind transfer programs of budgeted total expenditure rose from 17 percent in 2020 to 32 percent in 2021, public works increased from 6 percent in 2020 to 22 percent in 2021, and budgeted expenditures related to fee waivers and targeted subsidies decreased during the same period. Table 3.1 Social Assistance Programs by Program Classification, 2020 – 21 (% of total expenditures on social assistance programs) Program classification 2020 2021 1. Cash transfers 5.7 3.0 2. Food transfers 4.9 5.2 3. In-kind transfers 17.0 32.2 4. Public Works 6.3 22.0 5. Fee waivers and targeted subsidies 51.2 30.5 5. Other social assistance 14.9 7.1 Total 100.0 100.0 Sources: General State Budget 2020 and 2021, Ministry of Finance. A. Cash transfers 5. Guinea-Bissau’s main cash transfer program is the US$15 million Social Safety Nets and Basic Services Project (Projecto de Redes Sociais e Serviço de Base), financed by IDA. The project provides unconditional cash transfers with nutrition-related accompanying measures in Bissau and the regions of Gabú, Cacheu, and Oio. Under implementation since 2018, the project seeks to build a well-targeted safety net program, including a social registry. By the end of September 2021, 5,239 households (about 50,000 individuals) had benefitted from at least one quarterly cash transfer, paid at bank counters in Bissau or via mobile money elsewhere. Preliminary outcomes from a randomized controlled trial impact evaluation provide strong evidence of socioeconomic improvements in consumption, total expenditures, diet diversity, the value of assets, and educational outcomes. 6. The Ministry of Defense and Homeland Freedom Fighters implements a noncontributory public pension scheme (Social Pension Fund) for former combatants. Expenditures of US$199,000 were budgeted in 2021, funded by donors. It is unclear what the Social Pension Fund finances, but the authorities report making monthly payments of CFAF 49.5 million (equivalent to approximately US$92,000) through the banking system to 316 former combatants or their descendants, and CFAF 81.2 million (equivalent to approximately US$150,000) in cash payments to 1,934 former combatants or their dependents. 7. In partnership with the UN High Commission for Refugees, the Ministry of Interior implements the National Project for Refugees and Internally Displaced Persons (Projecto Nacional Para Refugiados e Deslocados Internos). According to the 2021 Budget, project financing is split between the government (US$43,000) and donors (US$127,000). As of 2019, the program had registered 3,707 refugees of the 8,000 refugees identified for naturalization.41 8. In May 2021, the World Food Programme (WFP) and the National Civil Protection Service (Serviço de Proteçao Civil) launched the Civil Protection Project ( Projeto de Proteçao Civil). This project provides four months of cash assistance to vulnerable households that lost their houses or crops during storms in July –October 2020. A total of 851 households (approximately 7,000 people) received a monthly allowance of CFAF 40,000 (roughly US$74) in May–August 2021, financed by the governments of Japan and Italy. An additional 59 households in the Buba sector of the Quinara region benefited from the same program during June–August 2021, also supported by Japan.42 41 See https://data2.unhcr.org/en/country/gnb. 42 For more information, see https://reliefweb.int/report/guinea-bissau/wfp-guinea-bissau-country-brief-may-2021. 24 Table 3.2 Social Assistance programs included in the 2020 and 2021 budgets (US$ thousand) 2020 2021 Program Responsible Ministry Source of Financing Source of Financing Government Donors Total Government Donors Total 1. Cash transfers Social Safety Nets and Basic Services Project Ministry of Planning and Regional Integration 0.00 1746.48 1746.48 0.00 692.88 692.88 Social Pension Fund Ministry of Defense and Homeland Freedom Fighters 0.00 0.00 0.00 0.00 199.03 199.03 National Project for Refugees and Internally Displaced Persons Ministry of Interior 18.54 195.03 213.58 42.65 127.25 169.89 Civil Protection Project Ministry of Interior 37.09 0.00 37.09 37.09 0.00 37.09 Sub-total 55.63 1,941.51 1,997.14 79.73 1,019.16 1,098.89 2. Food transfers School Feeding Program Ministry of Education 0.00 0.00 0.00 108.13 455.25 563.38 Integrated Support to Rural Development Project Ministry of Agriculture and Rural Development 0.00 1291.27 1291.27 0.00 415.06 415.06 Program to Treat MAM in Children between 6-59 Months Ministry of Public Health 0.00 322.63 322.63 0.00 322.63 322.63 Project to Fight Food Insecurity in the Regions of Oio and Cacheu Ministry of Environment and Biodiversity 0.00 0.00 0.00 0.00 261.06 261.06 Project to Support School Canteens and Nutrition Ministry of Education 0.00 0.00 0.00 0.00 162.50 162.50 Program to Support Food Security "Komo Battle" Ministry of Defense and Homeland Freedom Fighters 55.63 0.00 55.63 92.71 0.00 92.71 Program of Complementary Food Supplies for Children Ministry of Public Health 0.00 60.72 60.72 0.00 60.72 60.72 Sub-total 55.63 1,674.62 1,730.25 200.85 1,677.22 1,878.06 3. In-kind transfers Support to Aldeias Infantis SOS Ministry of Women, Family and Social Solidarity 27.81 2211.11 2238.92 37.09 6349.63 6386.72 Child Protection Project Ministry of Women, Family and Social Solidarity 0.00 1118.77 1118.77 0.00 3895.84 3895.84 Program for Basic Education and Gender Equality Ministry of Education 0.00 2316.01 2316.01 0.00 832.58 832.58 Family Strengthening Ministry of Women, Family and Social Solidarity 0.00 110.14 110.14 37.09 481.00 518.09 Project of Social and Humanitarian Support Ministry of Defense and Homeland Freedom Fighters 0.00 0.00 0.00 25.96 0.00 25.96 Special Food Security Program Ministry of Agriculture and Rural Development 166.89 0.00 166.89 18.54 0.00 18.54 Project to Fight Child Labor and Child Mendicity Ministry of Women, Family and Social Solidarity 0.00 0.00 0.00 9.27 0.00 9.27 Sub-total 194.70 5,756.03 5,950.72 127.95 11,559.05 11,687.00 4. Public Works Emergency Food Security Project Ministry of Agriculture and Rural Development 0.00 2225.15 2225.15 0.00 7977.35 7977.35 Sub-total 0.00 2,225.15 2,225.15 0.00 7,977.35 7,977.35 5. Fee waivers and targeted subsidies Program to reduce the Incidence of Tuberculosis Ministry of Public Health 27.81 2598.05 2625.87 92.71 2598.05 2690.77 Project to Reduce the Mortality and Mobidity due to Malaria Ministry of Public Health 27.81 6443.36 6471.17 92.71 1856.50 1949.21 Program for the Reduction of the Incidence of HIV in the Populations Ministry of Public Health 27.81 3648.64 3676.45 92.71 1794.35 1887.06 Vaccine Supply Support Program Ministry of Public Health 463.97 1852.78 2316.75 370.37 925.93 1296.30 Project to Strengthen Maternal Infant Health Services Ministry of Public Health 0.00 1526.22 1526.22 0.00 1155.37 1155.37 Children and AIDS Project Ministry of Public Health 0.00 1081.05 1081.05 0.00 1081.05 1081.05 Integrated Program for the Reduction of Maternal-Infant Mortality Program Ministry of Public Health 0.00 0.00 0.00 0.00 556.29 556.29 Project for the Implementation of Social Development Programming Ministry of Women, Family and Social Solidarity 0.00 83.00 83.00 0.00 156.36 156.36 Project of Social Assistance to the Principal Military Hospital Ministry of Defense and Homeland Freedom Fighters 83.44 0.00 83.44 93.56 0.00 93.56 Program for the Prevention and Care of Infectious Diseases Ministry of Defense and Homeland Freedom Fighters 37.09 0.00 37.09 92.71 0.00 92.71 Social Mobilization and Fight against STD/HIV/AIDS Project Ministry of Women, Family and Social Solidarity 37.09 0.00 37.09 55.63 0.00 55.63 Project for Hospitalized Social Assistance and Support to Patients in Need Ministry of Public Health 0.00 0.00 0.00 46.36 0.00 46.36 Sub-total 705.03 17,233.09 17,938.13 936.78 10,123.89 11,060.66 5. Other social assistance Child Survival "Nutrition, Water and Sanitation� Program (WASH) Ministry of Public Health 0.00 5156.78 5156.78 0.00 2189.92 2189.92 Promotion of Income Generating Activities, Good Practices and Equity Ministry of Territorial Administration and Local Power 0.00 0.00 0.00 174.61 0.00 174.61 Support to the National AIDS Coordinatin Secretariat Presidency 37.09 0.00 37.09 92.71 0.00 92.71 Program for the Autonomy of Women who Process Agricultural Products Ministry of Women, Family and Social Solidarity 0.00 18.54 18.54 0.00 83.00 83.00 Women Have Words Platform Ministry of Women, Family and Social Solidarity 0.00 0.00 0.00 0.00 18.54 18.54 Sub-total 37.09 5,175.32 5,212.41 267.32 2,291.45 2,558.77 Total 1,048.08 34,005.72 35,053.80 1,612.62 34,648.11 36,260.73 Sources: General State Budget 2020 and 2021, Ministry of Finance. 25 9. In November 2020, WFP launched an inclusive education project to support children living with disabilities in the regions of Oio and Cacheu. The Japanese government provides financial support through WFP; an NGO, Humanity and Inclusion, is responsible for implementation. The project aims to strengthen the capacity of the Ministry of Education’s recently-established General Directorate for Inclusive Education. The project identifies vulnerable households with children with disabilities, procures hygiene kits to prevent the spread of COVID-19, and conducts sensitization activities for communities and stakeholders. At the end of May 2021, 110 children living with disabilities had benefitted from at least one monthly cash transfer under the program. This program is not included in the budget because it was prepared after the submission of the 2021 General State Budget to the National Assembly. 10. In 2020, the Ministry of Women, Family and Social Solidarity spearheaded the COVID-19 Rapid Response Program with implementation support from UNICEF, WFP, and UNDP. The program is included neither in the 2020 budget (because it was prepared after budget submission) nor in the 2021 budget (because it was completed by end-2020). It provided unconditional cash transfers to 1,200 vulnerable households in Gabu, Oio, Cacheu, and Biombo. The program targeted the most vulnerable in the selected areas, providing three monthly payments of US$70 in October, November, and December 2020 (a total of US$210 per household). 11. In 2021, together with the Global Partnership for Education and the Portuguese cooperation agency,43 UNICEF is implementing an unconditional cash transfer program in the regions of Gabú, Bafata, and Oio to vulnerable households with at least one child enrolled in school. By end-October 2021, 1,400 households had benefitted from six monthly cash transfers of CFAF 40,000 paid via mobile money. This program was not included in the national budget. 12. Cash transfers from NGO’s—financed by external donations—are also not included in the national budget. For example, an Italian NGO, Manitese, finances cash transfers under a program to combat violence against women through awareness, measures for women’s socioeconomic autonomy, and support for victims of violence and forced marriage. A Senegalese NGO, ENDA-Tiers Monde, financed by the European Union and LuxDev (Luxembourg’s development cooperation agency), provides cash transfers to socially-excluded groups, including child laborers, sex workers, and lesbian, gay, bisexual, transgender, and intersex (LGBTI) persons, persons with HIV/AIDS, and prisoners. The program also provides microcredit loans to finance income-generating activities in the regions of Canchungo and Gabú. B. Food transfers 13. Two school feeding programs fall under the responsibility of the Ministry of Education: (i) The School Feeding Program is the main school feeding program in the budget document. Catholic Relief Services (CRS) implements this four-year (2019–23) program, which is financed by the United States Department of Agriculture under the McGovern-Dole Food for Education Program in the amount of US$17 million. The program provides donations of U.S. agricultural commodities and financial and technical assistance to support school feeding. Budgeted expenditures in 2021 were US$563,000 (comprising US$108,000 from the government budget and US$455,000 from the United States Agency for International Development). The program is implemented in partnership with Plan International, Caritas Guinea-Bissau, the Ministry of Education, and the Ministry of Public Health. It operates in 350 schools in five regions (Oio, Cacheu, Quinara, Bafata, and Gabu). (ii) The Project to Support School Canteens and Nutrition (Projecto de Apoio para Cantinas e Nutrição) is implemented by WFP and financed by donations from Japan and the Republic of China totaling US$163,000. The project, which provides over 173,000 hot meals daily at 43 Camões–The Institute of Cooperation and Language (Instituto Camões da Cooperação e da Lingua). 26 schools to encourage school enrolment and attendance, operates in Oio, Bafata, and Gabu regions. In addition, take-home food rations for female students encourage girls to attend and remain in school. WFP is working to strengthen the government’s capacity to manage the school meal program so that it can eventually take ownership. 14. The Ministry of Agriculture and Rural Development is responsible for the Integrated Support to Rural Development Project (Projecto de Apoio Integrado ao Desenvolvimento Rural). This US$1.0 million, four-year (2019–22) project, implemented by WFP with funding from the European Union, supports nutrition monitoring and food subsidies for vulnerable populations. It includes a food-for-asset component that provides food, training, and other services in exchange for building community infrastructure.44 15. The Ministry of Public Health is responsible for the following nutrition programs: • The Program to Treat Moderate Acute Malnutrition (MAM)45 in Children 6–59 Months (Programa Tratamento de MAM das Crianças de 6-59 Meses). This US$323,000 program, financed by the government of Japan and implemented by WFP, provides nutritional support to fight malnutrition in children under the age of five years and pregnant and lactating women. It aims to treat 2,000 children per year. • The Complementary Food Supply for Children Program (Programa de Fornecimentos de Alimentos Complimentares para Crianças). Sweden and Norway finance this US$61,000 program (2021), which WFP implements. The program provides super cereal food complements CSB++46 to children suffering from MAM. It seeks to prevent stunting in 6,681 children in Oio, Bafatá, and Gabu, the areas with the highest stunting rate in Guinea-Bissau. 16. The Ministry of Environment and Biodiversity implements the Project to Fight Food Insecurity in the Regions of Oio and Cacheu (Luta Contra a Insegurança Alimentar nas Regiões de Oio e Cacheu in Guiné Bissau), which includes in-kind transfers financed by donors totaling US$260,000 in 2021. 17. The Ministry of Defense has a commitment to execute a small program to provide food support to families that participated in the “Komo battle.� However, the authorities report that this program has not been implemented. C. In-kind transfers 18. The international NGO SOS Children’s Villages International (SOS Aldeias Infantis) implements a program to provide housing, food, education, and health services to 252 orphans in Bissau, Canchungo, and Gabu. Budget expenditures in 2021 total US$6.4 million, financed from the NGO’s resources from private donations from the Netherlands and a government contribution of US$37,000. 19. The Ministry of Women, Family, and Social Solidarity (Ministério da Mulher, Família e Solidariedade Social) is responsible for the Child Protection Project (Projeto de Proteçao da Criança). The program provides support to the Woman and Child Institute (Instituto Mulher e Criança) in the form of training to enhance the technical capacity of social workers, development of communication tools to raise awareness about child protection, interventions for child protection, and 44 See https://ec.europa.eu/europeaid/projects/monitoring-nutrition-and-livelihoods-support-vulnerable-population-guinea- bissau_en. 45 In children aged 6–59 months, MAM is defined as moderate wasting (that is, weight-for-height between –3 and –2 Z- scores on the WHO Child Growth Standards median) and/or mid-upper-arm circumference (MUAC) greater or equal to 115 mm and less than 125 mm. 46 For more information on CSB++, see https://documents.wfp.org/stellent/groups/public/documents/communications/wfp252207.pdf. 27 integral support to foster homes (training educators, monitoring the situation of children, and so on). It is financed largely by UNICEF and the United Nations Population Fund (UNFPA). Budgeted amounts were US$1.1 million for 2020 and US$3.9 million for 2021. 20. The Program for Basic Education and Gender Equality (Programa Educação Base e Igualdade Dos Géneros) is implemented by the Ministry of Education with budgeted expenditures of US$2.3 million in 2020 and US$833,000 in 2021, financed by donors. 21. The Ministry of Women, WFSS, is responsible for the Family Strengthening (Fortelecimento Familiar) budget line, which provides food, medicine, hygiene kits, and free education to more than 400 orphans living with host families and microcredits to families. Budget expenditures are US$518,000 in 2021, of which US$481,000 is provided by the international NGO SOS Children’s Villages International (SOS Aldeias Infantis) and US$37,000 from domestic resources. 22. The Secretary of State for Combatants at the Ministry of Defense implements the Project of Social and Humanitarian Support (Projecto de Apoio Social e Humanitario) financed from the national budget in the amount of US$26,000 in 2021. It covers the cost of medical assistance, including medicine, surgical operations, orthopedic prostheses, wheelchairs, and funerals for former combatants and their descendants. 23. The Special Food Security Program (Programa de Especial da Segurança Alimentar), with budgeted expenditures of US$167,000 in 2020 and US$19,000 in 2021, is financed with government resources. However, according to the Ministry of Agriculture and Rural Development, this program is not being implemented. 24. The Project to Fight Child Labor and Child Mendicity (Projecto para Combater o Fenómeno do Trabalho e da Mendicidade Infantil) provides support to vulnerable street children. It is implemented by the Woman and Child Institute under the oversight of the Ministry of Women, Family, and Social Solidarity and financed by government resources (US$9,000 in 2021). D. Public works 25. The Emergency Food Security Project (Projecto de Urgencia de Segurança Alimentar), financed by IDA in the amount of US$15.0 million, includes a US$2.5 million cash-for-work component in the regions of Cacheu and Oio. The project aims to provide food security to households affected by job losses by mitigating income shortfalls through community-level public works. As a result, the project also contributes to public infrastructure development. The Food and Agriculture Organization (FAO) is expected to implement the cash-for-work component, which will pay wages, procure tools and equipment, and pay costs related to the payment of wages via mobile money. The project is expected to benefit 10,000 workers. 26. The Resilience Building Project, funded by the Japanese government and implemented by WFP and local NGOs, includes a cash-for-work component aimed at rehabilitating mangroves in the regions of Bafata, Gabu, and Oio. The project seeks to protect the livelihood of vulnerable households and build their resilience to food crises while improving rural communities’ access to basic social services. It is expected to benefit roughly 2,400 households with a daily wage of CFAF 1,679 (about US$1.80) for 60 days. The Resilience Building Project also includes a food-for-work component targeting 1,150 households in the Tombali region, paid with rice vouchers. This project is not included in the budget. 28 E. Fee waivers and targeted subsidies 27. The Global Fund finances the following programs, which fall under the Ministry of Public Health:47 • Program to Reduce the Incidence of Tuberculosis (Programa da Redução da Incidência da Tuberculose). With a budget allocation of US$2.7 million, this program was financed almost entirely by the Global Fund in 2021. It finances Hospital Raoul Follereau, which specializes in treating tuberculosis. • Project for the Reduction of Malaria-Related Mortality and Morbidity (Projeto da Disminuição da Mortalidade e Morbilidade relacionadas com a Malaria). This project provides insecticide-treated bed nets, malaria tests, and malaria treatment free of charge. Budgeted expenditures are US$6.5 million in 2020 and US$1.9 million in 2021. • Program for the Reduction of HIV Incidence in the Population (Programa para a Redução a Taxa de Incidência do HIV nas Populações em Guiné Bissau). This program provides HIV testing and HIV/AIDS treatment free of charge. Budgeted expenditures in 2021 were US$1.8 million from donors and US$93,000 from domestic resources. • The Children and AIDS Project (Projecto Crianças e SIDA). UNICEF implements this project, which seeks to respond to the high prevalence of HIV/AIDS among children (see Chapter 1). With budgeted expenditures of US$1.1 million in both 2020 and 2021, the project seeks to increase diagnostic capacity, provide access to treatment, and target the vertical transmission (from others to infants) of HIV/AIDS. • Social Mobilization and Fight against HIV/AIDS Project (Projecto de Mobilização Social e Luta contra “IST/VIH/SIDA�). With a national budget allocation of US$55,630 in 2021, this project—implemented by UNICEF and UNFPA—raises awareness of HIV/AIDS among children and adolescents and provides treatment to those affected. The National Youth Committee (Comite Nacional de Juventude) and the Youth Institute (Instituto de Juventude) support project implementation. 28. With the support of UNICEF, the Ministry of Public Health implements routine vaccination campaigns financed through the Vaccine Supply Support Program (Programa de Suportes de Aprovisionamento de Vacinas).48 Budgeted expenditures were US$2.3 million in 2020 (US$464,000 from the government and US$1.9 million from the GAVI Alliance49) and US$1.3 million in 2021 (US$370,000 from the government and 926,000 from GAVI). The government financed the minimum immunization package for children below nine months of age, including tetanus, polio, measles, pneumococcus (PCV13),50 and BCG.51 However, these vaccines are frequently out of stock due to a lack of financing, which has led donors to cover the cost (UNICEF in recent years and IDA in 2021). GAVI finances other vaccines such as yellow fever, amaryllis, rotavirus, and pentavalent vaccine.52 In addition, UNICEF and WHO also provide logistical support for additional vaccination campaigns 47 The Global Fund, present in Guinea-Bissau since 2004, is an international financing and partnership organization that aims to attract, leverage, and invest additional resources to end the epidemics of HIV/AIDS, tuberculosis. and malaria. For more information on the Global Fund, see https://en.wikipedia.org/wiki/The_Global_Fund_to_Fight_AIDS,_Tuberculosis_and_Malaria. 48 For more, see https://www.unicef.org/guineabissau/child-and-maternal-health 49 Gavi, officially Gavi, the Vaccine Alliance is a public–private global health partnership with the goal of increasing access to immunization. Gavi is co-leading COVAX, the vaccine pillar of the Access to COVID-19 Tool in poor countries. 50 The pneumococcal conjugate vaccine (PCV13) protects against 13 types of bacteria that cause pneumococcal disease. 51 BCG (Bacille Calmette-Guerin) is a vaccine against tuberculosis (TB). 52 Pentavalent vaccine provides protection to a child from 5 life-threatening diseases: Diphtheria, Whooping cough (Pertussis), Tetanus, Hepatitis B and Hib disease (Haemophilus influenzae type b). 29 such as polio vaccination campaigns for children under age five years or pentavalent vaccine for children under age one year. 29. The Project to Strengthen Maternal-Infant Health Services (Projecto de Fortalecimento dos Serviços de Saúde Materno-Infantil), financed by IDA in the amount of US$25 million, seeks to increase the demand for key reproductive, maternal, and child health care services through outreach activities, promoting disease-preventing behaviors through community-based interventions, and providing stipends to Community Health Workers (see below).53 Until its closing date of December 2025, the project is expected to provide essential health, nutrition, and population services to 73,000 beneficiaries, allow 65,000 children below age one year to be fully vaccinated, finance basic nutrition services to 10,000 women and children, and provide at least one healthcare consultation to 150,000 children between one and five years of age. The project will be implemented in partnership with UNICEF and NGOs with a local presence in Guinea-Bissau, including Instituto Marquês de Valle Flôr (IMVF), and Caritas. The budget allocation in 2021 is US$1.2 million. 30. In 2009, UNICEF recommended that the government revitalize community-based health interventions with the aim of reducing maternal, neonatal, and infant mortality . In 2010, with UNICEF's support, the Ministry of Public Health developed the Operational Plan to Scale Up High- Impact Interventions in Guinea-Bissau (Plano Operacional de Passagem à Escala Nacional das Intervenções de Alto Impacto relativamente à Redução da Mortalidade Materna e Infantil, or POPEN). Starting in 2013, the European Union began supporting POPEN and financing the Integrated Program for the Reduction of Maternal-Infant Mortality Program (Programa Integrada para a Redução da Mortalidade Materno-Infantil em Guinea-Bissau, or PIMI). Since September 2014, the program has financed (i) doctor consultation fees for children below age five years, pregnant women, and the elderly, and the cost of basic medicines, medical analyses, and chirurgical cesareans; (ii) technical assistance, institutional capacity building, provision of medical equipment and materials, and regular formative supervision of health facilities (currently 35 maternal wards in all 11 health regions of Guinea-Bissau) to improve the availability and quality of maternal and neonatal care; and (iii) the creation of a national network of approximately 4,000 Community Health Workers to promote health awareness, good practices, and increase health center attendance in rural communities. The initial financing of €3.0 million (PIMI 1)—coordinated by UNICEF and implemented by international NGOs54—was completed in 2018 in five regions of Guinea-Bissau. The program was gradually expanded nationwide with other EU funding from EU Health (€5 million) and PIMI 2 (€6.0 million).55 The 2021 Budget includes US$556,000 for PIMI 2. Its future activities are expected to be financed from the IDA-financed Project to Strengthen Maternal-Infant Health Services (see above). 31. Under the Project for the Implementation of Social Development Programming – Scholarship for Excellence (Projecto de Implementação da Programação de Desenvolvimento Social – Bolsa Excelência), the Woman and Child Institute implements a program that provides scholarships to vulnerable girls and victims of forced marriage. The Economic Community of West African States (ECOWAS) finances the project, which had a budget allocation of US$156,000 in 2021. 32. The Ministry of Defense finances the Principal Military Hospital Social Assistance Project (Projecto de Assistência Social ao Hospital Militar Principal), which had a budget allocation of US$94,000 in 2021. It also finances and implements the Program for the Prevention and Care of 53 Community Health Workers are not health professional. However, they are expected to treat simple diarrhea in children under five with Oral Rehydration Solutions (ORS) and zinc and pneumonia with amoxicillin. They promote 16 key family practices to prevent diseases in children, including exclusive breastfeeding up to six months, nutrition of young children, handwashing, and use of a mosquito net. They also promote birth registration. 54 These NGOs included Instituto Marquês de Vale-Flor (IMVF), Voluntariado Interancional para o Desenvolvimento Africano (VIDA), and the Associazione Italiana Amice di Raoul Follereau (AIFO) 55 See https://ec.europa.eu/international-partnerships/stories/reducing-maternal-and-child-mortality-guinea-bissau-pimi- ii_en. 30 Infectious Diseases (Programa de Prevenção a Assisténcia à Doença Infectocontagiosa) in the amount of US$37,000 in 2020 and US$93,000 in 2021. Both projects provide free consultations and medicines to vulnerable patients. 33. The Project for Hospital Social Assistance and Support to Patients in Need (Projecto de Assistência Social Hospitalar, Apoio aos Pacientes Carenciados) provides social services and medicines to vulnerable families at Simão Mendes National Hospital and health centers in Bissau. This project is financed entirely from the national budget in the amount of US$46,000 in 2021. 34. Between 2017 and 2019, UNICEF financed nine Kangaroo Mother Care Units to improve the health care of newborns (0–28 days) at a cost of US$1.5 million.56 Forty hospital health staff were trained in situ on Kangaroo Mother Care. Currently, UNICEF only provides technical support financed from its own resources. This activity is not included in the national budget. 35. Two COVID-19 Response and Recovery Funds (US$1.0 million total) were initiated in May 2020 as part of the United Nations COVID-19 Response Multi-Partner Trust Fund (UN COVID-19 MPTF). Implemented by the International Organization for Migration (IOM), UNDP, UNICEF, WFP and WHO. These seek to mitigate the negative impacts of COVID-19 on Guinea- Bissau’s most vulnerable populations.57 Support from IDA was provided through the second phase of the Regional Disease Surveillance Enhancement (REDISSE) Project that provided US$6.5 million to UNDP to procure Personal Protective Equipment (PPE) to limit the spread of COVID-19. In addition, a COVID-19 Vaccine Project in the amount of US$5.0 million, to be implemented by the Office of the High Commission for COVID-19, was approved by IDA in June 2021 and an additional financing in the amount of US$2.2 million is being processed. F. Other social assistance programs 36. The “Nutrition, Water, and Sanitation� Child Survival Program (Programa Sobrevivencia das Crianças “Nutrição, Agua, Saneamento�) is the Water, Sanitation, and Hygiene (WASH) program implemented by UNICEF with financing from a Multi-Donor Trust Fund financed with resources from the governments of Japan, the United Kingdom, and the Netherlands, and UNICEF. This large program has budgeted expenditures of US$5.2 million in 2020 and US$2.2 million in 2021. It provided innovative latrine designs in 20 schools in Bafatá and Oio, accompanied by the introduction of the Three-Star Approach for WASH in Schools, with special attention to menstrual hygiene.58 37. The Ministry of Territorial Administration and Local Power implements cash transfers under the budget line for Promotion of Income-Generating Activities, Good Practices, and Equity (Promoção De Actividades Geradoras De Rendimentos, Boas Praticas, Equidade), financed in the amount of US$175,000 in 2021 from domestic resources. According to the Ministry of Territorial Administration and Local Power, this program has not been implemented. 38. The Ministry of Women, Family, and Social Solidarity is responsible for the Program for the Autonomy of Women who Process Agricultural Products (Programa de Autonomização de 56 Kangaroo mother care is a method of care of preterm infants. The method involves infants being carried, usually by the mother, with skin-to-skin contact. This guide is intended for health professionals responsible for the care of low birth weight and preterm infants. Designed to be adapted to local conditions, it provides guidance on how to organize services at the referral level and on what is needed to provide effective kangaroo mother care. For more details, see https://www.who.int/publications/i/item/9241590351. 57 For more information, see https://mptf.undp.org/factsheet/country/GNB. 58 The Three Star Approach for WASH in Schools is designed to improve the effectiveness of hygiene behavior change programs for children. It complements UNICEF's broader child-friendly schools initiative and the German Corporation for International Cooperation's (Deutsche Gesellschaft für Internationale Zusammenarbeit, or GIZ) “Fit for School� approach, which promotes safe, healthy, and protective learning environments. 31 Mulheres Transformadoras de Produtos Agricola), which provides small grants to women working in the agricultural sector to initiate small food processing businesses (palm oil, mango marmalade, and so on). It is financed entirely by ECOWAS (US$83,000 in 2021) and implemented by the Woman and Child Institute. 39. The Ministry of Women, Family, and Social Solidarity is responsible for the budget line “Women Have Words Platform,� with a budget allocation of US$19,000 in the 2021 Budget. The 50 Million African Women Speak (50MAWS) platform is a digital community intended to empower millions of women in Africa to facilitate an exchange of ideas among women entrepreneurs, using in-built social media functionality to connect them with one another in ways that will foster peer-to-peer learning, mentoring, and the sharing of information and knowledge within communities, and access to financial services and market opportunities between urban and rural areas, and across borders and between countries. 40. With UNICEF’s support, the Civil Registry Service at the Ministry of Justice administers a free birth registration service for children under age seven years. In 2019, it was estimated that only 46 percent of Guinea-Bissau’s children under age five years and 36 percent of children under age one year had a birth certificate (Guinea-Bissau 2020, p. xliv).59 The service’s main donors are UNICEF, Plan International, the Portuguese cooperation agency, and the United Nations Economic Commission for Africa (UNECA). This program is not included in the budget documents. Expenditures in 2020 hover around US$220,000. 41. UNICEF is also providing support to the Ministry of Education with annual financing of approximately US$1.5 million from the French and Norwegian cooperation agencies and other donors, including the UN Peacebuilding Fund in 2021. UNICEF’s support for education in Guinea- Bissau includes three programs. (i) The Child Friendly School program supports the establishment of national school standards, the rehabilitation and construction of primary schools (including latrines), teacher training, and basic school materials. It also supports the Ministry of Education to strengthen the quality of education. (ii) The Inclusive Schools program supports the NGO “Humanity and Inclusion� to identify children with disabilities and provide them with education through a pilot program in the Oio region. (iii) The Out-of-School Children program seeks to provide life skills and vocational training to adolescents who are out of school. It also raises awareness of harmful practices (forced marriage, female genital mutilation, and so on) among young girls. 42. NGOs also provide social assistance to targeted groups. The Portuguese NGO Fé e Cooperação (FEC) works to protect children through various social assistance activities. For example, FEC supports a network of social workers that detect, assess, and monitor cases of child abuse. The group also implements two activities under the Casa Bambaram project—a foster home for 30 children who were abandoned because of a disability and an inclusive school attended by children with disabilities (financed by Caritas Germany). FEC also developed the project Build Land for Infancy (Kumpu Tera di Mininesa), funded by the European Union and implemented by Caritas Guinea-Bissau, Rede Ajuda, and the Ministry of Women, Family, and Social Solidarity. 43. Céu e Terras, a national NGO that seeks to reduce the vertical transmission of HIV/AIDS, provides free consultations for people affected by HIV, including prenatal and pediatric consultations. On average, the NGO finances 1,200 consultations per month, 74,000 lab tests per year, and antiretroviral treatment to 2,300 patients free of charge. It also operates a scholarship program and pays school fees for the children of low-income HIV/AIDS patients. With funding 59 See the Sixth Multiple Cluster Indicator Surveys (MICS-6), available at https://mics.unicef.org/surveys. 32 (€75,000) from the regional government of Galicia (Spain), Ceu e Terras pays its staff, purchases computer equipment, operates a database of beneficiaries, and provides diagnostic analysis and access to essential drugs to 18,500 patients. It also receives financial support from the Global Fund, the Italian chapter of Ceu e Terras, and individual donors. 44. Caritas Guinea-Bissau runs the following initiatives in collaboration with other partners:60 • Twenty-four nutritional centers providing nutritional support to children and pregnant women with high obstetric risk at an average cost of CFAF 33,000 (approximately US$61) per child and CFAF 80,000 (US$148) per woman. • A pediatric hospital, a hospital for the treatment of leprosy, HIV-AIDS, and tuberculosis, including an accommodation site for those affected by perosis, and the Dom Settimio Ferrazzeta health center, all located in Cumura in the region of Biombo. • A nutrition project (Nô Kume Sabi) that finances health and nutrition-related training courses based on the use of local produce in Cacheu. • A technical training center (Possibilities Fair) for agriculture, beekeeping, fruit and vegetable processing, livestock farming, and natural medicines in Bafata. 45. The Spanish NGO AIDA (Ayuda, Intercambio y Desarrollo) implements several social assistance projects in Bissau and the region of the Bijagós with funding from the European Union, Spanish and Italian local governments. These include: a. The Primary Health Care Service to Vulnerable Populations project seeks to improve emergency care in hospitals and health centers in Bissau and procure and maintain stocks of medicines and medical equipment. AIDA’s network of social workers identifies vulnerable patients. AIDA provides free medicines to low-income households and basic medical equipment and surgical materials to the emergency services at the Simão Mendes National Hospital. The project also conducts regional and national awareness campaigns via radio to raise awareness of patients’ rights, availability of health services, and preventive health care measures. The European Union finances €565,000 of the project, which targets 100,000 beneficiaries, and the regional government of Cantabria (Italy) finances €150,000 to support 30,000 patients. b. An office to promote and defend health patients, financed by the European Union (€175,000) that targets 15,000 beneficiaries. c. The Sustainable Development Project in the Bijagós islands seeks to establish transportation links between islands, improve hygienic and sanitary conditions, build drinking water supply facilities supplied with solar energy, and increase economic activities to reduce the isolation of island populations. The project targets 15,000 beneficiaries from the islands of Bolama, Galinhas, and Soga. The European Union finances the project in the amount of €2.25 million. d. Activities to promote food security through the creation of vegetable gardens and the transformation of agricultural and sea products. The initiative provides cooking demonstrations using seasonal and locally-grown fruits and vegetables to promote a balanced diet. The regional government of Galicia (Spain) finances the project (€175,000), which targets 550 women from the island of Bolama. 60 Caritas works with government agencies Instituto Mulher e Criança (IMC) and Secretariado Nacional da Luta contra SIDA (SNLS); local NGOs Tiniguena, Radio Sol Mansi, Associação dos Amigos da Criança (AMIC), Cooperativa Jovens Quadros de Canchungo (COAJOQ); and donors and international NGOs, including the European Union, CRS, Caritas Italy, WFP, UNFPA, UNICEF, Cooperazione Paesi Emergenti (COPE), the French Embassy, and IMVF. 33 e. The rehabilitation of the health center on Galinhas island with financing from the provincial government of Albacete (Spain) in the amount of €15,000. 46. AIDA also finances several activities directly, including: • The evacuation of critically ill children (about 40 annually, mostly with a heart-related conditions) to Europe, as well as the costs of travel, lodging, and food benefits. • A classroom in the pediatric ward of the Simao Mendes National Hospital in Bissau. • A pediatric rehabilitation health center providing health care and support (schooling, physiotherapy, materials, cognitive and language stimulation, and so on) to 97 children with developmental disorders (cerebral palsy, epilepsy, Down syndrome) in 2020. • Training for seven school administrators and teachers to welcome students with functional disorders, resulting in the enrollment of 24 children during the 2020/21 academic year. • With support from the European Union, AIDA (Ayuda, Intercambio y Desarrollo, a Spanish NGO) is improving access to health services for vulnerable groups in Bissau and the islands of Bolama, Galhinhas, and Soga in the Bijagós islands. 34 Chapter 4 Recommendations for Improving Social Assistance Developing a social assistance strategy in Guinea-Bissau will require an increase in government leadership, institutional alignment, and resources. The Ministry of Women, Family and Social Solidarity could lead the process in close coordination with other ministries and donors involved in social assistance. Under its leadership, the “clusters� discussed in Chapter 2 could be strengthened and organized around specific objectives to reduce the vulnerabilities of the identified priority groups. However, the needed increase in government leadership can only occur with an overall increase in government expenditures on social assistance. This chapter outlines the main principles of a social assistance strategy and provides recommendations to assist the government in improving its strategy and monitoring implementation. These principles include prioritizing vulnerable groups, evaluating and rationalizing existing social assistance programs, increasing local and community participation, establishing a national registry of beneficiaries, and developing targeting mechanisms to reach the priority groups. The strategy should also include resources to monitor the implementation of the strategy itself, and its impacts on the vulnerabilities of the population. ______________________ A. Defining a social assistance strategy 1. Developing a social assistance strategy will require an increase in government leadership, institutional alignment, and resources. The Ministry of Women, Family and Social Solidarity could lead the process in close coordination with other ministries and donors involved in social assistance (see Table 3.1). However, in the short term, the Ministry of Women, Family and Social Solidarity would need strengthening to exert a leadership role and develop information systems to define and target priority groups and mechanisms to monitor social assistance expenditures. Under its leadership, the “clusters� discussed in Chapter 2 could be strengthened and organized around specific objectives to reduce the vulnerabilities of the identified priority groups. In these fora, participants would exchange information and coordinate programs around particular goals (for example, reducing nutritional deficiencies or supporting the poor affected by disability). However, the needed increase in government leadership can only occur with an overall increase in government expenditures on social assistance. As noted in Chapter 3, the government finances less than 3 percent of Guinea- Bissau’s social assistance programs; donors fund the rest. In this context, decisions regarding the definition and implementation of social assistance programs are driven mainly by individual donors’ agendas—not by the authorities. As a result, the government’s ability to define and prioritize programs is limited. A.1 Prioritizing vulnerable groups 2. Guinea-Bissau’s social assistance strategy could prioritize demographic groups according to the vulnerabilities identified in Chapter 1 (Table 4.1). For example, the approach could prioritize pregnant women and young children to reduce nutritional deficiencies and morbidities. Medium priority could be assigned to at-risk children not registered at school, the poor affected by disability, the elderly poor, refugees and internally displaced persons. The strategy could give special attention to girls who face more pronounced risks, including early pregnancy. 35 3. The strategy could also prioritize groups within geographic regions. For example, programs that target the rural destitute could receive top priority. Medium priority could be given to the poor living in areas affected by natural disasters, including the coastline, where climate change has the most significant impact. The strategy could adopt mitigation measures and prepare emergency plans to alleviate the immediate effects of natural disasters and health hazards. Table 4.1 Priority Groups for Social Assistance (*** = top priority, ** = medium priority, * = priority) Demographic group Priority level Children under age five years and pregnant women. Guinea-Bissau has one of the highest maternal mortality rates globally, and 57.4 percent of children aged under five years live in poverty; 22 percent of children are affected by stunting. Infants and young children *** face multiple vulnerabilities, including a lack of physical, cognitive, and psychosocial development. Children live in an impoverished environment that perpetuates the poverty cycle. Vulnerabilities are particularly costly to individuals, society, and future generations when risks materialize at the early stages of life. At-risk children outside the formal education system, including those affected by child ** labor or mendicity. Reintegrating these children into the education system is challenging. The disabled poor affected by disability. The poor affected by disability are among the most vulnerable populations. The Ministry of Women, Family and Social Solidarity ** finances a cash transfer scheme that provides monthly cash transfers to roughly 900 persons with disabilities (see Chapter 2). The elderly poor. The elderly poor are reliant on family, friends, and neighbors, and NGOs or religious organizations. Outside of the (contributory) social insurance system, only the ** social pensions scheme assists poor elderly citizens. This scheme, financed by the Ministry of Defense and Combatants for Freedom of the Homeland, provides a monthly pension to approximately 3,600 former combatants (see Chapter 2). Refugees and internally displaced persons. Since 2017, the government has provided naturalization to all refugees in partnership with the National Commission for Refugees. ** Geographic group Priority The rural destitute. A large share of the rural population lives in extreme poverty. A poverty map would help to identify specific regions with high concentrations of rural poor. *** The poor living in areas most affected by natural disasters. This group includes those living on the coastline, the area of Guinea-Bissau most affected by climate change. ** A.2 Evaluating and rationalizing social assistance programs 4. A thorough evaluation of existing social assistance programs could be a practical first step toward reducing vulnerability. This review could guide the rationalization of existing programs to reach priority groups. Developing consistent targeting mechanisms for program and service delivery plans could also help channel more resources to vulnerable groups. 5. Guinea-Bissau’s cash transfer programs could be evaluated and harmonized, and a single list of beneficiaries could be compiled to avoid duplication. As noted in Chapter 3, preliminary outcomes from a rigorous randomized controlled trial impact evaluation of the cash transfer financed 36 by the IDA-financed Social Safety Nets and Basic Services Project provide strong evidence of socioeconomic improvements in terms of consumption, total expenditures, diet diversity, asset value, and educational outcomes. Targeting methods, the amount and frequency of cash transfers, and payment mechanisms could be harmonized across programs to increase efficiency. The authorities could also register beneficiaries in a dedicated national registry (see below). 6. The government could also review, rationalize, and streamline social assistance programs to improve nutrition among children and pregnant women into a well-targeted nutrition program. Existing programs (see Table 3.1) address key vulnerability issues related to nutrition, compensatory nutrition, and tailored interventions for specific areas. However, these could be streamlined and linked with the cash transfer programs, establishing a more comprehensive and efficient approach. Recommended actions include: • Conducting a thorough review of the impact and efficiency of food transfer programs, including nutrition and feeding programs, on the targeted demographic groups included in Table 4.1; • Scaling up nutrition programs to cover the targeted demographic groups nationwide;61 • Developing mechanisms to ensure donor assistance continuity and increase annual budget allocations. 7. In 2020, the IDA-financed Emergency Project for Food Security introduced public works projects as a mechanism to increase food security. However, the effectiveness of introducing public works in a small country like Guinea-Bissau—where cash transfer and community-based small infrastructure programs are already in place—is questionable. Also, the rehabilitation or construction of small basic infrastructure in rural areas (water pumps, feeder roads, schools, and so on), which are currently taking place under several IDA-financed programs (Social Safety Nets and Basic Services Project and the Emergency Project for Food Security, for example), could be harmonized. In particular, the standards and norms of small infrastructures and the mechanism followed to maintain them could be harmonized in collaboration with national and local authorities. 8. The Ministry of Health implements Guinea-Bissau’s large fee waivers and targeted subsidy programs (see Table 3.1), all of which aim to reduce mortality and morbidity. As noted in Chapter 3, these programs rely heavily on a national network of approximately 4,000 community health workers who promote health awareness and good practices and ensure that those in need of health care have access to rural health centers. However, the stipends (subsídios or in English, subsidies) paid to community health workers are dependent on donor financing. The European Union paid these stipends under the second Integrated Program for the Reduction of Maternal-Infant Mortality Program (Programa Integrada para a Redução da Mortalidade Materno-Infantil em Guinea-Bissau or PIMI) until May 2020, when the IDA-financed US$25 million Strengthening Maternal and Child Health Service Delivery Project, approved in May 2018, began paying them (see also chapter 3). Considerations for the government now include: • Start financing from domestic revenues the network of community health workers for the implementation of preventive and referral health care interventions in poor and rural areas, with an emphasis on maternal-infant health, vaccines, potable water, prevention and early detection of tuberculosis, malaria, family planning, and health education including HIV/AIDS awareness programs; 61Kakietek and others (2017) show that nutrition-specific interventions represent a highly cost-effective approach to reducing child malnutrition and stunting. They conclude that investments in nutrition can generate very substantial health and economic benefits, with US$1 of spending on nutrition interventions resulting in returns of approximately US$10 over the productive lives of children. 37 • Review the existing procurement, storage, and distribution of medication by the public sector for higher efficiency. 9. Several programs described in Chapter 3 have considerable impacts on specific vulnerable groups identified in Table 4.1 and could be pursued or scaled up. These include: • The birth registration program to provide identity documents to children under age seven years, implemented by the Ministry of Justice with support from UNICEF; • The project to protect children against child abuse, implemented by the Portuguese NGO Fé e Cooperação (FEC); • The project to support children living with disabilities, supported by the World Food Programme, which could be extended beyond the regions of Oio and Cacheu; • The project to improve access to health services, including potable water and income- generating activities, implemented by AIDA, which could be extended to other islands of the Bijagós; and • The program to naturalize refugees and internally displaced persons implemented by the Ministry of Interior in partnership with the UN High Commission for Refugees. 10. Following a community-driven development approach, the authorities could scale up the delivery of basic infrastructure (water points, feeder roads, schools, and so on) in communities (tabancas or clusters of tabancas). Although demand is high for the construction or rehabilitation of basic infrastructure, several factors diminish these investments’ economic rate of return, including a lack of complementary inputs (absence or poor attendance of teachers or lack of books at school, for example), sustainability challenges (water points not repaired and feeder roads not maintained), a lack of implementation of national standards and norms, particularly for feeder roads (which tend to be oversized) but also for schools, and cases of infrastructure misuse (use of a feeder road for illegal logging for example). The choice of infrastructure differs by geographic area, but good practice indicates specific priorities—water points, schools, local roads, and vegetable gardens—for rural areas. A.3 Increasing local and community participation 11. Involving local authorities and communities in service delivery could improve the effectiveness of social assistance interventions. The social assistance strategy could emphasize the role of both the local administration and the deconcentrated services of central ministries in the implementation of social assistance programs. Doing so would improve accountability and the quality and sustainability of service delivery. The strategy could also highlight the importance of showing the state’s presence at the level of communities, which have mainly been disenfranchised from access to basic services. Some approaches include: • Use NGOs working at the community level as intermediaries to identify, design, and implement social programs; • Select community health workers or teachers from the communities themselves, as they are likely to be more motivated and more accountable; • Procure food items locally for the school lunch programs; and • Rely on community preferences when selecting investments and services provided by line ministries. 38 A.4 Establishing a national registry of beneficiaries 12. Expanding the beneficiary registry initiated under IDA’s Social Safety Nets and Basic Services Project would allow fast and accurate identification and targeting of potential beneficiaries for social assistance programs. A registry would reduce opportunities for fraud, benefit duplication, and access to benefits by illegitimate actors. It would also allow for improved social assistance program monitoring. A central ministry, such as the ministry responsible for social solidarity, could maintain and update the national registry. The provision of administration documents to identify beneficiaries could accompany the development of such a national registry. A.5 Developing targeting mechanisms to reach priority groups 13. Establishing targeting mechanisms to channel social assistance benefits to priority groups is essential. Targeting improves cost-effectiveness and impact by concentrating resources on the neediest. However, targeting can be a challenge when means testing is not feasible in the absence of verifiable earnings records. In response, governments and development practitioners design tools that can direct program benefits to the targeted population without the need for earnings records. For example, the government could consider the following three main targeting mechanisms: • Self-targeting, used in workfare programs where potential workers decide whether to participate in a public works program; • Community-based targeting, based on a subjective assessment by communities to identify the poor; and • Household survey-based targeting, using household survey data to determine eligibility. In particular, proxy-means testing (PMT) targeting, the most used household-based targeting method which predicts consumption per capita based on household variables—family size, education, and housing conditions—selected based on their correlation with consumption, could be considered.62 14. Eventually, targeting can be based on administrative data from existing registries such as those developed for pension programs or land ownership. In practice, the selected method or combination of methods depends on each country’s data availability, which is highly correlated with its level of economic development. Because data are scarce at the household level in low-income economies like Guinea-Bissau, social programs typically use self-targeting, community targeting, and proxy variables. For example, cash transfers under IDA’s Social Safety Nets and Basic Services Project target some specific areas (geographic targeting) and then use a PMT to determine eligibility, followed by a validation of beneficiaries by the community. 62The proxy means test targeting method is an econometric method that proceeds in two steps. First, practitioners use a household survey that includes consumption (or expenditures) data and empirically regress (log of) per-capita consumption on a number of independent variables using Ordinary Least Square. The independent variables are self- reported by households during field visits. They typically include household size, household characteristics (age of household head, marital status and occupation, religious and ethnic groups, etc.), household composition (percentage of children by sex, percentage of elderly, and so on), housing conditions (roof, wall, floor, etc.), access to services (water, sanitation, lighting, etc.) and selected household’s assets (radio, television, motorbi ke, etc.). Second, practitioners conduct a household survey to collect the independent variables (those most correlated with per-capita consumption) for all the households in the area of program intervention. Then, they use the PMT formula to predict per-capita consumption. The households who are below a determined cut-off point are deemed eligible to benefit from the social program. 39 B. Monitoring the implementation of the social assistance strategy and its impact on vulnerability 15. Monitoring social assistance strategy implementation and its impact on vulnerability will be critical. Adequate resources should be made available for this task. The strategy could include the following key monitoring components: • Monitoring and evaluating the social assistance strategy. The authorities could take steps to monitor the implementation of the social assistance strategy, including detailing actions for the strategy period in an action plan, specifying actions for each year, and developing monitoring indicators that each institution could track. In addition, program-specific questions could be included in household surveys to facilitate such monitoring. Although all ministries included in Table 3.1 have some responsibility for ensuring the implementation of the overall social assistance strategy, the Ministry of Women, Family and Social Solidarity could be responsible for the strategy’s coordination. Resources should be made available to reach these objectives. • Monitoring the vulnerability of the population. The government may want to develop a system to track living conditions, monitor vulnerability, and provide data to evaluate the impact of public interventions. The system could build on the 2018 EHCVM, which could be updated every few years. The incidence and coverage of all social assistance programs—cash transfers, food transfers, in-kind transfers, public works, fee waivers, and targeted subsidies—could be included in the survey. The survey could also help monitor the priority groups identified in Table 4.1. 40 Annex Table A.1 Expenditures on Social Assistance Programs included in the Public Investment Program of the 2021 State Budget Budget line Description 761941402 Projecto de Redes Sociais e Serviço de Base 219940301 Projecto Fundo de Pensões 421940301 Projecto Nacional para Refugiados e Deslocados Internos 661940201 Projecto de Protecção Civil 411942601 Plan School Feeding Program (Mcgovern-Dole) (USAID) 823949102 Projecto de Apoio Integrado ao Desenvolvimento Rural "Active" - Eixo III 611940401 Nutrição_Pam: Tratamento de Mam das Crianças de 6-59 meses 743940701 Luta Contra a Insegurança Alimentar nas Regiões de Oio e Cacheu na Guiné 619943201 Jp Projecto de Apoio para Cantinas e Nutrição (Educação Saúde) 831940193 Programa de Apoio a Segurança Alimentar "Batalha De Komo" 611940701 Nutrição_Pam: Fornecimentos de Alimentos Complementares para Crianças 359940122 Apoio á Aldeia Infantil SOS - Bissau/Gabú/Canchungo 611920101 Proteção da Criança 774910392 Programa Educação Base e Igualdade dos Géneros 359940223 Fortelecimento Familiar 211931104 Projecto de Apoio Social e Humanitário 774940501 Programa de Especial da Segurança Alimentar 669940801 Projecto de Combate a Fenómeno de Trabalho Infantil, das Crianças Mendiga 622920101 Projectode Urgência de Segurança Alimentar na Guiné-Bissau "Componente I e II" 622920201 Projectode Urgência de Segurança Alimentar na Guiné-Bissau "Componente III e IV" 613931501 Progama da Redução da Incidência da Tuberculose 613931601 Projeto da Diminuição da Mortalidade e Mobilidade relacionados com a Malaria 611941701 Programa para a Redução da Taxa de Incidência do HIV Nas Populações em Geral 611126301 Programa de Suportes de Aprovisionamento de vacina - Contrapartida de GAVI 611921201 Projecto de Fortalecimento dos Serviços de Saúde Materno-Infantil 611940601 Projecto Crianças e SIDA 611947901 Programa Integrada para a Redução da Mortalidade Materno-Infantil em Guiné 361940201 Projecto de Implementação da Programação de Desenvolvimento Social (Bolsa Excelência) 819921001 Projecto de Assistência Social ao Hospital Militar Principal 633940101 Programa de Prevenção a Assistência à Doença Infectocontagiosa 669940101 Projecto de Mobilização Social e Luta Contra "Ist/Vih/Sida" 611921202 Projecto de Assistência Social Hospitalar, Apoio aos Pacientes Carenciados 619940101 Programa Sobrevivência das Crianças "Nutrição, �gua Saneamento" 349940301 Promoção de Actividades Geradoras de Rendimentos, Boas Praticas, Equidade 611920802 Apoio ao Secretariado Nacional de Luta Contra Sida na Coordenação da Resposta 361940501 Programa de Autonomização de Mulheres Transformadoras de Produtos Agrícola 689990101 Plataforma de 50.000.000 Mulheres Tene Palavras Source: General State Budget 2020, Ministry of Finance. 41 Table A.2 Social Assistance Programs in Guinea-Bissau, 2021 Program Responsible Description Budget Beneficiaries Institution 1. Cash Transfer Social Safety Nets and Basic Ministry of Quarterly cash transfers of CFAF 10,000 US$692,880 5,239 households Services Project Economy, per household member and nutrition- 50,000 (Projecto de Redes Sociais e Planning and related accompanying measures in the individuals Serviço de Base) 1 Regional regions of Gabú, Cacheu and Oio. Integration Social Pension Fund. Ministry of Non-contributory public pensions to US$242,000 2,250 former (Projecto Fundo de Pensões) 1 Defense and former combatants and their descendants. per month. combatants. Homeland Freedom Fighters National Project for Refugees Ministry of Provide Identity Document to refugees US$170,000 3,707 refugees and Internally Displaced Interior in identified for naturalization. among 8,000 Persons partnership with identified. (Projecto Nacional para UNHCR Refugiados e Deslocados Internos) 1 Civil Protection Project Ministry of Cash assistance program for vulnerable US$265,000 910 households. (Projecto de Protecção Civil) 1 Interior in households who lost their houses and crops partnership with following the floods and strong winds. WFP Cash Transfers for disable Ministry of Cash transfer to vulnerable households US$32,560 110 households. children Education, with children with disabilities, providing WFP and also hygiene kits to prevent COVID-19. Humanity and Inclusion COVID-19 Rapid Response Ministry of Unconditional cash transfers to vulnerable US$252,000 1,200 Program 2 Women, Family households in the regions of Gabu, Oio, for 2020. households. and Social Cacheu and Biombo. Solidarity, UNICEF, WFP and UNDP. Cash transfer for women Manitese Cash transfer program to fight violence Not available Women survivors against women of gender-based violence hosted in a Women Refuge. Cash transfer to socially ENDA-Tiers Cash transfer to socially excluded groups: Not available Child laborers, excluded groups Monde child laborers, sex workers, LGBTI sex workers, collective, persons with HIV/AIDS and LGBTI prisoners. collective, persons with HIV/AIDS and prisoners. 2. Food transfers Plan School Feeding Program Ministry of Provides hot meals for school children, US$563,000 Children of 350 (Mcgovern-Dole) (USAID) 1 Education and encouraging school enrollment and schools CRS, Plan attendance as well as agricultural Internacional commodities, financial and technical and Caritas assistance, in schools located Oio, Cacheu, Quinara, Bafata and Gabú regions. Integrated Support to Rural Ministry of Nutrition monitoring and food subsidies US$415,000 A representative Development Project Agriculture and for vulnerable populations. sample of the 42 Program Responsible Description Budget Beneficiaries Institution (Projecto de Apoio Integrado Rural population in all ao Desenvolvimento Rural Development regions of the "Active" - Eixo III) 1 and WFP country Program to Treat Moderate Ministry of Nutritional support to fight malnutrition in US$323,000 2,000 people. Acute Malnutrition Public Health children under the age fo five and pregnant (Nutrição_Pam: Tratamento de and WFP and lactating women. Mam Das Crianças de 6-59 meses) 1 Project to Fight Food Ministry of In-kind transfers to combat food US$260,000 Population in Oio Insecurity in the Regions of Environment insecurity. and Cacheu. Oio and Cacheu and (Luta Contra a Insegurança Biodiversity Alimentar nas Regiões de Oio e Cacheu na Guiné) 3 Project to Support School Ministry of Provides more than 173,000 hot meals for US$163,000 173,000 children Canteens and Nutrition Education and school children, encouraging school receive daily a (Jp Projecto de Apoio para WFP enrollment and attendance. Schools meal Cantinas e Nutrição) 1 located in Oio, Bafata and Gabu regions. “Komo Batle� Program Ministry of Food support to families. US$92,710 Not available (Programa de Apoio a Defense and Segurança Alimentar "Batalha Homeland de Komo") 3 Freedom Fighters Program of Complementary Ministry of Provides super cereal food complements US$61,000 6,681 children Food Supplies for Children Public Health CSB++ to children who suffer from from Oio, Bafatá (Nutrição_Pam: Moderate Acute Malnutrition and seek to and Gabu Fornecimentos de Alimentos prevent stunting. regions. Complementares para Crianças) 1 3. In-kind transfers Support the international NGO Ministry of Housing, food, education and health US$6.4 252 children SOS Children’s Villages Women, Family services to orphans in Bissau, Canchungo million (Apoio à Aldeia Infantil SOS - and Social and Gabu Bissau/Gabú/Canchungo) 1 Solidarity and SOS Children’s Villages International Child Protection Program Ministry of Support to Woman and Child Institute: US$3.9 Not available (Proteção da Criança) 1 Women, Family training to social workers, communication million and Social tools, integral support to foster homes. Solidarity and UNICEF The Program for Basic Ministry of Not available US$833,000 Not available Education and gender Equality Education (Programa Educação Base e Igualdade dos Géneros) 3 Family Strengthening Ministry of Food, medicines, hygiene kits and free US$518,000 400 orphans (Fortalecimento Familiar) 1 Women, Family education for orphans living with host and Social families as well as microcredits to Solidarity and families, in Bissau, Cachungo and Gabu. SOS Children’s Villages International Project of Social and Ministry of Covers the cost of medical assistance US$26,000 6686 veterans Humanitarian Support Defense and including medicine, surgical operations, registered when Homeland 43 Program Responsible Description Budget Beneficiaries Institution (Projecto de Apoio Social e Freedom orthopedic prostheses, wheelchairs and required medical Humanitário) 1 Fighters funerals to former combatants. assistance. Special Food Security Ministry of Not available US$19,000 Not available (Programa de Especial da Agriculture and Segurança Alimentar) 3 Rural Development Project to Fight Child Labor Ministry of Support to vulnerable street children. US$9,000 Not available and Child Mendicity Women, Family (Projecto de Combate a and Social Fenomino de Trabalho Infantil, Solidarity das Crianças Mendiga) 1 4. Public works Emergency Food Security Ministry of Provide food security to households in US$2,5 10,000 workers Project Agriculture and communities affected by job losses, by million (2020- (Projecto de Urgencia de Rural mitigating the shortfall of income through 2023) Segurança Alimentar na Development community-level public works. Guiné-Bissau) 1 Resilience Building Project 4 WFP Cash-for-work aiming at rehabilitation US$383,400 3,550 households mangroves. It seeks to protect the paid in cash or livelihood of vulnerable households and with rice- build their resilience to food crises while vouchers. improving rural communities’ access to basic social services, in the regions of Bafata, Gabu, Oio and Tombali. 5. Fee waivers and targeted subsidies Program for the Reduction of Ministry of Fight against tuberculosis US$2.7 2,100 people per the Incidence of Tuberculosis Public Health million year (Programa da Redução da Incidência da Tuberculose) 1 Project for the Reduction of Ministry of Provides insecticide-treated bed nets, US$1.9 Country Malaria-Related Mortality and Public Health malaria tests and malaria treatment free of million population Morbidity charge. (Projeto da Diminuição da Mortalidade e Mobilidade relacionados com a Malaria) 1 Program for the Reduction of Ministry of Provides HIV tests and HIV/AIDS US$1.8 Not available the Incidence of HIV in the Public Health treatment free of charge. million Populations (Programa para a Redução da Taxa de Incidência do HIV nas Populações em Geral) 1 Vaccine Supply Support Ministry of Routine vaccination campaigns. US$1.3 Children below 9 Program Public Health million months of age (Programa de Suportes de and UNICEF Aprovisionamento de vacina - Contrapartida de GAVI) 1 Project to Strengthen Maternal Ministry of Provide essential health and nutrition US$1.2 75,000 Infant Health Services Public Health services to pregnant women and children. million beneficiaries (Projecto de Fortalecimento (until 2025) dos Serviços de Saúde Materno-Infantil) 1 Children and AIDS Project Ministry of Seeks to increase the diagnostic capacity US$1.1 Not available (Projecto Crianças e SIDA) 1 Public Health among children, provides access to million and UNICEF treatment and prevent the vertical transmission of HIV/AIDS. 44 Program Responsible Description Budget Beneficiaries Institution Integrated Program for the Ministry of Provide essential health and nutrition US$556,000 Pregnant women Reduction of Maternal-Infant Public Health services to pregnant women and children. and children Mortality Program and UNICEF below 5 years (Programa Integrada Para a around the Redução da Mortalidade country Materno-Infantil em Guiné) 1 Project for the Implementation Ministry of Scholarship to vulnerable girls and victims US$156,000 Girls and victims of Social Development Women, Family of forced marriage. of forced Programming – Schoolarship and Social marriage for Excellence Solidarity (Projecto De Implementação Da Programação De Desenvolvimento Social - Bolsa Excelência) 1 Project of Social Assistance to Ministry of Free consultations and medicines to US$94,000 Vulnerable the Principal Military Hospital Defense and vulnerable patients. patients of (Projecto de Assistência Social Homeland Military Hospital ao Hospital Militar Principal) 1 Freedom Fighters Program for the Prevention and Ministry of Free consultations and medicines to US$93,000 Vulnerable Care of Infectious Diseases Defense and vulnerable patients. patients of (Programa de Prevenção a Homeland Military Hospital Assisténcia à Doença Freedom Infectocontagiosa) 1 Fighters Social Mobilization and Fight Ministry of Seeks to raise awareness to HIV/AIDS US$55,630 Children and against HIV/AIDS Project Public Health, among children and adolescents and adolescents (Projecto de Mobilização UNICEF and provide treatments to those who are around the Social e Luta Contra UNFPA affected. country "Ist/Vih/Sida") 1 Project for Hospitalized Social Ministry of Social services and medicines to US$46,000 Vulnerable Assistance ans Support to Public Health vulnerable families at Simão Mendes patients of Simão Patients in Need National Hospital and health centers Mendes Hospital (Projecto de Assistência Social located in Bissau and Bissau Hospitalar, Apoio aos Health Centers Pacientes Carenciados) 1 Sustainable Development AIDA (Ayuda, Seeks to establish transportation links €2.25 million 15,000 people Project 5 Intercambio y between islands, improve hygienic and from the islands Desarrollo) sanitary conditions, build drinking water of Bolama, supply facilities supplied with solar Galinhas and energy, and increase economic activities to Soga reduce the isolation of island populations Primary Health Care Service to AIDA (Ayuda, Seeks to improve emergency care in €715,000 130,000 patients Vulnerable Populations project Intercambio y hospitals and health centers in Bissau and 6 Desarrollo) procure and maintain stocks of medicines and medical equipment COVID-19 Vaccine Project 1 Ministery of COVID-19 vaccine to mitigate the US$6.5million Guinea-Bissau Public Health negative impacts of COVID-19 population 6. Other social assistance Child Survival “Nutrition, Ministry of Water Sanitation and Hygiene (WASH) US$2.2 Guinea-Bissau Water and Sanitation� Public Health program. It provided innovative latrine million population (Programa Sobrevivência das and UNICEF designs in 20 schools in Bafatá and Oio Crianças "Nutrição, �gua which was accompanied by the Saneamento") 1 introduction of the tgree-star approach for school sanitation, with special attention to menstrual hygiene management 45 Program Responsible Description Budget Beneficiaries Institution Promotion of Income Ministry of This program has not been implemented US$175,000 Not available Generating Activities, Good Territorial Practices and Equity Administration (Promoção de Actividades and Local Geradoras de Rendimentos, Power Boas Praticas, Equidade) 3 Support to the National AIDS Presidency Fight against HIV/AIDS US$92,710 Guinea-Bissau Coordination Secretariat population (Apoio ao Secretariado Nacional de Luta Contra Sida na Coordenação da Resposta) 3 Program for the Autonomy of Ministry of Provides small grants to women who work US$83,000 Not available Women who Process Women, Family in the agricultural sector to initiate small Agricultural Products and Social food processing businesses (Programa de Autonomização Solidarity de Mulheres Transformadoras de Produtos Agrícola) 1 “Women have Words Ministry of Empower women in Africa to facilitate an US$19,000 Not available Platform� Women, Family exchange of ideas among women (Plataforma de 50.000.000 and Social entrepreneurs, access to financial services Mulheres Tene Palavras) 1 Solidarity and market opportunities Birth Registration Program Ministry of Free birth registration service for children US$220,000 Children under Justice and under age seven years seven years of UNICEF age Child Friendly School Ministry of The Child Friendly School program US$1.5 Children enrolled program, Inclusive Schools Education and supports the establishment of national million in primary school program and Out-of-School UNICEF school standards, the rehabilitation and Children program 7 construction of primary schools (including latrines), teacher training, and basic school materials. The Inclusive Schools program supports the NGO “Humanity and Inclusion� to identify children with disabilities and provide them with education through a pilot program in the Oio region. The Out-of-School Children program seeks to provide life skills and vocational training to adolescents who are out of school. It also raises awareness of harmful practices (forced marriage, female genital mutilation, and so on) among young girls. Social assistance programs to Fé e FEC supports a network of social workers Not available 30 children who protect children and Casa Cooperação that detect, assess, and monitor cases of were abandoned Bambaram 8 (FEC) child abuse. The group also implements because of a two activities under the Casa Bambaram disability project—a foster home for children with disability and an inclusive school attended by children with disabilities Ceu e Terras project Ceu e Terras Seeks to reduce the vertical transmission of €75,000 2,300 patients HIV/AIDS, provides free consultations, diagnostic analysis and access to essential drugs for people affected by HIV, including prenatal and pediatric consultations Nutritional centers 9 Caritas Guinea- Twenty-four nutritional centers providing An average Children and Bissau nutritional support to children and cost of CFAF pregnant women pregnant women with high obstetric risk 33,000 46 Program Responsible Description Budget Beneficiaries Institution (approximately US$61) per child and CFAF 80,000 (US$148) per woman Dom Settimio Ferrazzeta health Caritas Guinea- A pediatric hospital, a hospital for the Not available Biombo and SAB center 9 Bissau treatment of leprosy, HIV-AIDS, and population tuberculosis, including an accommodation site for those affected by perosis Nô Kume Sabi 9 Caritas Guinea- A nutrition project that finances health and Not available Cacheu Bissau nutrition-related training courses based on population the use of local produce 9 Possibilities Fair Project Caritas Guinea- A technical training center for agriculture, Not available Bafata population Bissau beekeeping, fruit and vegetable processing, livestock farming, and natural medicines Food security in Bolama island AIDA (Ayuda, Activities to promote food security through €175,000 550 women from 10 Intercambio y the creation of vegetable gardens and the the island of Desarrollo) transformation of agricultural and sea Bolama products. The initiative provides cooking demonstrations using seasonal and locally- grown fruits and vegetables to promote a balanced diet Health center on Galinhas AIDA (Ayuda, The rehabilitation of the health center on €15,000 Galinhas island island 10 Intercambio y Galinhas island population Desarrollo) Children evacuationError! AIDA (Ayuda, The evacuation of critically ill children to €35,000 40 children per Bookmark not defined. Intercambio y Europe, as well as the costs of travel, year Desarrollo) lodging, and food benefits. Classroom in the pediatric AIDA (Ayuda, Activities for long term patients of the €4,000 Patients in the ward 10 Intercambio y pediatric ward or the Simão Mendes pediatric ward of Desarrollo) National Hospital the Simão Mendes National Hospital Pediatric rehabilitation health AIDA (Ayuda, Providing health care and support Not available 97 children with center 10 Intercambio y (schooling, physiotherapy, materials, developmental Desarrollo) cognitive and language stimulation, and so disorders on) to children with developmental disorders (cerebral palsy, epilepsy, Down syndrome) 1 This program is included in the General State Budget 2021, Ministry of Finance. 2 This program is not active in 2021. 3 The authorities report that this program has not been implemented. 4 https://docs.wfp.org/api/documents/WFP-0000132605/download/ 5 https://www.ong-aida.org/que-hacemos/guinea-bissau/bolama-mejora-condiciones-vida-union-europea/ 6 https://www.ong-aida.org/que-hacemos/guinea-bissau/centros-salud/ and https://www.ong-aida.org/que-hacemos/guinea- bissau/acceso-a-servicios-sanitarios-de-atencion-primaria-a-la-poblacion-mas-vulnerable-del-sector-autonomo-de-bissau/ 7 For more information, see: https://www.unicef.org/guineabissau/education 8 For more information, see: https://www.fecongd.org/ 9 For more information, see: https://caritas-africa.org/caritas-guinea-bissau/ 10 For more information, see: https://www.ong-aida.org/que-hacemos/proyectos-guinea-bissau/ 47 References African Development Bank Group. 2021. 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