Guinea-Bissau
A Review of
Equity and child rights in Guinea-Bissau
1
2
Equity and child rights
A Review of
Equity and child rights in Guinea-Bissau
Equity and child rights
Acknowledgements UNICEF is grateful to all partners, from Government, civil society, national and international organizations, UN agencies and women and youth groups, for their valuable contributions to this document, which will inform future strategies and plans to improve the lives of children and women in Guinea Bissau with more equity over the next years. UNICEF appreciates in particular the contribution to the preparation of this document of the regional office (WCARO) through its Social Policy and Planning, Monitoring and Evaluation Units. Special thanks go to all UNICEF staff in Guinea Bissau for their dedication and hard work. Production, editing, layout & printing: Julie Pudlowski Consulting Photos: UNICEF/Pirozzi
4
Guinea-Bissau
Table of Contents
Acknowledgements
4
Table of contents
5
Figures
6
Tables
8
Acronyms
9
Foreword by UNICEF Representative
11
Executive summary
12
1. Children and women: Demography and economy
15
2. Inequities affecting children and women
21
2.1 Wealth inequities
22
2.2 Gender inequities
24
2.3 Geographic inequities
27
3. Child and maternal survival and development
31
4. HIV/AIDS
47
5. Equity and quality in education
53
6. Harmful practices affecting children and women
63
7. Pro-child budgeting
69
Annex Equity snapshot Bibliography
76 78
5
Equity and child rights
Figures Figure 1 Organization of administrative regions (region and sector)
15
Figure 2 Fertility rate, 1980-2009
16
Figure 3 Males and females by age group (population pyramid), 1990-2010
16
Figure 4 Proportion of the population under 18 years old by administrative sector, 2009
18
Figure 5 Political instability, civil war and slow economic recovery
19
Figure 6 Monetary poverty, 2002 and 2010
20
Figure 7 Monetary poverty by region, 2010
22
Figure 8 Women giving birth in a health centre by wealth quintile, 2010
22
Figure 9 Households with access to safe drinking water by wealth quintile, 2010 23 Figure 10 Primary net attendance for primary school by wealth quintile, 2010
23
Figure 11 Moderate stunting in children under five years by wealth quintile, 2010 23
6
Figure 12 Women who accept domestic violence, 2006 and 2010
24
Figure 13 Prevalence of HIV among those aged 15-49 years, 2010
25
Figure 14 Literacy rates among those aged 15 years and older, 2010
26
Figure 15 Mother’s education and socio-economic indicators, 2010
26
Figure 16 Mother’s education and socio-economic indicators, 2010
27
Figure 17 Children 0-5 years whose birth has been registered, 2010
28
Figure 18 HIV prevalence among pregnant women, 2009
28
Figure 19 Prevalence of FGM/C among women 15-49 years, 2010
29
Figure 20 Child mortality estimates per 1,000 live births, 1989-2013
31
Figure 21 Under-five and infant mortality rates by region (per 1000 live births), circa 2005
32
Figure 22 Women receiving skilled antenatal care (at least one visit), 2006 and 2010
33
Figure 23 Women receiving skilled antenatal care (at least one visit, at least four visits) and skilled birth attendance, 2010
33
Figure 24 Qualification of persons who provide assistance at birth, 2010
34
Figure 25 Health workers per 10,000 population, 2004 and 2007
35
38
Figure 27 Diarrhoea treatment – oral rehydration with continued feeding among children under five years, 2006 and 2010
38
Figure 28 Children under five years with a fever who received anti-malarial medication, 2006 and 2010
39
Figure 29 Children under five years suspected of having pneumonia who received treatment, 2006 and 2010
40
Figure 30 Prevalence of under-nutrition among children under five years, 2000-2010
41
Figure 31 Prevalence of malnutrition among children under five years by region, 2010
41
Guinea-Bissau
Figure 26 Improved vaccination coverage in children between one and two years, 2006 and 2010
Figure 32 Moderate stunting in children under five years by wealth quintile, 2010 42 Figure 33 Under-nutrition (-2 standard deviations) by age, 2010
42
Figure 34 Households with access to safe water, 2010
43
Figure 35 Use of improved water source by region, 2010
44
Figure 36 Use of improved sanitation, 2006 and 2010
44
Figure 37 Water and sanitation in schools, 2010/11
45
Figure 38 HIV prevalence by sex and age, 2010
47
Figure 39 Early sexual debut and comprehensive HIV knowledge among girls 15-24 years, 2010
48
Figure 40 Geographic correlation of comprehensive HIV knowledge and levels of stigma and discrimination among women aged 15-49 years, 2010
49
Figure 41 Students in the primary and secondary education system, 1997-2010
52
Figure 42 Net attendance rate in primary school, 2006 and 2010
55
Figure 43 Net attendance rate in primary school by wealth quintile, 2006 and 2010
55
Figure 44 GPI in primary school, 2010
56
Figure 45 Schooling profile – rates of transition in primary and secondary school, 1999-2010
57
7
Equity and child rights
Figures
Figure 46 Literate women 15-24 years, 2006 and 2010
57
Figure 47 Teachers not trained by region, 2004/05
59
Figure 48 Bottleneck analysis of primary education
61
Figure 49 Women 15-49 years subjected to FGM/C, 2006 and 2010
64
Figure 50 Child labour, children 5-14 years, 2006 and 2010
65
Figure 51 Girls aged 20-24 years who gave birth before 18 years by region, 2010
66
Figure 52 Children under five years whose birth has been registered, 2006 and 2010
67
Figure 53 Estimated ODA, 2007-2011
69
Figure 54 ODA disbursements by sector, 2010
70
Figure 55 Public versus private sources of health financing, 1995-2010
70
Figure 56 Sources of private expenditure on health, 1995-2010
71
Figure 57 Expenditure in the education sector, 1998-2010
71
Figure 58 Households versus government expenditures on education, 2010
72
Tables
8
Table 1 Population growth rate, 1991-2009
17
Table 2 Cholera cases, 1987-2008
45
Table 3 Key PMTCT indicators by region, end of 2011
50
Table 4 Overview of the progress of Guinea Bissau towards selected MDGs
73
ACT Artemisinine Combination Therapy ART Antiretroviral Therapy CECOME Central Purchasing Authority for Essential Drugs
Guinea-Bissau
Acronyms
CEDAW Convention for the Elimination of All forms of Discrimination Against Women CEP Community-led Empowerment Programme CGS Cross-generational Sex CLTS Community-led Total Sanitation CRC Committee on the Rights of the Child DENARP National Poverty Reduction Strategy EMOC Emergency Obstetrical Care FGM/C Female Genital Mutilation/Cutting GDP Gross Domestic Product GPI Gender Parity Index IMC Institute for Women and Children ITN Insecticide-treated Net MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MMFCSLP Ministry of Women, the Family, Social Cohesion and Poverty Reduction NCAHP National Committee for the Abandonment of Harmful Practices ODA Official Development Assistance PEN-III Third National Strategic Plan for HIV/AIDS PMTCT Prevention of Mother-to-child Transmission PNDS National Health Policy POPEN National Operational Plan to Accelerate Child and Maternal Mortality Reduction SAB Autonomous Sector of Bissau TB Tuberculosis
9
10
Equity and child rights
Foreword
Guinea-Bissau
by UNICEF Representative Children and women in Guinea Bissau are among the poorest in the world: almost 70% of the population lives on less than US$2 per day. This high level of poverty is linked directly to the country’s recurrent military and political instabilities and frequent changes in Government since independence in 1973. Some social indicators are improving, but at a rate insufficient to meet any of the Millennium Development Goals (MDGs) by 2015. The country continues to rely heavily on official development assistance, particularly for investment in public services, but receives low levels of aid compared with other countries in Sub-Saharan Africa. Although under-five child mortality declined from 210 to 161i child deaths per 1,000 live births between 1990 and 2010, this remains one of the highest rates in the world. Guinea Bissau also has one of the eight highest maternal mortality rates globally, estimated at 790 maternal deaths per 100,000 live births (the estimated averages in all developing regions and in Sub-Saharan Africa are 240 and 500, respectively). Malnutrition contributes significantly to child and maternal mortality: prevalence of all forms of under-nutrition in children under five years is still high, with 32% of under-five children stunted, 6% wasted and 18% underweight in 2010. People living in urban areas and with more financial resources have better access to water and sanitation facilities. While 84% and 35% of people in urban areas have access to safe water and adequate sanitation, only 53% and 5% in rural areas benefit from such services. HIV remains a significant problem: the national prevalence rate among adults is 5.3% – significantly higher than that in the West and Central Africa region (estimated by the Joint UN Programme on HIV/AIDS at 2% or under in 12 countries in 2009). The number of children in primary schools more than doubled between 2000 and 2010, with gross enrolment increasing from 70% to 117%. However, educational outcomes remain extremely low, as demonstrated by the 2011 national examination results (76% of children failed Grade 9) and the low rate of literacy among women aged 15-24 (40%). Poverty, tradition and culture are interlinked in a complex manner, which reinforces harmful social norms and limits communities’ and households’ capacities to access services. The number of children whose births are registered declined from 39% in 2006 to 24% in 2010, which constrains their access to basic services. Meanwhile, a range of harmful practices affect children and women, such as female genital mutilation/cutting (FGM/C), early marriage, domestic violence, child labour and child trafficking. To respond to these diverse issues affecting children and women, the Government is working to meet the recommendations of the Committee on the Rights of the Child (CRC) and the Committee for the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). The second National Poverty Reduction Strategy (DENARP-II) provides a planning framework for partners across key sectors. Moreover, legislation is being updated; two important pieces of legislation, one criminalizing FGM/C and one prohibiting human trafficking, were published in 2011. Lastly, the Third National Strategic Plan for HIV/AIDS (PEN-III) is guiding the country’s HIV response, and lays out ambitious targets for the elimination of mother-to-child HIV transmission. However, significant legislative, policy and funding gaps still exist in relation to meeting CRC and CEDAW recommendations and with regard to funding DENARP-II and PEN-III. The Government of Guinea Bissau must create a more conducive sociopolitical environment, make pro-child budget allocations and foster partnerships to meet the needs of its population, all within the framework of DENARP-II. To this end, there is a need for a renewed focus so as to be able to reach the most deprived children and women in Guinea Bissau. Orienting efforts to target the biggest inequities will make the greatest gains in terms of achieving the MDGs. Geoff Wiffin UNICEF Representative
11
Equity and child rights
Executive summary This report analyses the socio-economic status of children and women in Guinea Bissau, and the reasons why they do not or cannot access services or realize their rights. Section 1 examines the slow demographic transition in the country and how it places pressure on household economies. The population of Guinea Bissau increased from 960,000 in 1990 to 1.5 million in 2009. Children under 15 years old make up 42% of the population, and life expectancy remains at 47 years, leading to a high community and household dependency rate, and thus a need for more health services and more schools. Political and military instability has had a negative impact on economic growth and the BissauGuinean economy is highly reliant on the export of raw cashew nuts. Section 2 discusses the wealth, geographic and gender inequities that affect children and women in the country. Children in the poorest household wealth quintile are less likely to ever attend school, be born at a health centre or have access to safe water and more likely to be chronically malnourished (stunted) compared with children in the richest households. With the Autonomous Sector of Bissau (SAB) the only major urban centre in Guinea Bissau, geographic inequities are deepest between this and the rest of the country. The capital has far lower poverty rates, higher access to social services and a greater protective environment for children and women. For example, the extremely limited presence and capacity of the Government in rural areas means children and women generally have further to travel to access services, with about 50% of the population living more than 5 km from a health facility. Gender inequities are also significant: while mothers bear the major responsibility for providing for their children, in many communities and households they play a subservient role. Women are less likely to be literate than men: only 26% of women in regions outside SAB are literate compared with 57% of men. Women are almost three times more likely to be HIV positive than men (6.9% versus 2.4%). Sections 3-6 address the most significant social challenges facing children and women, giving an overview of health, nutrition, water and sanitation, HIV/AIDS, education and protection, all from an equity perspective. These sections also examine how the Government is working to meet the recommendations of the Committee on the Rights of the Child (CRC) and the Committee on the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) in the social sectors. While significant progress has been made in terms of strengthening and speeding up the revision and harmonization of national laws and policies, major gaps remain, particularly in terms of implementation.ii The second National Poverty Reduction Strategy (DENARP-II) and the supporting Priority Action Plan (2011-2015) provide a national development framework, one that incorporates sector planning targets. The Third National Strategic Plan for HIV/AIDS (PEN-III) (2011-2016) incorporates ambitious targets for the elimination of mother-to-child HIV transmission. However, maintaining progress to improve children’s rights requires socio-economic stability and growth, and the events of April 2012 may erect significant barriers to implementing the structural reforms required to overcome social inequities. Section 3 analyses child and maternal survival and development, showing that, while child mortality has declined, large inequities in child survival remain, and major efforts are needed to meet the Millennium Development Goal (MDG) targets. While there have been commendable achievements in immunization and in the treatment of malaria and diarrhoea, there has been little progress on malaria prevention, and malnutrition remains a serious concern. Access to safe water remains low and, although there have been small improvements in access to sanitation, it is still almost non-existent outside the capital.
12
Guinea-Bissau Section 4 illustrates that girls and women are three times more likely to be infected with HIV than boys and men, and describes factors that influence this vulnerability, including low knowledge about HIV prevention, early sexual debut, cross-generational sex (and child marriage) and inequitable access to high-quality HIV prevention, care and treatment services. High HIV stigma and discrimination are correlated with low HIV knowledge and hamper access to these services. This section also emphasizes the pressing need to mobilize resources for HIV prevention, care and treatment. Section 5 discusses education access and achievement. More children are entering the education system than ever before, but quality levels remain low, with insufficient trained teachers and pedagogical materials. There is a low transition rate from basic education to secondary school, and gender and geographic inequities remain large. Section 6 looks at the protective environment for children in Guinea Bissau. Children and women are affected by several harmful social practices, from low birth registration to high rates of female genital mutilation/cutting (FGM/C), early marriage, domestic violence, child labour and child trafficking, with children in in the east disproportionately affected. Section 7 looks at pro-child budgeting. The series of political-military and financial shocks Guinea Bissau has faced since independence have significantly limited the allocation of national resources to basic social services and the promotion of children and women’s rights. Economic stagnation has led Guinea Bissau to rely on official development assistance (ODA) for public sector investment, but the country continues to receive low levels of ODA compared with the Sub-Saharan African average, leading to chronic underinvestment in public services. This, coupled with poverty, leads to low access to and use of services. The Annex provides an ‘equity snapshot’ of child rights indicators, to show the achievement of rights by geography, wealth and gender. It looks at children’s rights to an adequate standard of living, survival and health, early childhood development and education and civil rights and freedoms. The colour coding allows the reader to identify inequities as they compare with the national average.
13
14
Equity and child rights
Guinea-Bissau
Children and women Demography and economy Figure 1: Organisation of Administrative Regions in Guinea-Bissau (Region and Sector)
Source: INE 2012
The population has grown significantly and remains overwhelmingly young The population of Guinea Bissau increased from 960,900 to over 1.5 million between 1990 and 2009, and continues to grow at an estimated rate of 2.45% per year. Since independence, total fertility has remained persistently high, reaching 5.1 children per woman in 2009 (Figure 2). Life expectancy in Guinea Bissau has increased very slowly, from 39.2 years in 1980 to only 47.3 years in 2009: it is now almost the lowest in the world, well below the average life expectancy in Sub-Saharan Africa (53.6 years) and also below that of neighbouring Guinea Conakry, where it increased from 38.8 to 53.2 years in the same time period. Low life expectancy and persistently high fertility rates have combined to create an extremely young population (Figure 3). In 2010, children under five accounted for 15% of the total population; altogether, 51% of the population is under the age of 20.
15
Equity and child rights
Children and women
Demography and economy
Figure 2: Fertility rate, 1980-2009
Source: WDI
Figure 3: Males and females by age group (population pyramid), 1990-2010
Source: UNDESA population data
16
Guinea-Bissau
The population is distributed unequally across the territory, with approximately 25% of the concentrated in the Autonomous Sector of Bissau (SAB) (Table 1). Oio, Bafatá, Gabú and Cacheu each comprise about 15% of the total population, Biombo and Tombali 7% and 6%, respectively, and Bolama/Bijagós 2%.
Table 1: Population growth rate, 1991-2009 Population Growth rate (%) 1991
2009
Number
%
Number
%
979,203
100
1520,830
100
2.45
Tombali
71,065
7.3
94,939
6.2
1.61
Quinara
42,960
4.4
63,610
4.2
2.18
Oio
155,312
15.9
224,644
14.8
2.05
Biombo
59,827
6.1
97,120
6.4
2.69
Bolama/Bijagós
26,891
2.7
34,563
2.3
2.39
Bafatá
145,088
14.8
210,007
13.8
2.05
Gabú
136,101
13.9
215,530
14.2
2.55
Cacheu
146,570
15.0
192,508
12.7
1.51
SAB
195,389
20.0
387,909
25.5
3.81
Guinea Bissau
Source: INE, RGPH (1991-2009)
Rural administrative sectors have the highest concentration of children under five and under 18 years old (Figure 4). The sectors with the highest concentrations of children are Farim and Mansaba (Oio); Contuboel and Xitole (Bafatá); Pitche, Pirada and Boe (Gabú); and Cacine (Tombali) – sectors that also have the highest levels of extreme poverty in the country.
17
Equity and child rights
Children and women
Demography and economy
Figure 4: Proportion of the population under 18 years old by administrative sector, 2009
Source: INE 2009
A population with few economic opportunities and highly vulnerable to fluctuations in the price of imported food and cashew nuts Guinea Bissau became independent in 1973 after a decade-long war of independence against Portugal. Since then, the country has experienced near-constant political instability, culminating in a civil and regional war that lasted from June 1998 to early 1999 and saw the displacement of an estimated 300,000 civilians (a quarter of the population). The conflict also caused severe disruptions to the economy as well as massive destruction to the public infrastructure, from which the country is still reeling. In the past decade, continued political instability has hindered reconstruction and economic recovery, with the latest presidential elections interrupted by a military coup on 12 April 2012.iii Economic recovery has therefore been difficult and has not been able to keep pace with the increase in population. In 2010, gross domestic product (GDP) per capita (US$161 in constant 2000 US$) was still below the level at independence (US$168 in constant 2000 US$) (Figure 5).
18
Guinea-Bissau
Figure 5: Political instability, civil war and slow economic recovery
Source: WDI 2011
The Bissau-Guinean economy remains dominated by agriculture, which in 2010 contributed more than 40% of GDP and employed 95% of the population.iv Subsistence agriculture (food crops such as rice, millet, sorghum and maize) constitutes the mainstay for the vast majority, with cash income coming almost exclusively from the production and marketing of raw, unprocessed cashew nuts.v The export of raw cashew nuts increased from 5,500 metric tonnes in 2002 to reach a peak of almost 175,000 metric tonnes in 2011. With almost no processing taking place in country, however, a significant proportion of the value chain of cashew production and sales is lost. Concentration on cashew nut production and low food crop productivity mean rural households are highly vulnerable to fluctuations in the price of imported rice relative to cashew nuts, as well as to global economic shocks, which affect the flow of remittances to the country.vi
19
20
Equity and child rights
Guinea-Bissau
Inequities affecting children and women Monetary poverty has increased significantly in recent years, particularly in rural areas The proportion of the population living in monetary poverty increased markedly between 2002 and 2010. For people living on less than US$2 per day, the increase was four percentage points, to 69%. The increase in extreme poverty (less than US$1 per day) was even greater, from 21% to 33% (Figure 6). The large disparity between the capital and the rest of the country also widened between 2002 and 2010: extreme poverty increased from 25% to 40% in the regions, compared with an increase from 9% to 13% in SAB. Levels of absolute and extreme poverty are extremely high outside of the capital (Figure 7). Between one-third and half of the population live on less than US$1 a day in the seven poorest regions, and absolute poverty is pervasive throughout the country. Even in the best performing region, Bolama/Bijag贸s, almost half the population lives on less than US$2 a day, and in Gab煤 absolute poverty is close to universal, affecting 84% of the population. Widespread poverty underlines the vulnerability of the population: an extreme lack of financial resources constrains the ability of communities to provide their children with health care, education and a protective environment. A combination of factors has led to this increase in poverty, including political and military instability. Sluggish economic growth with an underdeveloped agriculture sector focused on monoculture and the export of raw cashew nuts means limited opportunities for communities to generate an income. Although the country is small, transport infrastructure is inadequate and this limits market access.
Figure 6: Monetary poverty, 2002 and 2010
76% 70%
80% 70% 60%
51%
69% 65%
52%
50% 40%
40%
33%
30% 20% 10%
25%
2002 2010
21%
13% 9%
0% SAB
Other regions
Total
<US$1/day
SAB
Other regions
Total
<US$2/day
Source: ILAP 2002 and ILAP-2 2010
21
Figure 7: Monetary poverty by region, 2010 Population on less than US$ or US$2 per day
Equity and child rights
Inequities affecting children and women
90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
<US$2 per day <US$1 per day Source: ILAP-2 2010
2.1 Wealth inequities Compared with a child growing up in the richest quintile, a child in the poorest quintile is: â&#x20AC;Ś four times less likely to be born in a health centre Figure 8: Women giving birth in a health centre by wealth quintile, 2010 80% 65%
39% 29% 20%
Lowest
Second
Middle
Fourth
Highest
Source: MICS 2010
Woman B (Canquelifa) â&#x20AC;&#x201C; When a pregnant woman needs to be evacuated, we have a lack of transport, and the telephone network is not good here. To contact someone who can help us with a car we walk to get network coverage. If the patient is in a very serious condition they may die before the car arrives. We also lack medicines at the health centre.
22
Figure 9: Households with access to safe drinking water by wealth quintile, 2010
Guinea-Bissau
… two times less likely to have access to safe drinking water
94% 80% 67% 55% 40%
Lowest
Second
Middle
Fourth
Highest
Source: MICS 2010
… almost two times less likely to be in primary school Figure 10: Primary net attendance for primary school by wealth quintile, 2010 84%
87%
65% 52%
Lowest
56%
Second
Middle
Fourth
Highest
Source: MICS 2010
… twice as likely to be stunted Figure 11: Moderate stunting in children under five years by wealth quintile, 2010 42% 37% 31% 24% 18%
Lowest
Second
Middle
Fourth
Highest
Source: MICS 2010
23
Equity and child rights
Inequities affecting children and women
2.2 Gender inequities Gender inequality and discrimination are among the main drivers of poverty and vulnerability, particularly in rural areas Bissau-Guinean society is patriarchal: power and authority lie with men as the head of the family, the community and religion. Women in rural areas are often solely responsible for domestic work, such as collecting water and firewood, cooking and child welfare, but they have little control over resources and family planning. They also gain any land use rights only through their husbands. The high poverty rate among divorced women and widows is often related to discrimination in customary law: after her husbandâ&#x20AC;&#x2122;s death, a widow does not inherit, but rather becomes her husbandâ&#x20AC;&#x2122;s familyâ&#x20AC;&#x2122;s responsibility. Single, widowed or abandoned women thus have less access to land and economic potential.vii Physical, psychological and sexual violence against women is widespread, but remains underreported because of male authority over women. Domestic violence is rarely brought to the attention of law authorities except in cases involving major tragedies or divorce. In addition to households, other areas of potential aggression against women and girls are schools and through door-to-door sales in the informal labour market.viii Despite improvements, a large proportion of women still think their husband has a right to beat them (Figure 12).
Figure 12: Women who accept domestic violence, 2006 and 2010 63% 52%
52%
53% 47% 47% 42%
40%
37% 29%
Total
SAB
Source: MICS 2006 and 2010
24
East
North
South
2006 2010
According to the Multiple Indicator Cluster Survey (MICS) 2010, poor women are twice as likely to have sex with men 10 years (or more) older than them; seven times less likely to use contraception; and more than twice as likely to give birth while they are still teenagers, compared with the richest women. Around 27% of girls aged 15-19 years are married and 33% of women aged 20-24 years have given birth before the age of 18. This is particularly because of a preference for very large family sizes, which leads to low birth spacing. Adolescent girls who become pregnant have a much higher risk of dying, as do their children, as their bodies are not mature enough to cope with the experience. Women and girls have poor knowledge of reproductive health and, combined with limited access to antenatal and postnatal care, this contributes to high HIV prevalence (almost three times higher than that among men, Figure 13) and difficult pregnancies and deliveries.
Guinea-Bissau
Wealthier and educated women are significantly more likely to protect their own and their childrenâ&#x20AC;&#x2122;s rights
Figure 13: Prevalence of HIV among those aged 15-49 years, 2010 9,9% 7,4%
6,9% 5,3% 4,2%
4,1%
2,9%
2,4% 1,4%
Male Female
15-49 years
15-25 years
25-49 years
All
Source: INASA 2010
The literacy rate for women aged 15 or over is 38%, compared with 67% for men; outside the capital, literacy for women is half that of men, at 26% compared with 57% (Figure 14). Educated mothers are more likely to protect their own and their childrenâ&#x20AC;&#x2122;s rights. A total of 46% of women who have no education consider domestic violence acceptable, as opposed to 30% of those who are educated (Figure 15). And 65% of women who have no education have undergone female genital mutilation/cutting (FGM/C), compared with 28% who have secondary education (Figure 15); almost half of daughters of uneducated mothers are subjected to FGM/C, compared with 9% of daughters of highly educated women.ix Children of educated mothers are more likely to undergo birth registration (Figure 15). Educated women are more likely to adopt safer health behaviours, including using a condom in high-risk sex and giving birth at a health facility (Figure 16). The primary net attendance rate for girls whose mothers have secondary education or higher is 91%, compared with 55% for girls whose mothers have no education. Finally, 78% of children whose mothers have a high level of education have received all the necessary vaccinations, compared with 56% of children with uneducated mothers. â&#x20AC;&#x192;
25
Equity and child rights
Inequities affecting children and women
Figure 14: Literacy rates among those aged 15 years and older, 2010 90% 80% 67%
70% 57%
52%
Total Female
41%
38%
Male 26%
Guinea-Bissau
SAB
Other regions
Source: ILAP-2 2010
Figure 15: Motherâ&#x20AC;&#x2122;s education and socio-economic indicators, 2010 65%
46% 37% 27%
39%
37% 28%
None 30%
21%
Registered birth of child FGM/C (women 15-49 years) Accept domestic violence Source: MICS 2010
â&#x20AC;&#x192;
26
Primary Secondary +
81%
Guinea-Bissau
Figure 16: Motherâ&#x20AC;&#x2122;s education and socio-economic indicators, 2010
59% 45%
53%
48%
None Primary
34%
29%
Secondary +
18% 12%
Used condom in high-risk sex
Gave birth before 18 years
Gave birth in a health centre
Source: MICS 2010
The Government of Guinea Bissau has taken steps to advance gender equality The Government has ratified the Convention for the Elimination of All forms of Discrimination Against Women (CEDAW) and created the Institute for Women and Children (IMC) under the former Ministry of Women, the Family, Social Cohesion and Poverty Reduction (MMFCSLP). A National Policy on Gender Equality and Equity is being developed to guide the implementation of CEDAW recommendations. However, further steps are required to fully incorporate CEDAW into national policy and implementation, including the adoption of a law against domestic violence. Significant investment of human and financial resources is needed, particularly through the decentralization of services close to communities, so as to be able to identify and follow up on CEDAW-related work in communities.
2.3 Geographic inequities Rural children have significantly lower access to decent social services Infrastructure is particularly poor in rural areas, meaning children and women have to travel long distances to access social services. About half of the population lives within 5 km of a health centre, posing extreme difficulties, particularly in emergencies and during childbirth. The distance children have to travel to school, particularly after Grade 4, means many drop out early. There are significantly higher pupilâ&#x20AC;&#x201C;teacher ratios and severe shortages of pedagogic materials in rural areas. Decentralization remains nascent, and the Government has allocated resources to the regions only for salaries. The capacity to deliver services is thus stronger in the capital than in rural areas, and not all sectors have decentralized capacity, which has severe impacts in uncovered areas. Only three of the nine regions (Quinara, Tombali and BafatĂĄ) had a functioning system of delegation of water and sanitation in 2011. Moreover, the IMC is not present in any of the regions, which makes it very difficult to identify and follow up on cases of exploitation and abuse in communities. Figures 17-19 illustrate regional variations in birth registration, HIV prevalence among pregnant women and FGM/C rates, all of which disproportionately affect the east of the country.
27
Equity and child rights
Inequities affecting children and women
Children in Quinara and GabĂş have poor access to birth registration Figure 17: Children 0-5 years whose birth has been registered, 2010
Source: MICS 2010
Pregnant women in the east and south are more likely to be infected by HIV Figure 18: HIV prevalence among pregnant women, 2009
Source: INASA, 2009
28
Figure 19: Prevalence of FGM/C among women 15-49 years, 2010
Guinea-Bissau
Girls in the east of country are particularly vulnerable to abuse and exploitation
Source: INASA, 2009
29
30
Equity and child rights
Guinea-Bissau
Child and maternal survival and development Despite some improvements, infant and child mortality rates in Guinea Bissau remain among the highest in the world Since the early 1990s, child mortality in Guinea Bissau has declined by 23%, from 210 deaths per 1,000 live births in around 1990 to 161 in 2011 (Figure 20). By comparison, child mortality declined by 33% during the same period in West and Central Africa, by 48% in Eastern and Southern Africa and by 39% for the whole of Sub-Saharan Africa.x Today, Guinea Bissau has the seventh highest under-five mortality rate in the world: one in every six children dies before his or her fifth birthday, with one in ten dying during the first year of life.
Figure 20: Child mortality estimates per 1,000 live births, 1989-2013
Source: Inter-agency Group for Mortality Estimates 2011
Globally, child mortality owes mainly to preventable and treatable infectious diseases: pneumonia, malaria and diarrhoea, which together account for more than 60% of all under-five deaths.xi Pneumonia is responsible for 23% of under-five child deaths, followed by malaria (21%) and diarrhoeal diseases (19%). A total of 24% of child deaths occur during the neonatal period (the first 28 days of life).
Woman F (Kamiconde) â&#x20AC;&#x201C; Last year I had a problem during delivery and was transported by motorcycle to Cacine. When I arrived, the health centre was closed. A woman who was passing by saw me lying on the floor, and I told her that I was feeling labour pains. She went to inform the nurse that a woman was in labour at the health centre. When the nurse came, she attended only the people who had money, and then left. My child died because he was too tired [by the time I gave birth].
31
Equity and child rights
Child and maternal survival and development
Large inequities in child survival, with the east the most disadvantaged Progress in relation to child survival has been inequitably distributed across the regions of the country (Figure 21). Infant and child mortality rates in the east are about a third higher than the national average. Mortality is higher in the east (BafatĂĄ and GabĂş regions), where women have the lowest literacy levels. Other critical factors that put the east at a disadvantage include high HIV prevalence, child marriage, high levels of FGM/C, higher fertility rates (6.6 versus 3 in SAB) and a highly dispersed population.
Figure 21: Under-five and infant mortality rates by region (per 1000 live births), circa 2005 Infant mortality rate
227
Under- five mortality rate
173 142
140
165
150
143 123 97
93
SAB
East
81
78
North
South
Urban
102
Rural
100
Guinea Bissau
Note: Data collected in 2010 estimate mortality rates circa 2005 Source: MICS 2010 Child Mortality Rate, adjusted for Inter-agency Group for Child Mortality Estimation estimates
Low levels of maternal care: two women die every day while giving birth Maternal mortality in Guinea Bissau has been estimated at 790 women per every 100,000 live births, equivalent to a lifetime risk of maternal death of 1 in 25, one of the highest in the world and close to those of Liberia and Sierra Leone, two countries that have gone through similar periods of political and military instability.xii The causes of maternal deaths in Guinea Bissau are similar to those prevailing in most countries in Sub-Saharan Africa. Maternal deaths are the result of complications during the pregnancy, delivery or puerperal periods (haemorrhage, dystocia and eclampsia) as well as complications of abortions. As in the rest of West and Central Africa, antenatal care coverage has been high and has increased markedly in recent years. On average, in 2010, nine out of ten pregnant women in Guinea Bissau attended their first antenatal care visit and were received by a skilled health personnel. In the east, there was a 50% increase in attendance, from 64% in 2006 to 92% in 2010, demonstrating that the population understands the importance of antenatal care and is increasingly demanding this service (Figure 22).
32
97%
91%
84%
92%
91% 82%
Guinea-Bissau
Figure 22: Women receiving skilled antenatal care (at least one visit), 2006 and 2010
81%
64% 2006 2010
SAB
East
North
South
Source: MICS 2006 and 2010
However, coverage for the fourth antenatal care visit drops to 68% on average and is below 80% in all regions (Figure 23). It drops sharply in the north from 91% coverage for the first antenatal care visit to 61% for the fourth visit. This decline is thought to occur because many pregnant women start antenatal care as late as the third trimester of pregnancy. There is a need to communicate to pregnant women the importance of coming for their first antenatal visit during the first quarter of their pregnancy and of completing the recommended number of visits. When it comes to giving birth, nationwide, only four in ten pregnant women have a skilled attendant (Figure 23). Only 29% of women in rural areas, compared with 69% of women in urban areas, deliver in a health facility, with the east, once again, the most disadvantaged.
Figure 23: Women receiving skilled antenatal care (at least one visit, at least four visits) and skilled birth attendance, 2010 At least one visit with skilled personnel 96% 74% 69%
At least four visits 97%
91%
74% 73% 64%
91%
Skilled birth attendance 92%
91%
72% 61% 40%
29%
Urban
Rural
67%
36%
27%
SAB
East
North
South
Source: MICS 2010
33
Equity and child rights
Child and maternal survival and development
Delivery with skilled attendance is one of the most important factors in helping women survive complications during and after delivery. However, in rural areas, 65% of women deliver with unskilled attendance (family, friends and traditional birth attendants). Midwives who are not trained adequately, work in ill-equipped health facilities and are not able to deal with all complications at birth deliver 23% of births. In urban areas, while the majority of deliveries are attended by midwives (56%), as many as 26% of births are still attended by unskilled persons. It is thus obvious why maternal mortality remains high in Guinea Bissau. To compound the matter, the availability of emergency obstetrical care (EMOC) nationwide is still low. The unequal distribution of skilled personnel, with a big share reserved for urban areas, reduces the availability of maternal care in rural areas. Figure 24 illustrates this uneven distribution. Saving the lives of mothers will require stepping up efforts to ensure EMOC is available both at health centres (basic EMOC) and in hospitals (comprehensive EMOC). This means providing training and essential commodities and reorganizing services in health facilities in ways that favour access to and delivery of EMOC. Communities will have to play their part to ensure decisions are made in time to seek care before and during delivery. The costs incurred in benefiting from EMOC constitute major barriers to access. Removing financial barriers will also require the involvement of communities, for instance through the setting-up of mutual health insurance schemes.
Figure 24: Qualification of persons who provide assistance at birth, 2010 Urban
Rural
56% 41%
23%
5%
8% 1%
Doctor
18% 8%
5%
Nurse
24%
1% 0% Midwife
Traditional birth attendant
Friends and family
Others
4% 5% Non -assisted
Source: MICS 2010
Man B (Gabú) – We do not want our women giving birth at home because we know that this has consequences. But also because of the cost in the hospitals we are relieved if our wives have a safe home delivery.
A highly constrained and under-funded health system Geographic barriers of access to health facilities. About half of the population lives within 5 km of a health facility, which translates into high transport costs for the population. Geographic barriers are worse in the east (Bafatá and Gabú) where the population is highly dispersed. Removing these geographic barriers and bringing health care closer to the population in the east requires intensification of outreach service delivery, as well as communication and education (literacy) programmes targeted at these scattered populations.
34
Health facilities suffer degraded infrastructure and insufficient equipment and materials.xiii Health centres operate as semi-autonomous units: the Government pays salaries but offers little other support, financial or otherwise, and nurses (or the doctor if one is present) must manage the health facility to be self-sustaining.
Guinea-Bissau
Degraded infrastructure.
A critical shortage and unequal distribution of health personnel, particular in rural areas. Over half of health workers are concentrated in the capital, and 80% of physicians are based in urban areas. Nurses and midwives remain in short supply in rural areas and those who are there face difficult living conditions and are unlikely to remain long. Furthermore, recruitment has not kept pace with population growth and the health worker– population ratio has worsened in recent years, falling far short of international benchmarks (Figure 25).xiv All levels of health workers suffer from low wages, which are often paid late, leading to frequent strike actions by personnel. The quality of formal training provided to health personnel is insufficient for them to perform their roles. Low morale results in a high staff turnover: the Ministry of Health estimates that 48% of health care staff will have left the sector by 2015.xv
Figure 25: Health workers per 10,000 population, 2004 and 2007 7 5,78
2004 2007
2 1,03
1 0,98
1,37 0,15
Doctors
Nurses
Laboratory technicians
Midwives
0,02
Pharmacy Anaesthetists technicians
Source: African Health Observatory 2010
Man B (Kamiconde) – The whole sector in Cacine has no doctors, only nurses. The health sector is like a ladder: each person has their own level, and today there are many diseases that nurses cannot treat, it goes beyond the knowledge of the nurse. In cases that require evacuation, when the family has no money to hire an ambulance patients face the risk of death because of a lack of human resources.
Woman E (Gabú) – My child was sick recently, I went to the hospital but there were not enough nurses in the paediatric ward. My child was there for three days but on the floor, because there were no beds. The three nurses there were insufficient.
35
Equity and child rights
Child and maternal survival and development
Highly deficient drug supply system. The Central Essential Drugs Purchasing Authority (CECOME) is unable to satisfy the needs of the population, owing to low managerial capacity, weak collaboration across key health programmes and inadequate funding. The country relies almost entirely on external financial assistance for the procurement of essential drugs, vaccines and commodities for the treatment of major killers (malaria, tuberculosis (TB), HIV/AIDS and vaccine-preventable diseases). However, there are major threats to the continuity of this external support, given Government inability to honour its co-financing and other commitments (e.g. 6% upfront contribution for vaccines, with the Global Alliance for Vaccines and Immunisation providing 94% of the funding). The weak managerial capacity of CECOME, and lack of collaboration across programmes, also undermines the continuity of this external support. Continued support from the Global Fund is threatened by the slow pace of reform of CECOME, which needs to be restructured and recapitalized to be able to function with greater autonomy. CECOME has a central structure at national level and depots in nine of the country’s eleven health regions. Only the central structure has a computerized logistics system, and it distributes drugs only as far as the regional depots. Health centre staff have to travel to these depots to buy drugs. This weak distribution capacity results in shortages, particularly in rural areas, and a lack of quality control of pharmaceuticals has resulted in out-of-date drugs being dispensed. Meanwhile, following a kerosene shortage on the local market in 2008, which disrupted the vaccine storage cold chain, each of the 114 health centres was equipped with solar-powered refrigeration for vaccine storage. However, storage capacity remains insufficient to cope with increasing quantities of vaccines (the country plans to introduce two new vaccines (pneumococcus and rotavirus) in 2013-2014). Moreover, issues remain with maintenance, which jeopardizes the stability of the cold chain.
Financial barriers – a major obstacle to accessing health care. Health centres in Guinea Bissau must generate revenues through the sale of drugs and through consultation fees in order to be able to pay their expenses, including for the renewal of stocks of medicines and incentives for auxiliary staff. However, because of frequent stock-outs of essential drugs through the CECOME system, health centres and hospitals revert to the private sector to procure drugs at a relatively higher cost, which is then transferred on to the patient. Communities must pay for every service (including for consultation fees, the purchase of gloves, candles, etc.) before they can be attended to. These costs, coupled with extremely high levels of monetary poverty, act as powerful disincentives to seeking treatment. Sick individuals and pregnant women are frequently unable to pay transport costs to often distant health centres, resulting in a low institutional birth rate and low treatment of diseases.
Woman B (Kamiconde) – A consultation card for a pregnant women costs FCFA 1,500, vaccines cost FCFA 500 and drugs FCFA 750. This is the first visit, and then every time you go to the hospital you have to pay FCFA 1,000, and consultation costs are FCFA 250 and new medicines FCFA 750. There you can get just three types of medication, the rest you will have to buy.
Woman A (Canquelifa) – A problem is the lack of drugs. Sometimes when you go to the health centre you can’t get the necessary medicines, so you have to buy them in a private pharmacy.
36
Guinea-Bissau
Man B (Gabú) – In the pharmacies, you will find someone who is not a pharmacist. They will give you a medicine that is not good, maybe it has even expired. There is no inspection of pharmacy services.
National policies address the principal killers of children and women, but require significant investment. To achieve Millennium Development Goals (MDGs) 4 and 5 by 2015, the Government of Guinea Bissau is implementing the National Operational Plan to Accelerate Child and Maternal Mortality Reduction (POPEN) 2011-2015. This promotes the delivery of integrated health, nutrition, HIV/AIDS and water, sanitation and hygiene interventions, including service decentralization for some of the hardest-to-reach communities. It integrates interventions by the Ministry of Health under the National Policy for the Development of the Health Sector 2008-2017 and the National Food and Nutrition Policy; by the Ministry of Energy and Natural Resources under the National Water and Sanitation Sector Master Plan 2010-2020; and by the National Secretariat to Fight AIDS under the Third National HIV/AIDS Strategic Plan (PEN-III) 2012-2016. The National Health Development Plan (PNDS) covers the period 2008-2017 and focuses on two priority areas: strengthening the capacity of the National Health Service (2008-2012) and improving the health outcomes of the population (2013-2017). The former is to be achieved by reinforcing governance and improving infrastructure, equipment, human resources and pharmaceuticals. Health outcomes will be improved through inter-sectoral collaboration and integrated disease surveillance. Monitoring and evaluation and the development of essential care and referrals will also be strengthened.
Achievements in coverage of high-impact interventions in recent years Since 2006, incidence of major child killers has been reduced substantially thanks to successful implementation of high-impact interventions.
Successful mass vaccination campaigns for measles, polio and tetanus. Vaccination campaigns have sustained positive results over time and narrowed the gap in immunization coverage between urban and rural areas. Between 2008 and 2011, nine children’s health days were conducted, involving the vaccination of on average 280,000 children per campaign against polio and other diseases. In 2011, three national polio vaccination campaigns were organized and implemented with a focus on the hardest-to-reach populations. Mass measles vaccination campaigns were also organized nationwide in 2006 targeting children 9 months to 14 years, and in 2009 targeting children 9-59 months. In 2007-2008, three rounds of mass tetanus vaccination campaigns targeting women of child-bearing age were organized and conducted. These strategies achieved universal coverage for their respective targets. As a result, the country has been ‘polio free’ since 2009 and the reported incidence of measles is near zero. In February 2012, maternal and neonatal tetanus was declared eliminated as a public health problem in Guinea Bissau.
Significant strengthening of routine immunization programmes. Provision of vaccines, cold chain and transport logistics, the training of personnel, additional operational support to outreach and mobile vaccination strategies, greater efforts on behaviour change communication and an improved monitoring and evaluation system to assess progress have collectively led to improvements in immunization programme performance. Coverage rates for BCG, Polio 3 and DPT 3: 94%, 79% and 81%, respectively, increased in 2010 (Figure 26). The proportion of pregnant women protected against tetanus also increased significantly, from 52% to 70%, between 2006 and 2010. On the other hand, the proportion of children fully vaccinated before the age of one year declined from 54% to 42% and the immunization rate for
37
Equity and child rights
Child and maternal survival and development
measles from 75% to 69% between 2006 and 2010. Efforts need to be stepped up to further strengthen routine immunization, both to overcome coverage gaps in the next two years (2013-2014) and to sustain currents gains in the reduction of morbidity and mortality from vaccine-preventable diseases.
Figure 26: Improved vaccination coverage in children between one and two years, 2006 and 2010 94% 89%
94%
89%
82%
81% 75% 69%
74% 62%
61% 50%
2006 2010
BCG
DPT 1
DPT 2
DPT 3
Measles All vaccinations
Source: MICS 2010 and 2006
Significant improvements in access to diarrhoea treatment.
Access to diarrhoea treatment doubled from 25% in 2006 to 54% in 2010 (Figure 27). This progress was achieved thanks to the availability of oral rehydration salts on the market and awareness campaigns targeted at health personnel on the management of diarrhoea. In spite of this increase, diarrhoea is still responsible for one out of five child deaths. Efforts need to be stepped up to enable oral rehydration to reach a much higher proportion of children with diarrhoea, as well as to strengthen prevention interventions. â&#x20AC;&#x192;
Figure 27: Diarrhoea treatment â&#x20AC;&#x201C; oral rehydration with continued feeding among children under five years, 2006 and 2010
Source: MICS 2006 and 2010
38
According to the MICS, between 2006 and 2010 there was a decline in the percentage of children under five years sleeping under a mosquito net, from 73% to 62% (for any kind of net) and from 39% to 36% (for insecticidetreated nets (ITNs)), although this is still well above the average coverage level for West and Central Africa of 10%. For pregnant women coverage levels also declined, from 86% (sleeping under any kind of net) and 43% (sleeping under an ITN) in 2007xvi to 63% and 43%, respectively, in 2010.
Guinea-Bissau
Little progress on malaria prevention.
There have been efforts recently to improve these coverage levels. A major nationwide mosquito net distribution campaign was conducted in November 2011, delivering 867,300 nets, representing 99% coverage of the population on the basis of one net for every two persons. A total of 94% of households received long-lasting ITNs on this basis. An impact survey is pending, which will inform on both the level of effective utilization of nets and the impact on the reduction of morbidity from malaria. The challenge for Guinea Bissau is to sustain the level of ownership of bed nets while ensuring their effective use by women and children within the family. To address this will require sustained communication for behaviour change to promote net utilization.
Improved access to anti-malarial treatment in rural areas. The percentage of children under five years receiving anti-malarial treatment increased from 18% to 37% in rural areas between 2006 and 2010, bringing the national coverage level to 37% (about the average coverage level in West and Central Africa). Part of this increase was brought about thanks to Global Fund support to the national malaria programme, which introduced artemisinine combination therapy (ACT) as the first-line treatment for malaria in 2006xvii and rolled it out in 2007.xviii Constraints to implementation included delayed training and revision of guidelines, as well as problems related to the storage and distribution of ACT.xix In 2010, 89% of the children who received anti-malarial drugs were given chloroquine, which is still prescribed and often, at double the normal dosage with the expectation of increasing its efficacy,xx against the decision of the country to use only combined therapy. This practice has resulted from the non-withdrawal from the countryâ&#x20AC;&#x2122;s pharmaceutical market of the hitherto used antimalarial drugs, given that the Government could not provide ACT in quantities to meet all the needs of the entire population. In addition, ACT has sold and still sells at a very high price in private sector pharmacies. For a country that depends greatly on external funding for its health sector, including for the provision of essential drugs and in the midst of an increasing difficult relationship with the Global Fund, Guinea Bissau stands at a significant risk of regression on most indicators in the area of its malaria control programme. Well-targeted and sustained advocacy will be necessary to find solutions to this situation. Figure 28 shows the trend in access to anti-malarial treatment.
Figure 28: Children under five years with a fever who received anti-malarial medication, 2006 and 2010
Source: MICS 2006 and 2010
39
Equity and child rights
Child and maternal survival and development
Little progress on treatment of pneumonia with antibiotics. The proportion of under-five children with pneumonia who received antibiotic treatment dropped from 42% in 2006 to 35% in 2010 (Figure 29). Three factors explain this situation. Within a context where close to 70% of the population lives under the poverty line and with a health system that operates on a cost recovery basis to sustain itself, financial barriers reduce accessibility of treatment for pneumonia. Second, health facilities go through long periods of drug stock-outs, given the countryâ&#x20AC;&#x2122;s weak capacity in drug supply management. Finally, as mentioned earlier, the health system depends almost entirely on external financial assistance to sustain itself and so far no funding assistance has focused on the management of pneumonia.
Figure 29: Children under five years suspected of having pneumonia who received treatment, 2006 and 2010
Source: MICS 2006 and 2010
Malnutrition Slow progress on addressing under-nutrition. Sustained advocacy for nutrition to be considered among the priorities of the Government is reflected by the establishment of a Nutrition Department at the central level of the Ministry of Health in 2008. The enactment of the National Nutrition Policy in 2010 was another important step forward; this identifies nutrition priorities and strategies and provides guidelines for the coordination of implementing partners. However, malnutrition, the underlying cause of 35% of under-five child mortality globally, remains a major health concern in Guinea Bissau, with 32% of under-five children stunted, 6% wasted and 18% underweight (Figure 30). All types of under-nutrition witnessed a decline between 2000 and 2010 according to MICS data. The rate of underweight dropped from 25% in 2000 to 19% in 2006 and 18% in 2010. The prevalence of wasting or acute malnutrition decreased from 10% in 2000 to 7% in 2006; there was then stagnation through to 2010, owing to a lack of specific initiatives to prevent acute malnutrition and ineffective management of acute malnutrition. A national protocol for the management of acute malnutrition was enacted in 2007 but its implementation is limited to four health regions. The prevalence of stunting oscillated between 2000 and 2010, ending up almost at its 2000 level of 30% (41% in 2006 and 32% in 2010).
40
41%
30%
Guinea-Bissau
Figure 30: Prevalence of under-nutrition among children under five years, 2000-2010
32% 25%
2000
19%
2006
18%
2010
10% 7%
Stunting
Underweight
6%
Wasting
Source: MICS 2006 and 2010
There are large disparities in the levels of child malnutrition across the regions: more than 40% of under-five children in Oio, GabĂş and Cacheu are stunted, compared with 20% in SAB and 24% in Quinara (Figure 31).
Figure 31: Prevalence of malnutrition among children under five years by region, 2010
Source: MICS 2010
Poverty exacerbates the nutritional problems of under-five children in Guinea Bissau, with the poor twice as likely to be stunted (Figure 32).
41
Equity and child rights
Child and maternal survival and development
Figure 32: Moderate stunting in children under five years by wealth quintile, 2010 42% 37% 31% 24% 18%
Lowest
Second
Middle
Fourth
Highest
Source: MICS 2010
Addressing stunting levels will require tackling persistently high levels of malnutrition among very young children: 15% of infants under six months of age are underweight and 5% are wasted; by the age of two years, 35% of children are already stunted (Figure 33). Malnutrition at such an early age points to the negative effects of maternal malnutrition and inappropriate feeding practices on childrenâ&#x20AC;&#x2122;s nutritional status.
Figure 33: Under-nutrition (-2 standard deviations) by age, 2010
41% 36%
35% 27%
25% 20% 14%
5% <6 months
Underweight 20%
21%
17%
7%
6-11 months
Stunting
16%
18%
Wasting
9% 5% 12-23 months
24-35 months
4% 36-47 months
5% 48-59 months
Source: MICS 2010
Despite significant improvements in exclusive breastfeeding (from 16% in 2006 to 38% in 2010) and early initiation of breastfeeding (from 23% to 55%), breastfeeding practices continue to be inadequate. In the first months of life, over 30% of newborns are given water in addition to breast milk, lowering the positive benefits of exclusive breastfeeding, and only 44% of infants receive complementary feeding at six to eight months of age with continued breastfeeding. With the current levels of under-nutrition, there is a real need to strengthen behaviour change communication to promote the timely introduction of complementary feeding alongside continued breastfeeding.
42
Guinea-Bissau
In 2006, 58% of pregnant women and 75% of preschool-aged children were anaemic.xxi The first 1,000 days of a child’s life (from pregnancy up to two years of age) are a critical window of opportunity to prevent stunting. A complete package of high-impact nutrition interventions (iron supplementation, exclusive breastfeeding, complementary feeding, food fortification, vitamin A supplementation, deworming, iodized salt consumption) needs to reach the pregnant mother and the child during this crucial time period. Since 2008, mass campaigns for vitamin A supplementation and deworming achieved 100% coverage of 6-59-month-old and 12-59-month-old children, respectively. Availability of adequate iodized salt at the household level has improved more slowly, from 1% to 12% between 2006 and 2010, with very marked disparities between the regions. A total of 71% of Guinea Bissau households consume non-iodized salt. In the regions where availability of iodized salt is lowest (Biombo, 0.3%; Bolama/Bijagós, 0.6%), the abundance of locally produced and non-iodized salt remains an issue to be addressed. Most of the progress in the availability of iodized salt has been observed in the east (81% in Bafatá and 56% in Gabú), given the greater market availability of iodized salt imported from Senegal. Support to the effective implementation of the country’s law on universal iodization of salt should accelerate the attainment of global targets (95%). A major bottleneck to this implementation remains the low level of Government authority in the commercial sector. To adequately address the issue of malnutrition in Guinea Bissau, efforts will have to be made to strengthen human resources as well as to mobilize financial resources for the implementation of the National Nutrition Policy (enacted in 2010) and the National Protocol for the Integrated Management of Acute Malnutrition, as well as to strengthen links between nutrition and other health services, including HIV/TB care and treatment interventions (see below).
Water, sanitation and hygiene Low access to safe water and almost non-existent access to sanitation outside the capital.
A third of the population of Guinea Bissau, and half of the population in rural areas, does not have access to safe water (Figure 34). Woman B (Canquelifa) – In the tabanca (village) we have three water pumps; two are damaged and there is only one that works and to get water takes hours and hours because there are many people.
Figure 34: Households with access to safe water, 2010 84% 66% 53%
Total
Urban
Rural
Source: MICS 2010
With no operational national spare parts chain and non-existent or malfunctioning water facility maintenance structures, existing water points are not maintained adequately, and broken hand-pumps go unrepaired for long periods. The north and south of the country are particularly affected. In Quinara and Tombali, where there has been no maintenance of old water points in the past decade, only 356 of the 881 existing water points are operational, reducing coverage levels to 25% in Tombali and 43% in Quinara (Figure 35).
43
Equity and child rights
Child and maternal survival and development
Figure 35: Use of improved water source by region, 2010
Source: MICS 2010 and UNICEF/Ministry of Energy and Natural Resources, 2011 for breakdown
Access to adequate sanitation has improved only marginally in recent years, leaving more than 80% of the population in need (Figure 36). Even in urban areas, more than two-thirds of the population does not have access to improved sanitation, and, where sanitation infrastructure exists, it is generally poorly maintained.xxii The absence of organized systems of drainage and waste treatment in urban centres means two-thirds of urban dwellers are deprived of adequate sanitation.xxiii In SAB, only 20% of the population benefits from an improved sanitation system that is not shared with other people.
Figure 36: Use of improved sanitation, 2006 and 2010 35% 29% 2006
18%
2010
11% 5% 2% Total
Urban
Rural
Source: MICS 2006 and 2010
Weak sector policy, strategy and institutional framework.
The National Water Policy and the National Sanitation and Hygiene Policy were drafted in 2011 but there has been no progress towards review and approval of these key sector documents during 2012. All Government actors in the water, sanitation and hygiene sector are concentrated at the central level, with only two of the nine regions having decentralized services (regional delegations of the Ministry of Energy and Natural Resources) in 2011. None of these had a functional spare parts supply chain. Poor water and sanitation infrastructure means cholera continues to be endemic. Between 1994 and 2008, there were at least eight cholera outbreaks, with a total of 83,635 cases and 1,895 deaths (equivalent to a mortality rate of 2.3%) (Table 2). SAB, Biombo and Bijag贸s are generally the most affected by epidemics, followed by the coastal areas of S茫o Domingos, Oio (Nhacra), Quinara (Tite) and Tombali (Bedanda and Catio).xxiv Following a commendable stepup of cholera preventative measures after the 2008 outbreak, the country was cholera free from 2009 to 2011, only to be hit by another outbreak in 2012, with over 1,000 cases as of October, with the capital city as the epicentre.
44
Guinea-Bissau
Table 2: Cholera cases, 1987-2008 Year
Cases
Deaths
1987
6,000
68
1994-95
15,875
292
1996-97
26,976
961
2002
1,132
8
2004
227
3
2005-6
25,219
399
2008
14,229
225
Source: Ministry of Health 2009
Woman G (Kamiconde) – There are cases of diarrhoea here, imagine 100 people sharing one bathroom.
Poor hygiene behaviours.
In 2011, in 39 communities of eight of nine administrative regions of the country, only 36% of the population washed their hands with soap before food preparation, 41% washed their hands with soap before eating and 55% washed their hands with soap after using a latrine. These findings are being used to inform the behaviour change communication component of all future interventions.
Way forward: community-led total sanitation (CLTS) and school-based programmes.
Comprehensive efforts from Government and partners to improve rural sanitation and hygiene practices have also begun with the launch of the CLTS programme in 2010. Since 2010, 250 communities (with 74,000 people) in the north, south and east have been declared open defecation free. The programme needs to be scaled up nationwide and at a much quicker pace to enable Guinea Bissau to attain MDG 7. Efforts to improve access to safe water and sanitation in schools will target areas where the needs are greatest, according to an assessment carried out in schools in Gabú, Oio, Tombali and Quinara (Figure 37).
Figure 37: Water and sanitation in schools, 2010/11 Water points with hand pump (%) Sanitation facilities (separate for boys and girls) (%) 61%
34% 23% 16%
20% 13%
6% Oio
1% Gabú
Tombali
Quinara
Note: Data available for only four regions where survey was conducted Source: MERN 2010 (Gabú and Oio); UNICEF 2011 (Tombali and Quinara)
45
46
Equity and child rights
A generalized epidemic, affecting girls and women disproportionately
Guinea-Bissau
HIV/AIDS
Guinea Bissau is confronted with a generalized HIV epidemic with a prevalence of 5.3% in the general adult population (15-49 years old) in 2010 (Figure 38), more than twice the average HIV prevalence of West and Central Africa (2%).xxv Today, there are more than 24,000 people living with HIV (PLHIV), including 12,000 women and 2,100 children (age 0-14).xxvi Women are disproportionately affected by HIV compared with men: 6.9% versus 2.4%. Men aged 25-49 years have the same HIV prevalence as girls aged 15-24 (4.1% and 4.2%, respectively).
Figure 38: HIV prevalence by sex and age, 2010 9,9% 7,4%
6,9% 5,3% 4,2%
4,1% 2,9%
2,4%
15 -49 years
15 -24 years
TOTAL
Female
Male
TOTAL
Female
Male
TOTAL
Female
Male
1,4%
25 -49 years
Source: INASA National Seroprevalence Survey 2010
Among pregnant women, the HIV prevalence rate is 5.8%. In the east (Bafatá and Gabú), fully one in ten pregnant women are HIV positive (10.3% and 9.6%, respectively).xxvii In addition, more than one in ten children treated at nutrition recuperation centres are HIV positive.xxvi Other groups at increased risk of HIV include sex workers (54.6% in SAB are HIV positive)xxix and the military (14.6%).xxx Girls’ vulnerability to HIV owes to a convergence of biological, behavioural and societal factors, summarized in the scheme below. Young people have sex early Knowledge about HIV prevention is extremely low Girls have sex with (and marry) older men Condom use is not common in marriage Older men are more likely to be HIV + than younger men Men have low access to HIV prevention, care and treatment High stigma prevents people living with HIV and AIDS from seeking treatment and disclosing their status
47
Equity and child rights
HIV/AIDS
Factors contributing to girls’ vulnerability to HIV Low knowledge of HIV prevention, early sexual debut and cross-generational sex (CGS). In Guinea Bissau, one in three girls aged 15-24 years has her first sexual experience before the age of 15 years, and, worryingly, only 15% have comprehensive knowledge of HIV (Figure 39).
Figure 39: Early sexual debut and comprehensive HIV knowledge among girls 15-24 years, 2010 28% 26%
20% 16%
15%
14%
% girls aged 15-24 who had first sex before age 15 Guinea Bissau
% girls aged 15-24 with comprehensive HIV knowledge
West and Central Africa
Sub -Saharan Africa
Source: MICS, 2010 A total of 38% of girls aged 15-24 years are married, and among these almost half are married to a man 10 or more years older, and one-third are in a polygamous union. The larger the gap in age between sexual partners, the greater the likelihood of being infected by HIV.xxxi A secondary analysis of MICS 2010 data was carried out to identify factors associated with CGS in Guinea Bissau, to develop strategies most likely to reduce girls’ risk of HIV infection. The results showed that CGS was higher in SAB, Biombo, Tombali, Gabú and Bafatá, and that marital status was the strongest factor associated with CGS. Unmarried girls who were currently in school were less likely to engage in CGS, indicating that HIV prevention programmes must reach girls in early adolescence, before marriage, and keep them in school. Age-appropriate sexuality education (including on HIV/AIDS) in schools is known to increase knowledge and contribute to more responsible sexual behaviour. However, the teaching of content related to sexual behaviour and HIV prevention practices (including condoms) depends on the existence of a supportive policy, on appropriate teacher training and on the dissemination of clear curricula and teaching materials. In Guinea Bissau, the strategic plan to combat HIV/ AIDS in the education sector (2010-2013) lays out clear actions to be taken, but little progress has been made.
Low access to HIV prevention, care and treatment by men. Although women have a three-fold greater vulnerability to HIV than men, HIV-positive men who need antiretroviral therapy (ART) are much less likely to access it than women (39% versus 72%) in Guinea Bissau. Without knowing their HIV status, HIV-positive men will transmit the virus to their wife/wives/sexual partners, and, furthermore, put their own children at risk of mother-to-child transmission. This situation is worrying given the common practice of polygamy: 48% of 15-49-year-old women interviewed in MICS 4 were in a polygamous union. To increase awareness on HIV prevention and access to care and treatment for older men, all interventions targeting community leaders/older men should address HIV. Lastly, it is critical to explore underlying cultural and social norms on CGS (and related issues of child marriage and polygamy) in communities where these practices are common, to identify indigenous strategies to reduce age disparity in sex and marriage.
48
Low knowledge on HIV correlates with high stigma about people living with HIV and AIDS in women aged 15-49 years (Figure 40). This is a result of lack of resources for communication for behaviour change (mass media and community levels) and lack of incorporation of HIV into pre-service teacher training and school curricula, among other factors.
Guinea-Bissau
High stigma and discrimination.
%
Figure 40: Geographic correlation of comprehensive HIV knowledge and levels of stigma and discrimination among women aged 15-49 years, 2010
40 35 30 25 20 15 10 5 0
Agree with four attitudes of acceptance of HIV
Comprehensive knowledge
Source: MICS 2010
Inequitable access to high-quality prevention of mother-to-child HIV transmission (PMTCT) and ART services With effective ART and care, transmission rates from HIV-positive mothers to their babies can be reduced to as low as 2%.xxxii However, at the end of 2011, only 64% of health centres in Guinea Bissau offered PMTCT services, and only 25% had a minimum of two health care workers trained in PMTCT. In BafatĂĄ and GabĂş, where one in ten pregnant women are HIV positive, only 15% of these, and 4% and 2% of their HIV-exposed infants, respectively, have completed prophylaxis, compared with national maternal and infant completion rates of 30% and 24%. As mentioned above, HIV-positive men are not accessing the services they need. Coverage of treatment of HIVpositive children is also seriously low, with only 16% of such children aged 0-15 years accessing ART. Pediatric ART services are not yet decentralized: Biombo and SAB account for 93% of children currently on ART.
49
Equity and child rights
HIV/AIDS
Table 3: Key PMTCT indicators by region, end of 2011 Administrative region
HIV prevalence among pregnant women1
Coverage of PMTCT services2
Maternal PMTCT prophylaxis completion rate3
Infant PMTCT prophylaxis completion rate4
ART coverage in children aged 10-14 years5
Bafatá
10.3%
53%
7%
0%
6%
Gabú
9.6%
30%
10%
1%
0
SAB
7.5%
100%
39%
29%
31%
Tombali
6.0%
50%
13%
3%
2%
Quinara
5.8%
100%
9%
5%
0%
Cacheu
3.8%
68%
25%
8%
0%
Bolama/Bijagós
3.7%
75%
6%
0%
3%
Biombo
3.5%
56%
203%6
236%
88%
Oio
2.7%
47%
6%
2%
0%
National
5.8%
64%
30%
24%
15%
INASA HIV and Syphilis Prevalence Study among Pregnant Women 2009 % of antenatal care sites offering integrated antenatal care/PMTCT services % of HIV+ pregnant women needing PMTCT prophylaxis (estimated by Projection Spectrum 2011) who complete PMTCT prophylaxis according to national norms 4 % of infants born to HIV+ pregnant women (estimated by Projection Spectrum 2011) who complete PMTCT prophylaxis according to national norms 5 % of eligible HIV+ children aged 0-15 years (estimated by Projection Spectrum 2011) receiving ART 6 Rates are higher in Biombo, a region neighbouring SAB, given health referral patterns (Cumura Mission Hospital, one of the first sites offering PMTCT/ART in Guinea Bissau, reaches clients from all regions through fixed and mobile activities) 1 2 3
Way forward: a call to action to tackle inequities in access and mobilize resources for HIV prevention, care and treatment There is an urgent need to accelerate pre- and in-service training of health workers in PMTCT and paediatric ART, to expand coverage of PMTCT services, to expand early infant diagnosis and paediatric ART services beyond SAB and Biombo and to prioritize follow-up of HIV+ mothers/HIV-exposed babies, by: • Strengthening integration of follow-up into routine health centre outreach activities; and • Involving community health workers and ‘activists’ (people living with HIV/AIDS) in following up on ‘lost’ patients. To best orient limited resources towards unmet needs, an action plan for the elimination of mother-to-child transmission is being developed. The national HIV response is underfunded: the Global Fund is the main donor in Guinea Bissau’s HIV response and the Government of Brazil provides some HIV drugs and technical assistance. However, in August 2012, the Global Fund invoked its Additional Safeguard Policy on Guinea Bissau’s grants to fight AIDS, malaria and TB, given the continual political upheaval experienced during the years of grant implementation and weaknesses in programmatic and financial management by the principal recipients. As such, Global Fund support to primary prevention activities through mass media and community-based approaches – aimed at increasing knowledge and decreasing stigma about HIV in the general population and among key risk groups-- has
50
Guinea-Bissau
been eliminated. Furthermore, the transitional funding mechanism of the Global Fund from 2014 to 2015 will only maintain essential services to those beneficiaries it agreed to reach at the end of 2013; any additional requirements will need to be covered by non-Global Fund sources. At the end of 2013, 1,206 HIV-positive mothers needing PMTCT prophylaxis annually will not be covered by the Global Fund, and 3,418 HIV-positive adults and 1,259 HIVpositive children who require ART will not have access to it through the Global Fund. There is an urgent need for action from other partners to ensure that women, children and men access the life-saving HIV services they need.
The story of an activist from Oio I am 37 years old and I have known that I am HIV positive since 2006. I have five children, including a girl who is now studying law in Morocco on a scholarship. I was a mother at 15. My youngest son, who is also HIV positive, is six years old. In 2006, I was living SAB Bissau, working for a non-governmental organization called Thinking of Tomorrow, which fought against female genital mutilation. I got pregnant and started antenatal visits. At first, no problem was detected. But a week after the birth, my baby had many health problems, always has a fever. At the health centre in Mansoa, my son was diagnosed with HIV and immediately went on treatment. The doctor in Mansoa said that I should get tested too. I wanted to do the test. My sister had died at the age of 46 in 2004 with the same problem, but she was already very weak and unable to respond to treatment because she discovered her status too late. After taking the test, I learned that I was also HIV positive. I tried to convince my husband – who was a tailor in Mansoa – to take the test, but he refused. He insisted that the problem was not his, and we separated. To my knowledge, he has never taken an HIV test. Now I have no contact with him and he does not know the child or give any support. There are many people who are afraid to get tested for HIV, often because the staff of health centres do not respect confidentiality and tell their neighbors the HIV status of patients. And then people are discriminated against, abandoned by their families. That’s why I joined the Boa Esperança (Good Hope) Association. There, people living with HIV and AIDS feel more courageous and supported . I have no problem saying that I’m HIV positive. We do many djumbais (get-togethers) at our headquarters in Mansoa because we see that, after participating, people are happier, more aware of the need to take treatment and know that they have friends! The number of qualified medical staff in Guinea Bissau is very limited and therefore they are very busy. A doctor in their office will not worry about whether their patient will come to the next appointment or not; if they don’t, the doctor will not have the time to find out why. Boa Esperança activists have a closer relationship with patients. We will travel 10-15 km on foot to reach people in need. Sometimes, I have to ask young people to take me by bicycle. We do this follow-up to ensure they go to appointments and take medication. We have received horticultural materials for members to cultivate crops and have an animal shelter. But many members of the association would like to have access to literacy programmes because they can neither read nor write and this complicates their lives. For example, they cannot read the instructions for the doses and times to take each medicine. I am very worried about the future because we have heard that there is no funding and that stocks of medications for TB and HIV are running out. We must do everything in our power not to let our brothers and sisters die. Interview conducted by Elisabete Vilar, Communication Officer, RC Office, UNDP, Guinea Bissau.
51
52
Equity and child rights
Guinea-Bissau
Equity and quality in education Significant improvements in school access, despite the challenges Guinea Bissauâ&#x20AC;&#x2122;s education system has been particularly resilient in the face of rapid growth in its school-aged population and continued political instability. Since 1997, school enrolment has grown more than 2.5 times (Figure 41), from 135,000 pupils in 1997/98 to 357,000 in 2010/11. In 2010, 278,668 pupils (18% of the national population) were enrolled in 1,402 primary schools; 77,956 students (5%) in 113 secondary schools; and 9,044 pre-schoolers (1%) in 131 preschools. xxxiii
Figure 41: Students in the primary and secondary education system, 1997-2010 400.000 356.624
350.000 300.000
278.668
250.000 200.000
Primary Secondary
134.644
Total
150.000 118.723
100.000
77.956
50.000 0
15.921 1997/98 1999/00 2001/02 2004/05 2005/06 2009/10
Source: RESEN 2011
Improved access to education is reflected in substantial increases in enrolment and attendance rates in primary and secondary schools. The net attendance rate for primary and secondary schools increased from 54% to 67% of the primary school-aged population between 2006 and 2010.1 Gross primary enrolment also grew, from 70% in 2000 to 117% in 2010. Part of this increase in school attendance has been absorbed thanks to the involvement of communities, private providers and madrasas in the provision of schooling. Today, these institutions account for 30% and 18% of the primary and secondary school intake, respectively, up from 19% and 11% in 1999/00. xxxiv
The number of pupils in the official age group for a given level of education who attend school at that level, expressed as a percentage of the population in
1
that age group. It therefore excludes over-age individuals.
53
Equity and child rights
Equity and quality in education
On the other hand, improved access to education in recent years has benefited privileged children – rich, urban boys from SAB – rather than less privileged ones – poor, rural girls from the east, worsening inequity in education. At the same time, the increase in the intake of students into a fragile education system has put considerable pressure on the quality of the schooling available.
Guinea Bissau’s education system The Government has recently adopted a set of laws to strengthen the institutional framework in the education sector. A new Law on the Organization of the Education System, approved in March 2010, introduces important changes in the current structure of the education system, by expanding basic education from six to nine years in order to increase child literacy on completion of basic education. However, many basic education schools continue to offer classes only up to Grade 4. The Letter of Education Policy for the period 2009-2020 prioritizes the expansion of access to education and education quality. A three-year plan guides the sector for the 2011/12-2013/14 period, as the first of several such plans aimed at ensuring quality education for all. The plan is costed at US$71 million, with domestic resources to fund current salary expenditures and external resources required to cover most other expenses. In 2010, only 13% of government budget was allocated to education.
Worsening inequities in education: girls from poor families in rural east, and from Oio, are left behind Geographical inequities Rural/urban disparities in access to education are large and have increased over time. In urban areas, the net attendance rate increased from 69% in 2006 to 85% in 2010, while in rural areas it only increased from 46% to 57% (Figure 42). Today, a child living in urban areas is 1.5 times more likely to be attending school than a child living in rural areas, where three out of five school-age children remain out of school. School attendance has increased significantly across the country except in the east, where net attendance rate continued to lag at 53% in 2010. The largest improvement in school attendance can be seen in the south.
54
67%
71%
69%
64% 57%
54%
53% 48%
46%
Total
Urban
2006
87%
83%
Rural
SAB
East
49%
North
2010
Guinea-Bissau
Figure 42: Net attendance rate in primary school, 2006 and 2010
68% 51%
South
Source: MICS 2006 and 2010
Wealth inequities. Improvements in school access have benefited children from the richest families more than the poorer ones. Thus, the gap between the richest and the poorest wealth quintiles worsened from 29% in 2006 to 35% in 2010 (Figure 43). Only 52% of school-age children from the poorest quintile â&#x20AC;&#x201C; and only 47% of girls of this quintile â&#x20AC;&#x201C; attended primary schools in 2010, leaving one in two poor children out of school. By comparison, 87% of school-age children from the richest quintile are able to attend school.
Figure 43: Net attendance rate in primary school by wealth quintile, 2006 and 2010
Source: MICS 2006 and 2010
55
Equity and child rights
Equity and quality in education
Gender inequities. There are still more boys than girls in classrooms in Guinea Bissau. The Gender Parity Index (GPI)xxxv at the national level is still below 1 and worsened slightly between 2006 and 2010, from 0.97 to 0.94. Wider gender disparities can be found in rural areas, with 89 girls for every 100 boys in primary school, compared with 97 girls for every 100 boys in urban areas (Figure 44). Across regions, Oio is by far the worst performing, with a GPI of only 0.81. Apart from Quinara and Biombo, most other regions have a GPI below 0.95. Gender disparity is also pronounced more among poor households compared with the rich. Only 83 girls for 100 boys in the poorest households attend school. By comparison, 96 girls for 100 boys in the richest households are in school.
Figure 44: GPI in primary school, 2010 .99
.97
1
1 .97 .94 .90
.89
.81
.96
.92 .91
.83
Source: MICS 2010
Low quality of education reflected in low retention rates, poor exam results and low literacy levels The rapid increase in the number of pupils, alongside limited public investment in the education system in the past decade, has made it difficult to provide quality schooling for children, reflected in drops in enrolment rates after each grade of schooling as a result of high rates of repetition and dropout. The sharpest drops occur between Grades 1 and 2, as well as between Grades 4 and 5 (Figure 45). Only six out of ten children are able to complete primary school. xxxvi Completion rates in secondary school follow the same pattern, with substantial dropouts after each grade. In the end, only 22% of children who enter the schooling system complete secondary school. xxxvii
56
180%
Guinea-Bissau
Figure 45: Schooling profile â&#x20AC;&#x201C; rates of transition in primary and secondary school, 1999-2010
160% 140% 120% 100% 80% 1999/2000
60%
2009/2010
40% 20% 0%
1
2
3
4
5
6
7
8
9
10
11
Grade Source: RESEN 2011
The low quality of education is also reflected in an extremely poor acquisition level. A 2011 study found that 52% of boys and 63% of girls between 7 and years could not read words, and 55% of boys and 68% of girls could not do simple addition. xxxviii In the national exams conducted in 2011, only one out of four pupils in Grade 9 was able to pass Mathematics and in Portuguese. xxxix All these factors, taken together, result in low educational achievements and low literacy levels among girls, particularly in rural areas (Figure 46). Only one in three girls who enter primary school arrives in Grade 6, and finishing primary school does not guarantee that they can read and write. Indeed, only 35% of women who are able to complete primary school were literate. The situation is even worse in rural areas, with only 16% of young women literate.
Figure 46: Literate women 15-24 years, 2006 and 2010 63%
2006
2010
51% 40% 29%
16% 10%
Total
Urban
Rural
Source: MICS 2006 and 2010
57
Equity and child rights
Equity and quality in education
Factors impeding equitable access to education Late entry, child marriage and child labour. There are various barriers to children attending school. Children in Guinea Bissau often go to school at a later age than six years. In 2010, more than 50% of children in Grade 1 were eight years old or more. By Grade 6, 71% of pupils are three years or more over age. Late entry in school could have various causes. Very few are registered at birth, which means parents do not always know precisely the age of their children, even when they reach the age of entering school. Indeed, a survey conducted on 3,258 children in and out of school in 2011 revealed a significant difference in school attendance between those who had birth certificates (57%) and those who did not (47%).xl The fact that only 5% of Bissau-Guinean children have the chance to go to preschool also contributes to children starting late and not being ready to learn effectively.xli Late entry into school is particularly problematic for girls living in rural areas. Indeed, with one in ten women in rural areas married before the age of 15 years, girls who enter school late are more likely to drop out in order to be married. The 2011 Effective Intervention study revealed that 73% of girls who had dropped out of school had done so because of marriage, and 53% because of pregnancy.xlii Children who start school late face the dilemma of having to work to earn an income for the family while they are still in school. In 2010, 57% of children aged 5-14 years were involved in child labour.xliii When asked the reason for dropping out of school, one in four boys raised the need to earn a living as the reason.xliv According to a 2010 study, the school dropout rate reached as high as 30% during the cashew harvesting season in the region of Biombo, as children are also mobilized as a part of the labour force.xlv
Long distance to school. According to a survey conducted of 3,258 children in and out of school in 2011, 28% of children mentioned long distances to school as the reason for not attending.xlvi This is confirmed by the statistical analysis, which showed that the probability of school attendance decreased as distance to school increased. A child living within 15 minutes of a school is 44 percentage points more likely to attend compared with a child living 45-60 minutes away from a school.xlvii This problem is compounded by the fact that only 16% of primary schools have the complete primary cycle. This means that, in order to complete the full primary cycle, many children need to go to another school further away. This explains in large part the sharp decline in enrolment between Grades 4 and 5.xlviii
Man A (Canquelifa) â&#x20AC;&#x201C; We have children here who are studying to finish primary school, but we have only up to Grade 4 here. These children are forced to go to Pitche or GabĂş [from Grade 5] and they face many difficulties and eventually drop out. Parents have a hard time sending their children to study in GabĂş or Pitche because they lack the means such as food, [and money to] pay for the school.
58
Costs of schooling are a major barrier for children attending school. According to the survey on the reasons for not attending school mentioned earlier, over half of children could not attend because they were unable pay costs related to schooling or did not have enough money to buy school materials.xlix Households support 34% of the cost of education. Poor communities, especially in remote rural areas, are more fragile when faced by shocks, such as floods, storms and food crises, making it even more difficult to support schooling for children. The costs are particularly difficult to bear for poor households, which have to choose which child to send to school, if any. These financial barriers explain in large part the low progress in school enrolment among the poorest quintile mentioned earlier.l
Guinea-Bissau
Poverty and fragility.
Factors that cause quality of education to stay ineffective and inequitable Insufficient pedagogical materials. Until the 2011 nationwide donor-supported distribution of textbooks to all public and community primary schools, less than 1% of rural children had access to textbooks.li As a result, pupils spend most of their class hours copying from the blackboard what their teachers extract from the textbook. Given that 94% of public expenditure in the education sector is spent on salaries, there is not enough public funding for pedagogical or learning materials to support children’s learning.
Low quality and quantity of teachers. The number of teachers in Guinea Bissau is inadequate and they are allocated inequitably. The national primary pupil–teacher ratio was 52:1 in 2009/10. However, Gabú had a ratio of 66:1 compared with 31:1 in Bolama/ Bijagós.lii Meanwhile, the vast majority of teachers in primary school (78%) are male. With only 22% of teachers being female, girls are less likely to find a female role model.liii Teachers in public schools frequently go on strike because their salaries are unpaid. In addition, their training is highly inadequate. In 2004/05, 63% of teachers were not trained (with a high of 88% in Bafatá and a low of 45% in Bolama/Bijagós) (Figure 47). Pre-service training consisting of two years in class and one year in practice has low capacity to receive trainees, while in-service trainings led by various non-governmental organizations are not conducted in a harmonized manner. Furthermore, in rural community schools, 60% of teachers have never received any in-service training.liv
Figure 47: Teachers not trained by region, 2004/05 88% 81%
80%
63%
77%
75% 63%
57% 46%
45%
Source: Ministry of Education/GIPASE
59
Equity and child rights
Equity and quality in education
Limited class hours. Class hours are currently limited to 450 hours per year, which is considerably lower than the international benchmark of 850 to 1,000 hours per year.lv Moreover, the lack of pedagogical materials, teacher strikes, multigrade classes and the high pupil–teacher ratio reduce the actual number of hours dedicated to learning. Low motivation among teachers and pupils, as well as the cashew harvest and political crises, contribute to further losses of class hours.
Woman A (Bissora) – Children do not learn anything in schools with these permanent strikes. That is why we prefer private schools; even if we pay for the child to study we don’t have the problems like in the public schools where the students fail because of strikes.
Woman B (Gabú) – Mothers’ major concern about school is the successive strikes. How can a family enrol their child, buy books and uniforms and when the child starts school there is a strike for the first period and then also for the second period. The following year the parents are required to make the same investment without return.
Woman F (Gabú) – The problem is serious in our neighbourhood because we don’t have enough teachers. You can see one teacher teaching three or four classes. That is one teacher giving the first class at the same time as the second and third class. Like that, the students will not learn anything, the students in the first class maybe, but the second and third will not enjoy anything.
The above factors combined contribute to children not being able to complete primary education in Guinea Bissau. As illustrated in the bottleneck analysis below, limited availability of classrooms, teachers and schools with a complete cycle of six grades, as well as late entry to school, all contribute to children not completing school, not to mention progressing to secondary education.
60
Guinea-Bissau
Figure 48: Bottleneck analysis of primary education
Source: UNICEF calculations with data of Ministry of Education, RESEN and MICS 4
Way forward: tackling inequity in education from the bottom up Challenges in education seem vast, especially confronted by the Government’s limited capacity to manage the rapidly growing system. Nevertheless, the increasing number of community, private and madrasa schools shows the strong commitment of local communities and parents to securing education for their children and demonstrates their resilience despite being faced with repeated social and security crises. However, goodwill and efforts – especially in poor rural communities – to complement the inadequate public provision of education are reaching their limits, as evidenced by the worsening inequities in access to education mentioned above. In addition to capacity development of the Ministry of Education, as already proposed in the Education Policy and Sector Plan, the Government and its partners should develop a strategy to provide means and responsibility to communities, targeting those that are more deprived in terms of education opportunity (poor, rural girls from the east to begin with), so that local communities can assume a role in registering children at birth, preparing them for school through early childhood development and enrolling them and keeping them in school. Through local structures such as school management committees, local communities can also help improve the quality of their schools by overseeing teachers’ absenteeism and performance level. Indeed, an effective partnership with local communities will be a key strategy for Guinea Bissau to accelerate progress towards universal basic education and achieve education equity, by enabling the most marginalized population to benefit.
61
62
Equity and child rights
Guinea-Bissau
Harmful practices affecting children and women Strengthened legal framework, but the whole child protection system remains weak Although the legal framework of child protection has been strengthened, there is a strong need to reinforce positive social norms, to implement policies and to establish systems to protect children and women from violence, abuse and exploitation. Major steps taken to strengthen the legal framework for child protection in Guinea Bissau include the adoption in July 2011 of a law criminalizing FGM/C and a law against the trafficking of human beings. Guinea Bissau is also party to the Multilateral Cooperation Agreement to Combat Human Trafficking in West and Central Africa and has ratified the International Labour Organization’s Conventions on the minimum age for admission to employment (138) and on the prohibition and elimination of the worst forms of child labour (182). Child protection issues are included in the National Poverty Reduction Strategy (DENARP II) and in the Government’s Priority Action Plan. The programmatic framework comprises four National Action Plans addressing specific child protection issues: human trafficking, sexual abuse and exploitation, FGM/C and birth registration. The institutional framework includes the National Committee for the Abandonment of Harmful Practices (NCAHP), the Brigade de Menores and Guardian ad Litem. These are bringing about a restricted but efficient response to violence against women and girls and are facilitating their access to justice. A Child Protection System is being established progressively under the auspices of the IMC. Inter-sectoral measures to secure access to justice and health care for vulnerable children and women were adopted by the (previous) MMFCSLP, the Ministry of Health and the Ministry of Justice. The NCAHP is coordinating the interventions of eight non-governmental organizations promoting an end to FGM/C at the community level in addition to supporting the functioning of four networks of religious leaders promoting the delinking of FGM/C from Islam. Coordination mechanisms are being established among the Border Police, Guardian ad Litem and three national non-governmental organizations to identify, rescue, protect and reintegrate talibé children and others victims of trafficking. Such mechanisms are showing increased efficiency, although the enforcement of adopted legislation is still weak.lvi Service delivery at the operational level is mostly done by non-governmental organizations, mobilized by bilateral and multilateral partners, given the Government’s weaknesses in this area. A culture of silence and/or tacit assent prevails around the abuse and exploitation of children and women; four women out of ten believe their husbands have a right to beat them and physical punishment is necessary to educate their children.
Adverse social norms continue to jeopardize the well-being of children FGM/C. Under false cultural and religious pretexts, part or all of the external genitalia of girls and women are cut away, most of the time in horrendous conditions, resulting in lifelong health risks. FGM/C prevalence is alarmingly high and close to universal in the east of Guinea Bissau, with 94% of women aged 15-49 years having been excised (Figure 49). In addition, FGM/C increased by more than a third between 2006 and 2010 in the south, and now affects more than half of the women there.
63
Equity and child rights
Harmful practices affecting children and women
Figure 49: Women 15-49 years subjected to FGM/C, 2006 and 2010 93% 94%
55%
50% 45%
2006 32%33%
Total
SAB
32% 29%
East
North
36%
2010
South
Source: MICS 2006 and 2010
Man A (Gabú) – We are all adults here and we know what goes on during the fanado [FGM/C] of women. I am sure many children die during fanado not because they are sick but because of infections, and because the fanatecas [traditional FGM/C practitioners] use only one knife for a hundred children. There can be a child among them who has an HIV infection and can transmit it to the others. We know well that women bleed a lot when they are fanada [subjected to FGM/C] and also during childbirth; women can die in childbirth and the child is left without a mother.
FGM/C is viewed as a social norm followed by community members to avoid stigmatization and considered as a necessary step to raise a girl and to make her eligible for marriage. Adherence to this social norm is strong in the east of the country, where less than one-third of women desire an end to its practice. The Tostan Community-led Empowerment Programme (CEP), which merges human rights education and community development interventions, is yielding positive outcomes in the north and east, where 39 empowered communities alongside 105 adopted communities will declare the abandonment of FGM/C by the end of 2012. Actions to reduce the prevalence of FGM/C include: (i) scaling-up of the Tostan CEP to cover the five regions prone to FGM/C; (ii) increased access to education for women, as women with secondary education or higher are less likely to believe the practice should be maintained (6%) compared with women with no education (51%); (iii) support to the enforcement of legislation criminalizing FGM/C; and (iv) pursuance of efforts with networks of religious leaders to promote the delinking of Islam and FGM/C.
Child exploitation and labour. Exploitation of children in forced beggary is one of the worst forms of child labour affecting Guinea Bissau. Known as talibé, these children are smuggled by touts from their communities in the Bafatá and Gabú regions and taken to SAB, the capital city, and to The Gambia and Senegal, under the false pretext of being taken into Koranic education. Most of them end up in forced beggary in the streets. It is estimated that 30% of children begging in Dakarlvii and 1,650 children begging in Ziguinchor (south Senegal) are from Guinea Bissau.lviii Sadly, these children pay dearly for their parents’ desires to have them educated in prestigious madrasas.
64
Guinea-Bissau
Man C (Gabú) – It is not the Senegalese who send children to beg in the street. It is the Guinean Koranic masters who studied in Senegal and came back to bring children. They send children to beg every day. The children have to get 2 kg of rice and FCFA 500 per day.
Among youth from Balata and Felupe ethnic groups, having a job is synonymous with self-reliance for boys and an opportunity for girls to prepare their wedding trousseau. This triggers the risky movement of youth, resulting in the exploitation of boys in agricultural production in south Senegal and the exploitation of girls in domestic work in towns in Guinea Bissau and Senegal, with some exposed to abuse and sexual exploitation.lix Child labour denies children their childhood, their potential and their dignity and reinforces cycles of poverty by depriving them of their right to education. Child labour2 has increased nationwide, from 39% in 2006 to 57% in 2010,lx with 74% of children involved in child labour in the east (Figure 50). A total of 40% of children aged 12-14 years are engaged in more than 14 hours of paid labour a week to assist their families.lxi Cashew nut harvesting is the overriding type of paid labour, and often sees children from the poorest households drop from schools.
Woman D (Bissora) – It happens, but if you take your child out of school to collect cashews and the other children are made to take a test your child will fail. You will delay your child further the following year.
Woman A (Gabú) – I was a teacher in Daara but when the cars came all the children were sent to look for foli [local fruit] in the woods to sell. We were in school without students. I went to the house of each student and the parents told me they sent their children to look for fruit to earn money to buy rice. I could not say anything because I do not have money to give them.
Figure 50: Child labour, children 5-14 years, 2006 and 2010 74% 60%
57%
39%
43%
47%
49%50%
38%
2006 2010
14%
Total
SAB
East
North
South
Source: MICS 2006 and 2010
Some children in urban areas are involved in petty trade, moving around, generally door-to-door, to sell
65
Equity and child rights
Harmful practices affecting children and women
groundnuts or fruit. These children are at risk of sexual abuse and sometimes engage in commercial sex to avoid physical punishment when they are unable to reach the amount of income expected by their exploiter.lxii Drivers of child exploitation and labour and risky-cum-exploitative movement of children include poor levels of parental awareness of childrenâ&#x20AC;&#x2122;s rights, low enforcement of legislation against human trafficking and lack of quality education facilities (both formal and religious),lxiii as well as poverty.lxiv Actions are required to improve the coverage of school facilities alongside community-based Koranic schools, to develop vocational training structures for out-of-school youth, to enhance girl childrenâ&#x20AC;&#x2122;s school enrolment and retention and to promote the retention of children in their communities through the enforcement of anti-trafficking legislation.
Child marriage. According to the Civil Code, girls under the age of 16 years and boys under the age of 14 years cannot marry. Marriage between 16 and 18 years old is allowed only with the consent of a parent or guardian. However, child marriage is often a survival strategy for poor families, and girls in Guinea Bissau are frequently forced to marry older men, who are then able to access land through the institution of marriage. The law punishes threats, abduction or coercion related to forced marriage but these acts are not considered criminal offenses.lxv A third of girls are married before the age of 18; some marriages are arranged by parents when their children are very young (3-4 years old).lxvi Moreover, of the 20% of girls aged 15-19 years currently married in Guinea Bissau, 42% are married to a man over 10 years older. In the east, which has extreme levels of poverty, child marriage has increased by 40%. Child marriage exposes girls to the dangers of early pregnancy and HIV, and results in girls abandoning their education. In 2011, marriage and pregnancy were by far the largest reasons for girls dropping out school in rural areas.lxvii Figure 51 shows that one-third of girls aged 20-24 years give birth before the age of 18.
Figure 51: Girls aged 20-24 years who gave birth before 18 years by region, 2010 46%
45%
42%
39% 38%
38% 40%
37%
33% 29% 24%
Source: MICS 2010
66
21%
Guinea-Bissau
Ensuring girlsâ&#x20AC;&#x2122; access to education and school retention will be instrumental to combat child marriage and CGS; to this effect, advocacy will be conducted to enable fee waivers, and community management committees will be established to engage and maintain community-level dialogue on the rights of girls. These committees will be supported to manage scholarship schemes to support parents to keep girls in school. Communication interventions will sensitize the population on the dangers and negative consequences of child marriage and offer information on criminal liabilities around forced marriage.
Birth registration. The proportion of children whose births are registered has declined significantly, from 39% in 2006 to 24% in 2010 (Figure 52), with the lowest rates observed in Quinara (11%) and GabĂş (12%).
Figure 52: Children under five years whose birth has been registered, 2006 and 2010 53%
39% 30% 24%
Total
33% 2006 21%
Urban
2010
Rural
Source: MICS 2006 and 2010
On the supply side, the routine registration system functions poorly, owing to a lack of human resources and of equipment and supplies at the decentralized level to register newborns. Mobile registration units are not functional, depriving children in hard-to-reach areas of their right to a name and a nationality. On the demand side, barriers to registration for families include poor understanding by the population of the importance of birth registration; low awareness of the rights or other benefits brought about by birth registration; and the financial cost of registering a child. Although birth registration has been declared free for children under five years, informal charges remain in place. Birth registration can be increased through the reinforcement of the operational capacities of civil registration offices; the establishment of birth registration units in health facilities; support to the functioning of mobile registration units to cover remote areas; advocacy on the waiving of birth registration fees for children; and increasing demand through community radio programmes that encourage families to register their children.
67
68
Equity and child rights
Guinea-Bissau
Pro-child budgeting
Guinea Bissau has weak tax collection capacity and is heavily dependent on official development assistance (ODA), but aid flows are not reliable Guinea Bissau’s fiscal situation is characterized by weak tax collection capacity as well as heavy dependence on external financial assistance. It is also vulnerable to external shocks because of its dependence on export earnings tied to one export crop – that of cashew nuts. In 2010, tax collected represented only 6.8% of GDP, well below the rate of tax collection among low-income countries, which was estimated at 11.8% in 2008.lxviii In total, tax collection makes up a third of total government revenue, overseas grants amount to more than half and fishing licences and compensation account for the remainder. Despite GDP growing from 3.2% in 2007 to 5.3% in 2011,lxix domestic revenue is not sufficient to meet the country’s funding requirements. In December 2010, Guinea Bissau achieved the completion point for Heavily Indebted Poor Countries, equivalent to debt relief of US$1.2 billion.lxx However, while debt forgiveness may provide the country with some fiscal space, further measures are necessary to reform and streamline the public sector and promote economic growth. Guinea Bissau remains heavily dependent on ODA, which represents up to 15% of its GDP, amounted to about 57% of total revenue in 2010 and funds over 50% of the country’s total expenditures and up to 95% of the investment component of the state budget.lxxi Over the past decades, aid flows to Guinea Bissau have been highly unstable, reflecting the political instability that has afflicted the country since independence, as well as donor countries’ stop-and-go aid policies and lack of long-term involvement.lxxii In addition, since 2009, ODA has shown a decreasing trend over time, exacerbated by political and military instability (Figure 53). In 2012, all major donors (the European Union, the World Bank, the AfDB and the International Monetary Fund) reduced or cancelled their planned budget support.
Figure 53: Estimated ODA, 2007-2011 163
129
126
116 US$ millions
109
2007
2008
2009
2010
2011
Source: MEPIR, DCR, UNDP 2010
In 2010, 67% of total aid went to health, governance and education (Figure 54). Increases in funding in the health sector were driven principally by greater disbursements from the Global Fund, which went from US$8 million in 2009 to US$25 million in 2010. Over the same period, education funding went from 8% to 14% of total ODA. There was a slight shift away from investment in infrastructure, going down from 15% to 9% of total aidlxxiii
69
Equity and child rights
Pro-child budgeting
Figure 54: ODA disbursements by sector, 2010
Source: MEPIR 2011
National budget allocations to social services are unacceptably low, and households are increasingly shouldering the burden Over the past year, state allocations to the social sectors have decreased slightly as a percentage of the total allocation. In 2012, 6% of the state budget was allocated to health compared with 7% in 2010. Allocations fell from 13% to 11% in education in the same time period. Meanwhile, defence, infrastructure and finance absorb well over a third of budget allocations.lxxiv Health sector allocations are well below the 15% of total government expenditures stipulated in the 2001 Abuja Declaration. Over 80% of this budget is devoted to wage payments, leaving the sector facing a critical financing shortage.lxxv Figure 55 illustrates that government expenditure on health decreased from 25% in 1995 to 10% in 2010, as a proportion of total health expenditure (THE).
Figure 55: Public versus private sources of health financing, 1995-2010
Private expenditure on health as % of THE 75%
84%
84%
90% General Government expenditure on health as % of THE
25%
1995
16%
16%
2000
2005
Source: National Health Accounts, WHO, as of March 2012
70
10% 2010
Figure 56: Sources of private expenditure on health, 1995-2010
59%
58%
61%
74%
Guinea-Bissau
In turn, the financial burden of health care on households has increased (Figure 56).
Non -profit institutions serving households (e.g. NGOs) Out-of- pocket expenditure
41%
42%
39%
26%
1995
2000
2005
2010
Source: National Health Accounts, WHO, as of March 2012
In the education sector, allocations are well below the 20% recommended by the Fast Track Initiative, with the majority (55%) directed at primary education.lxxvi In 2010, 94% of this expenditure was allocated towards personnel costs, leaving very little to finance the daily functioning of schools. Expenditure on staff (in constant terms) has increased by 227% since 1998, compared with an increase of 5% in other categories of expenditure in the sector (Figure 57).
Figure 57: Expenditure in the education sector, 1998-2010 Personnel
Goods & services
Transfers
Total education expenditures
6000
2010 FCFA millions
5000 4000 3000 2000 1000 0
1998
1999
2002
2003
2004
2005
2006
2007
2008
2009
2010
Source: RESEN 2011
71
Equity and child rights
Pro-child budgeting
Households contribute close to half of all expenditures on education. Household spending represents a third of total primary school expenditure and two-thirds of secondary school expenditure, altogether amounting to 49% of total education funding (Figure 58). Parents face high opportunity costs in education, particularly when their children enter secondary school.lxxvii
Figure 58: Households versus government expenditures on education, 2010 Household expenditures
Government expenditures
10000
in million 2010 CFA
8000 6000 4000 2000 0
Pre -school
Primary school
Secondary school
Total
Source: RESEN 2011
Without significant national and donor commitment, Guinea Bissau is unlikely to meet most international development targets Table 4 presents a summary of the MDGs most relevant to the situation of women and children in Guinea Bissau. Of the 33 indicators analysed, only seven are considered on track or have some potential to attain the target. Eleven of the indicators are unlikely to be achieved and insufficient data/no baseline was available for 15 of the indicators. The Government of Guinea Bissau must create a more conducive sociopolitical environment, make pro-child budget allocations and foster partnerships to meet the needs of its population, all within the framework of DENARP-II. Given the challenges, orienting efforts to target the biggest inequities will make the greatest gains towards achieving the MDGs.
72
Current situation
Target
Will the indicator be met?
Guinea-Bissau
Table 4: Overview of the progress of Guinea Bissau towards selected MDGs
Target 1.A Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day 1.1 Proportion of population 33% (ILAP, 2010) below $1 (1993 PPP) per day Goal 1: Eradicate Extreme Hunger and Poverty
13%
Unlikely
Target 1.C Halve, between 1990 and 2015, the proportion of people who suffer from hunger 1.8 Prevalence of underweight children under five years of age
18% (MICS, 2010)
13%
Food insecurity in 1.9 Proportion of population rural population: 20% (Republic of below minimum level of dietary energy consumption Guinea-Bissau/ WFP, 2011)
Potentially
Baseline not available
Target 2.A Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling Goal 2: Achieve Universal Primary Education
2.1 Net enrolment ratio in primary education
67% (MICS, 2010)
100%
Potentially
2.2 Proportion of pupils starting Grade 1 who reach Grade 5
83% (MICS, 2010)
100%
Potentially
2.3 Literacy rate of 15-24 year olds
Girls: 40% (MICS, 2010)
100%
Unlikely
Target 3.A Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015 Goal 3: Promote Gender Equality and Empower Women
3.1 Ratio of girls to boys in primary, secondary and tertiary education 3.3 Proportion of seats held by women in national parliament
Primary: 0.94 (MICS, 2010)
1
Potentially
Secondary: 0.73 (MICS, 2010)
1
Unlikely
10%
50%
Unlikely
Target 4.A Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate
Goal 4: Reduce Child Mortality
165/1,000 live 4.1 Under-five mortality rate births (MICS, 2010)
80/1,000 live births Unlikely (indirect method)
4.2 Infant mortality rate
100/1,000 live births (MICS, 2010)
47/1,000 live births Unlikely (indirect method)
4.3 Proportion of 1-year-old children immunized against measles
61% (MICS, 2010)
90%
Unlikely
73
Equity and child rights
Pro-child budgeting
Table 4: Overview of the progress of Guinea Bissau towards selected MDGs (cont.)
Current situation
Target
Will the indicator be met?
Target 5.A Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
Goal 5: Improve Maternal Health
5.1 Maternal mortality ratio
1,000/100,000 live births (World Bank Statistics)
5.2 Proportion of births attended by skilled health personnel
43% (MICS, 2010)
225/100,000 live births
Unlikely
Baseline not available
Target 5.B Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence 33% rate (MICS, 2010)
Baseline not available
5.4 Adolescent birth rate
141/1,000 (MICS, 2010)
Baseline not available
5.5 Antenatal care coverage (at least 1 visit and at least 4 visits)
At least 4 visits: 67% (MICS, 2010)
Baseline not available
5.6 Unmet need for family planning
6% (MICS, 2010)
Baseline not available
Target 6.A Have halted by 2015 and begun to reverse the spread of HIV/AIDS 6.1 HIV prevalence among population aged 15-24 years
Goal 6: Combat HIV/AIDS, Malaria and Other Diseases
2.9% (4.2% girls, 1.4% boys; INASA, 2011)
Baseline not available
6.2 Condom use at last high- Girls: 47% risk sex (MICS, 2010)
95%
Unlikely
6.3 Percentage of population aged 15-24 years with Girls: 15% comprehensive correct (MICS, 2010) knowledge of HIV/AIDS
95%
Unlikely
6.4 Ratio of school attendance of orphans to school attendance of nonorphans aged 10-14 years
1
Likely
1.09 (MICS, 2010)
Target 6.B Achieve, by 2015, universal access to treatment for HIV/AIDS for all those who need it 52% 6.5 Proportion of population (59% of adults with advanced HIV infection aged 15+, 16% 100% with access to antiretroviral children 0-15 drugs years, SNLS 2012)
74
Unlikely
Current situation
Target
Will the indicator be met?
Guinea-Bissau
Table 4: Overview of the progress of Guinea Bissau towards selected MDGs (cont.)
Target 6.C Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
Goal 6: Combat HIV/AIDS, Malaria and Other Diseases
6.6 Prevalence and death No data rates associated with malaria
No data
6.7 Proportion of children under 5 sleeping ITNs
35% (MICS, 2010)
Baseline not available
6.8 Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs
37% (MICS, 2010)
Baseline not available
6.9 Incidence, prevalence and death rates associated with TB
No data
No data
Target 7.C Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation
Goal 7: Ensure Environment Sustainability
7.8 Proportion of population with sustainable access to an improved water source, urban and rural
7.9 Proportion of population with access to improved sanitation, urban and rural
Total: 67% (MICS, 2010)
Baseline not available
Urban: 84% (MICS, 2010)
80%
Likely
Rural: 53% (MICS, 2010)
60%
Potentially
Total: 17% (MICS, 2010)
Baseline not available
Urban: 35% (MICS, 2010)
Baseline not available
Rural: 5% (MICS, 2010)
Baseline not available
75
76
Women (15-49 years) who have married or who lived in marital union before they were 15 (%)
Women (15-49 years) who have undergone FGM/C (%)
Children (0-5 years) whose birth was registered (%)
Children’s civil rights and freedoms
Children who have lost 1 or both parents (%)
Children living with both biological parents (%)
Children’s rights to a family environment and alternative care
Women (15-24 years) who are literate (%)
Cgildren of secondary school age attending secondary education or higher (%)
Cgildren of primary school age attending basic or secondary education (%)
Children under 5 years exposed to an ECD programme (%)
Women (15-49 years) who have heard of AIDS and demonstrate accepting attitudes towards people living with HIV/AIDS (%) Children’s rights to early childhood development and education
Women (15-49 years) who have comprehensive knowledge of how to prevent HIV (%)
HIV prevalence among pregnant women (%) HIV prevalence in the general population (15-49 years) (%)
Prevalance of wasting among children 0-5 years (%)
Prevalance of stunting among children 0-5 years (%)
Full immunization coverage among children under 1 year (%)
Births taking place in public health facilities (%)
Households using improved sanitation facilities (%) Children’s rights to life and basic health
Households using improved drinking water sources (%)
Households affected by food insecurity (moderate and severe) (%) (excluding SA) Households living in precarious structures (%)
Childhood poverty - children (5-18 years) affected by 2 or more severe deprivations (%)
Children’s rights to an adequate standard of living
Selected key indicators
Annex. Equity snapshot
39.0 49.0 20.0 89.0 65.6 59.8 17.5 41.4 35.9 61.2 49.6 32.2 40.9 5.8 7.2 5.8 5.3 13.8 15.8 7.9 29.4 15.1 67.4 53.7 23.5 7.7 39.8 28.6 54.8 59.9 11.3 11.3 24.1 38.9 49.8 44.5 6.9 7.3
2010 2006 2010 2006 2010 2006 2010 2006 2010 2010 2006 2010 2010 2010 2006 2010 2006 2010 2006 2010 2006 2010 2006 2010 2006 2010 2006 2010 2006 2010 2006
7
6
19 48 94 93 16 6
67 76 10 7
6 9 53 48 11 2.4 22 11
2
27 32 32 29 3 10
54 55 11 13
23 13 64 49 16 5.5 28 19
5
8 12
39
36
7 12
38 33 57
29 57 33 32 4 6
43 48 13 14
48 33 87 71 46 16.5 68 54
11
25 28
5
20
71 67 67
19 20 55 36 7 5
52 62 12 10
44 6 68 51 12 3.9 28 16
17
14 4
5
27
35 29 54
68.7 54.2 6.4
63.9 45.6 89.9 62.7 40.2 92.3 10.7 6.9 42.7 27 19 66
46.0 60.0
6.0 6.0
45.0 56.0 55.0 66.0
National East North SAB South average
2010 2006 2010 2009 2010 2006 2010
Year
5.4
24
36
12
38
21
10
20
10
53
71
50
67
14
4
4
7
10
5
29
73
70 32
49
11.5
19 95% 48
55
30
1.9
14 95% 71
39
Bafatá Biombo
19
9
42
40
18
81
44
4
4
26
72
36
14.5
30 95% 70
58
31
9
53
38
24
70
60
4
6
40
62
47
4.9
22 96% 58
42
Bolama/ Cacheu Bigajós
12
11
67
24
11
56
5
10
6
41
60
24
21.4
15 91% 55.4
33
Gabú
6
SAB
20
11
56
13
9
57
4
3
8
42
44
24
29
13
43
68
46
87
48
8
5
20
67
71
6.5 42.76
25 96% 75% 33.2 89.4
58
Oio
Equity and child rights
25
12
57
19
9
57
62
6
5
28
45
31
13.6
14 96% 67.8
44
12
13
50
34
61
79
37
6
7
24
58
39
2.5
41 98% 69.4
45
Tombali Quinara
77
Better off than the national average
Equal or close to the national average
Women (15-49 years) who have married or who lived in marital union before they were 15 (%)
Women (15-49 years) who have undergone FGM/C (%)
Children (0-5 years) whose birth was registered (%)
Children’s civil rights and freedoms
Children who have lost 1 or both parents (%)
Children living with both biological parents (%)
Children’s rights to a family environment and alternative care
Women (15-24 years) who are literate (%)
Cgildren of secondary school age attending secondary education or higher (%)
Cgildren of primary school age attending basic or secondary education (%)
Children under 5 years exposed to an ECD programme (%)
Women (15-49 years) who have heard of AIDS and demonstrate accepting attitudes towards people living with HIV/AIDS (%) Children’s rights to early childhood development and education
Women (15-49 years) who have comprehensive knowledge of how to prevent HIV (%)
HIV prevalence among pregnant women (%) HIV prevalence in the general population (15-49 years) (%)
Prevalance of wasting among children 0-5 years (%)
Prevalance of stunting among children 0-5 years (%)
Full immunization coverage among children under 1 year (%)
Births taking place in public health facilities (%)
Households using improved sanitation facilities (%) Children’s rights to life and basic health
Households using improved drinking water sources (%)
Households affected by food insecurity (moderate and severe) (%) (excluding SA) Households living in precarious structures (%)
Childhood poverty - children (5-18 years) affected by 2 or more severe deprivations (%)
Children’s rights to an adequate standard of living
Selected key indicators
Annex. Equity snapshot (cont.)
40 31 3 20 17 54 42 41 7 11 5 4 4 14 0 52 43 4 2 12 7 62 61 9 11 17 21 49 28 9 9
2.0 2.3 6.7 2.6 3.5 1.2 1.9
3.4 7.6 9.6 7.9 5.4 1.7 1.5 4.3 6.9 3.1 5.2 1.6 1.6 1.3 2.1 1.5 2.9 2.9 3.2 5.4 2.1
23 32 57 50 7 8
61 64 11 10
23 9 56 46 8 3 19 8
5
6 8
37 45 7 6
29 23 62
55 47 4
59 75
Second poorest 20%
Worse off than the national average
1.3
75 94
Poorest 20%
9.3 11.0
Ratio of highest to lowest
23 41 60 61 8 8
57 65 11 11
25 20 65 49 15 3 28 13
7
12 10
31 47 5 8
39 27 61
66 59 8
34 55
Middle 20%
29 48 44 49 6 8
45 61 14 10
44 15 84 60 40 7 56 30
10
20 23
24 36 5 7
65 51 63
79 72 23
7 17
Second richest 20%
35 61 40.5 36.1 4 5
44 46 13 14
47 33 87 72 49 19 73 62
12
26 29
18 32 5 4
80 75 65
93 91 59
3 3
Richest 20%
0.5 0.3 1.2 0.8 2.3 1.9
1.4 1.3 0.7 0.8
0.3 0.6 0.6 0.1 0.1 0.2 0.1
0.3
0.2 0.1
2.3 1.3 1.3 2.5
0.2 0.2 0.8
0.4 0.3 0.04
25.0 31.3
25 40
11
62
29 18
2.4
6
34
61
Ratio of poorest to Male richest
1.0 1.1
1.0
1.1
1.1 1.5
2.9
1.1
1.2
1.0
ratio of males to females
Guinea-Bissau
24 37
11
58
30 12
6.9
6
30
62
Female
MICS 2010 MICS 2006 MICS 2010 MICS 2006 MICS 2010 MICS 2006
MICS 2010 MICS 2006 MICS 2010 MICS 2006
MICS 2010 MICS 2006 MICS 2010 MICS 2006 MICS 2010 MICS 2006 MICS 2010 MICS 2006
MICS 2010
MICS 2010 MICS 2010 MICS 2010 MICS 2006 MICS 2010 MICS 2006 MICS 2010 MICS 2006 SNLS/INASA 2010 SNLS/INASA 2010 MICS 2010 MICS 2006
MICS 2010 MICS 2006 INE/WFP 2010 INE 2009 MICS 2010 MICS 2006 MICS 2010
Source
Equity and child rights
Bibliography i ii iii iv v vi vii viii ix x xi xii xiii xiv xv xvi xvii xviii xix xx
xxi xxii xxiii xxiv xxv xxvi xxvii xxviii xxix xxx xxxi xxxii xxxiii xxxiv xxxv xxxvi
78
Interagency Group, 2012, Levels and Trends in Child Mortality 2012 Committee on the Rights of the Child, 2001, Concluding Observations: Guinea Bissau, CRC/C/15/ Add.177, 13 June, 6(a) Lars Rudebeck, 2011, Electoral Democratization in Post-civil War Guinea Bissau 1999-2008; Barry Boubacar-Sid et al., 2008, Conflict, Livelihoods, and Poverty in Guinea-Bissau African Economic Outlook, 2011 WFP, 2011, Résultats de l’enquête approfondie sur la sécurité alimentaire et la vulnérabilité des ménages ruraux, République de Guinée-Bissau WFP, 2011 Barry Boubacar-Sid et al., 2008 Committee on the Elimination of Discrimination Against Women, Combined Initial, Second, Third, Fourth, Fifth and Sixth Periodic Report, Guinea Bissau, June 2009 MICS, 2010 Interagency Group, 2012 WHO, 2006 Trends in Maternal Mortality 1990-2008. Estimates developed by WHO, UNICEF, UNFPA and World Bank, 2010 Boussery, Günter et al., 2011, Harmonisation for Health in Africa (HHA). Community of Practice on the Service Delivery Study High Impact Interventions African Health Worker Observatory, 2010, Human Resources for Health. Country Profile Guinea Bissau African Health Observatory, 2010 Ministry of Health, 2006, National Survey on Bed Nets, Vitamin A and Mebendazole, 12 Months after the Integrated Campaign in November 2006 R. Shretta, 2007, Global Fund Grants for Malaria: Summary of Lessons Learned in the Implementation of ACTs in Ghana, Nigeria, and Guinea-Bissau A. Frosch et al., 2011, Patterns of Chloroquine Use and Resistance in Sub-Saharan Africa: A Systematic Review of Household Survey and Molecular Data Roll Back Malaria, 2008, Rapport de la mission conjointe des partenaires WARN en Guinée-Bissau, 28 April-3 May J. Ursing et al., 2009, Chloroquine Is Grossly Overdosed and Overused but Well Tolerated in GuineaBissau; J. Ursing et al., 2007, Chloroquine-resistant P. falciparum Prevalence Is Low and Unchanged between 1990 and 2005 in Guinea-Bissau: An Effect of High Chloroquine Dosage? B. de Benoist et al., 2008, Worldwide Prevalence of Anaemia 1993-2005, WHO Global Database on Anaemia Republic of Guinea Bissau and UNDP, 2010, Atualização do plano diretor da água e do saneamento da Guiné-Bissau Ministry of Economy, Planning and Regional Integration, 2011, DENARP-II F. Luquero, 2009, Time Series Analysis of Cholera in Guinea-Bissau, 1996-2008 UNAIDS, 2010 UNAIDS, 2010 INASA, 2009, Preliminary Report on HIV Prevalence in Pregnant Women, Guinea Bissau UNICEF, 2009-12, Hospital Cumura Reports INASA, 2009 Military Seroprevalence Survey, 2005 UNICEF, 2010, Progress for Children: Achieving the MDGs with Equity UNAIDS, UNICEF and WHO, 2007, Children and AIDS: A Stocktaking Report Ministry of National Education, Science, Culture, Youth and Sports, 2009/10 World Bank, 2009, Social Sector Review The Gender Parity Index measures girls’ net attendance divided by that of boys. RESEN, 2011
xxxix xl xli xlii xliii xliv xlv xlvi xlvii xlviii xlix l li lii liii liv lv lvi lvii lviii lvix lx lxi lxii lxiii lxiv lxv lxvi lxvii lxviii lxix lxx lxxi lxxii lxxiii lxxiv lxxv lxxvi
lxxvii
RESEN, 2011 Effective Intervention, 2011, Lacunas de conhecimento nas zonas rurais da Guiné-Bissau Ministry of Education, 2011, Resultado de exams nacionals (9e 12e ano) por regioes educativa e aeras curriculares UNICEF Guinea-Bissau/RECEPT-GB, 2011, Report on Survey and Psychosocial Questionnaire on Children between Age 6 and 12 in and out of School System RESEN, 2011 Effective Intervention, 2011 MICS, 2010 Effective Intervention, 2011 SNV, 2010, O impacto da campanha do cajú sobre o abandon escolar na região de Biombo UNICEF Guinea-Bissau/RECEPT-GB, 2011 RESEN, 2011 RESEN, 2011 UNICEF Guinea-Bissau/RECEPT-GB, 2011 RESEN, 2011 Effective Intervention, 2011 Author’s calculations based on Ministry of Education, 2009/10, Politica nacional para a igualidade e equidade do género, and RESEN, 2011 Author’s calculations based on Ministry of Education, 2009/10 Effective Intervention, 2011 Ministry of National Education, Science, Culture, Youth and Sports, 2011, Financial Request to the Global Partnership Education Fund João Riberio et al., Abuso e a exploração sexual de menores na Guiné-Bissau João Riberio et al. Kabontekoor, 2011, Report João Riberio et al. MICS, 2010 Ministry of Justice, 2011, Access to Justice Assessment in Guinea Bissau Ministry of Justice, 2011 Jónína Einarsdóttir et al., 2010, Child Trafficking in Guinea-Bissau. An Explorative Study João Riberio et al. Ministry of Justice, 2011 João Riberio et al. Effective Intervention, 2011 World Bank, 2012, World Development Indicators UNDP, 2012 IMF, 2011, Guinea-Bissau Country Report 11/355 UNDP, 2011, Enfrentando o desafio da coordenação da ajuda e das parcerias na Guiné-Bissau; African Economic Outlook, 2011 OECD, 2011, Relatório 2011 sobre a intervenção internacional em estados frágeis: República da GuinéBissau Ministry of Economy, Planning and Regional Integration with UNDP, 2011, Relatório cooperação para o desenvolvimento Guiné-Bissau 2007–2009 Republic of Guinea Bissau, 2011, State Budget Proposal 2012 Ministry of Health, 2010, Axes prioritiares du PNDS II à l’intention des partenaires UNESCO-BREDA, 2011, Eléments de diagnostic du système éducatif Bissau-guinéen: marges de manœuvre pour le développement du système éducatif dans une perspective d’universalisation de l’enseignement de base et de réduction de la pauvreté UNESCO-BREDA, 2011
Guinea-Bissau
xxxvii xxxviii
79
Equity and child rights
Contacts UNICEF United Nations Building PO Box 464, Bissau 1034 Guinea-Bissau
80