[{"bbox": [96, 152, 1134, 366], "category": "Text", "text": "and limited capacity (numbers and skills) at sub-national levels to generate and use health data for action. There are still other weak elements, such as the particular case of the Civil Registry subsystem, with minimal coverage of deaths and a lack of information on the causes of deaths inside and outside the national health structures, as well as the registration of births that take place outside the health structures. The epidemiological surveillance system provides rather inconsistent data and the information system for surveillance on nutrition: SISSAN (Food Security and Nutrition Monitoring System), providing geographically specific data on food insecurity and malnutrition, is totally dependent on external aid. Also, the analysis and dissemination of data is insufficient and not structured enough. The current gaps in the efficiency of the systems undermine the capacity of decision makers."}, {"bbox": [96, 377, 1069, 405], "category": "Section-header", "text": "## 2- Provision, access and distribution of essential medical products, especially in primary health care"}, {"bbox": [96, 416, 1134, 816], "category": "Text", "text": "Access to medicines has experienced serious constraints linked to stock-outs resulting from a low level of supply and control of the entire supply chain, which has jeopardised the availability of essential medicines and supplies for the diagnosis and treatment of diseases such as malaria, HIV/AIDS and tuberculosis. And this continues to be the case despite all the investment that has been made in the Purchasing Centre for Medicines (CECOME), which was recently dissolved due to inefficiency and high corruption and is being restructured in 2024, as a new semi-autonomous structure with a new statute and a new administration. Other issues have to do with the non-fixing of prices for medicines and the non-traceability of the origin of certain medicines. There is also a lack of effective regulation and supervision of the pharmaceutical sector, despite the efforts of the West African Economic and Monetary Union (WAEMU) effort to establish a harmonized regulatory framework across its member states, leading to the appearance on the market of pharmaceutical products of dubious origin, as well as the sale of fake medicines at low prices throughout the country, thus contributing to a serious problem for the health of the population. Despite the World Health Organisation (WHO) updating the national list of essential medicines, an efficient mechanism to measure the needs for medicines and medical products is lacking. Purchasing at controlled prices and distributing medicines and medical products equitably and efficiently through the public health system, remain major challenges. Additionally, weaknesses persist in storage capacity and stock management."}, {"bbox": [96, 827, 552, 854], "category": "Section-header", "text": "## 3- Development of human resources for health"}, {"bbox": [96, 865, 1134, 1079], "category": "Text", "text": "Human resources for health are still insufficient in number and poorly qualified. There is a shortage of specialised doctors and qualified nurses, and their distribution throughout the country does not allow an equitable access to primary health care. Moreover, there is poor human resources retention capacity, and salaries are low and often paid late. The budgetary constraints have contributed to a rather precarious, low-skilled and unmotivated health workforce. The lack of an effective mechanism for hiring and managing the health workforce and the consequent supervision, the absence of career paths and a mechanism for regulating the activities of the different professional groups make the health professions unattractive and drive many health professionals towards behaviours that do not comply with professional ethics."}, {"bbox": [96, 1090, 1134, 1197], "category": "Text", "text": "The conditions for minimum international standards for provision of services are lacking and deserve to be reinforced especially at primary health care level. A health human resources reform is claimed at all levels, to establish standards for professional practice, recruitment, career path and national distribution in all levels of health care delivery services."}, {"bbox": [96, 1208, 1134, 1396], "category": "Text", "text": "The distribution of health workers across regions is not proportional to the number of facilities. Bissau capital has 43.6% of all the country's health workers in only 11 facilities, while Quinara has only 5.1% of all health workers in nearly the same number of facilities. The large majority of health workers (86.5%) are concentrated in urban areas¹⁶. The distribution of health centres is also quite uneven, with 66% of the population with difficult access to a health structure. This situation has a particular impact on the percentage of women who decide to give birth in a health facility, which is estimated to be around 45%, with disastrous consequences on the maternal and infant mortality rate."}, {"bbox": [96, 1406, 1134, 1515], "category": "Text", "text": "In this context, improving health system governance and quality of training should take precedence over expanding human resources for health. A bloated and ineffective workforce must be better managed and upskilled, in order to improve skills and productivity, and a gender-responsive reform should lead to the construction of a system capable of providing responses to the strong demand for sexual and reproductive health services."}, {"bbox": [86, 1620, 697, 1646], "category": "Footnote", "text": "¹⁶ World Bank, Guinea-Bissau: Service Delivery Indicators Report, 2019."}, {"bbox": [1034, 1679, 1144, 1706], "category": "Page-footer", "text": "Page 7 of 26"}]