Executive Summary

Sub-Saharan Africa (the terms "sub-Saharan Africa" and "Africa" are used interchangeably) is experiencing a period of extraordinary change. Across the continent, policy reforms are contributing to dynamic economic growth. Greater political openness has strengthened the commitment of African governments to meeting the basic needs of their people.

Despite these positive trends, sub-Saharan Africa remains the world¹s greatest development challenge. Much of the continent's population remains desperately poor. With record numbers of adolescents entering their childbearing years, in less than three decades Africa's population is projected to double again from the current level of 620 million. Meanwhile, many African nations are struggling to provide health and education services to populations expanding at about three percent a year. In many countries, rapid population growth is contributing to degradation of the environment and undermining prospects for prosperity.

Africa's hopes for a better future depend in large part on improving the health of its people. Better access to good quality reproductive health services, particularly family planning, is key to improving health status — especially for women. The reality of reproductive health in Africa, however, is far from ideal. Women begin childbearing in their teens and have an average of six children. Just 18 percent use contraception, and the level of unmet need for family planning — over one-quarter of married women or more than 22 million women — is higher than in any other region. Early and frequent childbearing means that 1 in 15 women in Africa dies in pregnancy or childbirth. Meanwhile, AIDS has struck hard in eastern, central, and southern Africa, where roughly 1 in 10 adults — both men and women — are infected with HIV.

Yet traditional attitudes favoring large families are changing rapidly, owing to the growth of cities, the rising cost of living and lower child death rates, among other factors. Demand for family planning has increased dramatically in some countries, and the decline in birthrates‹limited as recently as a decade ago to only a few countries in the region‹ appears to be spreading steadily across the continent.

In much of Africa, however, large families are still the norm. This situation is reinforced by low levels of education, particularly among women, and social barriers to the full economic participation of women. Yet, school enrollment rates declined or came to a standstill during the economic crisis many African countries experienced in the 1980s. Compared to countries in other developing regions, African countries have only recently begun to adopt population policies and initiate family planning and related reproductive health programs. Since the 1980s, however, African governments increasingly recognize the individual and societal benefits of smaller families. In the last decade there has been steady growth in the number of countries establishing national family planning programs and in the scope of these efforts. In Botswana, Kenya and Zimbabwe, which established family planning programs early on, family planning use now approaches or exceeds 40 percent of married women of childbearing age.

Still, Africa has a long way to go. In addition to meeting the growing need for family planning and reproductive health services, African countries must expand access to education for girls and economic opportunities for women. This will require significantly increased financial contributions from African governments and households, as well as international donors. In sum, addressing poor reproductive health and rapid population growth is a daunting task requiring comprehensive action on many different fronts. Priority areas for action by governments and international donors are summarized below.