1. Sub-Saharan Africa: The Challenge of High Fertility John F. May Lead Population Specialist Africa Region, World Bank Washington, DC, July 16, 2008

2.  SSA annual rate of growth: 2.5% (it could even accelerate if mortality declines faster)  Total population could reach 1.8bn people by 2050 - from 800 million today - if fertility declines rapidly  TFR is above 5 today and needs to decrease to 2.5 in 2050 to match these projections  HIV/AIDS will not fundamentally change the demographic equation (except in Southern Africa)  2 out of 3 people are under 25 (youth bulge) Key demographic features

3.  Health rationale as highlighted in “Fertility Regulation Behaviors and Their Costs”  Reduce population pressure on land tenure and ecosystems  Human capital investments (e.g., education and health) and fiscal space Rationale for intervention

4. Modifying the age structure (1)

5. Modifying the age structure (2)

6. Modifying the age structure (3) Three key messages: The bottom of the population pyramid needs to take a rectangular shape to facilitate the formation of human capital Such a process will require the acceleration of the fertility transition Fertility will need to drop to low levels to change the shape of the population pyramid

7.  Women do want services (large unmet needs)  Politicians, traditional & religious leaders, and civil society are more open to discuss Pop/RH issues However  Need for more proactive policies  Scarcity of real champions  Weakness of M&E framework Changing attitudes in SSA

8. A few key interventions vs. scattered programs:  Stronger and more persistent advocacy  More consistent provision of family planning and reproductive health services  Breastfeeding programs  Contraceptive security plans  Female education and legal reform (e.g., age at marriage)  More involvement of men What can be done?