Young People in West and Central Africa

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1 November 2017 i

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3 Acknowledgments The preparation and publication of this report were made possible through generous grants to the African Population and Health Center (APHRC) from the David and Lucile Packard Foundation (Grant # ) and the Segal Family Foundation (Grant # ). Core funding support to APHRC by Sida (Grant # ) and the William and Flora Hewlett Foundation (Grant # ) is also gratefully acknowledged. We are grateful to Carol Gatura, Danielle Doughman and Lauren Gelfand of the Policy Engagement and Communication Division at APHRC for reviewing and commenting on earlier drafts of this report. Authors Chimaraoke Izugbara, Frederick Wekesah, Joshua Amo-Adjei, Caroline Kabiru, Zacharie Tsala Dimbuene, and Jacques Emina. About African Population and Health Research Center (APHRC) APHRC is a pan-african, non-profit research institute headquartered in Nairobi, Kenya. The Center was established in 1995 with funding from the Rockefeller Foundation. APHRC has three key mandates: i) research and evaluation, ii), policy engagement, and iii) research capacity strengthening. APHRC s priority research and evaluation areas include population dynamics, sexual and reproductive health, maternal and child health, urbanization and well-being, health challenges and systems, aging, and education. How to cite this report: Izugbara, C.O., Wekesah, F.M., Amo-Adjei, J., Kabiru, C.W., Tsala Dimbuene, Z.T., & Emina, J. (2017). : Health, Demographic, Education, and Socioeconomic Indicators. African Population and Health Research Center (APHRC), Nairobi, Kenya. iii

4 Executive summary West and Central Africa (WCA) is a 24-country contiguous area with a population of million people. A third of the sub-region s current population, projected to reach 1.2 billion by 2050, is aged between 10 and 24 years old. By 2025, WCA will not only have the largest number of young people globally but will also be the only sub-region of the world where the population of young people will continue to grow. Protecting the lives and ensuring the well-being of these young people is a precondition for development and progress in the sub-region. However, while robust evidence is key to informed development policies and agendas regarding youth in WCA, much of the existing evidence on this critical group of people in the sub-region is fragmented: it is often not packaged to meet the knowledge and practice needs of decision-makers and policy actors, nor is it consolidated to offer cross-national and comparative insights into the lives and circumstances of the sub-region s young people. This report synthesizes essential evidence consolidated from Demographic and Health Surveys (DHS) and other data sources on key socioeconomic, educational, health, and demographic situations of young people in the WCA sub-region as part of the current drive towards the sub-region s first demographic dividend (DD). It also identifies critical evidence gaps as well as opportunities and prospects for addressing them. Available data show that young people in WCA comprise about a third of the global population of outof-primary-school children and that the region has the lowest school enrolment rates globally. School intake ratios, learning outcomes, and completion and progression rates remain dismal at all levels of education in WCA. At all schooling levels, girls and children in poor households are disproportionately out of school, and compared with boys and children in non-poor households, they enroll less, progress less, and learn fewer fundamental skills for their grades in school. Youth unemployment in WCA is among the highest in sub-saharan Africa (SSA) and the world. Only about one-third of females and two-thirds of males aged 15 to 24 in WCA are employed. Millions in the sub-region remain trapped in child labor, working primarily as farmhands, hawkers, bonded domestic servants, and slaves. Child and early marriage remain common in WCA, with the median age of marriage for women standing at about 19 years old, compared with 20 years in Eastern Africa and 21 years for Latin America and the Caribbean. The sub-region also has the highest global percentage of women aged who give birth by age 18. For instance, in Niger, half of all women give birth before age 18. Early age at first sex, high numbers of sexual partners, low contraceptive prevalence, and sexual and gender-based violence also remain common among young people in the sub-region. Adolescent mortality is high in WCA. Maternal conditions, including unsafe abortion, top the causes of mortality among girls and young women in WCA while unintentional injuries are the top cause of death for boys and young men. Although the burden of HIV/AIDS is higher in Southern and East Africa, young people in WCA remain at substantial risk. HIV prevalence among persons aged 15 to 24 years in WCA is generally higher for females, and in some countries in the sub-region, the number of new infections among young people remains high. Comprehensive, accurate knowledge about HIV among young people is poor in WCA, with girls generally having less comprehensive knowledge compared with boys. These health challenges are worsened by a growing burden of substance abuse and other non-communicable diseases, such as mental illnesses, cancers, injuries, and cardiovascular diseases among the sub-region s young people. Some of the major data gaps relate largely to critical sexual and reproductive health and rights (SRHR) matters such as abortion, sexual orientation, and gender-based violence. There is a paucity of data on young people s access to resources in the region such as healthcare, capital, farmland, and housing. iv

5 Information on young people as either victims or perpetrators of violence is scarce throughout WCA. There is also a lack of robust data on morbidity, disability, political participation, mental health, substance use, and migration among young people. In many instances, existing datasets are not properly disaggregated on the basis of age and gender. Ensuring a positive future for young people in WCA requires investment to address existing data gaps; expand access to quality education at all levels for all young people, paying particular attention to girls and poor young people; create and sustain economic opportunities for young people and through effective and workable laws and policies, protect them from socioeconomic and other vulnerabilities including violence, child marriage, servitude, and labor exploitation; develop and implement effective health promotion programs to address poor health among young people; ensure health systems that deliver efficient, accessible, and affordable services to prevent and control diseases and suffering as well as reduce threats to young people; foster the involvement of youth in governance as well as the development and articulation of solutions to the issues which face them; support research on the causes of the challenges facing young people as well as solutions to sustainably address these challenges. v

6 List of abbreviations and acronyms CAR CPR DD DHS DRC FGC GDP GPI HDI HIC LMICs MDGs MICs NCDs SDGs SMAM SRH SRHR SSA UNDP UNFPA WCA Central African Republic Contraceptive prevalence rate Demographic dividend Demographic and health survey Democratic Republic of Congo Female genital cutting Gross domestic product Gender parity index Human development index High-income countries Low and middle-income countries Millennium development goals Multiple indicator cluster surveys Non-communicable diseases Sustainable development goals Singulate mean age at marriage Sexual and reproductive health Sexual and reproductive health and rights Sub-Saharan Africa United Nations Development Programme United Nations Population Fund West and Central Africa vi

7 Table of contents Acknowledgments iii Executive summary iv List of abbreviations and acronyms vi 1. Background The WCA sub-region Objectives of the report Methodology and structure of the report 5 2. The education of young people in WCA Out of school children Primary school intake Gender disparities in education Primary school completion and secondary school progression Quality of education indicators in WCA Socioeconomic circumstances of young people in WCA Young people and employment Child labor in WCA Family formation and sexual and reproductive health of young people in WCA Child marriage Mean age at marriage Adolescent childbearing Young people and sex Contraceptive behavior of young people in WCA Abortion Sexual violence among young people in WCA Female genital cutting in WCA The health of young people in WCA Causes of death among young people Non-communicable diseases among young people in WCA HIV and young people in WCA Mental health and substance use among young people in WCA Gaps in data and research Conclusions and recommendations References 44 vii

8 List of tables Table 1: Selected socioeconomic indicators for WCA countries 3 Table 2: Population of young people aged in WCA 4 Table 3: Trends in primary school completion rate for both male and female (%) in WCA 11 Table 4: Population of young people aged 15-24, ever married (%) and SMAM (in years) in WCA 20 Table 5: Median age at first sex among young people in WCA 24 Table 6: Percentage distribution of young people (15-19) having multiple partners 25 Table 7: Classification of countries according to the reasons for which abortion is legally permitted 27 Table 8: Abortion and post-abortion care in selected countries in WCA 28 Table 9: Sexual violence prevalence among girls and boys aged in WCA 30 Table 10: Top five causes of death for young people by sex and region (%) 33 List of figures Figure 1: Map of WCA 2 Figure 2: Actual and projected population of young people aged across the world (as % of total population). 5 Figure 3: Proportion of out-of-school children across regions of the world by sex (%) 7 Figure 4: Proportion of out-of-school children by world region (%) 7 Figure 5: Out-of-school children by household wealth across different regions of the world (%) 8 Figure 6: Out-of-school children across WCA, (%) 8 Figure 7: Primary school intake ratio in WCA, Figure 8: Gender parity index (GPI) for primary school gross enrolment in WCA 10 Figure 9: GPI for literacy rate for children aged in some countries in WCA 10 Figure 10: Rates of progression to secondary school in WCA 12 Figure 11: Pupil-teacher ratio in primary school education in WCA 12 Figure 12: Proportion of students learning basics and dropping out of school in WCA, Figure 13: Employment-to-population ratios among children aged in WCA 15 Figure 14: Youth unemployment, total (percentage of total labor force aged 15-24), Figure 15: Children in employment as a percentage of children aged 7-14 in WCA 17 Figure 16: Percentage of women aged who were first married or in union before age 18 (child marriage), Figure 17: Median age at first marriage for women aged between first-ever (baseline) and most recent (endline) 21 Figure 18: Adolescent fertility rate (births per 1000 women aged 15-19), Figure 19: Proportion of women aged who gave birth before age 18 in WCA 23 Figure 20: Percentage of adolescent girls and boys (15-19) with multiple partners who used a condom at last sexual intercourse, Figure 21: Contraceptive prevalence, any methods (% of women aged 15-24) in WCA 27 Figure 22: Proportion of girls and young women aged who have undergone female genital cutting in some countries in WCA 31 Figure 23: Top causes of death among young women aged in WCA (% of all deaths) 34 Figure 24: Top five causes of death among WCA young men aged (% of all deaths), Figure 25: Prevalence rates of non-communicable diseases among young people aged Figure 26: HIV prevalence among young people aged in Sub-Saharan Africa 35 Figure 27: Estimated number and percentage of new HIV infections among adolescents aged in WCA, Figure 28: Estimated percentage of AIDS-related deaths among adolescents aged in WCA, Figure 29: Percentage of adolescent girls and boys (aged 15-19) with comprehensive, correct knowledge of HIV in WCA, Figure 30: Substance use among young people aged in WCA (%) 38 Figure 31: Proportion of adolescents aged using tobacco 39 viii

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10 1. Background The centrality of young people 1 to Africa s future continues to be affirmed in several national, regional, and international strategic development agendas and frameworks. The African Union, in its African Youth Charter, launched in 2006, noted that: Africa s greatest resource is its youthful population and that through their active and full participation, Africans can surmount the difficulties that lie ahead. [1] The charter urges countries and governments to facilitate the creation or strengthening of platforms for youth participation in decision-making at local, national, regional, and continental levels of governance [1]. Young people are also at the heart of the Sustainable Development Goals (SDGs). At least 10 of the 17 SDGs are directly related to the development, education, health, employment, empowerment, security, and equality of young people as well as their participation in the conversations that affect them and their environment [2]. However, for these efforts to deliver their anticipated outcomes, they need to be guided by robust evidence. This report presents evidence on the situation of young people in WCA. It specifically addresses the health, economic, educational, demographic, and other conditions related to young people in the sub-region, and highlights essential evidence in the drive towards the sub-region s first demographic dividend 2 and much-vaunted vision of shared prosperity for all its citizens. 1.1 The WCA sub-region WCA is a 24-country contiguous area that lies between latitudes 17 N and longitudes 29 E. It is home to about 470 million people or approximately 6% of the world s population. Poverty, internal conflict and instability arising from political and ethnoreligious crises trouble the sub-region which also has some of the world s most resource-rich countries and vast reserves of natural resources and mineral wealth. For instance, the value of untapped raw mineral deposits in the Democratic Republic of Congo (DRC) alone is in excess of US$24 trillion [3] while Nigeria s petroleum industry is the largest in Africa. In 2014, Nigeria also became the largest economy in Africa [4, 5]. Figure 1: Map of WCA Cape Verde Senegal Mauritania Guinea Bissau Guinea Sierra Leone Liberia Côte d'ivoire Mali Burkina Faso Ghana Benin Togo Nigeria Niger Cameroon Chad Central African Republic Equatorial Guinea São Tomé and Príncipe Gabon Congo Democratic Republic of Congo Source: UNICEF Humanitarian Action for Children, Available at 1 We rely on the United Nations (2015) definition of young people as persons aged between years. 2 The UNFPA (2015) defines demographic dividend as the economic growth potential that results from shifts in a population s age structure, mainly when the share of the working-age population (15 to 64) is larger than the non-working-age share of the population (14 and younger, and 65 and older). 2

11 As shown in Table 1 below, the sub-region also suffers poor development indicators (measured by the Human Development Index (HDI) 3 and gross domestic product (GDP) 4. Table 1: Selected socioeconomic indicators for WCA countries Country Real GDP rate % (2015) HDI (2015) Experience of major war, violent conflicts, or militancy in the past 10 years Benin No Burkina Faso Yes Cameroon Yes Cape Verde No Central African Republic Yes Chad Yes Congo No Côte d Ivoire Yes DRC Yes Equatorial Guinea * 0.47 Yes Gabon Yes Gambia No Ghana No Guinea Yes Guinea-Bissau Yes Liberia Yes Mali Yes Mauritania No Niger Yes Nigeria Yes São Tomé and Príncipe No Senegal No Sierra Leone * 0.42 Yes Togo No Note: *The negative sign indicates a negative GDP growth rate. Source: International Monetary Fund (2016) Currently, WCA has one of the world s youngest populations. A third (35%) of the sub-region s million population, projected to reach 1.2 billion by 2050, is people aged between 10 and 24 years old [6]. Data also suggest that more young people in the sub-region are increasingly moving to live and work in urban areas. In countries like Gabon and São Tomé and Príncipe, the urban share of young people stands at 88% and 66% respectively (see Table 2, below). 3 HDI is a summary measure of a country s life expectancy, education, and per capita income indicators. Scores closer to a value of 1 indicate a longer average lifespan, high education levels and per capita incomes. 4 GDP is the monetary value of all finished goods and services produced within a country s borders during a specific time period. GDP includes all private and public consumption, government outlays, investments and exports minus imports that occur within a defined territory. GDP is a broad measurement of a nation s overall economic activity. Read more at com/terms/g/gdp.asp#ixzz4ct9oqh36. 3

12 Table 2: Population of young people aged in WCA Country Total population Young people aged 10-14; % of total population Young people aged 15-19; % of total population Young people aged 20-24; % of total population Proportion of young people living in urban areas M F M F M F Benin 11,166, Burkina Faso 18,633, Cameroon 23,924, Cape Verde 526, CAR 4,998, Chad 14,496, Congo 4,741, Côte d Ivoire 23,258, DRC 79,722, Equatorial Guinea 869, Gabon 1,763, Gambia 2,054, Ghana 28,033, Guinea 12,947, Guinea-Bissau 1,888, Liberia 4,615, Mali 18,134, Mauritania 4,166, Niger 20,715, Nigeria 186,987, São Tomé and Príncipe 194, Senegal 15,589, Sierra Leone 6,592, Togo 7,496, Source: UNDESA (2015), World Population Prospects: Key findings and advanced tables; Population Reference Bureau (2016), Population Pyramid of the World from , available at M=Male, F=Female. By the year 2025, WCA will not only have the largest number of young people globally about 33% of their population but will also remain the only world sub-region where the population of young people will continue to grow (see Figure 2). 4

13 Figure 2: Actual and projected population of young people aged across the world (as % of total population). East Africa Southern Africa Central Africa West Africa Oceania Europe Latin America/Carribean North America Asia Africa World Source: Population Reference Bureau (2016): Population pyramid of the world ; available at Objectives of the report Robust evidence is key to informed development policies and agendas regarding youth in WCA. However, much of the existing evidence on young people in the sub-region is fragmented and often not robust enough to meet the needs of decision-makers and policy actors [7, 8]. Recent studies on youth in Africa provide little information on the essential drivers and contexts of young people s lives across the region [9, 10]. This report provides evidence and information on the situation of young people across WCA countries, synthesising existing data on demographic, health, educational, and socioeconomic circumstances. The report also identifies key data gaps on young people in WCA. 1.3 Methodology and structure of the report Data presented in this report are generated from published and unpublished sources, including research papers, reports, and datasets. Where necessary, we reanalyzed data from Demographic and Health Surveys (DHS) and other national household surveys, including Multiple Indicator Cluster Surveys (MICS) in the 24 countries. The report is organized into eight chapters. Chapter two highlights evidence on the educational situation of young people in WCA, paying attention to literacy levels, gender parity issues in literacy levels and primary school enrollment, and progression to secondary school. The socioeconomic circumstance of young people forms the crux of chapter three, where we highlight trends in employment and issues related to child labor. Chapter four deals with issues regarding family formation, fertility, sexual and reproductive health, contraceptive use and abortion. Issues related to female genital cutting (FGC) and violence among WCA s young people are addressed in chapter five. Young people s health situation is discussed in chapter six, while chapter seven focuses on gaps in evidence and data. In chapter eight, we highlight emerging issues from the report and offer recommendations for improving the conditions of young people in WCA. 5

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15 2. The education of young people in WCA Education is a critical tool for reducing inequality and poverty [11, 12]. It lays the foundation for sustained socio-economic development and equips young people with the skills for innovation and to contribute meaningfully to societal progress. Despite the importance of education, particularly for the achievement of inclusive growth and socioeconomic development, WCA experiences large numbers of out-of-school children, low primary school enrollment, high student-teacher ratios, and critical gender gaps in school enrollment and progression. 2.1 Out of school children In 2013, about a third of the global 59 million out-of-primary-school children, the majority of whom were girls, lived in WCA [13]. In Nigeria alone, a staggering 8 million children of primary school age were out of school in 2013 [13]. In 2014, 52% of children out-of-school in WCA were girls, highlighting the gender imbalances in school enrollment and performance. Rates of out-of-primary school-age children stood at 28% for males and 31% for females in WCA in 2015, compared to 21% (male) and 22% (female) in Eastern and Southern Africa (Figure 3). Essentially, WCA has one of the highest disparities in the number of boys and girls who are out of school, comparable only to South Asia, the Middle East and North Africa. Figure 3: Proportion of out-of-school children across regions of the world by sex (%) - East Asia and Pacific South Asia Middle East and North Africa WCA Eastern and Southern Africa Female Male Source: UNICEF (2016). UNICEF Global Databases, available at Children in rural WCA households are 1.3 times more likely to be out of school compared with their counterparts in urban households. The rural/urban difference in the percentages of out-of-school children in WCA is also disproportionately high compared with other world regions (Figures 4 and 5). Figure 4: Proportion of out-of-school children by world region (%) - 4 East Asia and Pacific 3 - South Asia Middle East and North Africa WCA Eastern and Southern Africa Rural Urban Source: UNICEF (2015) Data: Monitoring the Situation of Children and Women. The State of the World s Children Report. 7

16 Figure 5: Out-of-school children by household wealth across different regions of the world (%) Richest Fourth Middle Second Poorest East Asia and Pacific South Asia Middle East and North Africa WCA Eastern and Southern Africa Source: UNICEF (2015) Data: Monitoring the Situation of Children and Women. The State of the World s Children Report. Burkina Faso, Guinea, Liberia, Niger, and Senegal have had persistently high rates of out-of-school children in the past decade and a half (Figure 6). For instance, in 2014 alone, 62% of school-age children in Liberia were out of school. However, countries such as Cape Verde and São Tomé and Príncipe made sustained achievement in enrolling and keeping children in school. Figure 6: Out-of-school children across WCA, (%) Benin Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo Côte d Ivoire Equatorial Guinea Europe Gambia Ghana Guinea Guinea-Bissao Liberia Mali Mauritania Niger Nigeria North America Oceania São Tomé and Príncipe Senegal South America Togo Africa Source: World Bank (2014): World Development Report, available at 8

17 2.2 Primary school intake Most WCA countries did not achieve the Millennium Development Goals (MDGs) 2015 target on universal primary education [13]. The primary school intake ratio, defined as a number of children enrolled in primary school regardless of age, divided by the population of the age group that officially corresponds to primary school, currently stands at 79.9 in WCA countries. The corresponding figures for Eastern and Southern Africa and Latin America are higher: at 92.0 and respectively. Figure 7 below shows trends in primary school intake ratio for males and females between 1994 and During this period, primary school enrollment among boys was nearly twice that of girls in most WCA countries. Overall, primary school enrollment recorded slow growth, and in some countries, declined particularly for girls in the past few decades. Figure 7: Primary school intake ratio in WCA, Benin Burkina Faso Benin Cape Verde Central African Republic Chad DRC Congo Côte d Ivoire Equatorial Guinea Gambia Ghana Guinea Liberia Mali Mauritania Niger Nigeria São Tomé and Príncipe Senegal Togo Latin America and Caribbean* Eastern and Southern Africa* WCA* Male 1994 Female 2004 Male 2004 Female 2014 Male 2014 Female Source: World Bank (2014): World Development Report, available at Gender disparities in education Gender disparities in educational outcomes 5 are most acute in WCA compared with other sub-regions in Africa and several parts of the world [13]. Male/female disparities in primary school enrollment in WCA range from 0.66 in CAR to 1.06 in the Gambia (Figure 8). 5 The Gender Parity Index (GPI) indicates parity between girls and boys. A GPI of less than 1 suggests girls are more disadvantaged than boys in learning opportunities and a GPI of greater than 1 suggests the other way around. 9

18 Figure 8: Gender parity index (GPI) for primary school gross enrolment in WCA Benin (2005) Burkina Faso (2005) Cameroon (2005) Cape Verde (2005) 0.95 Central Africa Republic (2005) Chad (2005) Congo (2005) 0.92 DRC (2003) Côte d Ivoire (2003) Equatorial Guinea (2005) Gabon (2004) Gambia (2004) 1.06 Ghana (2005) 0.96 Guinea (2005) 0.84 Guinea-Bissau (2001) 0.67 Mali (2005) 0.80 Mauritania (2005) 1.01 Niger (2005) 0.73 Nigeria (2005) 0.86 São Tomé and Príncipe (2005) 0.98 Senegal (2005) 0.97 Sierra Leone (2001) 0.71 Togo (2005) Source: United Nations (2016): UN Data: Gender Development Index, available at Similar gender parity index (GPI) disparities exist in secondary and tertiary education enrollments, with most of the countries having about 0.5 or less GPI for secondary gross enrollment; and 0.3 or less for tertiary gross enrollment [14]. Gender disparities also exist in literacy levels (Figure 9), with girls remaining disadvantaged. Figure 9: GPI for literacy rate for children aged in some countries in WCA Benin (2002) Burkina Faso (2005) Central African Republic (2000) Chad (2000) Côte d Ivoire (2000) DRC (2001) Ghana (2000) Guinea (2003) Niger (2005) São Tomé and Príncipe (2001) Senegal (2002) Sierra Leone (2004) Togo (2000) Source: World Bank (2016): World Development Indicators, available at FM.ZS?locations=ZG 10

19 2.4 Primary school completion and secondary school progression Primary school completion (Table 3) and secondary school progression (Figure 10) rates are also generally low in WCA compared with the rest of Africa and the world. Overall, primary school completion rates stood at 59% 62% for boys and 57% for girls from 2009 to 2015 [13]. Although primary school completion rates improved in the decades between 1994 and 2014, they were consistently lower for girls compared with boys. Table 3: Trends in primary school completion rate for both male and female (%) in WCA Country F M F M F M F M Benin Burkina Faso Cameroon NA NA Cape Verde Central African Republic NA NA NA NA Chad NA NA Congo NA NA Côte d Ivoire NA NA NA NA DRC NA NA NA NA Equatorial Guinea NA NA NA NA Gambia Ghana NA NA NA NA Guinea Guinea-Bissau NA NA NA NA NA NA Liberia NA NA NA NA NA NA Mali NA NA Niger NA NA Nigeria NA NA NA NA São Tomé and Príncipe NA NA Senegal Togo WCA* Eastern and Southern Africa* The Middle East and North Africa* Latin America and the Caribbean* Source: World Bank (2016), UNICEF Global databases, based on MICS, DHS and other national household surveys. (2016); *Regional averages ( ); NA = not available. 11

20 Figure 10: Rates of progression to secondary school in WCA Benin Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo Côte d Ivoire DRC Gambia Ghana Guinea Mali Mauritania Niger São Tomé and Príncipe Senegal Sierra Leone 79.2 Togo *WCA *Middle East and North Africa *Eastern and Southern Africa Male 2004 Female 2011 Male 2011 Female 2013 Male 2013 Female Source: World Bank (2016): World Development Indicators, available at & UNICEF (2016), UNICEF Global databases, available at *Low secondary completion rates ( ). 2.5 Quality of education indicators in WCA One key measure of the quality of education is the pupil-teacher ratio, which is an indicaton of the number of students who attend a school in relation to its number of teachers. In WCA, this ratio remains generally high, suggesting underfunding of schools and low-quality teacher support to learners. For example, between 2005 and 2010 in the Central African Republic (CAR), there were between 89 and 84 pupils per one teacher. The information on other countries in the sub-region is summarized in Figure 11 below. Figure 11: Pupil-teacher ratio in primary school education in WCA Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo Côte d Ivoire DRC Equatorial Guinea Gambia Ghana Guinea Guinea Bissau Liberia Mali Mauritania Niger Nigeria São Tomé and Príncipe Senegal Togo Sub-Saharan Africa Benin Source: World Bank (2016): World Development Indicators, available at 12

21 Further, the proportion of pupils who learn the fundamental skills for their grade that, is the key skills and knowledge that pupils are expected to possess given their level in school remained low in WCA (Figure 12). In 2014, the proportion of pupils who learned grade basics ranged between 5% in Niger to 52% in Gabon, while the percentage of pupils who reached grade 4 but did not learn the basics ranged from 19% in Gabon to 56% in Niger. On average, less than 40% of all pupils in WCA countries learn the basics for their grades (Figure 12 below). Figure 12: Proportion of students learning basics and dropping out of school in WCA, 2014 Benin Burkina Faso Cameroon Chad Congo Côte d Ivoire Gabon Liberia Mali Niger 39 5 Senegal Togo Did not reach grade 4 Reached grade 4 but did not learn the basics Reached grade 4 and learned the basics Source: UNICEF (2016): UNICEF Global databases based on MICS, DHS and other national household surveys, available at unicef.org 13

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23 3. Socioeconomic circumstances of young people in WCA The socioeconomic achievements recorded in many WCA countries in the past few years were not inclusive [7,15]. While absolute poverty in WCA has reduced in the past 15 years, the gap between the rich and the poor increased [16-19]. Young people are among the worst hit by the growing rich-poor gap [20]. 3.1 Young people and employment Young people constitute a very small proportion of the workforce in their countries. Youth unemployment, particularly underemployment, is high in WCA, while most young people who work are in the informal sector. In some WCA countries, such as Mauritania and Gabon (Figures 13 & 14), more than a third of all young people are unemployed. In Burkina Faso, work histories between 1980 and 2000 show increasing unemployment and informalization of youth employment in urban parts of the country. Young women faced increased employment instability [21] during the same period. Employment-to-population ratios among year-olds are generally low in WCA. Only about onethird of females and two-thirds of males in this age group are employed in the sub-region (see Figure 14). Figure 13: Employment-to-population ratios among children aged in WCA Benin Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo Côte d Ivoire DRC Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo Female Male Source: United Nations Statistics Division (2016): UNSD Statistical Database, available at 15

24 Figure 14: Youth unemployment, total (percentage of total labor force aged 15-24), 2014 Benin 1.7 Burkina Faso 5.0 Cameroon 6.7 Cape Verde 18.8 Central African Republic 11.9 Chad 10.5 Congo 10.7 Côte d Ivoire 5.8 DRC 11.9 Equatorial Guinea 12.6 Gabon 35.5 Gambia 10.6 Ghana 3.3 Guinea 1.7 Guinea-Bissau 11.1 Liberia 4.6 Mali 10.5 Mauritania 46.6 Niger 7.1 Nigeria 13.6 Senegal 13.0 Sierra Leone 4.9 Togo 10.7 Sub-Saharan Africa* 12.0 Source: United Nations (2016): UN Data: Gender Development Index, DocumentData.aspx?id=380, ACET (2016): Report on unemployment in Africa, available at Child labor in WCA Child labor is defined as work that deprives children of their childhood, their potential and dignity, and is harmful to their physical and mental development. It entails work that is mentally, physically, socially or morally abusive and dangerously harmful to children; interferes with their schooling by depriving them of the opportunity to attend school; obliging them to leave school prematurely; or requiring them to attempt to combine school attendance with excessively long and heavy work [22, 23]. Globally, more than 168 million children are currently trapped in child labor, and most are living in developing countries, predominantly in Africa [24]. The high incidence of child labor, especially in Africa, is driven by high levels of poverty; the predominance of a poorly developed agricultural sector; high fertility rates; and low educational attainment [23, 25, 26]. WCA has the highest incidence of child labor worldwide [27], particularly among boys (see also Figure 15 below). While agriculture is by far the largest employer of child laborers in WCA, a good number of child laborers in the sub-region are also involved in hawking (peddling items/goods for sale on the streets, especially in towns and cities) and bonded domestic labor [28, 29]. 16

25 Figure 15: Children in employment as a percentage of children aged 7-14 in WCA Benin (2012) Burkina Faso (2010) Cameroon (2011) Central African Republic (2010) Chad (2010) Côte d Ivoire (2012) DRC (2010) Congo (2012) Gabon (2012) Gambia (2005) Ghana (2012) Guinea (2012) Guinea-Bissau (2000) Liberia (2010) Mali (2005) Mauritania (2011) Niger (2012) Nigeria (2011) Senegal (2011) Sierra Leone (2010) Togo (2010) Middle East and North Africa WCA Female Male Source: World Bank (2016): World Development Indicators, available at & UNICEF (2016), UNICEF global databases, available at 17

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27 4. Family formation and sexual and reproductive health of young people in WCA Family formation patterns and sexual and reproductive health (SRH) behaviors have critical implications for society. For instance, the timing and sequencing of marriage and births affect well-being, health outcomes, and livelihoods among individuals, households, and communities [30, 31]. 4.1 Child marriage Child marriage is defined as a formal marriage or informal union of a young person before age 18. It is estimated that 34% of young women aged years in Africa are married before the age of 18. The proportion is higher in WCA: 41% from DHS data collected between 2000 and Roughly 125 million women currently living in Africa today were minors (i.e., were below the legal adult age in their country, usually 18) when they were married. With the projected rise in the number of girls on the continent to 465 million by 2050, the number of women married as children could hit 310 million. Child brides have heightened risk for gender-based violence, HIV, dropping out of school, complications during childbirth, and neonatal mortality. Child marriage remains prevalent 6 in WCA. Globally, the top five countries with the highest rates of child marriage are all in WCA: Niger, CAR, Mali, Chad and Guinea. Child marriage is also common in Mauritania, DRC, Côte d Ivoire, and Nigeria. Statistics indicate that there are currently about 23 million child brides in Nigeria alone [32-34]. Figure 16: Percentage of women aged who were first married or in union before age 18 (child marriage), Burkina Faso (DHS 2010) Cameroon (DHS 2011) Cape Verde (DHS 2005) 18 3 Central African Republic (MICS 2010) Chad (MICS 2010) DRC (DHS ) Côte d Ivoire (DHS ) Equatorial Guinea (DHS 2011) 30 9 Gabon (DHS 2012) 22 6 Gambia (DHS 2013) 30 9 Ghana (DHS 2014) 21 5 Guinea (DHS 2012) Guinea-Bissau (MICS 2010) 22 7 Liberia (DHS 2013) 36 9 Mauritania (MICS 2011) Niger (DHS 2012) Nigeria (DHS 2013) São Tomé and Príncipe (DHS ) 34 5 Senegal (DHS 2014) 32 9 Sierra Leone (DHS 2013) Togo (DHS ) 22 6 WCA ( ) Sub-Saharan Africa ( ) Married by 18 Married by 15 Source: UNICEF Global databases, 2016, based on DHS, MICS and other nationally representative surveys. 6 Child marriage prevalence is the percentage of women years old who were rst married or in union before they were 18 years old (UNICEF State of the World s Children, 2016). 19

28 4.2 Mean age at marriage Table 4 presents data on marriage among year-olds and the singulate mean year at marriage in the sub-region. The median age at marriage for women in WCA currently stands at roughly 19 years old. The percentage of ever-married girls in the aged range is generally high, ranging from 9.4% in Ghana to 60.6% in Niger. The rate of child marriage in Niger is the highest globally, which also explains the highest levels of fertility found in this country. More than 25% of girls aged were either married or had been married in 15 of the 24 WCA countries. Although a substantial number of boys in the region marry early, child marriage in the sub-region is more common among girls. The singulate mean age at marriage (SMAM), defined as the average length of single life expressed in years among those who marry before age 50, stands at about 20 years for females in 18 of the 24 WCA countries and about 25 years for males in 20 of the 24 WCA countries. Table 4: Population of young people aged 15-24, ever married (%) and SMAM (in years) in WCA Country Population ever married (%) SMAM Aged Aged (in years) Year F M F M F M Benin Burkina Faso Cameroon Cape Verde Congo DRC Ghana Guinea Guinea Bissau 2006 NA NA 58.9 NA NA NA Liberia Mali NA NA NA Niger Nigeria São Tomé and Príncipe Senegal Sierra Leone Africa NA NA Developed countries NA NA Source: United Nations Statistics Division (2016): UNSD Statistical Database, available at United Nations (2012); SMAM=Singulate mean age at marriage. NA = data not available The percentage of women aged 20 to 24 years who were first married or in union before age 18 ranged from as high as 28% and 76% respectively in Niger in 2012, to as low as 3% and 18% in Cape Verde in 2005 (Figure 17). 20

29 Figure 17: Median age at first marriage for women aged between first-ever (baseline) and most recent (endline) Benin Burkina Faso Cameroon Central African Republic 17 Chad Congo DRC Côte d Ivoire Gabon Gambia 19 Ghana Guinea Liberia Mali Mauritania 17 Niger Nigeria São Tomé and Príncipe 19 Senegal Sierra Leone Togo Endline DHS Baseline DHS Source: Demographic and Health Surveys * Baseline = Earliest, Endline = Current. 4.3 Adolescent childbearing Adolescent pregnancy and motherhood within and outside marriage are exceptionally high in WCA. The highest rates of adolescent fertility are currently in Niger (204 live births per 1,000 girls and young women aged years old); Mali (175 per 1,000); and Guinea (142 per 1,000). Côte d Ivoire, DRC, Congo, Nigeria, Cameroon, Liberia, Sierra Leone, Burkina Faso, and Chad are other countries where adolescent fertility is high (Figure 18). 21

30 Figure 18: Adolescent fertility rate (births per 1000 women aged 15-19), Benin Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo DRC Côte d Ivoire Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria São Tomé and Príncipe Senegal Sierra Leone Togo Sub-Saharan Africa Source: World Bank (2016): World Development Indicators, available at 22

31 WCA countries have some of the highest numbers of women aged who gave birth by age 18 (Figure 19 below). WCA also has the highest rates of teenage pregnancy (27.9%) in Africa currently [35, 36]. Figure 19: Proportion of women aged who gave birth before age 18 in WCA Benin - DHS_2011/12 23 Burkina Faso - DHS_ Cameroon - MICS KFR_ Cape Verde - DHS (IDSR-II)_ Central African Republic - MICS_ Chad - MICS_ Congo - MICS KFR_2014/15 26 DRC - DHS_2013/14 27 Côte d Ivoire - DHS_2011/12 31 Equatorial Guinea - DHS_ Gabon - DHS_ Gambia - DHS_ Ghana - DHS_ Guinea - EDS-MICS_ Guinea-Bissau - MICS KFR_ Liberia - DHS_ Mali - DHS_ Mauritania - MICS_ Niger - EDSN_MICS_ Nigeria - DHS_ São Tomé and Príncipe - MICS KFR_ Senegal - DHS_ Sierra Leone - DHS_ Sierra Leone - MICS_ Togo - DHS_2013/ Source: UNICEF Global databases 2015 based on DHS, MICS and other nationally representative surveys. 4.4 Young people and sex Early age at first sex [37, 38] and concurrent multiple sexual partners might have critical health implications and outcomes for young people [39, 40]. As shown in Table 5, young women initiate sex earlier than young men in WCA. In nearly half of the countries in the sub-region, the median age of initial sexual encounter among young girl is 17 or below. 23

32 Table 5: Median age at first sex among young people in WCA Country Survey period Women [20-24] Men [20-24] Benin Burkina Faso NA Cameroon Central African Republic Chad Congo Côte d Ivoire DRC Gabon Gambia NA Ghana Guinea Liberia Mali NA Niger NA Nigeria NA São Tomé and Príncipe Sierra Leone Togo Source: Most recent country DHS data; NA = Data not available Multiple sexual partnerships among young people in WCA Multiple sexual partnerships are widespread among young people in WCA. In 2012, as many as 29% of young males in Benin and 27% in Congo had sex with more than one partner in the previous year (Table 6). Countries such as Burkina Faso, Côte d Ivoire, Gabon, and Cameroon also have very high percentages of young men having multiple sexual partners in the past year. The highest percentage of girls (12.4%) who reported multiple partners in the past year was found in Gabon (Table 6). Cameroon, Liberia, and Sierra Leone also have large percentages of young girls involved in multiple sexual partners. 24

33 Table 6: Percentage distribution of young people (15-19) having multiple partners Country Year Women [15-19] Men [15-19] Benin Burkina Faso Cameroon Chad Congo Côte d Ivoire DRC Gabon Gambia Ghana Guinea Liberia Mali Niger Nigeria São Tomé and Príncipe Senegal Sierra Leone Togo Source: Most recent country DHS data. Information on girls and boys aged with multiple partners who used a condom at last sexual intercourse is summarized in Figure 20 below. Condom use among young people who have multiple sexual partners in the sub-region is generally low, particularly among women. In countries like Cameroon, the DRC, Sierra Leone, Ghana, and Equatorial Guinea, condom use among girls and boys in multiple sexual partnerships is well below 30%. 25

34 Figure 20: Percentage of adolescent girls and boys (15-19) with multiple partners who used a condom at last sexual intercourse, Benin - DHS Burkina Faso - DHS Cameroun - DHS Central African Republic - MICS Congo - DHS DRC - DHS Côte d Ivoire - DHS Equatorial Guinea - DHS Gabon - DHS Ghana - DHS Guinea - DHS Guinea-Bissau - MICS Liberia - DHS Nigeria - DHS São Tomé and Príncipe - MICS Sierra Leone - DHS Togo - MICS Boys Girls Source: UNICEF Global HIV and AIDS databases (June 2016) based on MICS, DHS, AIS and other nationally representative household surveys, Some countries e.g. São Tomé and Príncipe and Guinea Bissau have missing data for one of the genders. 4.5 Contraceptive behavior of young people in WCA Contraceptive prevalence rate (CPR) among young people aged in WCA remains low, with many of the countries posting less than 15% CPR in this age group (Figure 21). The contraceptive prevalence rate in this age group in most of WCA countries is lower than the SSA regional average of 28%. CPR is as low as 5.6% in Guinea, an interesting finding considering that only 30% of girls aged who have multiple sexual partners used a condom in their last sexual encounter (Figure 21). Currently, it is only in Cape Verde and DRC that more than 50% of sexually active young women aged or their partners use modern contraceptives. 26

35 Figure 21: Contraceptive prevalence, any methods (% of women aged 15-24) in WCA Benin Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo Côte d Ivoire DRC Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria São Tomé and Príncipe Senegal Sierra Leona Togo Source: Most recent DHS & United Nations, Department of Economic and Social Affairs, Population Division (2015). Available at Abortion There is a paucity of data on abortion in WCA, largely because abortion laws remain restrictive [41]. As shown in Table 7, abortion on request or for economic or social reasons is illegal in all WCA countries except Cape Verde. In much of WCA, abortion is only permitted to save the life of a woman, when the pregnancy results from rape, or in the case of fetal abnormality. In some WCA countries, providers are often required to explain how and why the requested abortion will save the life of the woman. People convicted of providing and obtaining an abortion in most WCA countries risk long jail terms [42, 43]. Table 7: Classification of countries according to the reasons for which abortion is legally permitted Reasons Prohibited altogether, or no explicit legal exception to save the life of a woman To save the life of a woman To preserve physical health (and to save the life of a woman)* To preserve mental health (and all of the above reasons) Without restriction as to reason. Countries CAR, Congo, DRC, Gabon, Guinea-Bissau, Mauritania, São Tomé and Príncipe, Senegal Cote d Ivoire, Mali, Nigeria Benin (a, b, c), Burkina Faso, Cameroon (a), Chad, Equatorial Guinea (a, b, c), Togo (a, b, c) The Gambia, Ghana (a, b, c, d), Liberia (a, b, c), Sierra Leone Cape Verde Source: Adapted from Guttmacher Institute s Fact Sheet on Abortion in Africa: Incidence and Trends, May Key: Grounds on which abortion is permitted: a) rape b) incest c) fetal impairment d) other grounds e) abortion permission requires spousal authorization. *Includes countries with laws that refer simply to health or therapeutic indications that might be interpreted more broadly than physical health. 27

36 While region-wide data on induced abortion for WCA are limited, available evidence suggests that girls below the age of 25 bear the brunt of unsafe abortion. A 1989 study conducted in Nigeria indicated that 55% of post-abortion patients were under age 20, and 85% of the cases reported were single women. More recently, Lamina estimated that two-fifths of women seeking induced abortion in one Nigerian state were aged 24 years or younger [44]. Another study published in 2015 showed that maternal near-miss 7 events due to unsafe abortion are disproportionately high among girls and young women in Nigeria [45]. Other available evidence on induced abortion in WCA shows that women aged 24 or younger comprised 23% and 55% of women treated for unsafe abortion in Burkina Faso in 2008 and Senegal in 2012, respectively. In 2010, girls and young women (aged years) comprised 60% of unsafe abortion patients and 36% of women who sought facility-based induced abortion in Ghana (see Table 8). Table 8: Abortion and post-abortion care in selected countries in WCA Country Nigeria Burkina Faso [15-24] Senegal Ghana % of women treated for unsafe abortion aged 24 or younger 55% (1989) 23% (2008) 55% (2012) 60% (2010) % of women seeking induced abortion aged 24 or younger 33% (2012) 65% (2014) 32% (2012) 36% (2010) Sources: Bankole et al (2014); N Bouke, et al (2012) & Sedgh et al, (2016). 7 According to the WHO, a maternal near-miss case is defined as a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy. 28

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38 5. Sexual violence among young people in WCA Sexual- and gender-based violence against young people remains pervasive but underreported in the sub-region. Africa has the highest prevalence of sexual abuse globally [46]. The consequences of sexual abuse and violence include sexual dysfunction, low self-esteem, alcohol and drug use, depression, suicide attempts, and sexual risk-taking [47]. Table 9 shows the percentage of girls and boys aged 15 to 19 years who ever experienced forced sexual intercourse or any other forced sexual acts (including in childhood) in selected WCA countries. Available evidence indicates that more girls than boys experience sexual violence in WCA countries [48, 49]. In countries like Cameroon and DRC, more than 20% of girls aged reported experiencing some form of sexual violence. Table 9: Sexual violence prevalence among girls and boys aged in WCA Lifetime experience of sexual violence (%) Source of data Countries and territories Male Female Cameroon 2 22 DHS 2011 Côte d Ivoire NA 5 α DHS DRC NA 21 α DHS 2007 Equatorial Guinea NA 17 DHS 2011 Gabon NA 14 DHS 2012 Ghana NA 17 DHS 2008 Liberia NA 13 DHS 2007 Nigeria NA 6 DHS 2013 São Tomé and Príncipe NA 9 DHS Source: UNICEF Global databases 2014, based on DHS, MICS and other nationally representative surveys. α=data differ from the standard definition or refer to only part of the country. NA = Not available. 5.1 Female genital cutting in WCA Female genital cutting (FGC), defined as the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons, [50, 51] remains widespread in several WCA countries despite various national and regional efforts to eliminate the practice. The percentage of young women who underwent FGC is as high as 74% in Mali and 56% in the Gambia and Mauritania (Figure 22). FGC is also prevalent in countries like Guinea (46%), Guinea-Bissau (30%), Sierra Leone (31%), and Chad (18%). 30

39 Figure 22: Proportion of girls and young women aged who have undergone female genital cutting in some countries in WCA Benin 0.2 Burkina Faso 13 Cameroon 1 Central African Republic 1 Chad 18 Congo 20 Côte d Ivoire 10 DRC 12 Equatorial Guinea 14 Gabon 20 Gambia 56 Ghana 1 Guinea 46 Guinea-Bissau 30 Mali 74 Mauritania 56 Niger 1 Nigeria 17 São Tomé and Príncipe 10 Senegal 13 Sierra Leone 31 Togo 0.3 Source: UNICEF. Female Genital Mutilation/Cutting: A Global Concern. New York: UNICEF (2016):

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41 6. The health of young people in WCA Due, in part, to the association of young people and good health, young people s health issues are largely neglected in global public health discourses [52]. In this section, we highlight a number of key trends related to the health of young people in the sub-region and shine the spotlight on major causes of disability and death, including HIV/AIDS, non-communicable diseases (NCD), mental health, substance abuse, and injuries. 6.1 Causes of death among young people Worldwide, more than two in five deaths among early adolescent and young adults are due to intentional and unintentional injuries [53]. In WCA, adolescent mortality is high [13]. Maternal conditions, including unsafe abortion, remain the leading cause of death among young women in Africa, contributing to 69% of deaths in this age group (Table 10). Table 10: Top five causes of death for young people by sex and region (%) World High-income countries (globally) Low and middle-income countries (globally) Africa M F M F M F M F Complications of pregnancy NA 48 NA 25 NA 65 NA 69 HIV/AIDS and tuberculosis Acute lower respiratory infection Injury Violence and suicide Source: WHO (2014). WHO Methods and Data Sources for Global Causes of Death Global Health Estimates Technical Paper WHO/HIS/HSI/GHE/2014.7, WHO, Geneva. *age group years. WCA is currently considered the riskiest world region for girls and women to get pregnant and/or give birth in. Maternal conditions cause 20.4% of deaths among girls and young women in Nigeria, 11.7% in DRC (Figure 23) [54]. 33

42 Figure 23: Top causes of death among young women aged in WCA (% of all deaths) Benin Burkina Faso Cameroon Central African Republic Chad Congo Côte d Ivoire DRC Equatorial Guinea 0.1 Gabon Gambia 0.2 Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria São Tomé and Príncipe Senegal Sierra Leone Togo HIV/AIDS Maternal conditions Tuberculosis Malaria STDs excluding HIV Source: WHO (2016). Global Health Observatory (GHO) Data. Life Expectancy World Health Organization, Geneva. Available at Across WCA, the leading cause of death among young men is unintentional injuries (Figure 24). Interpersonal violence also contributes to mortality rates among men, particularly in countries such Sierra Leone and DRC. Figure 24: Top five causes of death among WCA young men aged (% of all deaths), 2016 Benin Burkina Faso Cameroon Central African Republic Chad Congo Côte d Ivoire DRC Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria São Tomé and Príncipe Senegal Sierra Leone Togo HIV/AIDS Tuberculosis Violence Unintentional injuries Malaria Source: WHO (2016). Global Health Observatory (GHO) Data. Life Expectancy World Health Organization, Geneva. Available at

43 6.2 Non-communicable diseases among young people in WCA Non-communicable diseases (NCDs) refer to cardiovascular diseases, diabetes, chronic respiratory diseases, cancers, mental illnesses, and injuries [55]. The burden of diseases in SSA has shifted from infectious to chronic conditions, and the region is currently facing a double burden of disease, defined as the coexistence of high levels of infectious and non-communicable diseases [56]. The burden of NCDs among young people has also grown in some WCA countries, including Nigeria and DRC (Figure 25). Available data show that young females in WCA are more affected by NCDs compared with their male counterparts. According to the 2015 global burden of diseases study, more than 63% of young women in Nigeria and 32% in DRC live with an NCD [57]. Figure 25: Prevalence rates of non-communicable diseases among young people aged Benin Burkina Faso Cameroon Central African Republic Chad Congo DRC Equatorial Guinea Gabon Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leonne Togo Male Female Source: Global Burden of Disease Study 2015, Life Expectancy, All-Cause and Cause-Specific Mortality HIV and young people in WCA Despite the growing burden of NCD, HIV/AIDS remains a leading cause of death among young people in Africa [52, 53]. The average HIV prevalence in WCA is substantially lower than in Eastern and Southern Africa, although young women are twice more likely to be infected with HIV than young men (Figure 26). However, many countries in WCA have a high, yet unmet need for antiretroviral therapies as well as face a lack of health systems that address the needs of those living with HIV and AIDS. Figure 26: HIV prevalence among young people aged in Sub-Saharan Africa Sub-Saharan Africa (2016) East and Southern Africa (2015)* WCA (2015)* Female Male Source: WHO (2016). Global Health Observatory (GHO) Data. Life Expectancy. World Health Organization, Geneva; *UNAIDS AIDSinfo available at 35

44 New HIV infections and AIDS-related deaths among persons aged years in WCA are shown in Figures 27 and 28. More than half of all new HIV infections and nearly half of all AIDS-related deaths among young people in the sub-region occur in Nigeria. Figure 27: Estimated number and percentage of new HIV infections among adolescents aged in WCA, 2015 Equatorial Guinea Cape Verde Gambia Gabon Mauritania Guinea-Bissau Liberia Senegal Benin Togo Burkina Faso Sierra Leone Congo Niger Central African Republic Chad Guinea Mali Ghana DRC Côte d Ivoire Cameroon Nigeria ,000 10,000 15,000 20,000 25,000 Source: UNAIDS 2016 estimates. Adapted from UNICEF Global databases, 2016 Figure 28: Estimated percentage of AIDS-related deaths among adolescents aged in WCA, 2015 Cape Verde Equatorial Guinea Mauritania Gambia Guinea-Bissau Gabon Sierra Leone Senegal Benin Liberia Congo Niger Guinea Mali Togo Burkina Faso Central African Republic Chad Ghana Côte d Ivoire Cameroon DRC Nigeria 0.0% 0.2% 0.2% 0.3% 0.5% 0.5% 0.6% 0.8% 0.9% 1.0% 1.3% 1.5% 1.5% 2.1% 2.4% 2.5% 2.9% 3.3% 4.5% 7.4% 8.2% 9.0% % Source: UNAIDS 2016 estimates. Adapted from UNICEF Global databases, Available at global-regional-trends/ 36

45 6.3.1 Comprehensive and correct knowledge about HIV and AIDS Fewer than 30% of young people in most WCA countries (Figure 29) have comprehensive knowledge about HIV and AIDS, which according to the UNAIDS is defined as correctly identifying the two major ways of preventing the sexual transmission of HIV (using condoms and limiting to one faithful, uninfected partner), rejecting the two most common local misconceptions about HIV transmission, and knowing a healthy-looking person can transmit HIV. Generally, boys in WCA have more comprehensive knowledge about HIV than girls (Figure 29). Figure 29: Percentage of adolescent girls and boys (aged 15-19) with comprehensive, correct knowledge of HIV in WCA, Mauritania: MICS 2011 Chad: DHS 2015 Guinea-Bissau: MICS 2010 Niger: DHS 2012 Côte d Ivoire: DHS 2012 Congo: DHS 2012 Central African Republic: MICS 2010 DRC: DHS 2014 Equatorial Guinea: DHS 2011 Ghana: DHS 2014 Guinea: DHS 2012 Gambia: DHS 2013 Nigeria: DHS 2013 Mali: DHS 2013 Togo: DHS 2014 Benin: DHS 2012 Cameroon: DHS 2011 Senegal: MICS 2011 Sierra Leone: DHS 2013 Gabon: DHS 2012 Burkina Faso: DHS 2010 Liberia: DHS 2013 São Tomé and Príncipe: MICS Girls Boys Source: Adapted from UNICEF global HIV and AIDS databases (June 2016) based on MICS, DHS, AIS and other nationally representative household surveys, Data on boys missing in Mauritania. 6.4 Mental health and substance use among young people in WCA Mental health conditions and substance abuse pose an increasing burden in Africa [58]. Substance abuse and other mental health conditions often emerge during adolescence [59]. Both trap young people in a cycle of poor educational and professional achievement, ultimately limiting their productivity and potentials [58]. Short-term experimental drug and alcohol use among young people has detrimental effects on progress in school, and the resultant impaired judgment can increase their likelihood of engaging in other risky behaviors, such as unprotected sex, drunk driving, and violence [58, 60]. The burden of substance abuse among young people in WCA in 2016 is shown in Figure 30. Substance use and abuse are generally higher among males compared with the females, except in CAR, Gambia, and Sierra Leone, where substance use is higher among young women and girls. 37

46 Figure 30: Substance use among young people aged in WCA (%) Benin Burkina Faso Cameroon Cape Verde Central African Republic Chad Congo DRC Côte d Ivoire Equatorial Guinea Gambia Ghana Guinea Guinea-Bissau Liberia Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo Female Male Source: WHO (2016) Global Health Observatory (GHO) Data. Life Expectancy Available: disease/life_tables/situation_trends_text/en/ Surveys by the World Health Organization and the Center Centers for Disease Control and Prevention on smoking [61] show that tobacco is one of the most commonly used substances by young people in WCA. Data on tobacco use 8 by both male and female adolescents in WCA is shown in Figure Prevalence of tobacco use among adolescents includes smoking as well as use of oral tobacco and snu among year olds on more than one occasion in the 30 days preceding the survey 38

47 Figure 31: Proportion of adolescents aged using tobacco Benin: 2003 Burkina Faso: 2006 Congo: 2006 Côte d Ivoire: 2003 Ghana: 2006 Mali: 2001 Mauritania: 2006 Niger: 2006 Nigeria: 2000 Senegal: 2007 Togo: Both sexes Male Female Source: World Health Organization Statistical Information System (WHOSIS) 2015, Available at 39

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