Africa is characterized by a spatial dispersion of a dynamic population, but with low purchasing power. However, demographic and economic projections give Africa a key role in globalization. With demographics, great changes that take place on the continent will be able to boost economic growth through new activities and rigorous governance.

1.1 Socio-demographic context

Based on 2020 UN data, the population of Africa is the 3rd in the world after South-East Asia and the Western Pacific. Estimated at 1 120 161 000 people and growing continuously over the past ten years (26.9%), the population of the African Region represents 14.4% of the world population, estimated at 7 758 157 000 people.

In a single year, between 2019 and 2020, the population of the Region grew by 2.5%, which represents an increase of more than 28 million people. Five countries (Nigeria, Ethiopia, DR Congo, South Africa and Tanzania) out of the 47 represent more than 45% of the population of the Region. Nigeria and DR Congo only represent more than 45% of the populations of the West and Central Africa regional economic communities, while Ethiopia accounts for 20% of the population of the Southern and Eastern Africa.

In 2022, the United Nations publishes new world population projections. The threshold of 8 billion people should be crossed before the end of the year 2022, and the planet will have 8.51 billion people in 2030, 9.7 billion inhabitants in 2050 and peak at around 10.4 billion in the 2080s. The population of the African Region is expected to almost double by 2050 to 2.09 billion, while that of Europe and North America will increase by only 0, 4%. Indeed, the annual population growth in Africa is the highest in the world, 2.7% (varying between 0.8% in Lesotho and 3.7% in Niger) against 1.1% at global level for the year 2020. This growth is linked to a higher fertility rate than elsewhere. The population density in the Region (36 inhabitants per km) is not high, compared to other parts of the world. In fact, many countries are uninhabitable, while some countries with a smaller area have many inhabitants or the concentration of populations in certain cities. Population density is a very important parameter for the implementation of health policies and for governments more broadly, because of access to various services.

Indeed, difficulties in accessing services, including those related to health, create and reinforce inequalities, which, with the deficits in education, gender, rurality or low socioeconomic status, are obstacles to poverty reduction. For emphasis, cities with large populations (Lagos with 20 million inhabitants or Kinshasa with 14 million people) and with very high densities faces enormous challenges which may be mitigated by holistic planning of the different sectors including health.

The concept of demographic dividend supports the theory according to which African countries could experience an acceleration of economic growth, with the decline in fertility, which would lead to a change in the structure of the population, therefore the age pyramid. The share of the active population becoming larger than the non-active population (those over 65 and under 18). It is this tipping point where human capital will activate development. It is a real challenge and special attention in countries for the creation of jobs that will generate this development and activate economic growth.

1.2 Economic context

Gross domestic product is a reflection of the economic health of a country, an indicator that describes the level of development and reflects available resources. It also assumes access to services, including health. GDP remains low for the Region and low for a number of countries. The annual GDP growth of African countries was 4.8% between 2011 and 2019. For the year 2022, announced at 3.7%, the projections for 2023 place it at 4.0% based on growth projections according to the International Monetary Fund's World Economic Outlook Update released in July 2022. Globally, GDP growth projections are 3.2% and 2.9 % for the years 2022 and 2023.

In countries of the Region in 2020, inflation rates remain high. They ranged from 0.4% (Mali) to almost 30% (South Sudan) excluding extreme values. For the year 2022, the Trading Economics website publishes figures for the Region, which range from inflation rates of 14% in Benin to 33.5% in Ethiopia. Excluding Sudan and Zimbabwe, which have inflation rates of 149 and 285%. These two-digit inflation rates in most countries, due to soaring food prices, are putting food security objectives in jeopardy. The war in Ukraine and the energy and environmental crises do not offer a glimpse of an improvement, with the countries' economies already strained by disputes over agricultural land and the COVID–19 crisis. According to the World Bank, if nothing is put in place, 9 out of 10 poor people in the world will be Africans. Because of the pandemic alone, an estimated 29 million people have fallen into extreme poverty. The human development index, this composite indicator has shown enormous progress in several countries in terms of access to water, hygiene, quality of life, etc. Without letting down the guard for many countries that these improvements could be reversible if governments do not structure their health and economic systems in a solid and sustainable way. By 2050, demographic changes and rapid urbanization (more than 1.1 billion Africans will live in cities) will occur while Africa is caught in a poverty trap (160 million urban dwellers living in informal settlements and slums, nearly 1/3 of the population without access to clean water, sanitation, energy or mobility facilities, and 200 million young people about to enter the labor market, with little hope of finding decent work).

1.3 Health system organizational structure

There are links between the size of countries or the number of regions and the number of health districts. However, this relationship is not direct, because a country like Gabon (9 inhabitants/km²) is nearly twice as small as neighboring Cameroon (58 inhabitants/km²), has the same number of regions with 1/10th of population. Local and regional authorities (regions/states and subnational) are the first public authorities to have to deal with the consequences of situations arising from poverty and delays in the provision of infrastructure and basic services. The internal organization of countries and the very diverse realities explain the creation of health districts. It is about the supply of health care services and their availability in the country and the level of income of the population. The United Cities and Local Government (UCLG) report highlights key actions to integrate local and regional authorities in the implementation of the SDGs. These include better management of urbanization and the inter-connection of villages, medium-sized cities and large towns; allocation of adequate financial resources, combining decentralization of powers with decentralization of resources; and the creation of a network of local authorities.