Analysing government health expenditure in Africa: Trends, determinants and policy options.

Background: In April 2001, African Union (AU) Heads of State adopted the Abuja Declaration, pledging to allocate at least 15% of government expenditure to health. More than two decades later, many African health systems remain underfunded, with external aid increasingly unsustainable as official development assistance declines. Aim: This article examines progress towards the Abuja target, the role of political economy in shaping government health expenditure (GHE), and policy options for sustainable domestic financing. Setting: The authors examined the Global Health Expenditure across 53 AU Member States. Methods: The authors analysed the Global Health Expenditure Database on GHE as a proportion of total government expenditure between 2000 and 2022. Additional political economy analysis explored the governance and economic correlates of GHE. Results: Mean GHE in Africa has stalled, rising only 0.5% points since 2001. In 2022, only South Africa met the 15% Abuja benchmark, with seven countries allocating 10% - 14.9% and 45 countries allocating less than 10%. Compared to slightly better off countries, low-income countries such as Rwanda and Mozambique allocated a larger proportion of their government expenditure to health, indicating the importance of political will. Conclusion: Progress toward the Abuja target has been slow and uneven, highlighting the need for a multi-pronged approach to expand fiscal space for health, anchored in strong regional governance and accountability frameworks. Strengthening these foundations will be critical to building resilient health systems, reducing reliance on external aid, and accelerating progress toward universal health coverage in Africa. Contribution: This study advances existing research by demonstrating that political commitment and institutional factors, rather than gross domestic product per capita alone, are key determinants of health spending priorities, thereby challenging the prevailing assumption in the health financing literature that fiscal capacity is the primary driver of health budget prioritisation.