Beyond aspiration: An expenditure-based evaluation of progress towards the Abuja Declaration target and implications for domestic health financing in Africa.

In 2001, African Union (AU) member states committed to allocating 15% of their annual budget to health under the Abuja Declaration (AD). However, after more than two decades, health allocations across many countries still fall short of the target. This study uses an expenditure-based proxy for the AD to examine the likelihood and timing of attainment of the benchmark under historical fiscal trajectories.We compiled a 2002-2023 panel for 54 African countries using WHO and World Bank data. We distinguished observed, first and sustained attainment. Kaplan-Meier and Weibull models characterised time to first attainment, country-specific linear trends projected benchmark-crossing years through 2063, system GMM assessed expenditure-share persistence, and country and year fixed-effects models examined associations with primary health care (PHC) and immunisation expenditure per capita.In 2023, South Africa was the only one of 54 countries at or above the expenditure-based 15% benchmark. Five countries had attained it at least once during 2002-2023, and three sustained it for at least three consecutive years. Under the primary trend specification, which included the 51 countries with complete series, 42 (82.4%) were off track to attain the benchmark by 2063. Among the 48 countries without previous attainment, the median adjusted conditional probability of first attainment during 2023-2063 was 7.9% (IQR 4.6%-13.3%). The primary system-GMM lag coefficient was 0.821 (95% CI 0.635 to 1.006), indicating strong expenditure-share persistence. Higher government health prioritisation was associated with higher domestic government PHC expenditure per capita, while the association with total immunisation expenditure per capita was not statistically significant.Attainment of the expenditure-based Abuja benchmark remains uncommon and is unlikely to become widespread by 2063 if historical trends continue. While the 15% target remains politically useful as an accountability signal, efforts should target improving public health expenditure per capita, fiscal capacity, budget execution, financial protection and service coverage.