Persistent shortfalls in government health expenditure: a decade-long analysis of Abuja 15% target attainment across 52 African countries, 2014-2023.

backgroundIn 2001, African governments committed through the Abuja Declaration to allocating at least 15% of annual government budgets to health. More than 2 decades later, the extent to which this commitment has been achieved consistently, rather than in isolated years, remains unclear. We assessed recent trends, persistence of attainment, country trajectories and convergence in government prioritisation of health among the original Abuja Declaration endorsers.

methodsWe conducted a longitudinal country-level (ecological) panel analysis of 52 original Abuja Declaration endorsers with complete comparable data from 2014 to 2023, supplemented by an analysis of all available data for 2001-2023. Annual data on domestic general government health expenditure as a percentage of general government expenditure were obtained from the World Bank World Development Indicators, drawing on the World Health Organisation Global Health Expenditure Database. Attainment was defined as an expenditure share of at least 15%. We summarised annual and subregional distributions, persistence of attainment and country-specific linear trends. Overall temporal change was examined using country fixed-effects regression with standard errors clustered by country. Exploratory beta- and sigma-convergence analyses, including specifications robust to regression to the mean, assessed whether lower-spending countries improved faster and whether between-country dispersion narrowed. Sensitivity analyses addressed classification thresholds and trend heterogeneity.

resultsThe unweighted mean government health-expenditure share increased from 6.73% in 2014 to 7.09% in 2023, while the median increased from 5.91 to 6.05%. Only South Africa met the 15% benchmark in 2023. Across the 10-year period, 48 countries (92.3%) never attained the benchmark, 3 (5.8%) attained it occasionally, and only South Africa demonstrated sustained attainment. Southern Africa had the highest mean share in 2023 at 13.79%, whereas Western Africa had the lowest at 5.87%. The average within-country linear trend was small and statistically uncertain at 0.053 percentage points per year (95%CI -0.052 to 0.157; p = 0.316). Country-specific trends varied substantially (standard deviation of slopes 0.32 percentage points per year; p < 0.001). Apparent catch-up by lower-baseline countries (β = -0.382; 95%CI -0.667 to -0.097) was not robust to regression to the mean, and dispersion did not consistently narrow. Over 2001-2023, 47 countries never attained the benchmark and the average within-country trend was 0.012 percentage points per year (95%CI -0.032 to 0.057).

conclusionsGovernment prioritisation of health among original Abuja Declaration endorsers remained substantially below the 15% benchmark during 2014-2023. More than nine in ten countries never attained the target, and only one demonstrated sustained attainment. This stagnation is long-standing, and since 2001, the continental distribution has barely moved. The Abuja benchmark should be accompanied by stronger accountability mechanisms and complementary measures of absolute spending adequacy, fiscal capacity and financial protection.