Beyond Aspiration: Evaluation of Abuja Declaration and the Future of Domestic Health Financing in Africa

Background: Nearly a quarter of a century after African Union member states adopted the Abuja Declaration (AD), most of these countries continue to miss their targets. A crucial forward-looking question remains whether countries can meet the target under the current situation. This paper examines the likelihood that AU member states will meet the AD target under existing fiscal patterns and within what timeframe.

Methods: We used panel data on 51 AU member states from 2002 to 2023, sourced from the WHO and the World Bank’s data repositories. We used discrete-time survival analysis to model first-time compliance and estimated the unconditional probability of meeting the target by 2063, in line with the AU agenda. To address concerns about sustained compliance, we complement this analysis with trend-based projections to determine the number of years required to reach the target under a status quo scenario.

Findings: We observed rare first-time compliance during the study period, with five countries meeting the target and 2 countries meeting the 15% health budget share target in 2023. The probability of meeting the target by 2063 was less than 1% for more than 90% of the countries in the sample. This is consistent with trend-based projections showing that more than three-quarters of AU member states were off track to meet the AD target if current fiscal patterns persist, based on historical performance and current fiscal conditions. In addition, where domestic resource is mobilized for health, governments appear to have a higher willingness to pay for system-oriented investments (like Primary Health Care) than for vertical programmes such as immunization. 

Interpretation: The findings highlight persistent health financing challenges across AU member states, with AD compliance unlikely for most countries. Without deliberate efforts to improve and sustain domestic financing, the future of health financing could remain bleak. With the worsening landscape of health aid, the need for deliberate and sustained commitment to reprioritize domestic resources for health has become inevitable, requiring a recalibration of the AD and other continental health financing effort.