Abuja Declaration: How to Revamp Health Budgets to Revive a Sick Continent

Abject poverty is a paradox of the richness of Africa, and widespread diseases underline the sick state of the continent. On a board of intrigues, corruption and misplaced priorities, hapless Africans are considered pawns in a floundering health system strewn across the continent. Bayo Akinloye writes that financing health on the continent is a balancing act

It was the first year after the millennium of 2000, precisely in 2001, that African leaders swore to revamp its decrepit health systems and salvage a sick continent from the vice-grip of several deadly diseases. As a continent rich in natural resources and human capital, the plague of communicable and non-communicable is striking down millions of its inhabitants. Fund was a critical condition hampering an up-to-date and responsive health sector in Africa, its leaders said when they met in 2001.

“We commit ourselves to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively utilised. In addition, We pledge to set a target of allocating at least 15% of our annual budget to the improvement of the health sector. We also pledge to make available the necessary resources for the improvement of the comprehensive multi-sectoral response and that an appropriate and adequate portion of this amount is put at the disposal of the national commissions/councils for the fight against HIV/AIDS, tuberculosis and other related infectious diseases,” said the African leaders who met in Abuja, Nigeria, declaring the battle against HIV/AIDS, tuberculosis and other infectious diseases as their top priority for the first quarter of the 21st century.

It is called the Abuja Declaration. The declaration emerged from the Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases, sponsored by the Organisation for African Unity and hosted by Nigeria’s Federal Ministry of Health between April 24 and 27.
In 2021, global life expectancy at birth was 74 years, whereas in sub-Saharan Africa, it was 66 years. Yet in that same year, $92 per person was spent on health in sub-Saharan Africa, which is roughly one-fifth of what the next lowest geographic region—North Africa and the Middle East—spent ($379), according to a report, ‘Financing health in sub-Saharan Africa 1990– 2050: Donor dependence and expected domestic health spending’.

Empty promise?

According to many observers, the Abuja Declaration has remained largely an empty pledge or a broken promise. The Abuja Declaration set a target for African governments to allocate at least 15% of their national budgets to health. However, as of 2021, only two countries—Cabo Verde and South Africa—met this target. On average, African governments allocated only about 7.4% of their national budgets to health care, below their commitments. One report indicated that many countries are experiencing stagnation in health funding, with some nations spending less on health per person than they did before the Abuja Declaration was adopted. Countries like Madagascar and Benin saw reductions of over 60% in per capita spending since 2000.
Regarding health spending in the sub-continent, Antoine Lacroix, a consultant with expertise in public finance and service delivery and Cathal Long, an expert in local government financing for service delivery and public financial management reforms, conclude that government health expenditure in sub-Saharan Africa has been “lagging behind other regions, and not catching up.”

Figures do not lie

Nigeria, Ghana, Cameroon and Kenya are few among the many African countries failing to fulfil their pledge. For instance, the highest the so-called ‘Giant of Africa’ committed to financing health in the last six years is 5.1%. ( 2019: 4.1% of the total budget; 2020: 4.1%; 2021: 4.2%; 2022: 4.6%; 2023: 4.8% of total budget; 2024: 5.1%). Ghana committed 5.6% of its total budget to health in 2024; 2023, 5.3%; 2022, 5.1%; 2021, 4.7%; 2020, 4.5%; and 2019, 4.6%. Cameroon fares as bad with 5.3% of total budget dedicated to health in 2019; 2020, 5.6%; 2021, 5.8%; 2022, 6.1%; 2023, 6.3% and 2024, 6.6%. Kenya is another unflattering example of health financing on the continent (2019, 6.1% of total budget; 2020, 5.9%; 2021, 6.2%; 2022, 6.5%; 2023: 6.8%; and 2024, 7.1%).

In 2021, Cabo Verde, with 15.7% and South Africa, with 15.3%, met the target. In 2011, Rwanda with 23.8%, Liberia with 18.9%, Malawi with 18.5%, Zambia with 16%, Togo with 15.4% and Madagascar with 15.3% met and surpassed the 15% target. However, the furrows on the foreheads of stakeholders are widening over the sustainability of health financing amid declining external funding sources, pointing to the fact in 2021, about half of Sub-Saharan African nations relied on external resources for more than 20% of their health expenditures.
Meanwhile, statistics show that the reliance on out-of-pocket averaged 35.8% of current health expenditure from 2012 to 2020. This does not bode well for vulnerable populations who are cash-strapped. Sub-Saharan Africa’s health financing may just be on life support, with some nations allocating as little as 2.1% of total government expenditure to the sector.

The Institute for Health Metrics and Evaluation projects that without significant changes in policy and funding priorities, Sub-Saharan Africa may face increasing gaps in health financing, jeopardising public health systems and outcomes. To address these challenges, there is a call for greater political will to prioritise health investments within national budgets and to enhance coordination between finance and health ministries. Strengthening domestic revenue generation through improved tax policies and reducing reliance on external aid are also critical steps recommended for sustainable health financing.
“Development assistance for health is expected to decline in Sub-Saharan Africa, and domestic spending on the issue is not rising quickly enough to close the gap despite forecasted economic growth,” says Dr Angela Apeagyei of IHME. “The trend is driven by a range of internal and external pressures, including shifting donor priorities and low political will.”

Apeagyei adds, “For countries in Sub-Saharan Africa, the projected growth in donor and government funding for health is expected to be significantly lower compared to countries in other regions. This worrying trend underscores the need to prioritise innovative financing strategies to strengthen health systems in line with the region’s economic growth and the broader health needs of its population.”

Dr Matshidiso Moeti, WHO Regional Director for Africa, explains that “investing in health is not a cost.” Moeti states, “It’s an investment in the future of Africa. To increase health expenditure, African countries must prioritise health in their national budgets, explore innovative financing mechanisms, and leverage international partnerships.”
Dr John Nkengasong, former Director of the Africa Centres for Disease Control and Prevention (Africa CDC), notes that Sub-Saharan African countries can increase their health expenditure by improving domestic revenue mobilisation, reducing reliance on external aid, and allocating a greater share of their budgets to health. He, however, admits this will “require strong political commitment, efficient use of resources, and effective governance.”

Growing economy, declining healthcare funds

Despite projected economic growth in Sub-Saharan Africa, the share of GDP allocated to health is anticipated to decrease in several subregions (Central, Eastern, and Western Africa). This paradox highlights a disconnect between economic indicators and health financing priorities. Experts argue that budget allocations will only be sufficient with a shift in perspective regarding health as an investment in economic development.

To achieve universal health coverage, African countries must increase their health expenditure to at least 5% of their GDP, and this can be achieved through a combination of government funding, private sector investment, and innovative financing mechanisms such as health insurance and public-private partnerships, according to Dr Githinji Gitahi, Group CEO of Amref Health Africa.
Dr Owen Kaluwa, WHO representative to Ethiopia, adds that increasing health expenditure in sub-Saharan Africa requires a multifaceted approach that involves government, private sector, civil society, and international partners. The WHO official also mentions the need to focus on efficiency, effectiveness, and equity to ensure that resources are used optimally and that all citizens have access to quality healthcare.

To achieve Universal Health Coverage, countries must reduce fragmentation by increasing pre-payment through tax funding and mandatory health insurance, Dr Lizah Nyawira of the Strategic Purchasing Africa Resource Centre recommends. She notes that this allows for greater risk pooling and an equitable health system where ability-to-pay determines financing contributions.

Health financing experts say that economic growth in Sub-Saharan Africa has a complex relationship with funding health. For instance, they argue that economic growth generally leads to increased national income, which can enhance government revenues. This, in turn, makes more resources available for health financing as studies show that health expenditure positively impacts economic growth by improving productivity and reducing disease burden, thereby fostering a healthier workforce. This also impacts health infrastructure. Economic growth usually provides a leeway to invest in health infrastructure and services, which can lead to improved health outcomes, among other things.
In the meantime, it appears the sub-Saharan region has to battle declining external funding, with development assistance having “plateaued or is decreasing.” That is bad news for several countries that rely heavily on these funds to support their health systems.

In Sub-Saharan Africa, government health spending accounts for only about 34.4% of total health expenditures, compared to a global average of approximately 59.7%. This indicates a heavy reliance on external funding and out-of-pocket payments by individuals, which can lead to financial hardship for many. The proportion of government spending on health in sub-Saharan Africa averages around 7.2%, significantly lower than the global average of about 3.3%. Out-of-pocket payments constitute a substantial portion of health financing in sub-Saharan Africa, averaging about 35.8% of current health expenditures from 2012 to 2020. This is one of the highest rates globally, indicating a critical financial burden on households. Experts note that out-of-pocket payments should not exceed 15-20% of current health expenditure to “ensure affordability and access.”

“African countries can learn from each other’s experiences in increasing health expenditure. For example, Rwanda’s community-based health insurance scheme has been successful in increasing access to healthcare,” says Dr Francis Ruiz, a health expert. “Similarly, Ghana’s National Health Insurance Scheme has improved financial protection for its citizens.”

Lessons from South Africa and Cabo Verde

The 15% commitment of annual budgets to the health sector by African nations, known as the Abuja Declaration, still haunts. The primary goal of the pledge was to enhance healthcare outcomes and alleviate the burden of disease on the continent. Yet, more than 20 years after, only a handful of countries have apparently lived up to their words.
South Africa’s success in meeting the 15% health budget target can be attributed to a multifaceted strategy that involves various stakeholders and tactics. Dr Nicholas Crisp, a health economist at the University of the Witwatersrand, notes that South Africa’s health budget “has been steadily increasing over the years, driven by a growing recognition of the importance of healthcare in the country’s development agenda.”
Observers note that establishing a national health insurance (NHI) scheme is crucial to South Africa’s success. The NHI aims to provide universal access to healthcare services, and significant increases in health spending have accompanied its implementation. Crisp also mentions that “the NHI has helped mobilise additional resources for the health sector, enabling the country to meet the 15% target.”
It is said that the South African government’s strong leadership and commitment to healthcare have also played a vital role. The government has prioritised healthcare in its development agenda, recognising its critical role in driving economic growth and reducing poverty. Dr Anban Pillay, Deputy Director-General at the National Department of Health in South Africa, highlights that “the government’s commitment to healthcare is reflected in the increasing budget allocations to the sector over the years.”
In Cabo Verde’s case, the success in meeting the 15% health budget target can be attributed to efficiency and effectiveness in the health sector. Dr Maria da Graça, a health expert, observes that Cabo Verde “has made significant progress in improving healthcare outcomes in recent years, driven by a strong focus on efficiency and effectiveness in the health sector.”

For the country, a key factor is considered to be the implementation of a results-based financing scheme, which provides financial incentives to healthcare providers to deliver high-quality services, which has helped improve healthcare outcomes and reduce costs. Da Graça says that the scheme has been instrumental in improving the efficiency and effectiveness of healthcare services in Cabo Verde.
Health analysts note that Cabo Verde also benefits from the significant support of development partners, including the WHO, the World Bank, and the European Union, in helping to strengthen its health system and improve healthcare outcomes, with da Graça stating that the partnership between the government and development partners “has been critical in supporting the development of the health sector in Cabo Verde.”

Paying it forward

The experiences of South Africa and Cabo Verde can spur other African countries seeking to meet the 15% health budget target. Speaking on the African Union’s 2001 Abuja Declaration on funding national health budgets, two health experts, Nkechi Olalere and Agnes Gatome-Munyua, point out that the “big question here is not ‘who has reached the target?’ Rather, the questions should be ‘Has there been a difference?’, ‘has it resulted in real progress in health indicators?’ and ultimately, ‘Are people healthier and more prosperous?'”
The duo want health ministries to advocate for adequate resourcing, with strong and clear arguments to invest in health as a productive sector that builds human capital, reduces poverty and inequity, safeguards health security from pandemics, improves workforce productivity and provides employment.

“We should reduce spending on ineffective or inequitable public programmes, such as fuel subsidies that disproportionally benefit the well-off, can be repurposed to increase government revenue, and possibly, increase allocations for health and social sectors,” they say.
The health experts add, “We should demonstrate effective use of health resources. As we rally for more resources, “getting more health for our money” becomes a priority. Many times, we hear criticism of the health sector’s absorptive capacity – how well health resources are spent and what results can be shown for it.”
They call for strategies to make better use of existing resources, including improving the timeliness and flow of health resources, reducing health budget underspending; incentivizing health worker productivity and efficiency; and proactively managing the procurement of medical commodities and supplies.
Apeagyei says several African countries are exploring the potential for public health insurance programmes to support universal health coverage.

“Outside access to services, this involves making sure that when people show up to the facility, it’s not a death trap,” she adds. “Patients need to receive care that will improve their health. They need to see appropriate health workers, drugs in the facility, and cleaning agents so they can feel confident that infections are not spread.”
The push to improve coverage through the public provision of insurance is one of the positive things that Apeagyei wants to see in the next few years countries make progress on, “both on the demand side and the supply side: encouraging people to go, but making sure that the services are good quality.”