On April 27, 2001, exactly 22 years ago, African governments made an historic pledge to allocate at least 15% of their annual budgets to the health sector. This vow was made because more resources were required to address the pressing health challenges of that time, including HIV and AIDS, Malaria and Tuberculosis. That pledge became popularly known as the Abuja Declaration. African governments frequently reference this declaration in health sector goals and policy documents. Thus, the Abuja Declaration became a rallying call to mobilise more resources from government coffers for the health sector.
Twenty-two years later, physicians are asking: what has become of this promise?
At the heart of Africa’s fragile health systems is the perennial failure by governments to prioritise health and allocate it adequate resources. The Abuja Declaration sought to correct this by securing a commitment of at least 15% of national budget for the health sector. But this target has proven elusive for many countries.
In 2011, ten years after the declaration, 27 African countries had increased the proportion of their expenditure allocated to health. However, only three countries – Rwanda, Tanzania and South Africa – had reached the 15% target. Regrettably, seven had even reduced their health budgets as a proportion of their national budgets.
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By 2016, the situation had further deteriorated. A total of nineteen African countries were spending less on health as a percentage of their public spending than in the early 2000s. Instead of progression, they regressed. No, hold your horses, Nigeria is and was not one of them.
Did the Abuja declaration work? Yes and No.
Even though many African countries have marginally increased health spending overall, only a handful of countries, not as many as the fingers on one hand, have met this target in any given year.
Experts say the big question here is not “who has reached the target?” because African countries’ ability to meet the target has varied over time, and, as a wise person once said, “15% of an elephant is not the same as 15% of a chicken”. Rather, we 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 responses to these are more nuanced.
I will leave you to answer these questions.
According to the WHO report, prioritising health on the continent has no direct relationship to a country’s wealth. What this means is that being a rich country does not automatically translate to better healthcare funding. The report found that several countries with high per capita income – such as Algeria, Botswana, Equatorial Guinea, Gabon, Mauritius, Seychelles and South Africa – do not systematically spend more of their budgets on health. Meanwhile, some lower income countries – such as Ethiopia, Gambia and Malawi – have in fact surpassed the 15% Abuja target.
So even when African countries become richer, government spending on health does not automatically increase. Between 2001 and 2015, for example, government spending on health, as a proportion of its overall spending, decreased in 21 African countries. This worsened during the COVID-19 pandemic with reliance of donor agencies. Development assistance for health has crowded out government resources and created donor dependence – which is complicating the transition of countries with declining donor funding and inadequate plans to offset this shift in resources.
Additionally, low budget execution and wastefulness further diminishes available resources for health. Low government spending hurts citizens the most and results in high out-of-pocket spending and an inequitable health system that only guarantees access to those who are able to pay. Imagine spending N57.6 billion Naira on cars for lawmakers? Imagine the level of indifference, selfishness and heartlessness that went into that decision? Just a stroll into a general hospital in any of the rural general hospitals will show you how terrible the situation is. Health workers working with no gloves, antiseptic swabs or masks. Patients asked to buy syringes, cannulars and catheters for their use with their own money, because hospitals cannot afford it.
The government cannot afford syringes but it can afford luxury cars.
The truth is that, although there is consistent increase in the national budget over the last two decades, Nigeria has failed in its Abuja Declaration commitment to ensure 15% of its annual budgetary allocation goes toward health.
The Partnership for Advocacy in Child and Family Health (PACFaH) analysed the country’s Federal Ministry of Health and its agencies’ budgets between 2001 and 2021. Its findings showed that Nigeria neglected to follow through on its promise, oftentimes barely reaching a third of the pledged target.
So, what do we need to do?
Firstly, we need to move on from spending targets to asking: “What level of resourcing achieves improvements in population health and universal health coverage (UHC)? “Are the funds being used optimally to advance population health?”; and “Are there opportunities to improve efficiency and reduce leakages?”
Health ministries should 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.
Secondly, 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.
There are opportunities to develop advocacy partnerships with other social sectors to prioritize food security, water, sanitation, and education, that impact the population’s well-being and improve human development indicators. This requires, amongst other things, an understanding of the political economy and alignment of key stakeholders around these common objectives.
Thirdly, we need to demonstrate more 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.
Although, more spending on health is generally associated with better health outcomes, in Africa, health results vary considerably – at the same level of spending – due to major system inefficiencies. Evidence suggests that there is significant room to improve health spending and, in some cases, progress towards UHC is possible within current spending levels.
No one has all the answers, but there are best practices from the continent to learn from.
In February 2023, African leaders recommitted to implementing the Abuja Declaration Target. In 2020, only South Africa met the target. So far, Six AU Member States (Liberia, Madagascar, Malawi, Rwanda, Togo and Zambia) have achieved the Abuja target of allocating 15% of public expenditure to health, and a number of other countries e.g. Djibouti, Ethiopia, Lesotho and Swaziland are within reach of the 15% target.
And to think it was dubbed ‘Abuja declaration’.
I propose we change the name to ‘South African declaration’. This embarrassment is too much!
Private and external funds have become the predominant source of financing for these services. In 2017, 20 sub-Saharan countries were among the 26 countries worldwide that relied on donor funding for more than one-fifth of their health spending.
In Nigeria, the story is no different.
According to the WHO report, the average budget allocation to the health sector was about 4.7% across two decades. The highest allocation was in 2012 with 6.08 per cent, while the lowest was in 2010 with 3.73 per cent.