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

Background: In 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. Methods: We 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. Results: The 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