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Empty beds in a ward at the Kiambu Referral Hospital, Kenya, as doctors and medical practitioners strike to demand payment of their salaries and other grievances, April 23, 2024.
© 2024 Monicah Mwangi/Reuters
(Washington, DC) – African governments are falling far short in their commitments to prioritize public spending on health care, contributing to widespread inequalities in healthcare access and outcomes, Human Rights Watch and the Kampala-based Initiative for Social and Economic Rights (ISER) said today. As the 23rd anniversary of African Union states’ historic commitment approaches, new data reveal alarming stagnation, widening regional inequalities, and pointing up the need to correct course.
On April 27, 2001, African Union (AU) governments adopted the Abuja Declaration, in which they set a target of allocating at least 15 percent of their national budgets to improve health care. But recent analysis of two decades of data found that only two of the AU’s 55 member countries — Cabo Verde and South Africa — met this target in 2021, the most recent year for which data is available.
“It is disappointing that African countries have failed to meet health spending targets they set,” said Allana Kembabazi, the ISER program manager. “The impact of this is felt in lives lost as a result of underfunded, poor-quality public health systems. Covid-19 underscored that it is more important than ever for governments to finance health care.”
Despite the global surge in public healthcare spending amid the pandemic in 2021, on average African governments spent only 7.4 percent of their national budgets on health care, less than half of what they had pledged 20 years earlier. Overall, about 95 percent of people in Africa lived in a country that did not meet this spending target that year.
Domestic General Government Health Expenditure (GGHE-D) as % General Government Expenditure (GGE)
Source: World Health Organization, Global Health Expenditure Database (Domestic General Government Health Expenditure (GGHE-D) as % General Government Expenditure (GGE))
Data: Public Healthcare Spending as Percent of General Government Expenditure in Africa, 2021
Country
percent
Algeria
8.8%
Angola
8.8%
Benin
1.6%
Botswana
14.6%
Burkina Faso
9.8%
Burundi
7.3%
Cape Verde
15.7%
Cameroon
2.8%
Central African Republic
6.4%
Chad
4.8%
Comoros
4.7%
Congo (Brazzaville)
8.2%
Côte d’Ivoire
5%
Democratic Republic of Congo
4.3%
Djibouti
4.2%
Egypt
6.7%
Equatorial Guinea
5.3%
Eritrea
2.3%
Eswatini
12.3%
Ethiopia
7%
Gabon
9.5%
Gambia
7.5%
Ghana
8.2%
Guinea-Bissau
4.6%
Kenya
9.3%
Lesotho
7.9%
Liberia
3.7%
Madagascar
5.3%
Malawi
5.8%
Mali
5%
Mauritania
8.3%
Mauritius
10.2%
Morocco/Western Sahara
7.2%
Mozambique
8.2%
Namibia
11.2%
Niger
8.7%
Nigeria
4%
Rwanda
9.5%
São Tomé and Príncipe
13.1%
Senegal
4.4%
Seychelles
10.2%
Sierra Leone
6.9%
South Africa
15.3%
South Sudan
2.1%
Sudan
7.9%
Togo
2.6%
Tunisia
12.4%
Uganda
4.9%
Tanzania
5.1%
Zambia
9.3%
Zimbabwe
5.2%
Despite making clear commitments to prioritize national public healthcare spending in 2001, African governments’ allocations to health care grew minimally over the subsequent two decades, at about one-third the global average. By 2021, Africa’s regional average had become the lowest in the world.
When adjusted for inflation, seven AU countries spent less per person on health care through public means in 2021 than they did in 2000, the year before the Abuja Declaration. Madagascar effectively reduced its per person spending by 62 percent over this period, followed by Benin (-62 percent), Eritrea (-55 percent), Central African Republic (-44 percent), Chad (-37 percent), Sudan (-36 percent), and Cameroon (-8 percent).
Under international human rights law, including under the African Charter on Human and Peoples’ Rights, states have duties to use the maximum of their available resources toward the realization of economic, social, and cultural rights, such as the right to health.
Decreases in healthcare funding should be examined as potentially deliberate retrogressive measures, which would violate countries’ obligations on the right to health unless they are fully justified. Human rights bodies, including the African Commission on Human and Peoples’ Rights in its 2021 General Comment No. 7, have made clear that the bar for justifying deliberate retrogressive measures is quite high, for example, the existence of an armed conflict is not alone sufficient to justify retrogression.
African governments should commit to enacting policies, including through their budgets, that make good on this commitment, the human rights groups said. African governments should also seek to increase public revenues, including through policy measures to reduce tax abuses and illicit financial flows, as well as by considering progressive taxes.
For some countries, low levels of public healthcare spending may also reflect a confluence of external factors, including climate-related weather events and environmental changes, the cost of servicing external public debt, and public spending limits set by International Monetary Fund lending programs.
To address these external factors, international and other financial institutions and wealthier income governments—particularly those that have contributed most to climate change—should fulfill their human rights obligations to provide international assistance and cooperation by ensuring that African governments have adequate fiscal space and policy autonomy to meet spending benchmarks vital for the realization of the right to the highest attainable standard of health.
“African governments once led by example with the Abuja Declaration,” said Matt McConnell, economic justice and rights researcher at Human Rights Watch. “They need to do so again by making good on those commitments to finance more resilient, more sustainable, and more rights-realizing healthcare systems for all.”
