The Abuja Declaration At 25: Health Equity Still Out Of Reach

By Richard Olumakaiye Ph.D

In April 2001, African Union member states gathered in Abuja and pledged to allocate at least 15 percent of their national budgets to health. It was an ambitious commitment and a clear statement that governments would take responsibility for the well-being of their own people. Twenty-five years later, Nigeria, the country that hosted and named that declaration, has never met that target.

This is not simply a failure of budgeting. It is an equity concern, made more urgent by the scale and speed of Nigeria’s population growth. The population has more than doubled since the early 2000s and continues to expand rapidly. This growth places immense and compounding pressure on an already underfunded health system. More births, a larger youth population, and increasing numbers of adults living with chronic conditions are driving demand that the system struggles to meet.

When health spending does not keep pace with population growth, per capita investment declines, and access becomes more unequal.

The Abuja Declaration was originally framed around infectious diseases that disproportionately affect the poor, including HIV/AIDS, tuberculosis, and malaria. Over time, demographic and epidemiological changes have reshaped the health landscape. Noncommunicable diseases such as cancers, diabetes, cardiovascular conditions, and chronic respiratory illnesses are rising rapidly across low-income countries, and Nigeria is no exception. The poor are more exposed to these risks and less able to afford quality treatment.

For years, gaps in domestic health financing have been partially concealed by external and private funding. Support from agencies such as USAID and Gavi, alongside multilateral initiatives, has helped sustain critical services and expand access where government investment has fallen short. These interventions have delivered real gains, particularly for poorer populations, by expanding access to treatment and reducing mortality.

But this model is becoming increasingly fragile. Growing constraints and uncertainty in global development assistance, combined with shifting geopolitical priorities, are placing pressure on external health financing. The safety net that once compensated for domestic underinvestment is weakening at the very moment when Nigeria’s population is growing fastest and demand for care is accelerating.

The 2026 federal budget allocates 2.1 trillion naira to health and social welfare out of a total appropriation of 58.18 trillion naira, amounting to roughly 4 percent of federal spending. This falls far short of the 15 percent target agreed in Abuja. The gap does not disappear. It is shifted onto households through out-of-pocket payments, the most inequitable form of health financing, compounded by weak primary healthcare infrastructure.

Nigeria’s difficulty in raising sufficient revenue to finance health is not simply a matter of low income, but of structural constraints in how the state generates and manages resources. A narrow tax base, volatile dependence on oil revenues, and high debt servicing obligations have combined to limit the fiscal space available for sustained health investment. Without a significant increase in domestic public financing, the system will not be able to absorb the pressures created by population growth and epidemiological change. Meeting the Abuja target is therefore no longer simply a moral obligation. It is a practical necessity and requires deliberate policy choices.

Nigeria’s public sector has expanded over time, but this expansion has not consistently translated into better services. Overlapping agencies and duplicated mandates, often shaped more by political patronage than outcomes, absorb resources that could be directed toward essential services like health. This is not an argument for a smaller government in principle, but for a more effective one in practice. Streamlining government is therefore not a peripheral reform but a central one, because every naira saved from inefficiency is a naira that can be redirected toward domestic health financing.

Even so, higher spending alone will not guarantee impact. Health equity is not the same as equality. A government could meet the 15 percent threshold while directing most funds to tertiary hospitals in major cities that serve a small urban elite. Equity requires deliberate allocation to primary healthcare, rural infrastructure, maternal services, and underserved communities. In a country as diverse as Nigeria, this distinction is critical.

The Abuja Declaration still matters. It establishes a minimum standard for public investment, reinforces the principle that health is a responsibility of the state, and provides a benchmark against which citizens and institutions can measure performance and demand accountability.

As the country approaches another election cycle, the question for those seeking power is unavoidable. What is the plan for a health system in which most spending is borne by individuals? For one in which health workers continue to leave in large numbers, how do we create a national health system we can be proud of?

Health equity remains out of reach, not because it is unattainable, but because it has not been prioritised. A quarter of a century later, the Abuja Declaration still inspires a reckoning.

– Olumakaiye writes from Warwick, United Kingdom