Pandemic Preparedness Beyond Hesitancy: System Readiness and Governance in COVID-19 Vaccine Delivery Across Africa
1
Global Health & Innovation Lab, University of Western Ontario, London, Canada
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
COVID-19 vaccination coverage across Africa varied widely, revealing deep inequities not fully explained by individual hesitancy or biomedical access alone. While prior studies have examined either macro-level determinants or implementation-level barriers, limited work has integrated these perspectives to explain how health systems translate vaccine availability into population-level coverage. This gap is particularly relevant for pandemic preparedness and equitable immunization strategies.¹
METHODS:
This synthesis draws on two complementary bodies of evidence. First, a cross-country quantitative analysis examined associations between vaccination rates and systemic indicators including vaccine supply, governance, and socio-economic conditions. Second, a systematic review of peer-reviewed studies identified upstream barriers and facilitators to COVID-19 vaccination across African contexts, analyzed using the Consolidated Framework for Implementation Research.² Rather than pooling results, findings were integrated to develop a systems-level explanatory lens for vaccine implementation.
RESULTS:
Quantitative findings indicate that vaccine doses secured and governance quality, particularly public sector corruption, were among the strongest predictors of national vaccination coverage. The systematic review demonstrates how these macro-level conditions were mediated at the implementation level through infrastructure, workforce distribution, logistics, policy alignment, and community engagement. Countries with similar levels of supply or economic capacity experienced divergent outcomes depending on institutional readiness, coordination, and trust. Successful vaccination efforts were characterized by adaptive delivery models, integration with existing health services, and strong intersectoral partnerships, while stalled efforts reflected fragmentation between policy intent and delivery capacity.
CONCLUSIONS:
Together, these findings suggest that vaccination equity is not determined by access alone, but by the capacity of health systems to convert resources into sustained delivery. Advancing equitable and sustainable immunization within and beyond pandemic contexts requires moving beyond border-based supply metrics toward investments in governance, system readiness, and implementation infrastructure. This synthesis offers a transferable framework for strengthening vaccine preparedness and health system resilience across low- and middle-income settings.
COVID-19 vaccination coverage across Africa varied widely, revealing deep inequities not fully explained by individual hesitancy or biomedical access alone. While prior studies have examined either macro-level determinants or implementation-level barriers, limited work has integrated these perspectives to explain how health systems translate vaccine availability into population-level coverage. This gap is particularly relevant for pandemic preparedness and equitable immunization strategies.¹
METHODS:
This synthesis draws on two complementary bodies of evidence. First, a cross-country quantitative analysis examined associations between vaccination rates and systemic indicators including vaccine supply, governance, and socio-economic conditions. Second, a systematic review of peer-reviewed studies identified upstream barriers and facilitators to COVID-19 vaccination across African contexts, analyzed using the Consolidated Framework for Implementation Research.² Rather than pooling results, findings were integrated to develop a systems-level explanatory lens for vaccine implementation.
RESULTS:
Quantitative findings indicate that vaccine doses secured and governance quality, particularly public sector corruption, were among the strongest predictors of national vaccination coverage. The systematic review demonstrates how these macro-level conditions were mediated at the implementation level through infrastructure, workforce distribution, logistics, policy alignment, and community engagement. Countries with similar levels of supply or economic capacity experienced divergent outcomes depending on institutional readiness, coordination, and trust. Successful vaccination efforts were characterized by adaptive delivery models, integration with existing health services, and strong intersectoral partnerships, while stalled efforts reflected fragmentation between policy intent and delivery capacity.
CONCLUSIONS:
Together, these findings suggest that vaccination equity is not determined by access alone, but by the capacity of health systems to convert resources into sustained delivery. Advancing equitable and sustainable immunization within and beyond pandemic contexts requires moving beyond border-based supply metrics toward investments in governance, system readiness, and implementation infrastructure. This synthesis offers a transferable framework for strengthening vaccine preparedness and health system resilience across low- and middle-income settings.
| eISSN: | 2654-1459 |
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