Progress on implementation of immunization agenda 2030 (IA2030) in the WHO African region: achievements, lessons learned and priorities

¹World Health Organization, Regional Office for Africa, Brazzaville, Congo

^&Corresponding author
Aschalew Teka Bekele, World Health Organization, Regional Office for Africa, Brazzaville, Congo

Introduction    

Since its inception in 1974, the Expanded Programme on Immunization has saved over 154 million lives, including 146 million children under five, making it a highly effective public health intervention [1]. Building on the lessons learned from the implementation of the Decade of vaccines, the Global Vaccine Action Plan (GVAP) 2011-2020, a new global vision and overarching strategy, the Immunization Agenda 2030 (IA2030), was developed with extensive consultation of stakeholders across the levels, which was endorsed by Member States in August 2020 during the Seventy-third World Health Assembly [2,3].

With a global and regional commitment to move towards universal health coverage (UHC), the Immunization Agenda 2030 (IA2030) sets an ambitious global vision to ensure that everyone, everywhere, at every age benefit from vaccines for good health and well-being. It provides a comprehensive strategy for the decade 2021-2030, with specific indicators to track progress [2]. In August 2021, the WHO African Region adopted a regional implementation framework, endorsed by the Regional Committee that envisions a Region where everyone, everywhere, at every age, fully benefits from vaccines for good health and well-being by 2030. The framework is composed of four priority areas: (a) Increase immunization coverage and equity; (b) Sustain the wild polio-free status of the Region; (c) Achieve and sustain regional elimination of maternal and neonatal tetanus, and accelerate progress towards regional elimination of measles, rubella and hepatitis B; and (d) Prevent and control other Vaccine Preventable Diseases (VPDs) [4].

This framework serves to reinforce commitments and consolidate gains towards achieving disease eradication, elimination and control targets while expanding access to existing and new vaccines. The WHO African region joined the global polio eradication initiative in 1988 and was certified free from the indigenous wild polio virus in August 2020, and the region was able to sustain the polio free status since 2020 [5]. The World Health Assembly endorsed neonatal tetanus elimination in 1989 targeting 59 countries out of which 38 countries were in the WHO Africa region [6]. The strategy was relaunched in 1999 to include maternal tetanus elimination and renamed as maternal and neonatal elimination. Elimination is defined as reducing the number of neonatal tetanus cases to less than one per 1000 live births. The region also planned to achieve measles and rubella elimination in 80% of the member states by 2030 defined as reducing measles incidence to less than one per million population [7]. This requires achieving 95% coverage with two doses of measles vaccine supported by sensitive measles surveillance. Progress was assessed using seven impact goal indicators applicable to all the WHO regions. These are i) Number of future deaths averted through immunization , ii) Number and % of countries achieving endorsed regional or global VPD control, elimination and eradication targets; iii) Number of large VPD outbreaks; iv) Number of zero dose children; v) Number of new and under-utilized vaccine introduced in low- and middle-income countries; vi) Vaccination coverage across the life course; and vii) UHC Index of Service Coverage.

In addition, the WHO regions have set their own targets for strategic priorities based on their specific needs [8]. The COVID-19 pandemic disrupted IA2030 implementation, leading to an increase in zero-dose and under-immunization children, across multiple countries, and diverted health resources, affecting routine immunization efforts [9]. The number of zero-dose children increased from 6.1 million in 2019 to 7.3 million in 2022, leading to an estimated 27.5 million cumulative zero-dose children from 2019 and 2022. This figure represents 18.2% of the surviving infants from 2019 to 2022. Ten high-burden countries Nigeria, Ethiopia, Democratic Republic of the Congo, Angola, United Republic of Tanzania, Madagascar, Mozambique, Mali, Chad, and Cameroon account for 80% of the total zero-dose children in the region. In April 2023, WHO, UNICEF, Gavi, and partners, launched the big catch-up (BCU) initiative which aims to achieve three goals: catching up on missed vaccinations, restoring pre-pandemic coverage levels, and strengthening immunization systems as part of primary healthcare. The BCU and other global and regional recovery plans have been implemented to accelerate progress towards the IA 2030 targets [10]. This is the first detailed regional progress report after the pandemic, analyzing country-specific data, whereas previous reports focused on regional-level progress [11]. The objective of this study is to assess the implementation progress of IA2030 in the WHO African Region, with a primary focus on performance against impact goal indicators, while also highlighting progress on strategic priority indicators.

Methods     

Study design and setting: we cwonducted a cross-sectional descriptive analysis of immunization performance for the 47 WHO African Region Member States. These countries are Algeria, Angola, Benin, Burkina Faso, Burundi, Botswana, Cameroon, Cape Verde, Chad, Central African Republic, Congo, Comoros, Ivory Coast, Democratic Republic of Congo, Eritrea, Ethiopia, Eswatini, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome et Principe, Senegal, Seychelles, Sierra Leone, South Africa, South Sudan, Tanzania, Togo, Uganda, Zambia, Zimbabwe [12]. The analysis covered the period 2019-2023 and was performed in March 2025.

Data sources: we used the following sources: (i) WHO/UNICEF Joint Reporting Forms (JRF) for programmatic data available in the WHO/UNICEF JRF portal [13]; (ii) WHO-UNICEF Estimates of National Immunization Coverage (WUENIC) [14,15]; (iii) the IA2030 Monitoring & Evaluation Scorecard for region-level indicators [16] (e.g., lives saved, UHC index); and (iv) disease-specific databases and portals for polio, measles/rubella, yellow fever, and meningitis.

Indicators: progress was assessed against the seven IA2030 impact goal indicators: (1) future deaths averted through immunization; (2) VPD control, elimination, and eradication status; (3) number of large or disruptive outbreaks; (4) number of zero-dose children; (5) introductions of new and under-utilized vaccines; (6) vaccination coverage across the life course (DTP3, PCV3, MCV2, HPV); and (7) the Universal Health Coverage (UHC) Index of Service Coverage [8].

Analysis: administrative coverage data were triangulated with available survey data. Descriptive statistics, including proportions, counts, and year-to-year trend analyses for 2019-2023, were performed using Microsoft Excel. Country-level disaggregation was used for equity metrics. Where applicable, frequency analysis was used to summarize vaccine introductions, and regional scorecard data were used for modelled indicators.

Indicator-specific analysis: future deaths averted through immunization: Data source: IA2030 scorecard. To estimate future deaths averted through vaccination, the global IA 2030 M&E team used a modeling estimates derived from the Vaccine Impact Model Consortium (VIMC), Global Burden of Disease, and socio-demographic covariates). Analysis: regional estimates were extracted and summarized.

VPD control, elimination, and eradication: data source: polio and measles databases, MNTE epidemiological reports, and IA2030 scorecard. Analysis: trend analysis of reported cases and country validation status over time.

Large or disruptive outbreaks: data source: electronic Joint Reporting Form (eJRF) and IA2030 scorecard. Analysis: descriptive trend analysis of number and type of outbreaks by country.

Zero-dose children: data source: WUENIC estimates, 2019-2023. Analysis: trend analysis of regional and country-level zero-dose children across years.

New and under-utilized vaccine introductions: data source: JRF and IA2030 scorecard.

Analysis: frequency analysis of vaccine introductions by region and country between 2019 and 2023.

Vaccination coverage across the life course: data source: WUENIC reports, 2019-2023, and IA2030 scorecard. Analysis: trend analysis of DTP3, PCV3, MCV2, and HPV coverage by country, and number of countries reaching the IA2030 target of 90% coverage.

HC index of service coverage: data source: IA2030 scorecard. Analysis: regional trend analysis of the UHC index.

Strategic priority indicators: data for strategic priority indicators were mainly sourced from the WHO/UNICEF Joint Reporting Form (JRF). A descriptive analysis was conducted to compare regional and country-level trends over the years.

Results     

Impact goal indicators

The IA 2030 set three impact goals and seven indicators.

Indicator 1.1: Number of future deaths averted through immunization

In 2023, the WHO African Region saved an estimated 1.8 million lives through vaccination against 13 diseases (Figure 1). Five diseases namely measles (777,456), hepatitis B (315,879), pertussis (170,978), human papillomavirus (135,671), and yellow fever (121,174), accounted for 84% of lives saved. Despite this achievement, the region missed the target of 2 million lives saved, translating into an estimated 200,000 preventable deaths [16].

Indicator 1.2: VPD control and elimination

All 47 member states sustained wild polio-free status in 2023 [17]. A total of 43 countries achieved maternal and neonatal tetanus elimination, leaving Angola, Central African Republic, Nigeria, and South Sudan pending validation [18]. However, no country achieved measles or rubella elimination [19].

Indicator 1.3: large and disruptive outbreaks

In the WHO African region, the number of outbreaks decreased from 112 (2022) to 66 (2023), and 85 (2019). circulating vaccine-derived polio virus (27), measles (26), meningitis (7), cholera (4), and yellow fever (2) accounted for most outbreaks (Figure 2). Eleven countries contributed to 228 (50%) of the 453 large and disruptive outbreaks reported from 2019-2023. Compared to 2019, the number of outbreaks in 2023 increased in 26 countries, remained the same in 13 countries and decreased in 8 countries [13,16].

Impact Goal 2.1: Leave no child behind

The number of zero-dose children decreased from 7.3 million (2019) to 6.7 million (2023) (Figure 3). The number of zero-dose children in 2023 reduced in 21 countries while it either increased or remained unchanged in 26 countries compared to 2019. In 2023, ten countries accounted for 82% of zero-dose children. These countries are Angola, Cameroon, Ivory Coast, DRC, Ethiopia, Madagascar, Mozambique, Nigeria, South Africa, and Tanzania [14].

Impact Goal 2.2: new vaccine introduction

A total of 100 vaccines introductions occurred in the region between 2021 and 2023 which includes 45 countries that introduced COVID-19 vaccines in 2021. A total of 55 non-COVID-19 vaccines were introduced, primarily in Gavi-supported countries The most frequently introduced were second-dose Inactivated Polio Vaccine (IPV2), MCV2, HPV and Meningitis A vaccines comprised 80% of the vaccines introduced [13] (Figure 4). All countries except Seychelles introduced at least one vaccine between 2019-2023 (Table 1).

Impact Goal 3.1: deliver across the life course

In 2023 the DTP3 coverage was 74% compared to 73% in 2022, PCV3 coverage was 70% vs 68% in 2022, MCV2 was 49% vs 44% in 2022, and HPV coverage was 72% compared to 24% (Figure 5). In 2023,16 out of the 47 countries achieved the 90% DTP3 target, three countries achieved the 90% MCV2 target. The PCV3 and HPV coverage were achieved by 13 and 11 countries, respectively [14] (Table 2).

Indicator 3.2: strengthening universal health coverage (UHC)

UHC index score declined from 45 (2019) to 44 (2021). Index increased in 33 countries but declined in 14 [13,16].

Strategic priority indicators (Table 3)

A total of 15 strategic priority indicators are proposed in the IA 2030 framework where regions have selected the indicators applicable to their context. Out of the 15 indicators, reports were available for the 11 indicators [13,16]

Strategic priority 1

Immunization programs for primary health care and universal health coverage The number of countries with functional national immunization technical advisory groups (NITAGs) increased from 28 in 2022 to 32 in 2023. The overall health workforce density (HWF) in the region is at 14 per 10,000 population which is below the WHO standard. The number of HWF showed an increase in 25 countries but decreased in 22 countries. Regarding VPD surveillance, 34 of the 47 countries are categorized as meeting both measles and AFP surveillance performance indicators in 2023, nine were identified as needing attention. Over 90% of the AFR countries have a system in place to monitor vaccine availability at all levels. The percentage of districts that reported stockout of any of the tracer vaccines decreased from 66% in 2022 to 60% in 2023. In 2023, only 15 of the 47 countries reported at least one serious Adverse Events Following Immunization (AEFI) per million total population, using the appropriate form.

Strategic priority 2: commitment & demand

In 2023, 24 countries reported having legislation stating immunization as basic right and 72% of the countries reported having a strategy in place compared to 64% in 2022.

Strategic priority 3: coverage & equity

DTP3, MCV1, and MCV2 coverage in the 20% of districts with lowest coverage (mean across countries) was 69%, 66% and 43% respectively. In 2023, the DTP3 coverage gap between the 20% high performing and low-performing districts decreased to 41% points compared to 61% in 2022.

Strategic priority 4: life course- breadth of protection

In AFR this is measured by taking the mean coverage of 12 antigens. The breadth of protection increased from 62% in 2022 to 65% in 2023 with increased progress observed in 28 countries while decreased in 19 countries. Only three countries achieved the 90% target.

Strategic priority 5: outbreaks and emergencies

Data not reported on the timeliness of outbreak responses.

Strategic priority 6: supply and sustainability

This priority includes indicators on global health markets, which are monitored only at global levels, financial resources for primary health care, Domestic immunization financing. Only one country reported on status of financial resources for primary health care. The indicator on immunization expenditure from domestic resources analyzes domestic funding for immunization programs. Understanding domestic resource allocation is crucial for the sustainability of immunization initiatives.

Progress: domestic financing increased in 14 countries, remained unchanged/static in 22, and declined in 9, while data was unavailable for 2 countries. Limited financial resources for primary health care and immunization expenditures pose a challenge, impacting the sustainability of immunization programs.

Strategic priority 7: research and innovation

This includes indicator on capacity for innovation for which currently data is not available. The other indicator is on new vaccine development, which is under development.

Discussion     

The COVID-19 Pandemic has caused significant slowdown in the progress of IA 2030. Despite this the WHO African Region has made positive strides in immunization. The most notable progress was registered in maintaining wild polio virus-free status and introducing new and under-utilized vaccines. The second positive progress was made in reducing large and disruptive outbreaks, reduced number of zero-dose children by 600,000 compared to 2022 (8.3% reduction), and increased coverage of key antigens in 2023 compared to 2022 with a notable increase observed in MCV2 coverage as many countries introduced the vaccine even during the pandemic period. The target of increasing coverage with all vaccines to 90% coverage in 30% of member states was off track with only two countries reached 90% with the four key antigens. The number of zero-dose children was below the 2019 level in 45% (21) of the countries despite the regional average number of zero-dose remaining bigger than the 2019 baseline. The improved coverage and increased number of vaccines introduced led to 1.8 million lives saved in 2023 which is more than 2022 and 2019. However, the region missed the target of saving 2 million lives in 2023 which is translated to 200,000 future deaths.

Slow progress was made in elimination of maternal and neonatal tetanus with four countries yet to be validated with the region falling short of the 2023 target of achieving 100% elimination status. In addition, the target for universal health coverage index decreased by 1% in 2021 compared to 2019 missing the target set to increase the UHC index from the 2019 baseline. The least progress was made around measles and rubella elimination with no country achieved the status despite the region aimed at achieving elimination in at least 40% of the countries. Overall, the region hosted a disproportionately high number of zero-dose children and sub-optimal coverage with key antigens, reflecting persistent gap in vaccine access, particularly in conflict-affected and resource-limited settings. Additionally, despite the ambitious regional goals, no country has achieved measles and rubella elimination, indicating gaps in coverage, quality of supplemental immunization activities and outbreak responses.

To address these challenges, countries must adopt strategies to reduce the number of zero-dose children by strengthening access to immunization services including through regular and predictable outreaches and integration with other essential services. Addressing vaccine inequalities requires a focused approach, directing resources to underserved populations and strengthening routine immunization system in fragile settings. A strong and functioning NITAG, adequate health workforce, 100% vaccine availability at any time and places are crucial for optimal vaccine coverage supported by locally tailored innovative vaccine demand strategies. Additionally, enhancing domestic financing for immunization programs is essential for sustainability and ensuring long-term resilience. The improved progress made in 2023, the first-year post post-pandemic, compared to 2022 demonstrates that with strong political commitment, strategic planning, monitoring and accountability, and increased investment, the IA2030 goals remain within reach. A continued focus on equity, system strengthening, and innovation will be essential to sustaining and accelerating progress in the coming years. Limitations of the Study

Limitations of the study: this report resourced data from WUENIC which triangulates reported administrative coverage with latest available surveys. Not all countries have recent surveys, and the reported coverage are self-reported. The WUENIC estimates applies data control measures against extreme outliers of reported coverage in the absence of surveys. The data sources are acceptable and have been used for a long time.

Conclusion     

Immunization remains one of the most effective public health interventions, and the WHO African Region has made significant strides toward IA2030 goals. However, progress is uneven, and immunization coverage remains below target levels. Persistent challenges, including the high number of zero-dose children, stagnating coverage rates, and gaps in disease elimination efforts, highlight the need for sustained and adaptive strategies. Achieving IA2030 targets will require stronger integration of immunization into primary health care, equitable access to vaccines, and increased domestic investment in immunization programs. Addressing these challenges now will determine the region´s ability to prevent outbreaks, protect vulnerable populations, and ensure that every child receives life-saving vaccines. With renewed commitment, strategic innovation, and collaborative efforts, the WHO African Region can build on recent progress and move closer to achieving universal immunization coverage by 2030. Moreover, monitoring of the IA2030 needs to be systematically institutionalized and the national immunization programs need to holistically assess their progress beyond submitting the annual joint reporting format.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conceptualization: Aschalew Teka Bekele and Balcha Girma Masresha. Data curation: Aschalew Teka Bekele. Writing original draft preparation: Aschalew Teka Bekele and André Arsène Bita Fouda. Writing review and editing: Balcha Girma Masresha, Pamela Mitula Ado Bwaka, Sarah Wanyoike, Sidy Ndiaye, Amos Petu, Adidja Amani, Johnson Muluh Ticha, Charles Shey Wiysonge. Visualization: Aschalew Teka Bekele. Supervision: Charles Shey Wiysonge, Benido Impouma. All authors have read and agreed to the published version of the manuscript.

Tables and figures     

Table 1: number of new/under-utilized vaccines introduced by AFR countries 2020-2023

Table 2: overall progress of IA 2030 impact goal indicators

Table 3: overall progress of IA 2030 strategic priorities

Figure 1: number of future deaths averted through immunization-WHO African Region, 2019-2023

Figure 2: number of large or disruptive vaccine-preventable disease outbreaks-WHO African Region, 2019-2023

Figure 3: number of Zero-Dose children, AFR 2019-2023

Figure 4: number of Non-COVID-19 new and under-utilized vaccines introduced in AFR, 2021-2023

Figure 5: coverage of DTP3, PCV3, MCV2 and HPV in AFR, 2019-2023

References