GBS Global Biosecurity Global Biosecurity Global Biosecurity UNSW 7 Pandemic planning and preparedness in Nigeria: A search for entry points to integrate adult vaccinations into the health system Introduction The Nigerian health system Disease prevention through vaccination and immunization Opportunities for Nigeria: Learning from vaccination entry points in other countries Conclusion Technical Services Directorate, MSI Nigeria Reproductive Choices, Abuja. Plus-Circle Community Health Advancement Organization, Nigeria. Canadian Association for Black Health & Safety Professionals, Edmonton, Alberta, Canada. Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria. Corresponding author: Aanuoluwapo A. Afolabi, Email: afoannade@gmail.com, Tel: +2348146764516

Authors’ contributions

OSI and AAA conceptualized the research. AAA, OSI, and GI developed the manuscript. AAA and OSI reviewed the manuscript after receiving peer-review reports. All authors reviewed the manuscript for critical intellectual content and approved the final version of the manuscript.

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This commentary aimed to describe entry points to integrate adult vaccinations into the health system in Nigeria towards pandemic planning and preparedness. To enhance pandemic preparedness, leveraging established platforms can significantly increase vaccination coverage and community acceptance. Immunization clinics, which already play a crucial role in maternal health, can be optimized to include pandemic-related vaccinations for mothers, ensuring they are protected and informed. Targeting men in car parks and community halls taps into gathering points where health interventions are less frequent but could have a substantial impact, especially in engaging this often-underrepresented demographic. Advocacy to religious and traditional rulers is essential, as their influence can drive widespread acceptance and mobilization within communities, making them key allies in vaccination efforts.

Mass communication platforms, including social media, radio, and television, can amplify outreach, disseminating accurate information quickly and reaching diverse audiences. By integrating these strategies, a robust, multi-faceted approach can be developed that enhances community-based vaccination efforts. This not only strengthens immediate pandemic response but also builds long-term resilience, ensuring that communities are better prepared for future public health challenges.

Affiliations:

Keywords

Health systems, vaccination, Nigeria

 <!-- WARNING: Content in this section is NOT in the correct location. Check paragraph styling and re-export --> <p>Vaccination is celebrated as one of the most impactful and affordable health interventions ever developed, reducing the spread of infectious diseases, and saving countless lives (<xref ref-type="bibr" rid="r1">1</xref>, <xref ref-type="bibr" rid="r2">2</xref>). Despite its proven success, resistance to vaccination has been a recurring challenge, with opposition arising in various forms throughout history (<xref ref-type="bibr" rid="r2">2</xref>, <xref ref-type="bibr" rid="r3">3</xref>, <xref ref-type="bibr" rid="r4">4</xref>, <xref ref-type="bibr" rid="r5">5</xref>). Vaccine hesitancy in Nigeria stemmed from misconceptions and doubts about vaccine efficacy, compounded by vaccine distribution primarily through child-focused clinics (<xref ref-type="bibr" rid="r3">3</xref>, <xref ref-type="bibr" rid="r4">4</xref>, <xref ref-type="bibr" rid="r5">5</xref>, <xref ref-type="bibr" rid="r6">6</xref>). Vaccine acceptance is heavily reliant on the strength and effectiveness of the overall health system (<xref ref-type="bibr" rid="r7">7</xref>). A robust health system ensures the availability and accessibility of vaccines, comprehensive health education, communication, and trust-building efforts necessary to encourage vaccine uptake (<xref ref-type="bibr" rid="r7">7</xref>, <xref ref-type="bibr" rid="r8">8</xref>, <xref ref-type="bibr" rid="r9">9</xref>). This includes having well-trained healthcare professionals, reliable supply chains, adequate infrastructure, and a coordinated effort to address misinformation and cultural sensitivities (<xref ref-type="bibr" rid="r8">8</xref>, <xref ref-type="bibr" rid="r9">9</xref>). In such a system, many people will trust the safety and efficacy of vaccines, leading to higher acceptance rates and successful immunization programs (<xref ref-type="bibr" rid="r8">8</xref>, <xref ref-type="bibr" rid="r9">9</xref>). This commentary aimed to describe potential entry points to integrate adult vaccinations into the Nigerian health system towards promoting pandemic planning and preparedness.</p> <p>The Nigerian health system operates on three distinct tiers: primary, secondary, and tertiary levels, all overseen by the Ministry of Health and other governmental health agencies, collectively playing pivotal roles in healthcare delivery (<xref ref-type="bibr" rid="r10">10</xref>). Routine childhood immunization in Nigeria is comprehensive and systematically integrated across federal, state, and local levels to ensure wide coverage (<xref ref-type="bibr" rid="r11">11</xref>). Key vaccines include the DTwP-HepB-Hib vaccine given to infants at six, 10, and 14 weeks; the measles vaccine at nine and 15 months; and the meningococcal A conjugate vaccine at nine months (<xref ref-type="bibr" rid="r12">12</xref>, <xref ref-type="bibr" rid="r13">13</xref>). Infants also receive the pneumococcal conjugate vaccine (<xref ref-type="bibr" rid="r14">14</xref>), oral and inactivated polio vaccines, and the rotavirus vaccine at six, 10, and 14 weeks (<xref ref-type="bibr" rid="r15">15</xref>, <xref ref-type="bibr" rid="r16">16</xref>). Additionally, the BCG vaccine is administered at birth, Vitamin A at six months, yellow fever at nine months, and HPV vaccine to females aged nine years (<xref ref-type="bibr" rid="r12">12</xref>). The COVID-19 vaccine is provided to everyone aged 18 and older, including pregnant and lactating women (<xref ref-type="bibr" rid="r16">16</xref>, <xref ref-type="bibr" rid="r17">17</xref>, <xref ref-type="bibr" rid="r18">18</xref>).</p> <p>At the federal level, government health agencies and organizations plan, coordinate, and implement immunization programs (<xref ref-type="bibr" rid="r20">20</xref>). This involves formulating policies and guidelines and managing the procurement and distribution of vaccines (<xref ref-type="bibr" rid="r21">21</xref>). The National Primary Health Care Development Agency assumes a central role in coordinating nationwide immunization efforts, ensuring the equitable distribution of vaccines throughout the healthcare system (<xref ref-type="bibr" rid="r22">22</xref>). Tertiary healthcare is provided by facilities such as Federal Medical Centers and University Teaching Hospitals, offering specialized medical services, advanced diagnostics, and medical education (<xref ref-type="bibr" rid="r23">23</xref>). While immunizations may not be the primary focus at this level, immunization clinics exist where both adults and children receive vaccines (<xref ref-type="bibr" rid="r24">24</xref>).</p> <p>The secondary healthcare level encompasses general and teaching hospitals that offer specialized care, diagnostic services, and referrals, acting as a bridge between primary and tertiary healthcare (<xref ref-type="bibr" rid="r25">25</xref>). These facilities, including general hospitals and district health centers, contribute to the delivery of vaccination services, providing a broader range of healthcare services compared to primary healthcare centers (<xref ref-type="bibr" rid="r25">25</xref>).</p> <p>The primary health care level serves as the foundational and initial point of contact for patients where essential healthcare services, including immunization, maternal and child health, and health education, are provided (<xref ref-type="bibr" rid="r26">26</xref>). Local government health authorities oversee the supply of vaccines to service delivery points, with central cold rooms in each locality receiving and distributing vaccines to healthcare centers and hospitals across all levels (<xref ref-type="bibr" rid="r26">26</xref>). Primary healthcare facilities also act as the primary point for individuals seeking immunization services, administering routine immunizations like those in the expanded program on immunization (<xref ref-type="bibr" rid="r26">26</xref>, <xref ref-type="bibr" rid="r27">27</xref>). Community-based initiatives are critical at this level, with community health workers and volunteers conducting awareness campaigns, mobilizing communities, and facilitating vaccine administration during campaigns (<xref ref-type="bibr" rid="r26">26</xref>).</p> <p>Nigeria has a history of immunization programs that have been pivotal in controlling vaccine-preventable diseases, including routine immunization and supplementary immunization activities such as those for polio and other vaccines (<xref ref-type="bibr" rid="r28">28</xref>). These initiatives have involved various entry points, including routine clinics, house-to-house visits, and school-based immunization campaigns (<xref ref-type="bibr" rid="r28">28</xref>, <xref ref-type="bibr" rid="r29">29</xref>). Routine immunization programs in Nigeria have historically been focused on children below 1 year, with vaccination coverage rates for diseases being consistently low (<xref ref-type="bibr" rid="r28">28</xref>, <xref ref-type="bibr" rid="r29">29</xref>). According to the 2018 Nigeria Demographic Health Survey report, the rates of complete, incomplete, and non-immunization of childhood vaccinations in 2013 were 25%, 54%, and 21%, respectively (<xref ref-type="bibr" rid="r30">30</xref>). By 2018, these figures had shifted to 31%, 49.9%, and 19% (<xref ref-type="bibr" rid="r30">30</xref>). While these trends show some progress, they still fall significantly short of the sustainable development goal 3 target, which aims for over 90% coverage of all basic vaccinations among children aged 12–23 months (<xref ref-type="bibr" rid="r31">31</xref>).The coverage of DTP-3 (62%), BCG (74%), Hib-3 (62%), Hepatitis B vaccine (62%), Measles-containing vaccine (60%), Polio-3 (38%), PCV (62%) and Rotavirus vaccine (60%) have remained stagnant between 2020 and 2022 (Table 1) (<xref ref-type="bibr" rid="r31">31</xref>).</p> <p>Research conducted in African countries and other parts of the world has revealed a range of factors that affect childhood immunization rates. These factors include socio-demographic elements such as the mother's age, educational level of both parents, marital status, occupation, family income, wealth status, and ethnicity (<xref ref-type="bibr" rid="r32">32</xref>, <xref ref-type="bibr" rid="r33">33</xref>, <xref ref-type="bibr" rid="r34">34</xref>). A case-control study conducted in Ethiopia, involving 548 children aged 12 to 23 months, identified maternal age as a significant factor in childhood immunization uptake (<xref ref-type="bibr" rid="r35">35</xref>). The study found that mothers over the age of 19 were nearly 10 times more likely to have their children fully immunized compared to mothers under 19 years old (<xref ref-type="bibr" rid="r35">35</xref>). This disparity may be attributed to the greater knowledge and awareness that older mothers have regarding the importance of immunization, along with an understanding of the potential negative consequences of not vaccinating their children.</p> <p>Parents with low education and low socioeconomic status demonstrate higher levels of uncertainty towards vaccine uptake (<xref ref-type="bibr" rid="r36">36</xref>). In Mozambique, religious beliefs were found to significantly impact childhood immunization rates. Mothers who believed that immunization was contrary to their religious practices were less likely to fully immunize their children compared to those who did not hold such beliefs (<xref ref-type="bibr" rid="r37">37</xref>, <xref ref-type="bibr" rid="r38">38</xref>).</p> <p>In Nigeria, cultural beliefs opposing immunization have been identified as significant barriers to childhood immunization uptake (<xref ref-type="bibr" rid="r39">39</xref>, <xref ref-type="bibr" rid="r40">40</xref>). These beliefs are often fueled by the spread of misinformation through family and religious networks, such as the false notion that vaccines contain anti-fertility drugs that could harm the reproductive health of females (<xref ref-type="bibr" rid="r40">40</xref>). Given the high respect and trust placed in traditional and religious leaders, who are seen as guardians of cultural values, their active participation in immunization campaigns could significantly boost community acceptance and increase immunization rates.</p> <p>In Tanzania, the quality of the relationship between vaccine providers and clients was identified as a key factor influencing childhood immunization rates among 380 participants (<xref ref-type="bibr" rid="r41">41</xref>). Mothers who had a positive view of the interaction with vaccine providers were twice as likely to fully immunize their children compared to those who had a negative perception of this relationship (<xref ref-type="bibr" rid="r41">41</xref>).</p> <p>In Nigeria, the lack of vaccine availability when needed has been identified as a significant reason for lapses in childhood immunization (<xref ref-type="bibr" rid="r40">40</xref>, <xref ref-type="bibr" rid="r42">42</xref>). Many mothers, after spending considerable resources to access healthcare multiple times, often found that vaccines were unavailable (<xref ref-type="bibr" rid="r40">40</xref>, <xref ref-type="bibr" rid="r42">42</xref>). This inconsistency led to frustration and discouragement, causing some mothers to abandon their children's immunization schedules before completion (<xref ref-type="bibr" rid="r42">42</xref>). Obstetric factors, including the frequency of antenatal and postnatal care visits, the interval between births, and the location of childbirth, also influence immunization uptake (<xref ref-type="bibr" rid="r40">40</xref>, <xref ref-type="bibr" rid="r42">42</xref>).</p> <p>In Nigeria, the current vaccination focal points, primarily housed within primary healthcare centers, form the bedrock of routine childhood immunization initiatives (<xref ref-type="bibr" rid="r43">43</xref>). These centers deliver scheduled vaccinations and orchestrate supplementary immunization activities like national immunization days, specifically targeting children across diverse settings such as homes, schools, and communities to fortify vaccination coverage (<xref ref-type="bibr" rid="r44">44</xref>). Moreover, outreach programs are pivotal by extending immunization services to underserved regions, ensuring equitable vaccine access beyond traditional healthcare facilities (<xref ref-type="bibr" rid="r44">44</xref>). This strategy has proven effective for childhood immunizations in Hoima district, Uganda, helping to immunize 87.4% children aged 10-23 months from a cluster survey of 476 households, largely owing to the convenience of outreach sessions, and community mobilization prior to outreach schedule (<xref ref-type="bibr" rid="r45">45</xref>). Yet, while this approach has succeeded for childhood vaccinations, its feasibility for large-scale adult vaccination campaigns, appears limited.</p> <p>Pharmacy clinics have served as vaccination entry points in many countries, benefiting from frequent interactions with the adult population targeted for vaccination (<xref ref-type="bibr" rid="r42">42</xref>). In countries such as Australia and Canada, the laws and regulations governing which vaccines pharmacists can administer vary by region. For example, in Queensland, Australia, pharmacists are authorized to vaccinate individuals aged 16 and over against influenza, dTpa, and Measles Mumps Rubella (MMR) (<xref ref-type="bibr" rid="r46">46</xref>). In Australia, pharmacists can administer influenza and meningococcal vaccines to individuals aged 10 and over (<xref ref-type="bibr" rid="r47">47</xref>). Pharmacists administer vaccinations in 9 of the 13 provinces and territories in Canada (<xref ref-type="bibr" rid="r48">48</xref>). Ontario has recently expanded the scope of pharmacist vaccination authorization to include 13 vaccine-preventable diseases, in addition to the influenza vaccine (<xref ref-type="bibr" rid="r48">48</xref>). In the USA, the percentage of influenza vaccinations administered in community pharmacies rose from 18% in 2011 to 25% in 2017 (<xref ref-type="bibr" rid="r49">49</xref>). Patients primarily chose community pharmacies for vaccination services due to their convenience, such as the absence of appointment requirements or additional fees (<xref ref-type="bibr" rid="r49">49</xref>). A study also highlighted the pharmacist’s crucial role in improving vaccination rates during a pandemic, showing a significant increase in vaccination capacity and a faster achievement of national vaccination coverage (<xref ref-type="bibr" rid="r49">49</xref>). Another study that assessed the collaboration between community pharmacies and public health programs in pandemic preparedness found that over 85% of public health programs included pharmacies in their vaccine distribution plans, and 45% actively recruited pharmacists to serve as vaccine providers (<xref ref-type="bibr" rid="r50">50</xref>).</p> <p>In the United Kingdom, the potential to improve national vaccination rates through pharmacists in community pharmacies was recognized due to the convenience and easy access these pharmacies provide (<xref ref-type="bibr" rid="r51">51</xref>, <xref ref-type="bibr" rid="r52">52</xref>). The accessibility and extended operating hours of pharmacies align with the convenience preferences of adults, contributing to the success of this approach (<xref ref-type="bibr" rid="r52">52</xref>). Findings from a community-based qualitative study in Nigeria reported pharmacy-based immunization as an untapped resource that could be leveraged to increase the typhoid conjugate vaccine in Nigeria vaccine coverage in Nigeria (<xref ref-type="bibr" rid="r53">53</xref>). There is no documented explicit restriction on Nigerian pharmacists administering vaccines, though there is no established policy supporting it and most vaccination programs are yet to adopt using pharmacists to administer vaccines to the public (<xref ref-type="bibr" rid="r42">42</xref>).</p> <p>Tertiary institutions in Nigeria, especially during active academic sessions, house a substantial adult population engaged in diverse roles such as teaching, administration, support, and various businesses that cater to the university community (<xref ref-type="bibr" rid="r54">54</xref>). Many of these institutions provide on-campus accommodations, essentially functioning as complete communities with residents spanning all age groups (<xref ref-type="bibr" rid="r54">54</xref>). Staff clinics and hospitals within these institutions offer healthcare services to staff members and the broader university community, presenting an opportune setting for adult vaccinations.</p> <p>Employing educational institutions as vaccination centers, inspired by successful models in the United States, has proven effective (<xref ref-type="bibr" rid="r55">55</xref>, <xref ref-type="bibr" rid="r56">56</xref>). By targeting students, teachers, and staff at convenient centralized locations, vaccination outreach opportunities are maximized. Collaborating with these institutions to integrate vaccine information into wellness packages and occupational health programs can yield significant benefits due to their controlled environments (<xref ref-type="bibr" rid="r54">54</xref>, <xref ref-type="bibr" rid="r55">55</xref>). Similarly, establishing on-site vaccination clinics in workplaces, akin to educational institutions, is advantageous (<xref ref-type="bibr" rid="r55">55</xref>). This approach enhances accessibility for working adults and showcases corporate social responsibility. Government partnerships with workplaces having established health clinics can streamline the process, though it may incur additional costs for some employers. Effective leadership is essential for coordinating diverse employers, as smaller establishments might be disadvantaged. Supplementing vaccination access with alternative sites can mitigate this issue, ensuring equitable vaccine distribution.</p> <p>Creating vaccination centers in community halls and easily accessible venues emerges as a convenient strategy for engaging adults. Drawing inspiration from initiatives in India and South Africa, implementing vaccination centers in community hubs fosters community engagement and increases accessibility (<xref ref-type="bibr" rid="r55">55</xref>, <xref ref-type="bibr" rid="r56">56</xref>). This decentralized approach brings vaccination services closer to individuals in their residential and occupational spaces, eliminating potential barriers or stigma associated with seeking care in a hospital setting (<xref ref-type="bibr" rid="r57">57</xref>). While this community-centric approach aligns with cultural considerations, it may necessitate additional resources for setup and maintenance, introducing logistical challenges in ensuring the seamless flow of services in a decentralized environment.</p> <p>To enhance pandemic preparedness, leveraging established platforms can significantly increase vaccination coverage and community acceptance. Immunization clinics, which already play a crucial role in maternal health, can be optimized to include pandemic-related vaccinations for mothers, ensuring they are protected and informed. Targeting men in car parks and community halls taps into gathering points where health interventions are less frequent but could have a substantial impact, especially in engaging this often-underrepresented demographic. Advocacy to religious and traditional rulers is essential, as their influence can drive widespread acceptance and mobilization within communities, making them key allies in vaccination efforts.</p> <p>Mass communication platforms, including social media, radio, and television, can amplify outreach, disseminating accurate information quickly and reaching diverse audiences. By integrating these strategies, a robust, multi-faceted approach can be developed that enhances community-based vaccination efforts. This not only strengthens immediate pandemic response but also builds long-term resilience, ensuring that communities are better prepared for future public health challenges.</p> </sec> <sec sec-type="other1"> <title><bold>Table 1</bold><bold>: Routine immunization performance across African countries between 2020-2022</bold> (Source: World Health Organization) [20]
DTP-3 BCG Hib3 Hepatitis B Measles-containing vaccine-1 Measles-containing vaccine-2 Polio-3 PCV Rotavirus Vaccine
2020 2021 2022 2020 2021 2022 2020 2021 2022 2020 2021 2022 2020 2021 2022 2020 2021 2022 2020 2021 2022 2020 2021 2022 2020 2021 2022
Algeria 84 81 77 99 98 98 84 81 77 84 81 77 80 79 79 74 73 71 84 81 77 74 78 74 - - -
Angola 51 45 42 58 56 60 51 45 42 51 45 42 44 36 37 29 - 25 51 43 41 24 34 24 43 34 37
Benin 76 76 88 88 88 72 76 76 72 76 76 65 68 68 - - 73 75 75 73 73 73 62 76 76
Botswana 95 95 86 98 98 98 95 95 86 95 95 86 87 97 90 66 70 77 96 96 68 90 68 85 85 65
Burkina Faso 91 91 91 98 98 98 91 91 91 91 91 91 88 88 71 71 71 91 91 91 91 66 91 91 91 85
Burundi 93 94 91 83 95 94 93 94 91 93 94 91 90 90 89 83 85 85 93 94 91 91 94 91 96 94 91
Cabo Verde 93 93 93 98 98 98 94 94 94 94 94 94 95 95 95 86 86 86 94 94 94 - - - - - -
Cameroon 69 69 68 80 77 65 69 69 68 69 69 68 62 62 65 29 35 44 70 70 59 67 67 67 67 65 61
Central African Republic 42 42 42 61 61 61 42 42 42 42 42 42 41 41 41 - - - 46 46 46 40 40 40 - - -
Chad 52 58 60 60 67 67 52 58 60 52 58 60 47 55 56 - - 2 52 58 57 - - - - - -
Comoros 91 91 88 94 94 90 91 91 88 91 91 88 90 90 86 - - - 94 94 88 - - - - - -
Congo DR 70 65 65 83 67 77 70 65 65 70 65 65 62 55 56 - - 79 72 65 66 64 63 64 27 52 59
Congo 70 77 78 72 81 67 73 77 78 73 77 78 68 68 65 29 31 34 73 75 52 76 75 76 60 23 45
Cote d'Ivoire 75 76 76 91 93 92 75 76 76 75 76 76 66 68 65 - 1 20 67 73 73 61 57 61 65 58 65
Djibouti - - - - - - - - - - - - - - - - - - - - - - - - - - -
Egypt 96 97 96 97 94 96 97 94 96 97 94 96 96 - - - - - - - - - - - -
Equatorial Guinea 53 53 53 85 85 85 53 53 53 53 53 53 53 53 53 - 17 13 55 55 55 - - - - - -
Eritrea 95 95 95 97 97 97 95 95 95 95 95 95 93 93 93 85 85 85 95 95 95 95 95 95 96 96 96
Eswatini 83 77 97 97 97 97 83 77 97 83 77 97 76 80 83 70 69 77 82 61 97 96 63 96 63 85 99
Ethiopia 71 65 65 70 68 68 71 65 65 71 65 65 60 54 56 46 46 48 74 68 64 61 61 61 70 65 65
Gabon 63 75 60 85 86 82 63 75 60 63 75 60 53 64 52 - - - 62 69 59 - - - - - -
Gambia 85 82 79 85 81 83 85 82 79 85 82 79 82 79 74 61 61 52 89 89 69 75 78 75 85 97 -
Ghana 94 98 99 93 99 96 94 98 99 94 98 99 88 95 95 79 83 84 92 98 99 98 99 89 96 -
Guinea 47 47 47 73 73 73 47 47 47 47 47 47 47 47 47 - - 3 48 48 48 - - - - - -
Guinea-Bissau 74 67 74 67 34 80 74 67 77 74 67 74 72 63 75 - - 1 63 23 51 74 67 74 79 72 76
Kenya 89 91 90 92 97 97 89 91 90 89 91 90 88 89 90 53 57 56 89 91 87 91 92 91 89 91 23
Lesotho 87 87 87 96 96 85 87 87 87 87 87 87 90 90 81 82 82 75 87 87 65 87 87 87 87 74 87
Liberia 65 66 78 85 81 67 65 66 78 65 66 78 61 58 79 30 35 59 67 64 52 74 65 74 65 68 77
Libya 73 73 74 73 73 73 73 73 73 73 73 73 73 - - - - - - - - - - - -
Madagascar 68 57 57 75 52 63 68 57 57 68 57 57 55 44 44 14 32 67 55 55 57 57 57 65 53 53
Malawi 94 93 86 87 89 84 94 93 86 94 93 86 90 90 98 75 74 60 93 89 87 87 93 87 91 92 85
Mali 70 77 77 78 83 83 70 77 77 70 77 77 62 70 70 26 33 44 65 72 72 77 77 77 68 70 70
Mauritania 72 68 76 82 79 88 72 68 76 72 68 76 70 63 72 - - - 71 66 71 73 65 73 71 53 72
Mauritius 93 92 95 96 95 97 93 92 95 93 92 95 89 87 98 87 83 93 94 93 95 97 97 92 86 89
Morocco 99 99 99 99 99 99 99 99 99 99 99 - - - - - - - - - - - -
Mozambique 79 61 61 91 79 79 79 61 61 79 61 61 81 84 84 62 70 70 73 67 67 70 70 70 79 70 73
Namibia 93 94 84 99 93 93 93 94 84 93 94 84 90 91 91 63 56 79 92 73 86 85 79 85 77 42 55
Niger 81 82 84 94 95 95 81 82 84 81 82 84 79 80 65 60 66 42 81 82 84 84 82 84 83 85 86
Nigeria 62 62 62 74 74 74 62 62 62 62 62 62 60 60 60 38 38 38 62 62 62 60 60 60 - - 12
Rwanda 91 88 98 89 89 98 91 88 98 91 88 98 94 87 96 91 85 82 91 88 98 98 88 98 91 89 98
Sao Tome and Principe 96 97 97 94 93 93 96 97 97 96 97 97 86 77 77 75 69 69 94 93 93 97 97 97 87 78 78
Senegal 91 85 88 95 87 87 91 85 88 91 85 88 88 87 80 69 75 66 91 85 88 88 86 88 92 84 69
Seychelles 97 94 97 99 99 99 97 94 97 97 94 97 97 94 98 99 86 98 97 94 97 97 95 97 98 98 99
Sierra Leone 91 92 91 72 74 73 91 92 91 91 92 91 87 87 90 67 67 73 90 90 91 93 90 93 90 75 88
Somalia 42 42 37 37 42 42 42 42 42 42 42 46 46 46 - - - - - - - - - - - -
South Africa 84 86 85 86 86 84 84 86 85 84 86 85 84 87 86 76 82 87 84 86 85 89 87 89 85 83
South Sudan 67 69 73 69 71 72 67 69 73 67 69 73 69 74 72 - - - 65 69 72 - - - - - -
Sudan - 84 84 92 84 90 84 84 84 84 86 81 81 - - - - - - - - - - - -
Tanzania 86 81 88 87 83 90 86 81 88 86 81 88 84 77 86 67 62 76 65 70 88 83 80 83 82 77 67
Togo 82 83 82 96 98 91 82 83 82 83 82 69 70 71 46 50 57 80 81 75 82 83 82 78 80 79
Tunisia - 97 - - - - 97 - - 97 97 97 98 95 95 - - - - - - - - - - - -
Uganda 89 91 89 91 83 82 89 91 89 89 91 89 89 90 90 - - 49 88 91 90 90 91 90 88 87 84
Zambia 84 91 82 85 92 85 84 91 82 84 91 82 96 90 90 74 81 81 83 87 84 78 89 78 87 87 32
Zimbabwe 86 88 90 88 88 96 86 88 90 86 88 90 85 88 90 74 76 77 86 88 90 90 88 90 88 55

Competing interest

None declared.

 Data Accessibility statement

All data are publicly available.

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