Background: In light of the public health emergency brought about by the novel coronavirus, health authorities
actively promoted vaccination against SARS-CoV-2. The COVID-19 pandemic has brought to the forefront critical
questions concerning individual freedoms and the right to consent or decline vaccination. To better anticipate
and manage future epidemics, it is essential to engage in thoughtful philosophical and ethical reflec
tion—particularly regarding the legitimacy and implications of vaccine passport policies.
Objectives: This study aimed to assess COVID-19 vaccine acceptance and hesitancy in Sub-Saharan Africa, identify
reasons for refusal, and examine the ethical legitimacy of imposing a “green pass” for vaccination for foreign
travel.
Methods: A meta-analysis was conducted from January 2021 to April 2025 in sub-Saharan African countries, in
five databases (PubMed, Science Direct, Google Scholar, African Journal Online, and HINARI) to identify studies
related to acceptance and hesitancy toward COVID-19 vaccines in the general population and among healthcare
professionals. This study was registered under the PROSPERO database (CRD420251060375) and used the
PRISMA guidelines. The “proportional effect size” of acceptance and hesitancy was calculated using a random-
effects meta-analysis with STATA 17 software. Funnel plots and Egger's tests were used to assess publication bias.
Results: A total of 40 studies involving 107,478 participants across 23 African countries were included. The
pooled rates of vaccine acceptance and hesitancy were, respectively: 54.73 [95 % CI: 50.54 %–58.89 %], and
34.96 % [95 % CI: 27.95 %–42.30 %]. Eastern Africa had the highest acceptance rate (60.44 %), and lower rate
observed in West Africa (52.22 %). Reasons for hesitancy included misinformation, distrust of new vaccines, fear
of side effects, suspicion of authorities, and opposition to mandatory vaccination certificates.
Conclusion: The pandemic has brought to the fore fundamental issues relating to the right to accept or refuse
vaccination. To prepare for the management of future epidemics, it is necessary to reflect on the ethics of
requiring a vaccine passport.

COVID-19; vaccine; Acceptance; Hesitancy; Green pass; Ethic; Sub-Saharan Africa