The institutional roots of vaccine uptake and hesitancy: evidence from Africa.

Africa recorded some of the lowest COVID-19 vaccination rates in the world, with only 32% of the population having completed a primary vaccination series by the end of 2023, despite widespread vaccine availability. Differences in supply and access offer only a partial explanation, pointing to the role of institutional factors-particularly corruption perceptions and distrust in government-as demand-side barriers. This study provides causally identified estimates of the effect of institutional quality on COVID-19 vaccine uptake and hesitancy across 34 African countries. Using data from the Afrobarometer Round 8 survey, which covers 37,876 respondents, corruption perceptions and institutional trust are treated as endogenous and instrumented with leave-one-out regional means. Instrumental variable probit models are estimated, and average marginal effects are reported. General corruption perceptions reduce the probability of vaccine uptake by 2.7 percentage points and increase the probability of hesitancy by 6.3 percentage points. General institutional trust raises uptake by 9.0 percentage points and reduces hesitancy by 10.6 percentage points. COVID-19-specific corruption perceptions have no significant independent effect on either outcome once trust in the government's handling of vaccine safety is controlled for. Vaccine-specific trust raises uptake by 16.9 percentage points and reduces hesitancy by 24.9 percentage points, suggesting that corruption operates indirectly by eroding vaccine-specific confidence rather than through an independent direct channel. These findings indicate that sustained investment in governance and credible vaccine communication are both required to improve vaccination rates in Africa, and that the two constitute complementary rather than substitutable public health interventions.