Background: The end of the COVID-19 public health emergency of international concern (PHEIC) in May 2023 marked a transition from disruption to recovery and rebuilding of health systems. The WHO African Region entered this period with declining routine immunization coverage, widening inequities, and fragile surveillance systems. We conducted a critical narrative synthesis of post-PHEIC recovery and the transformation of immunization systems in the region from 2023 to 2025. Methods: We thematically analyzed publicly available data from the WHO and other sources using a systems-oriented framework covering immunization coverage, equity, vaccine introductions, disease control, governance, financing, and data systems. Results: Regional coverage for most antigens was restored to 2019 pre-pandemic levels by 2024, e.g., three doses of diphtheria-tetanus-pertussis-containing vaccines at 76%. However, progress remains insufficient to meet the Immunization Agenda 2030 (IA2030) target of 90% coverage. In addition, there were 6.7 million zero-dose children in the 2024 birth cohort (6.3% higher than the 6.3 million in 2019), concentrated in a few countries. The IA2030 target is a 50% reduction in the number of zero-dose children by 2030, compared to 2019. Recovery initiatives have restored services, while accelerated introductions (e.g., malaria vaccines introduced in 20 new countries in 2024–2025) signal renewed system momentum. Yet, progress has plateaued at pre-pandemic levels, reflecting structural constraints rather than sustained transformation. Concurrently, recurrent outbreaks of measles, yellow fever, and other vaccine-preventable diseases highlight persistent immunity gaps and surveillance limitations. Structural constraints (including financing fragility, subnational inequities, and system fragmentation) continue to limit sustained progress. Conclusion: This study offers important insights that can inform immunization policymaking in the WHO African Region and beyond. Current post-PHEIC trends reflect recovery without transformation. Achieving IA2030 targets will require a shift from broad coverage expansion to precision delivery approaches that prioritize zero-dose and underserved populations. Immunization must be positioned as a central pillar of primary health care and health security systems.

The end of the COVID-19 pandemic in May 2023 marked a pivotal transition from emergency response to recovery and rebuilding of health systems across the world. The WHO African Region entered this period with declining routine immunization coverage, widening inequities, and fragile surveillance systems. This review critically synthesizes post-pandemic immunization and vaccine-preventable disease (VPD) trends using publicly available data. Regional coverage for most vaccine doses returned to 2019 pre-pandemic levels by 2024. However, 6.7 million zero-dose children remain concentrated in a small number of countries. Accelerated recovery efforts – including the Big Catch-Up initiative, policy normalization of catch-up vaccination, and strengthened social and behaviour change strategies – have mitigated further backsliding. Concurrently, accelerated disease control initiatives - targeting measles, yellow fever, tetanus, meningitis, and poliomyelitis - have highlighted both renewed momentum toward elimination and eradication, and persistent vulnerabilities driven by immunity gaps, climate shocks, urbanization, and conflict. The strongest marker of regained momentum has been accelerated introductions of vaccines against malaria (in 20 new countries), human papillomavirus (in 10 new countries), and other VPDs across the region. However, sustained progress will require institutionalizing catch-up vaccination, systematically using implementation research to strengthen subnational tailoring, enhancing integrated surveillance systems, and securing predictable domestic financing within the framework of the Immunization Agenda 2030.