Who will pay for the malaria vaccines in Africa?

Abstract Malaria remains one of the most persistent infectious threats in sub-Saharan Africa, where the burden of disease and mortality are disproportionately concentrated among children under five years of age. The World Health Organization’s endorsement of the RTS, S/AS01 vaccine in October 2021 and the R21/Matrix-M vaccine in October 2023 represents a major scientific advance; however, the central question confronting African policymakers, donors, and governments is no longer scientific but financial. In 2024, an estimated 282 million malaria cases and 610,000 deaths occurred worldwide, with the African region accounting for more than 94% of cases and 95% of deaths. The Vaccine Alliance has committed to malaria vaccine introduction through its advance market commitment model; however, its tiered co-financing framework places a fiscal burden on the highest-burden, lowest-income countries. The experience of the COVID-19 pandemic illustrates how vaccine nationalism and concentrated manufacturing can delay equitable access in Africa. Effective vaccine delivery also requires sustained investment in cold-chain systems, the health workforce, and immunisation platforms reaching conflict-affected areas, the costs of which are frequently excluded from procurement estimates. Most African Union member states remain below the Abuja Declaration target of 15% national health spending, sustaining dependence on external financing and undermining health sovereignty. Coordinated action by donors, governments, and manufacturers, including predictable multi-year financing, differential pricing, and measurable domestic allocations, is needed to prevent distribution by purchasing power rather than by epidemiological need. This comment aims to examine who will finance malaria vaccines in Africa and how equitable and sustainable delivery can be secured.