1 Introduction

Military takeovers in regional politics are not entirely new events; since World War II, such occurrences, to a variable degree, have been reported in over two-thirds of countries in Latin America, Asia, and Africa. A coup d’etat is typically characterized by a sudden, unconstitutional, and violent government toppling by a small group, usually military or police, who overthrow the existing leaders. It involves a power shift initiated from the top, leading to the sudden replacement of key government officials. However, it may not bring about changes in the state’s core socio-economic policies or significantly redistribute power among political groups [1]. This group of security forces illegally seizes power from the existing government, sometimes with the assistance of others within the administration. It differs from ‘revolutions’, which are movements by a larger population seeking socioeconomic or political change [2]. Among the 54 countries of the African continent, 45 nations have experienced at least one attempted coup d'état since 1950, resulting in millions of deaths [3]. Research by Powell and Thyne showed that from 1950 till date, the African region experienced the most coup attempts (217), of which 109 were successful [3]. In their study, they define a successful coup as an unlawful and overt attempt by the military or other elites within the state apparatus to overthrow the current executive, where the perpetrators manage to seize and maintain power for a minimum of 7 days [3]. Before 1990, military coup d'etats were the most common form of leadership change in most African countries [4]. Although the early 1990s brought with it a wave of constitutional reforms rendering such military transitions illegitimate, pockets of such events still occur, but their popularity has waned greatly across the continent [5]. However, it has been argued that the reduced success rates of coups experienced in the 1990s did not significantly reduce the military’s propensity toward further attempts [2].

The causes of coups in Africa are multifaceted and can be attributed to a complex interplay of personal, historical, geographical, economic, ethnic, political, and cultural factors that date far back as the post-Cold War era [6,7,8]. Global trends indicate that military takeovers and coups have been most frequent on the African continent, particularly in West Africa, over the past two decades. Since 2010, there have been 17 successful military coups in 10 African countries, with majority in the “coup belt” (Fig. 1) [9]. This highlights a significant and ongoing issue within the African political landscape. The military in most African countries is ethnically polarised and displays loyalty to ethno-regional sentiments above national interest [7]. While many countries have ethnoreligious diversity, researchers argue that diversity does not increase the likelihood of unrest; rather, what matters is how power is distributed in the post-colonial states [10]. Many nascent democracies in the region were plagued by socio-political issues leveraged by coup plotters, such as high poverty rates, poor economic policies, insecurity, poorly equipped militaries, civil unrest, non-transparent elections, and imported terrorism from neighbouring countries [11].

Fig. 1
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Geographic distribution of coups in Africa since 2010 [9]

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The departure from the duty of public safety and territorial integrity by the military regimes has adversely impacted economic and human capital development in the region, leading to morbidities and mortalities for millions of people from food insecurity and malnutrition [12,13,14]. The resultant erosion of legal frameworks creates an unfavourable climate for economic activities and foreign investment, even as fiscal impropriety and diversion of budgetary allocation from critical infrastructure like public healthcare increases the dependence on foreign aid [5]. Public health is also impacted by mass displacement of persons, mass casualty events, and mortalities, with a potential for the spread of epidemics [14]. Additionally, health service delivery is also hampered by the flight of health workers as health facilities may be targeted, and there is disruption of communication, power supply, logistics for cold-chain, and other medical supplies from border closures [15, 16]. Vulnerable populations like women, children, and persons living with disabilities are disproportionately impacted. Therefore, there is a need to investigate this further and ensure equitable access to healthcare for victims of these crises. This review explores the public health implications of the sociopolitical dimensions of military coups in Africa, aiming to identify critical areas for interventions and to develop recommendations and targeted solutions.

2 Methods

A comprehensive search of relevant electronic databases was conducted to synthesise evidence for this review. The search was conducted across PubMed, Scopus, and Google Scholar, utilising MeSH keywords, Boolean operators, and multiple search terms, such as ‘military coup,’ ‘coup d’etat,’ ‘public health,’ ‘population health,’ ‘Africa,’ ‘healthcare delivery,’ ‘military displacement,’ ‘civil unrest,’ ‘international health,’ and ‘global health.’ The searches were conducted between January and February 2024, which yielded relevant articles, reviews, books, book chapters, policy documents, and grey literature, including website-based information that was invaluable for this reviews. The inclusion criteria accepted all publications in the last 15 years—enabling us to assess the impact on the evolving public health space. All studies discussing military coups and armed crises in Africa, published in English language, were also included. Conversely, all other studies not meeting the above criteria or discussing coups with no bearing on public health were excluded.

We began with an initial screening of study titles and abstracts. Studies passing this initial screening were subjected to a detailed reading of full texts, and 11 studies meeting the eligibility criteria were included in this review. Two independent reviewers extracted data from the included studies. Pertinent information such as author(s) and publication year, study type, country of coupt, the year of the coup, coup leader (where available), the duration of the coup, status (successful or failed attempt), and the effect on public such as the impact on health policies and implementation, maternal and child healthcare, medicine and vaccine supplies, cold chain management, and the efficiency of health systems and workforce were included extracted. These data were summarized and presented in Table 1. The findings from various sources were highlighted and discussed comprehensively, trends were identified, and information meticulously synthesised.

Table 1 Studies discussing recent coups in Africa
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3 Discussion

3.1 Brief history of coups in Africa

The subversion of King Farouk in Egypt in the early 1950s marked the emergence of military ascendancy in African politics in the post-colonial era, with coups becoming a recurring theme [2, 17]. A coup d'etat is typically illegitimate and undemocratic, often marked by changes in socioeconomic policies and redistribution of power among political groups. Giovanni termed African coups a “crisis,” with the second-largest continent witnessing 71 occurrences (60% successful) between 1952 and 1980 [18, 19]. Recently, military takeover and violent displacement of power have remained largely confined to Africa, often fueled by a mix of political instability, economic factors, and simmering public discontent [2, 18]. External state actors that prioritise unpopular local leaders amenable to neo-colonial interest have been implicated in the causality of coups [18]. Growing regional insecurity and crippling poverty rates in commodity-dependent countries breed frustration and perception of incompetence and corruption with even transparent governments, creating fertile grounds for coup d’etat [7].

The legacy of colonialism is deeply ingrained in the aetiology of coups in Africa. Colonialism in Africa is widely recognized as a causative factor in the region's political instability. Colonial powers drew arbitrary borders, grouped diverse ethnic groups, and established governance systems favouring colonial interests over local benefit [1]. Upon independence, many African nations inherited weak political structures, deep ethnic divisions, and economies designed to benefit the colonizers [20]. These challenges led to political instability in post-colonial Africa, with coups becoming a common means of changing governments. Countries like Nigeria, Ghana, and Uganda, all former colonies, have experienced multiple coups justified by claims of addressing corruption, poor governance, and ethnic favouritism—issues rooted in the colonial legacy [1]. Liberia, founded by freed African-Americans in 1847 and never colonized by Europe, has also experienced significant political instability, including two civil wars and subsequent public health crises. It is reported that the Americo-Liberians who settled in Liberia created a governance system that marginalized the indigenous population, resulting in a dual society where Americo-Liberians held political and economic power, while the majority indigenous population were excluded [21]. The resultant division and resentment persisted for over a century. Although the post-war period has seen relative peace, political and economic challenges continue to contribute to instability across African countries.

In the aftermath of the Cold War, Charles Piot offered a nuanced analysis of the factors underpinning political instability in Togo and the African region, noting how internal conflicts resulted from a combination of weak state structures, ethnic tensions, economic disparities, and the proliferation of small arms [22]. Some armed conflict theorists like Robert Bunker highlighted the shift from conventional to unconventional warfare, while Robert Muggah explored the intersection between violence, crime, and conflict within the context of state and non-state actors [23, 24]. The role of non-state actors, including criminal organisations in the origins of contemporary conflicts has been further supported by Danilo Mandic, as these actors frequently influence political and territorial stability [25]. In Africa, the abrupt disintegration of colonial structures left behind weak governance frameworks, which are further strained by economic mismanagement and growing external debt crises. Ethnic and sectarian divisions, often exacerbated by colonial-era governance, have fueled many conflicts, with leaders manipulating these identities to maintain power. Additionally, there has been an increased involvement of non-state actors, including transnational criminal networks, multinational corporations, and private military contractors, further complicating the landscape of internal armed conflicts [26]. Furthermore, there has also been a shift in the nature of international interventions following these armed conflicts in Africa. Initially, multilateral interventions like the United Nations or regional organisations like the African Union were common. Whereas, in the aftermath of recent coups in Africa, countries like China and Russia are noted to be actively engaged in strategic partnerships and investments in conflict-prone regions, forcing the breakdown of relations between the African countries and the United States or France [27]. The globalised and complex nature of these coup events further highlights the need for a multifaceted approach towards understanding and addressing these challenges.

It has become imperative to analyse trends and investigate the impacts of coups in the region following such events. The Total Military Intervention Score (TIMS) is a quantitative measure used to assess the frequency and intensity of military interventions within a country or region, and it considers factors such as the number of coups, attempted coups, military takeovers, and other forms of military interference in politics [2]. The score is computed for each state or nation and analysed over time to identify and understand patterns in coup activities [2]. It was used to explore trends in coup incidents, showing a decline post-1980 due to decolonisation, yet some West African states faced 21st-century coups [2]. Although this region of 16 countries labelled the “coup belt” has exhibited vulnerability, Senegal stood as a rare coup-free exception due to effective civilian-military relations [19, 28]. Researchers have utilized indicators such as a history of recent coups, the presence of authoritarian regimes, massive corruption, limited human rights, and leadership in transition to assess the degree of vulnerability to coups d’etats (Fig. 2) [9]. Many West African countries faced recurring coups, security challenges, governance deterioration, and declining living standards, accentuated by factors like the 2020 pandemic, climate change, and rising living costs [29].

Fig. 2
figure 2

African regions’ degree of vulnerability to coups d’etats [9]

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Post-coup trajectories, as reported in previous studies, reveal a discrepancy between the purported promises of political and economic rejuvenation and the attendant socioeconomic contraction and heightened insecurity [3, 17]. This challenges the narratives that legitimise coups d’etat as vehicles for positive change. For example, in Gabon, the restrictions on trade and border closures following the 2023 coup have caused detrimental economic effects [3, 29]. Such countries are also ostracized by regional decision-making bodies like the Economic Community of West African States (ECOWAS) and the African Union (AU) [3]. Empirical evidence suggests that investments are rarely attracted following a coup, whereas the healthcare sector is severely compromised [30]. The reality underscores the need for alternative political and economic development pathways other than coups [30, 31]. Understanding this trajectory offers insight into the strain and stretch suffered in the region in modern times, particularly in sustaining international relationships, attracting foreign investments and strengthening global collaboration towards strengthening public health interventions.

3.2 Coups and global health

3.2.1 The current landscape of Africa’s public health sector

Africa has recorded commendable growth in various aspects of public health despite looming challenges. The 2023 United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) report indicates a 51% reduction in global under-five mortality (U5M) since 2000. Despite sub-Saharan Africa having the highest U5M rates, countries in the region, such as Rwanda and Malawi, have recorded significant improvement in reducing their U5M rates by over 75% [32]. This achievement suggests the potential for substantial reductions in childhood deaths in the region.

The epidemic control of infectious diseases is another public health domain where significant advances have been recorded in the African region. In 2020, Africa became the 5th WHO region to be certified free of wild polio, joining the Americas, Western Pacific, Europe, and Southeast Asia regions [33]. Additionally, eight African countries have demonstrated exponential progress in meeting the 2025 Global Technical Strategy target for malaria control [34]. The region has also recorded complete eradication of some neglected tropical diseases (NTD), such as dracunculiasis in Kenya (2018), human African trypanosomiasis in Togo (2022), and trachoma in Togo, Gambia, Ghana, and Malawi (2022) [35]. By 2022, new HIV infections had plummeted to a third of 2010 levels, highlighting remarkable progress in transmission reduction due to concerted efforts towards achieving UNAIDS’ 95:95:95 2030 targets [36]. The region has also witnessed increased adoption of technology in healthcare. Mobile health (mHealth) and telemedicine, coupled with mobile clinics and disease surveillance networks, bridge geographical gaps, thereby improving healthcare delivery for remote populations [37, 38]. Persistent workforce shortages, poor infrastructure, and inequitable service distribution overshadow Africa’s healthcare advances [38, 39]. The SARS-CoV-2 pandemic, by forcing scarce resource reallocation to mitigate its spread, widened pre-existing cracks in public health systems under the pandemic’s strain, leaving the continent navigating the consequences.

3.2.2 Socioeconomic and political dimensions of coups and their impact on public health

Recent coups in Mali (2021), Guinea (2021), Burkina Faso (2022), Gabon (2023), and Niger (2023) raise concern about the vulnerability of democratic institutions and their direct impact on access to quality healthcare, one of the 2030 sustainable development goals (SDG) [15, 16, 38,39,40]. The political turbulence in the setting of a coup, stemming from corrupt activities targeted at individual gains rather than a common good, often results in dysfunctional systems that impair the quality of service delivered. These practices undermine governance structures, leading to weakened institutions that are unable to manage resources or provide public services effectively. This outcome highlights the nexus between coups and global health [40].

The political scene undergoes a brutal restructuring and power redistribution during a coup, leaving lingering scars on government agencies, public trust, and vital healthcare initiatives. Political upheavals result in mass disillusionment and loss of confidence in government health agencies, resulting in a sharp decline in participation in critical public health programs like vaccination campaigns and disease surveillance initiatives [41]. This erosion of trust can have cascading effects, potentially jeopardizing entire regions as infectious diseases spread unchecked. Furthermore, coups trigger a drastic shift in resource allocation, prioritizing security and military needs at the expense of healthcare investments [42]. Africa’s marginalisation from the global economy is due to inadequate enabling environments for foreign investments fuelled by political instability rather than a shortage of viable investment opportunities [43]. According to the United States Institute of Peace, only about 3% of the world’s foreign direct investment (FDI) is allocated to Africa - a continent that houses approximately 16% of the global population [43]. This is partly due to the weak rule of law in the region, which undermines foreign investment. The consequences for the African public health landscape negatively impact infrastructural development, medicine and vaccine supplies, and public health programs such as immunisation and HIV epidemic control programs, which are hugely dependent on external funding. This underfunding cripples an already failing healthcare system, leaving vulnerable populations exposed to outbreaks of preventable diseases or without access to essential healthcare and basic amenities [44].

Research has shown that conflicts slow development per capita income and lead to high unemployment rates, export dependency, and weakened central authority. Poor fiscal policies and the potential for another coup also characterize such countries [45]. Human capital flight is a consequence of such events due to forced displacement and social unrest, and this exacerbates the migration of professionals, including health workers, and undermines the development of future health workers [38, 46].

3.3 Outcomes necessitating attention and interventions

3.3.1 Maternal health

Providing effective maternal healthcare is a vital component of the sustainable development goal. Each year, about 210 million women become pregnant worldwide, resulting in 140 million live births [47]. According to a 2022 report, the maternal mortality rate (MMR) in Africa declined from 718 to 442 maternal deaths per 100,000 live births between 2000 and 2017 [48]. However, the degree of improvement is uneven as North Africa records the lowest MMR, and the West African region still maintains the highest rates [48, 49]. Coincidentally, 60% of sub-Saharan and over 90% of West African nations have experienced coups since the Cold War, and this has been shown to correlate with poor maternal health indices [50, 51].

The impact of conflicts on negative maternal health outcomes is explained by the worsening local economy and destruction of health infrastructure, which widens the healthcare gaps and potentiates poor healthcare-seeking behavior. Previous studies have shown that geographical proximity to organized violence reduces the likelihood of medically supervised births [51]. Beyond limited access to skilled birth assistance or institutional delivery, maternal mortality is more likely during armed conflicts.

3.3.2 Child health

Studies have reported a correlation between armed conflicts and childhood malnutrition, although the degree of association with nutritional status is dependent on socioeconomic status [52]. In the event of coups, undernutrition results from exacerbation of food insecurity and forced displacements of families [53]. Between 1990 and 2015, sub-Saharan Africa (SSA) accounted for one-third of global childhood malnutrition [52]. The most prevalent form of malnutrition is undernutrition, which threatens childhood survival, growth, and development. Undernutrition in children is characterized by wasting and stunting due to deficiency in essential nutrients like proteins, carbohydrates, and minerals [54]. This decline in health indices has been shown to impede economic advancement, thus creating a vicious cycle [55].

3.3.3 Medicine supplies and vaccines cold chain disruption

A common aftermath of coup d’etat is the creation of leadership vacuums in healthcare administration that contribute to disruptions in the continuity of health service [56, 57]. Political instability in Mali hinders access to medicines, particularly vaccines, as it affects all domains of the medical supply chain [56]. In Sudan and most of Africa, healthcare systems rely on imported medicines and vaccines due to low local production, which is less than 15% [31, 58]. This high level of dependence on imports renders the healthcare system susceptible to disruptions in international supply chains. The limited access to foreign exchange during these coups further depletes the vaccine supply and interrupts the cold chain needed to dispatch available products to rural areas [56]. From the preceding, the coup weakens local production and prevents the importation of essential medical supplies. This makes vaccination programs difficult to implement, even as gains made in controlling vaccine-preventable diseases like polio, meningitis, and hepatitis may be lost.

3.3.4 Public health policies and implementation

Military coups may result in significant modifications to healthcare policy. These changes are often motivated by personal interests rather than systematic and public-centered agendas. In the aftermath of an abrupt power change, such as that caused by a coup, it is not uncommon for inexperienced personnel to take on influential roles [56]. As a result, policies are often put into effect without proper experimentation, thoughtful planning, or thorough deliberation. This can lead to negative consequences and undesirable outcomes. One such is an undue strain on international collaborations and relations, such as those from donors and funding organisations [56]. The public, who depend on these health interventions and relief, suffer not from the coup's civil unrest but from the unavailability of essential needs.

3.3.5 Healthcare service delivery and availability of medical personnel

In the event of a military coup, essential service delivery can be severely hindered due to the crippling of communication systems and disabling of power infrastructure. Shutting down mobile networks severed communication between citizens, health authorities, and emergency responders. Closure of transport networks also prevents health workers from accessing health institutions or transporting patients in need of emergency care. The 2021 Sudanese coup saw workers in Khartoum and other major cities cut off from healthcare facilities due to roadblocks by counter-coup groups [16]. Eventually, non-critical health services were suspended, leaving emergency response nonoperational. The narrative in Mali was in keeping with the aforementioned, where all community clinics in the city, including the second largest city in Northern Mali, were shut down, leaving only four volunteer physicians to meet the healthcare needs of the teeming population [15]. With the collapse of the government-run health systems in Northern Mali, medical illnesses skyrocketed, fueled by food shortages and inadequate medical supplies. The urban–rural health inequalities are reversed, as urban cities bear the brunt of the damage in the wake of a coup, and to a lesser extent, rural areas suffer from scarcity of medical resources and worsening socioeconomic factors that affect health [16, 55, 56].

The recurrent military coups in Mali paralyzed the healthcare sector, sending about 65% of refugees in Mali to seek shelter in neighboring countries [59]. The United Nations High Commissioner for Refugees (UNHCR) reported in 2022 that approximately 402,000 people had been displaced from Mali by the civil unrest resulting from the coup [59]. The COVID-19 pandemic restrictions led to worsened living conditions, decreased food security, and limited healthcare access [58, 59].

While coups are acute events, their consequences on the health sector are debilitating and linger for the foreseeable future. From our review of the literature, there has been only one recorded coup in Africa, with no major adverse effect on the healthcare system. Guinea’s most recent military takeover had healthcare services in good operation with continuous distribution of the COVID-19 vaccines [60, 61].

3.4 Strengths and limitations of the study

This timely review fills critical gaps in our understanding of coups’ impact on the African public health sector. It offers invaluable insights for academics and practitioners working to strengthen regional health security. By delving into case studies, analyzing trends, and drawing connections between socioeconomic and political consequences of coups and health outcomes, the review provides a nuanced and actionable roadmap for building resilient health systems. The study also delineates the effects of coups on maternal and child health, medical supplies and vaccine cold chains, health policy implementation, and service delivery.

Some limitations were also noted. Variations in account of events by sources in different regions may have impacted our analysis. This study did not examine political implications extending beyond the immediate post-coup events. There is a dearth of longitudinal studies assessing the impact of coups on various aspects of public health in Africa, which implies the lack of a snapshot estimating the incidence and prevalence of specific outcomes in these periods. This absence limits the scale of policy formulation that can mitigate the adverse consequences, leading to a self-perpetuating cycle of ill-preparedness towards a possible coup in the future.

4 Conclusion

Military coups directly impact the pipeline to the attainment of universal health coverage in Africa. With over 214 attempts and about 109 successful coups in the last seven decades, Africa, particularly West Africa, remains the epicentre of coup d’etats in the world. Arguably, various factors have been studied as contributing to its recurrence in the region; however, the interplay of personal, historical, geographical, economic, ethnic, political, and cultural factors holds. Political instability and poor governance remain the hallmarks. This political unrest disrupts public service, leading to a breakdown in healthcare delivery systems. Negative health outcomes, including increased maternal mortality rates, significant undernutrition, disruption in key health interventions like vaccination programs, population displacements, and poor health policy implementation, have been identified as outcomes necessitating interventions. To foster resilience in the immediate post-coup era, improving health infrastructure by decentralising health facilities in the case of regional insurrection is important. Ensuring existing supply chains are strengthened by stockpiling essential medicines and supplies in different regions, particularly nations prone to war offers a useful strategy for ensuring the maintenance of medical supplies during coups. Strengthening healthcare systems from succumbing to the aftermath of coups is necessary; this can ensure that resilient systems are created to provide a degree of insulation to political instabilities. Building partnerships with donors and international rescue and relief organizations and agencies is invaluable. While our study recorded strengths, various limitations were also noted. By addressing these limitations, policymakers and analysts can build on our findings to develop strategies for preventing or mitigating future coup attempts.