Mapping legislative and regulatory frameworks for preventive audiology in Africa: progress and challenges

Highlights

• Published evidence on legislative and regulatory frameworks for preventive audiology remains heavily concentrated in South Africa, highlighting important geographical evidence gaps across the continent.
• Continental and global frameworks provide strong normative guidance, but national implementation remains inconsistent across the available evidence.
• Workforce shortages, limited financing, weak legislative enforcement, and the absence of statutory EHDI mandates continue to impede equitable preventive hearing care.

Integration of preventive audiology into UHC schemes, supported by tele-audiology, task-shifting, and strengthened governance, represents a promising direction for future policy development.

Introduction

Hearing impairment represents a profound and growing public health challenge, with the World Health Organization (WHO) reporting that over 430 million people currently live with disabling hearing loss. Projections suggest that by 2050, this number will exceed 700 million globally (World Health Organization (WHO), 2021). Within the African continent, the burden is particularly acute, with approximately 40 million people affected, representing a prevalence of 3.6%. Estimates indicate that this figure will rise to 54 million by 2030 and 97 million by 2050, with associated economic losses estimated at US$ 27.1 billion annually (Olusanya et al., 2014; World Health Organization (WHO), 2021). Despite these alarming figures, hearing healthcare remains largely “invisible” within national health agendas in many low- and middle-income countries (LMICs), where legislative attention and funding are prioritized for high-profile, life-threatening diseases such as HIV/AIDS, malaria, and tuberculosis (De Kock, 2025; Khoza-Shangase, 2025a).

Preventive audiology encompasses the strategies, policies, and practices aimed at preventing hearing loss and mitigating its consequences across the lifespan (Khoza-Shangase, 2022a; Olusanya, 2008; World Health Organization (WHO), 2023). A life-course perspective is fundamental to preventive audiology because hearing health risks, preventive priorities, and legislative requirements differ across population groups. Preventive interventions range from universal newborn hearing screening and early hearing detection and intervention programs during infancy, to hearing conservation among school-aged children and adolescents, occupational hearing conservation for economically active adults, ototoxicity monitoring for individuals receiving potentially ototoxic medications, and hearing care for older adults experiencing age-related hearing loss. Although Africa has a comparatively young population, demographic and epidemiological transitions make the adoption of a life-course approach increasingly important for ensuring that legislative and regulatory frameworks remain responsive to changing hearing healthcare needs across the population. It requires health professionals to maintain situational awareness of contextual risk factors, identify potential points of harm, and implement proactive measures to avert them. In the African context, preventive audiology aligns with re-engineered primary healthcare (PHC) frameworks and WHO guidance, addressing major burdens including early hearing detection and intervention (EHDI), middle ear pathologies, ototoxicity, and occupational noise-induced hearing loss (ONIHL) (Khoza-Shangase and Kanji, 2021; Hatzopoulos et al., 2025). Preventive measures are critical because hearing function is vulnerable to a combination of environmental exposures, lifestyle factors, genetic predisposition, and the high disease burden characteristic of LMIC settings (Dai La et al., 2026; Khoza-Shangase, 2022b; Olusanya, 2012).

The current legislative and regulatory environment across Africa is marked by significant heterogeneity and fragmentation (Petrocchi-Bartal et al., 2025; Khoza-Shangase, 2025a). Legislative and regulatory frameworks relevant to preventive audiology extend beyond hearing-specific statutes and include constitutional health rights, disability legislation, public health legislation, occupational health and safety laws, national health insurance legislation, professional regulatory standards, and broader health system policies. While global instruments, such as World Health Assembly Resolution WHA70.13, the WHO World Report on Hearing, and the H.E.A.R.I.N.G. Technical Package, advocate for the integration of ear and hearing care into PHC and universal health coverage (UHC), the translation of these commitments into enforceable national law remains inconsistent (World Health Organization (WHO), 2017, 2021, 2023). Many African states lack specific legislative mandates for universal newborn hearing screening (UNHS), resulting in the late identification of congenital hearing loss, often at 30 months of age, far exceeding the internationally recommended benchmark of detection by 1 month (Hatzopoulos et al., 2025; Kanji, 2021; Olusanya, 2008, 2012; Phanguphangu et al., 2025). Similarly, while occupational noise regulations exist in most countries, their enforcement is frequently weak, especially in high-risk sectors such as mining and manufacturing, leaving workers vulnerable to preventable hearing loss (Manning and Pillay, 2020; Moroe, 2020; Khoza-Shangase and Moroe, 2020; Khoza-Shangase, 2025b).

At the continental level, the African Union (AU) has developed legally significant instruments, such as the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Persons with Disabilities in Africa (2018). This protocol provides a binding rights-based framework, explicitly recognizing audiology as a component of habilitation and rehabilitation services, which states are obliged to ensure are accessible, affordable, and integrated into public health systems (African Union, 2018a; Ncube et al., 2021). However, the operationalisation of these high-level continental commitments into district and community-level service delivery remains uneven and fragmented, reflecting systemic challenges in governance, workforce capacity, and resource allocation. Furthermore, the available evidence demonstrates considerable geographical imbalance, with the majority of published studies originating from South Africa and comparatively limited evidence from many other African countries. Consequently, interpretations of continental patterns should be viewed within the context of this uneven evidence base.

This structured narrative review, reported in accordance with the PRISMA 2020 reporting guidelines to enhance methodological transparency, critically maps, and analyses legislative and regulatory frameworks shaping preventive audiology across Africa, focusing on the alignment, coherence, and gaps between national, continental, and global instruments. By examining systemic barriers, including workforce shortages, financial constraints, limited enforcement, and socio-cultural factors, the study identifies opportunities to strengthen regulatory environments and advance rights-based, contextually responsive preventive audiology, ultimately supporting equitable access to hearing care for African populations.

Methods

Study design

This study adopted a structured narrative review design, reported in accordance with the PRISMA 2020 reporting guidelines to enhance transparency in literature identification, screening, and reporting, while recognizing that this review did not seek to meet the methodological requirements of a formal systematic review (Ferrari, 2015). The narrative review approach was selected to provide a comprehensive and interpretive synthesis of the available evidence while maintaining methodological transparency and rigor. Unlike purely quantitative systematic reviews, this design allows for the critical integration of diverse sources, including empirical studies, narrative and systematic reviews, policy analyses, peer-reviewed scholarly book chapters, legislation, and continental and global normative instruments that shape preventive audiology in Africa. The narrative approach is particularly suited to mapping heterogeneous and contextually fragmented data in LMIC settings, where policy implementation and operationalization vary widely and where evidence originates from multiple disciplines rather than a single body of primary research.

Search strategy and information sources

A comprehensive and systematic search of multiple online databases was conducted to identify relevant evidence. Primary databases included PubMed, Scopus, Web of Science, and African Journals Online (AJOL). Supplementary searches were performed in Google Scholar to ensure inclusion of recent publications and regionally relevant sources not indexed in global databases.

The search was limited to publications from 2000 to 2025 to capture contemporary policy shifts, legislative developments, and emerging frameworks for preventive audiology across Africa. Search terms were constructed in English and combined keywords, Medical Subject Headings (MeSH) terms, and Boolean operators, including but not limited to: “preventive audiology” AND Africa, “hearing healthcare policy” AND “Africa,” “legislative framework” AND audiology, “newborn hearing screening” OR “universal newborn hearing screening” AND legislation., “occupational noise-induced hearing loss” OR ONIHL AND Africa, “ear and hearing care” AND regulation, “African Union” AND hearing, and “World Health Organization” AND hearing care. Database-specific search syntax was adapted where required while maintaining conceptual consistency across databases. Reference lists of all eligible publications were also manually screened to identify additional relevant studies not retrieved through electronic database searching. The search strategy prioritized studies addressing legislation, regulation, governance, policy implementation, policy coherence, or regulatory oversight relevant to preventive audiology in individual African countries or at continental initiatives.

Eligibility criteria

Inclusion criteria were designed to ensure the relevance, credibility, and applicability of the evidence. Eligible sources included peer-reviewed journal articles; peer-reviewed scholarly book chapters; high-authority legislative, regulatory, and policy documents issued by recognized national, continental, or international organizations (e.g., African Union and World Health Organization) where these constituted the primary subject of analysis; gray literature (including government reports and policy documents) identified through peer-reviewed publications or manual searching where they represented primary legislative or policy instruments relevant to the review objectives; publications directly addressing legislative, regulatory, governance, or policy frameworks relevant to preventive audiology; publications focusing on African national, regional, or continental contexts; and publications written in English.

Exclusion criteria were applied to reduce methodological noise and maintain focus on the review objectives. Clinical studies without reference to legislative, regulatory, governance, or policy issues; conference abstracts without full publications; opinion pieces lacking substantive policy analysis; duplicate publications; and studies conducted outside Africa without an explicit African comparative or policy context were excluded. The study selection process followed four stages: identification, duplicate removal, title and abstract screening, and full-text eligibility assessment. Disagreements regarding eligibility were resolved through iterative discussion among the review team until consensus was achieved. The search process is depicted in (Figure 1).

Data extraction and analysis

Data extraction followed a pre-defined framework developed specifically for this review and aligned with the objectives of this study. The framework captured:

• Evidence characteristics: author(s), publication year, country or region, publication type, study design, and geographical scope.
• Legislative and regulatory content: legislation, policy, guideline, or regulatory framework examined, year enacted or updated; and primary regulatory focus (e.g., EHDI, occupational hearing conservation, ototoxicity, professional regulation, and disability rights).
• Institutional oversight: responsible ministries, professional councils, regulatory agencies, continental organizations, or international bodies.
• Implementation status: legislative status, operationalization, implementation progress, monitoring mechanisms, and enforcement approaches.
• Systemic factors: workforce capacity, financing, governance, equity, awareness, technological infrastructure, cultural considerations, implementation barriers, and enabling factors.

To address the diversity of evidence included in this review, extracted data were first categorized according to evidence type (empirical studies, narrative/systematic reviews, legislative instruments, policy documents, and global or continental normative frameworks) before being synthesized across common themes. This distinction enabled interpretation of empirical findings alongside normative policy guidance without conflating these different forms of evidence.

The extracted data were analyzed thematically (Ahmed et al., 2025), identifying recurring patterns, gaps, and emerging trends across the African continent. Themes were organized around the review objectives: (1) mapping legislative and regulatory instruments, (2) evaluating coherence with continental and global commitments, (3) examining implementation status and systemic barriers, and (4) identifying opportunities to strengthen legislative and regulatory environments for preventive audiology.

Data saturation

Data saturation was achieved through an iterative review and synthesis process whereby successive publications did not yield substantively new legislative frameworks, regulatory themes, implementation barriers, or enabling factors. Instead, additional publications primarily reinforced or expanded existing thematic categories identified during earlier stages of analysis. The consistency of findings across multiple evidence types, including empirical studies, narrative reviews, legislation, and continental and global policy documents, provided confidence that the principal concepts relevant to the review objectives had been comprehensively captured.

Quality appraisal

The methodological rigor of included narrative review articles was evaluated using the Scale for the Assessment of Narrative Review Articles (SANRA) (Baethge et al., 2019). This six-item instrument assesses: (1) justification of the article's importance, (2) clarity of aims, (3) description of the literature search, (4) referencing, (5) scientific reasoning, and (6) presentation of data. Each item is scored 0–2, yielding a maximum total of 12. Because SANRA was specifically developed to evaluate narrative review methodology, it was applied only to narrative review articles included in this synthesis. It was not applied to primary empirical studies, legislation, policy documents, or continental and global normative instruments, as these represent fundamentally different forms of evidence requiring different evaluative criteria. Empirical studies were instead appraised according to their methodological rigor, considering study design, sampling, analytical transparency, and overall credibility. Legislative and policy documents were not subjected to methodological quality appraisal because they constitute primary normative sources rather than research studies; instead, they were assessed according to their legal authority, jurisdictional relevance, and policy significance within the African regulatory landscape.

Synthesis approach

A convergent narrative synthesis was undertaken to integrate evidence across multiple evidence types. Findings from empirical studies, narrative reviews, legislative instruments, policy documents, and continental and global normative frameworks were triangulated to identify areas of convergence, divergence, and evidence gaps. The synthesis examined how legislative and regulatory frameworks operate across different levels of governance; from global (WHO), continental (AU), and regional frameworks to national legislation, professional regulation, and implementation within health systems.

Particular attention was given to the coherence between these governance levels, the extent to which legislative commitments translated into operational implementation, and the systemic factors influencing successful or limited implementation. This integrative approach enabled a comprehensive understanding of the preventive audiology regulatory landscape while remaining consistent with the objectives of a structured narrative review.

Results

Profile of the included evidence

The review identified 31 sources that collectively examined o legislative, regulatory, and policy frameworks relevant to preventive audiology in Africa, while also incorporating global normative guidance where appropriate. The evidence comprised peer-reviewed narrative reviews, scoping and systematic reviews, policy analyses, qualitative studies, scholarly book chapters, editorials, and continental and international policy instruments. Narrative reviews constituted the largest proportion of the included evidence (n = 14; e.g., Olusanya, 2008, 2012; Khoza-Shangase and Kanji, 2021; Khoza-Shangase, 2025b; Petrocchi-Bartal et al., 2025), followed by scoping and systematic reviews (n = 8; e.g., Hatzopoulos et al., 2025; Townsend et al., 2023; Moroe and Khoza-Shangase, 2020), policy analyses (n = 5; e.g., Manning and Pillay, 2020; Onyango et al., 2021; Savedoff et al., 2012), qualitative studies (n = 3; e.g., Moroe, 2020; Mtimkulu et al., 2023; Khoza-Shangase and Moroe, 2020), and continental or global normative instruments (n = 4; e.g., African Union, 2018a; World Health Organization (WHO), 2017, 2021). Scholarly book chapters and editorials provided additional contextually relevant evidence, particularly for South Africa (e.g., Khoza-Shangase, 2025a; Khoza-Shangase et al., 2020). The predominance of narrative and policy-oriented publications reflects the emerging nature of scholarship examining legislative and regulatory dimensions of preventive audiology across Africa.

Geographically, the evidence remained concentrated in Southern Africa, with South Africa accounting for approximately one-third of the country-specific evidence (e.g., Moroe, 2020; Manning and Pillay, 2020; Khoza-Shangase and Moroe, 2020; Petrocchi-Bartal et al., 2025), followed by West Africa (primarily Nigeria and Ghana, e.g., Olusanya, 2008, 2012; Republic of Ghana, 2012), East Africa (primarily Kenya, e.g., Onyango et al., 2021), and North Africa (primarily Egypt). Continental frameworks, notably AU instruments (e.g., African Union, 2018a; Disability Protocol; African Union, 2018b HRISA 2018–2030), formed an important component of the evidence base, highlighting both the increasing emphasis on continental governance and the relatively limited availability of cross-national analyses of audiology-specific legislation. Global normative instruments from the WHO (e.g., World Health Organization (WHO), 2017, 2021, 2023), provided essential benchmarks for preventive audiology, occupational hearing conservation, and EHDI integration.

Narrative review articles generally demonstrated good methodological quality when appraised using the SANRA tool, particularly regarding clearly articulated objectives, scientific reasoning, and transparent evidence synthesis. Primary empirical studies also demonstrated acceptable methodological rigor based on study-specific appraisal criteria. Global and continental policy instruments, although non-empirical, were included because of their recognized normative and regulatory authority within African health governance.

Evidence table: mapping legislative and regulatory frameworks in Africa

Table 1 presents the key data extracted from the relevant sources identified during the review, while Figure 2 provides a summary evidence map illustrating the legislative and regulatory landscape for preventive audiology across African regions. The figure synthesizes the principal legislative and policy instruments, relative implementation status, and cross-cutting barriers and opportunities identified from the included evidence in (Table 1).

Table 1. Comprehensive evidence synthesis of mapping legislative and regulatory frameworks for preventive audiology in Africa: progress and challenge.

Thematic analysis

Thematic analysis of the results revealed four themes.

Theme 1: Mapping of legislative instruments and regional variability

The evidence reveals a continent marked by substantial legislative and regulatory heterogeneity. At the continental level, the AU Protocol on the Rights of Persons with Disabilities (2018) provides a legally binding rights-based framework, mandating access to habilitation, rehabilitation, and assistive technologies, while explicitly recognizing audiology and speech-language services. However, domestication of these commitments into national legislation remains inconsistent, with many AU member states yet to enact enforceable legislation reflecting these principles (Abdulwahab et al., 2024; African Union, 2018a; Disability Protocol; Ncube et al., 2021).

At the national level, legislative frameworks are generally embedded within broader health legislation rather than within audiology-specific statutes. In Nigeria, the National Health Act (2014) and (Federal Republic of Nigeria, 2022) provide overarching governance for the health system but do not specifically mandate UNHS or structured audiology oversight (Federal Republic of Nigeria, 2022; Olusanya, 2012). In Kenya, the Health Act (2017) and the Constitution (Article 43) recognize the right to the highest attainable standard of health; however ear and hearing care services remain only partially integrated within essential health benefit packages (Hatzopoulos et al., 2025; Onyango et al., 2021). In Egypt, the evidence identifies the country as the only African nation with a nationwide mandatory UNHS program employing two-phase otoacoustic emissions (OAE) screening and confirmatory auditory brainstem response (ABR) testing, demonstrating that legislated national implementation is feasible within a middle-income African setting (Olusanya et al., 2014). The Egyptian Universal Newborn Hearing Screening (ENHS) program has a coverage of over 82% with a follow-up attendance rate to over 90% (Abdelbadei et al., 2025). In South Africa, professional guidance aligns with internationally recognized 1:3:6 benchmarks (screening by 1 month, diagnosis by 3 months, and intervention by 6 months), yet these recommendations lack statutory enforcement, contributing to considerable variation in implementation across provinces (Khoza-Shangase and Kanji, 2021; Petrocchi-Bartal et al., 2025).

Continental strategies, including the Africa Health Strategy 2016–2030 and Health Research and Innovation Strategy for Africa (HRISA) 2018–2030, emphasize health systems strengthening, research capacity, and policy harmonization, but provide limited operational guidance for integrating preventive audiology into national health systems (African Union, 2016, 2018b; HRISA 2018–2030).

Theme 2: Coherence and alignment with global and continental commitments

Analysis of national frameworks against WHO normative instruments, includingWHA70.13, World Report on Hearing, and H.E.A.R.I.N.G. Technical Package, reveals partial alignment with global priorities. These instruments advocate integration of ear and hearing care within primary healthcare (PHC) and universal health coverage (UHC), emphasizing prevention, early identification, and timely intervention ((World Health Organization (WHO), 2017, 2021, 2023)). However, the included evidence consistently suggests that ear and hearing care continues to receive substantially less policy attention than other major public health priorities, including HIV/AIDS, tuberculosis, and malaria, thereby limiting legislative translation and resource allocation (Hatzopoulos et al., 2025; Khoza-Shangase, 2025b; Petrocchi-Bartal et al., 2025; Savedoff et al., 2012).

The AU Disability Protocol and Health Strategy provide an important rights-based and strategic policy foundation. Nevertheless, a substantial gap persists between these high-level commitments and their translation into enforceable national legislation and operational service delivery (African Union, 2016, 2018a). Collectively, the evidence suggests that although many African countries actively participate in continental and global health governance, implementation of preventive audiology policies remains fragmented and inconsistent.

Theme 3: Implementation challenges and systemic barriers

The review identified five recurring systemic barriers that impede effective implementation of preventive audiology legislation. First, Workforce and Human Resource Constraints. Severe shortage of audiologists, particularly within rural and public sector services, continue to limit preventive audiology coverage (Khoza-Shangase and Moroe, 2020; Mtimkulu et al., 2023; Moroe, 2020; Pillay, 2020). South African evidence demonstrates that audiology services remain concentrated within urban private-sector settings, leaving many rural communities with limited or no access to preventive hearing care (Khoza-Shangase and Kanji, 2021; Manning and Pillay, 2020; Moroe, 2020). Second, Financial and Economic Barriers. High out-of-pocket expenditure for hearing aids, cochlear implants, diagnostic services, and hearing screening, together with limited reimbursement through national insurance schemes, restricts equitable access to preventive hearing care (Mtimkulu et al., 2023; Olusanya, 2012; Savedoff et al., 2012; Khoza-Shangase, 2025a).

Third, Weak Legislative and Regulatory Enforcement. Although occupational noise exposure limits are established in many jurisdictions, implementation and employer accountability remain inconsistent across mining and industrial sectors (Khoza-Shangase, 2025a,b; Manning and Pillay, 2020; Moroe, 2020; Onyango et al., 2021). Recent evidence further demonstrates that occupational hearing conservation legislation has not adequately evolved to address the combined risks associated with hazardous occupational noise exposure and ototoxic medications used in HIV management. This represents an important regulatory gap in countries with high HIV prevalence, where occupational and public health legislation continue to operate largely in parallel rather than through integrated preventive frameworks (Khoza-Shangase, 2025b). Similarly, a recent synthesis of South African legislative and policy frameworks confirms that, despite a strong constitutional and disability rights foundation, there remains no mandatory nationwide UNHS legislation, resulting in marked provincial variability in access to early identification and intervention services (Petrocchi-Bartal et al., 2025).

Fourth, Cultural Stigma and Lack of Awareness. Public understanding of hearing health remains limited across many African settings (Hatzopoulos et al., 2025; Moroe and Khoza-Shangase, 2020; Olusanya, 2008). Social stigma associated with hearing loss and deafness contributes to delayed help-seeking, reduced uptake of screening programmes, and poorer adherence to recommended interventions (Khoza-Shangase and Kanji, 2021; Olusanya et al., 2014; Mtimkulu et al., 2023; Petrocchi-Bartal et al., 2025). Fifth, Knowledge and Capacity Gaps. Limited awareness among healthcare professionals regarding legislative and regulatory provisions further constrains implementation of preventive audiology services and weakens policy translation into clinical practice (Hatzopoulos et al., 2025; Khoza-Shangase and Moroe, 2020; Ncube et al., 2021).

Theme 4: Gaps and opportunities for strengthening regulatory environments

The evidence identified several opportunities for strengthening preventive audiology across Africa:

• Rural-urban inequities: Rural populations continue to experience substantially reduced access to hearing screening and preventive audiology services, contributing to inequitable service delivery (Hatzopoulos et al., 2025; Moroe, 2020; Olusanya, 2008).
• Universal health coverage: Re-engineered PHC systems and emerging National Health Insurance initiatives present important opportunities to integrate preventive audiology into essential health benefit packages (Khoza-Shangase and Kanji, 2021; Khoza-Shangase, 2025a; Mtimkulu et al., 2023; Savedoff et al., 2012).
• Digital innovations Tele-audiology, mobile health technologies, AI-supported risk assessment, and digital occupational noise monitoring offer promising approaches to overcoming geographical barriers and strengthening regulatory implementation (Hatzopoulos et al., 2025; Townsend et al., 2023; World Health Organization (WHO), 2023).
• Research and innovation: HRISA 2018–2030 provides an important framework for strengthening African-led research, promoting contextually appropriate evidence generation, and supporting regulatory innovation within preventive audiology (Abdulwahab et al., 2024; African Union, 2018b HRISA 2018–2030; Ncube et al., 2021).

Evidence summary

Across the 31 included sources, a consistent pattern emerged despite differences in study design, geographic focus, and policy level. Continental and global frameworks provide important normative direction for preventive audiology; however, their translation into enforceable national legislation remains inconsistent. Where legislation exists, it is frequently generic rather than audiology-specific, contributing to uneven implementation of EHDI and broader preventive hearing care services. Workforce shortages, financial barriers, weak legislative enforcement, limited policy integration, and socio-cultural factors continue to constrain implementation across much of the continent. At the same time, the evidence consistently identifies opportunities to strengthen preventive audiology through UHC reforms, digital health technologies, tele-audiology, task shifting, and African-led research and innovation. Collectively, these findings suggest that the principal challenge lies not in the absence of continental or global policy aspirations, but in the limited translation of these commitments into sustainable, enforceable, and equitable hearing-care systems across diverse African contexts.

Discussion

The implementation gap: between rights and reality

The primary finding of this narrative review is the persistent implementation gap between rights-based legislative commitments and the operational delivery of preventive audiology services across the African continent. While Africa possesses a robust continental legal anchor through the AU Protocol on the Rights of Persons with Disabilities (2018), the translation of these commitments into functional district-, provincial-, and facility-level services remains inconsistent and highly variable across countries (African Union, 2018a Disability Protocol; Ncube et al., 2021). Importantly, this conclusion should be interpreted in light of the available evidence base, which is weighted toward Southern Africa, particularly South Africa, although supported by examples from West, East, and North Africa. The findings indicate that implementation challenges extend beyond clinical service provision to encompass legislative design, governance, financing, and accountability mechanisms. Across much of the available literature, legislative provisions relevant to hearing care are embedded within broader health or disability legislation rather than being operationalized through dedicated audiology-specific statutes or regulations. Consequently, many countries rely on professional guidelines, strategic plans, or pilot initiatives that lack the statutory authority required to secure sustainable funding, workforce planning, implementation targets, and monitoring systems (Kanji, 2021; Khoza-Shangase and Kanji, 2021; Moroe and Khoza-Shangase, 2020; Manning and Pillay, 2020).

The review identified Egypt as the clearest to document example of nationwide legislative and programmatic implementation of UNHS, demonstrating that legislated preventive audiology programs are achievable within an African middle-income setting (Abdelbadei et al., 2025). However, the findings do not suggest that this model can be directly transferred to all African contexts. Rather, it illustrates that sustained political commitment, statutory mandates, financing mechanisms, and coordinated implementation structures can substantially improve program coverage. In contrast, countries such as South Africa, Nigeria and Kenya continue to rely predominantly on professional guidance, regional initiatives or evolving strategic frameworks, resulting in variable implementation between provinces and health facilities (Hatzopoulos et al., 2025; Khoza-Shangase and Kanji, 2021; Khoza-Shangase, 2026; Olusanya, 2012; Petrocchi-Bartal et al., 2025).

Hearing care within competing public health priorities

A major finding emerging from the synthesis is the relatively low policy visibility afforded to ear and hearing care within national health agendas. Although hearing loss contributes substantially to disability, educational disadvantage and productivity losses, preventive audiology continues to compete with other pressing health priorities characteristic of many African health systems. The continent's triple burden of communicable diseases, non-communicable diseases, and injuries understandably directs policy attention toward HIV/AIDS, tuberculosis, malaria and maternal-child survival, often leaving hearing care insufficiently prioritized within health planning and financing (Savedoff et al., 2012; Waterworth et al., 2022). The review demonstrates that many national health laws establish broad governance frameworks but seldom specify preventive audiology services, resulting in limited budgetary allocation and inconsistent implementation. This finding was observed across several legislative contexts represented in the review, although the evidence is strongest for South Africa and Nigeria. Consequently, hearing care frequently remains dependent upon local champions, professional advocacy and provincial priorities rather than nationally mandated service delivery.

Within South Africa, the ongoing implementation of NHI presents an opportunity to reposition preventive audiology within UHC. However, achieving this objective requires a broader conceptualization of hearing loss that extends beyond clinical rehabilitation. Consistent with WHO recommendations, hearing health should be recognized as an essential contributor to early childhood development, educational participation, workforce productivity, healthy aging and social inclusion across the life course (Khoza-Shangase and Kanji, 2021; Mtimkulu et al., 2023; Waterworth et al., 2022). Viewing hearing care through a life-course public health lens also addresses one of the important gaps identified during this review, namely the limited legislative attention to preventive needs spanning newborns, school-aged children, occupationally exposed adults and older persons.

Toward contextually responsive and evidence-informed regulatory frameworks

Rather than advocating wholesale replacement of internationally recognized standards, the findings support greater contextual adaptation of global guidance to African health systems. The internationally recommended 1:3:6 EHDI benchmark remains an important evidence-based objective; however, implementation within many African settings is constrained by workforce shortages, geographic inequities, transportation barriers, infrastructure limitations and resource constraints. The review therefore supports regulatory approaches that combine adherence to international standards with contextually appropriate implementation strategies. These include:

• Legislative support for appropriately regulated task-sharing and task-shifting where supported by competency-based training;
• Integration of tele-audiology and digital health technologies within national regulatory frameworks;
• Greater incorporation of culturally and linguistically responsive models of service delivery; and
• Strengthened governance mechanisms that address accessibility, infrastructure, referral pathways and continuity of care alongside equipment standards.

These recommendations align with continental priorities articulated within HRISA 2018–2030, which emphasizes African-led research, innovation, health systems strengthening and locally appropriate policy development (Abdulwahab et al., 2024; African Union, 2018b HRISA 2018–2030; Khoza-Shangase, 2025a; Ncube et al., 2021).

Occupational accountability and the economic case for preventive audiology

Occupational hearing conservation provides one of the clearest examples of the disconnect between legislative existence and effective implementation. Across the reviewed literature, occupational noise regulations are generally well-established; however, enforcement remains inconsistent, particularly within mining and other high-risk industries. This suggests that regulatory effectiveness depends not only on legislative content but also on inspection capacity, intersectoral collaboration, employer accountability and routine monitoring (Khoza-Shangase, 2026; Ntlhakana et al., 2020; Swanepoel et al., 2020). Recent evidence further demonstrates important policy gaps at the intersection of occupational hearing conservation and communicable disease management. Khoza-Shangase (2025b) identified limited integration of HIV treatment protocols, ototoxicity surveillance and occupational hearing conservation despite their overlapping risk profiles within mining populations. These findings illustrate how sector-specific policies frequently operate independently, reducing opportunities for integrated preventive care.

The economic implications reinforce the importance of legislative reform. Untreated hearing loss is estimated to cost African economies approximately US$27.1 billion annually through reduced productivity, educational disadvantage and healthcare expenditure (World Health Organization (WHO), 2024). Conversely, investments in hearing technologies and preventive interventions demonstrate favorable economic returns in LMICs, suggesting that preventive audiology should be viewed as both a health and development investment rather than solely a disability service. Although cost-effectiveness evidence remains limited for many African countries, the available literature consistently supports integrating hearing care within broader health system strengthening initiatives.

Policy and health systems implications

The synthesis identifies several evidence-informed opportunities for strengthening legislative and regulatory environments for preventive audiology across Africa. First, integration of ear and hearing care into UHC and PHC reforms offers perhaps the greatest opportunity for expanding equitable access, particularly where benefit packages explicitly include preventive hearing services, early identification and rehabilitation. Second, digital health innovations; including tele-audiology, mobile health applications, AI-supported screening and remote occupational monitoring, have considerable potential to improve service accessibility while supporting regulatory compliance and quality assurance. Third, greater harmonization between continental frameworks, national legislation and professional regulatory standards could strengthen implementation consistency while allowing sufficient flexibility for country-specific adaptation. Finally, the review highlights the need for broader geographical research across Africa. Much of the available evidence originates from South Africa, with comparatively fewer studies from Central Africa, Francophone West Africa, Lusophone countries and several North African settings. Future comparative legislative analyses would provide a more comprehensive understanding of regulatory implementation across the continent and strengthen the evidence base for policy development.

Future directions: adopting a life-course legislative perspective

The findings also highlight the need for future legislative and regulatory development to adopt a more explicit life-course approach to preventive audiology. Although the current evidence is dominated by legislation relating to newborn hearing screening, occupational hearing conservation, and health system governance, comparatively little attention has been given to preventive hearing care for preschool and school-aged children, adolescents, middle-aged adults outside occupational settings, and older adults experiencing age-related hearing loss. As African countries continue to undergo demographic and epidemiological transitions, future policy development should ensure that preventive audiology frameworks address hearing health needs across the lifespan while remaining responsive to local disease burdens, occupational exposures, and population aging.

Limitations

This review should be interpreted in light of several limitations. Firstly, although the review incorporated high-authority gray literature, including WHO guidance and AU policy instruments, the research did not systematically include all national legislative repositories, parliamentary records or ministry websites across African countries. Consequently, recently enacted legislation or regulatory amendments that have not yet been described within published literature may not have been captured. Secondly, the review was restricted to English-language publications. Although several continental policy documents are available in multiple languages, this approach may have underrepresented evidence from Francophone, Lusophone, and Arabic-speaking countries, thereby contributing to the observed geographical imbalance.

Thirdly, the available literature was concentrated primarily in Southern Africa, particularly South Africa. Accordingly, some findings reflect stronger evidence from countries with more developed research output rather than uniform evidence across the continent. The conclusions should therefore be interpreted as representing the current published evidence rather than all legislative developments occurring across Africa. An additional limitation relates to the available evidence itself. Although this review adopted a broad preventive audiology perspective, the included literature was concentrated primarily on early hearing detection and intervention, occupational hearing conservation, and health systems or policy governance. Comparatively little published evidence was identified on legislative and regulatory frameworks addressing hearing health among preschool and school-aged children, adolescents, middle-aged adults outside occupational settings, or older adults. Consequently, the review was unable to provide an equivalent depth of legislative analysis across all stages of the life course. This represents an important gap in the African evidence base and highlights a priority area for future research and policy development. Finally, narrative reviews are inherently interpretive. Although this review employed a structured search strategy, PRISMA-informed reporting, predefined eligibility criteria, systematic data extraction and quality appraisal to enhance transparency and methodological rigor, the synthesis remains dependent upon the scope, quality and availability of published evidence. Future comparative policy analyses incorporating broader multilingual literature and systematically identified legislative documents would further strengthen understanding of preventive audiology regulation across Africa.

Conclusion

This narrative review mapped and analyzed the available legislative, regulatory, and policy evidence relating to preventive audiology in Africa. The findings indicate that, while continental rights-based instruments and global normative guidance provide an important foundation for preventive ear and hearing care, their translation into enforceable national legislation and routine service delivery remains uneven across the published evidence. The review identified considerable variability in legislative maturity, implementation capacity, workforce availability, financing mechanisms, and regulatory oversight across countries. Importantly, these conclusions should be interpreted within the context of the current evidence base, which is weighted toward Southern Africa, particularly South Africa, with comparatively fewer published studies from several other African regions. Among the countries represented in the literature, Egypt provides the strongest documented example of nationwide implementation of legislated UNHS, demonstrating that coordinated national programs are feasible within an African context. However, in many other settings, preventive audiology continues to rely on professional guidelines, strategic plans, provincial initiatives, or pilot programs rather than statutory mandates, contributing to variability in access and implementation.

Based on the available evidence, several priorities emerge for strengthening legislative and regulatory environments for preventive audiology across Africa:

• 1. Strengthen legislative support for preventive hearing care: Where appropriate within national health systems, governments should consider incorporating UNHS and EHDI into statutory or nationally endorsed health service frameworks, supported by sustainable financing and implementation mechanisms.
• 2. Integrate ear and hearing care into UHC: Explicit inclusion of preventive audiology services within UHC benefit packages and primary healthcare reforms has the potential to improve financial protection, service accessibility, and continuity of care.
• 3. Develop enabling regulatory frameworks for innovative service delivery: Regulatory authorities should establish governance mechanisms that support appropriately trained task-sharing approaches, tele-audiology, and digital health technologies while maintaining standards of quality, safety, and professional accountability.
• 4. Strengthen implementation and enforcement of occupational hearing conservation: Existing occupational legislation should be complemented by improved monitoring systems, employer accountability, intersectoral collaboration, and worker participation to reduce preventable occupational hearing loss.
• 5. Promote evidence-informed policy and investment: Greater use of economic evidence, implementation research, and locally generated data may assist policymakers in recognizing preventive audiology as an integral component of health systems strengthening, human capital development, and sustainable economic growth.

Collectively, these findings suggest that strengthening preventive audiology in Africa will require more than legislative reform alone. Sustainable progress will depend upon coordinated investments in governance, workforce development, financing, implementation capacity, research, and technological innovation, alongside continued alignment between national legislation, continental commitments, and global guidance.

Generative AI statement

The author(s) declared that Generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Adrian Fuente, Montreal University, Canada

Reviewed by: Virak Sorn, University of Puthisastra, Cambodia

Margarida Serrano, Polytechnical Institute of Coimbra, Portugal