Dying from lack of medicines

Encouraging local production, right policies the way out
From Africa Renewal: 
Nurses attending to patients at a hospital in Monrovia, Liberia. Photo credit: Panos/ Robin Hammond
Nurses attending to patients at a hospital in Monrovia, Liberia. Photo credit: Panos/ Robin Hammond

Approximately 1.6 million Africans died of malaria, tuberculosis and HIV-related illnesses in 2015. These diseases can be prevented or treated with timely access to appropriate and affordable medicines, vaccines and other health services. But less than 2% of drugs consumed in Africa are produced on the continent, meaning that many sick patients do not have access to locally produced drugs and may not afford to buy the imported ones.

Without access to medicines, Africans are susceptible to the three big killer diseases on the continent: malaria, tuberculosis and HIV/AIDS. Globally, 50% of children under five who die of pneumonia, diarrhoea, measles, HIV, tuberculosis and malaria are in Africa, according to the World Health Organisation (WHO). The organisation defines having access to medicine as having medicines continuously available and affordable at health facilities that are within one hour’s walk of the population.

In some parts of Zimbabwe, for example, some nurses give painkillers to sick patients as a “treat-all drug,” says Charles Ndlovu, a Zimbabwean living in Botswana. Some of his family members have been treated in hospitals in Zimbabwe. With most medicines unavailable, the nurses have little choice.

Dave Puo, from Mpumalanga in South Africa, says that in his country, “when you seek medical attention, you are often informed that there is no medication and advised to go to the big hospitals,” which the majority of the poor cannot afford. “The system does not care about your [empty] pockets.”

Inhibiting factors

About 80% of Africans, mostly those in the middle-income bracket and below, rely on public health facilities, reported the World Bank in 2013. With public health facilities suffering chronic shortages of critical drugs, many patients die of easily curable diseases.

Several factors inhibit access to medicines, but the major ones, according to the WHO, are the shortage of resources and the lack of skilled personnel.

“Low-income countries experience poor availability of essential medicines in health facilities, substandard-quality treatments, frequent stock-outs and suboptimal prescription and use of medicines,” says the world health body.

Africa’s inefficient and bureaucratic public sector supply system is often plagued by poor procurement practices that make drugs very costly or unavailable. Added to these are the poor transportation system, a lack of storage facilities for pharmaceutical products and a weak manufacturing capacity.

Africa’s capacity for pharmaceutical research and development (R & D) and local drug production still has a long way to go, say experts. Only 37 out of 54 African states have some level of pharmaceutical production. Except South Africa, which boasts some active local pharmaceutical ingredients, most countries rely on imported ingredients.

The result is that Africa imports 70% of its pharmaceutical products, with India alone accounting for nearly 18% of imports in 2011. Pharmaceutical imports in Africa include up to 80% of the antiretroviral drugs (ARVs) used to treat HIV/AIDS, according to trade data.

“Many African governments spend a disproportionate amount of their scarce resources on procuring medicines,” writes Carlos Lopes, former executive secretary of the United Nations Economic Commission for Africa.

To produce medicines, a country must abide by Current Good Manufacturing Practices (CGMP), which are enforced by the United States and other governments to ensure the quality of manufacturing processes and facilities. Many African countries do not have the technical, financial or human resources required for high-scale drug production.

But Egypt, Morocco, South Africa and Tunisia have made progress in local pharmaceutical productions. Morocco is Africa’s second-largest pharmaceutical producer (after South Africa), and has 40 pharmaceutical manufacturing companies that supply 70% of products for local consumption and also exports to neighbouring countries. Countries such as Ghana, Kenya, Nigeria and Tanzania are currently developing production capacity.

Suspicions

Many African political leaders and development experts believe that the world’s biggest pharmaceutical companies are reluctant to offer technical support to African manufacturers. For example, in 2001, 39 international pharmaceutical companies dragged the South African government to court to challenge its plans to manufacture and import cheap, generic HIV/AIDS drugs.

The companies claimed that South Africa’s plans breached their patent rights. Although they later withdrew the matter from court following pressure from groups that advocate for international access to medicines, South Africa’s late president Nelson Mandela accused the companies of exploiting the developing world by charging exorbitant fees for HIV/AIDS drugs. “That is completely wrong and must be condemned,” he said at the time.

There is evidence, however, that local production improves access and brings down the cost of medicines. “Ever since the high-tech generic drug production [facility], Cinpharm-Cameroon, was set up, it is relatively easier for Cameroonians to have access to medicines,” says Mr. Lopes. “Now a low-wage earner can access a course of antibiotics at a lower price than a Kenyan counterpart.” Worth $24 million, Cinpharm-Cameroon produces 40 different drugs.

The Trade Related Aspects of Intellectual Property Rights (TRIPS) regulation of the World Trade Organization (WTO), in force since 1986, curtails the right of companies to manufacture generic drugs, forcing countries to rely on brand-name products. However, the WTO in 2006 granted developing countries a 10-year waiver to manufacture generic drugs using the intellectual property rights of big pharmaceutical companies overseas.

Despite US objections, the waiver, which expired this year, was extended until two-thirds of WTO members decide to remove it. Experts believe that is unlikely to happen, as the US appears to be the only big country insisting on its removal.

WHO director-general Dr. Margaret Chan remarked in 2010 that the debate on access to medicine is often clouded by suspicions: “Suspicions that the rules governing international trade in pharmaceutical products are rigged to favour the rich and powerful; that economic interests will trump health concerns.”

The debate, Dr. Chan added, is complicated by deep mistrust. “Countries unskilled in trade negotiations fear they will be tricked or duped. Countries fear that pharmaceutical companies will use unfair tactics, really, every trick in the book, to reduce competition from lower-priced generics.”

Dr. Chan added that, while the ethical argument of not depriving people of access to life-saving medicines is a reasonable one, the for-profit pharmaceutical companies respond to market forces. “What incentives does this industry have to fix prices according to their affordability among the poor?”

Progress in some countries

Availability of medicines is one thing, but affordability is another important factor. Countries such as Ghana and South Africa have made efforts to make drugs affordable through insurance schemes, but these efforts have been largely feeble. Overall, insurance schemes cover less than 8% of the population of sub-Saharan Africa and do not cover prescription medicines on an outpatient basis.

To underscore the problem of affordability, WHO notes that treating a child for malaria in Uganda with artemisinin combination therapy will cost a household the equivalent of 11 days’ income. In Kenya, a seven-day treatment course of ciprofloxacin antibiotic could cost a month’s wages.

Despite obvious difficulties, some countries are making strides in improving access to medicine. Botswana is among the countries that could be malaria-free by the year 2020, reports WHO. Director-general of Botswana’s health ministry Shenaaz el Halabi told Africa Renewal, “We have seen a tremendous improvement in our health care system in recent years.”

Ethiopia has made considerable progress too, particularly in the control of HIV and treatment of malaria, tuberculosis and other diseases. “Ethiopia’s increased investments in expanding effective health coverage—it rose to 95% in 2013 to 2014—has already improved health indicators in the population, reducing child mortality and HIV/AIDS, malaria and tuberculosis,” states WHO.

Recourse to traditional medicines

Faced with difficulties in accessing modern medicines, many Africans resort to ritual and herbal remedies, known across diverse African societies as traditional medicine.

But Ali Arazeem Abdullahi, a sociology professor at the University of Ilorin, Nigeria, cautions that “it is a general belief in medical circles [in Africa] that traditional medicine defies scientific procedures in terms of objectivity, measurement, codification and classification.”

Acknowledging there are quacks that should be checkmated, Professor Abdullahi called for political will to rebrand and standardize traditional medicine practices.

Experts believe that Africa’s solutions to improving citizen access to medicine could lie in stimulating local production, developing the right policies and infrastructure, and training and retaining its medical talents.