A basic fundamental right of patients is access to good medical care as, and when required. The degree of quality of the healthcare provided is subjective, but I think we can all agree that ‘quality’ medical care must possess all the following attributes.

• It must involve the patient in all aspects of the decision-making process at every stage of treatment. The patient needs to be aware of the impact of the disease on their quality of life, know the available treatment options and the cost of management for each option.
• There should be a healthy relationship between the patient, caregivers, and health service providers. The patient’s caregivers have to be an integral part of the disease management process.
• Last but not least, the health care services provided must be affordable, convenient, easy to access and up to the minimum acceptable quality standards. Going by the attributes listed above, the minimum desired quality criteria for any medicine are: it must meet the required efficacy and safety standards, be affordable, and readily available.

Unfortunately, this is rarely the case in sub-Saharan Africa and patients often have to resign themselves to sub-par quality medicines which may either cause a worsening in their disease symptoms or, ultimately, loss of life.

Alternatively, they could end up buying more expensive brands that carve deep holes in their pockets.

What defines quality in a medication?

For a medication to achieve the minimum desired quality parameters, it must meet the required efficacy and safety standards, be affordable, and be readily available.

Poor access to quality medicine kills an estimated six million people every year in sub-Saharan Africa, from communicable diseases such as malaria, TB, and HIV/AIDS. These statistics do not take into account the number of people who die from non-infectious diseases like hypertension, diabetes, kidney diseases, and heart failure.

There are several obstacles to accessing quality medicine in sub-Saharan Africa and we can broadly classify these into four groups:

1. Poor quality control standards

2. Supply-chain issues

3. Affordability

4. The people factor

Poor quality assessment controls for Medicines in Sub Saharan Africa

• Inadequate regulatory facilities: The National Medicines Regulatory Authorities (NMRA) in the African region often lack the necessary equipment to conduct proper testing for the levels of active ingredients and contaminants. Tests for dissolution properties which would determine the bioavailability of the medicine in the body are often not carried out. Low-quality drugs, both locally produced and imported, are thus able to enter into circulation unhindered.
• Porous borders: Due to the porous borders, drugs are smuggled in easily from other countries. The challenge with some of these medicines is the poor storage conditions in which they may have been held for a while during the shipping process. This poor storage could lead to degradation of the active ingredient, rendering the drug ineffective to the final user. Another challenge is that such drugs enter the circulation without undergoing the proper quality control tests and may prove hazardous to patients.
• Improper storage of Medicines: This is often due to the frequent power outages in sub-Saharan Africa, especially in Nigeria. Medicines need to be preserved under ideal conditions to avoid loss of efficacy. Storage of vaccines, eye drops, and tetanus toxoids should always be at low temperatures.

Supply Chain and Availability Issues :

The availability issues affect both the multi-national pharma industries that import premium brands to sub-Saharan Africa as well as the generic companies that source raw materials for drug production from outside Africa. Most of these multi-nationals do not have direct trade rights within Africa and usually enlist third-party supply companies to get their brands into the country.

The unstable economic situation and fluctuations in the exchange rate often affect the availability of some of these medications. Unfortunately, because most of these multinationals sign exclusivity agreements with specific third-party agents, they are not at liberty to switch to an alternative source of supply in the interim. What this means is that a patient who has been on the medication has to find an alternative, which may or may not be of the same high quality. For locally produced drugs, availability depends on the supply of raw materials which are usually imported from outside the sub-Saharan region. Political unrest, import duties, and customs policies could affect the amount of these raw materials, and hence the production of the finished medicines.

Affordability issues impact access to quality medicines in sub-Saharan Africa

Statistics show that almost 3/4 of the population of sub-Saharan Africa live on two dollars per day. The average cost of medication for treating a common acute infection like malaria is 2-2.5 USD, which means the average person may have to forgo a day’s meal to afford common medications. The burden of managing chronic diseases like diabetes and hypertension that need regular medication could prove too much for the common man to bear. This prohibitive cost of treatment often leads to poor patient adherence to therapy and poor treatment outcomes.

The People Factor :

There is no gainsaying the fact that the human factor will always be involved in patient healthcare and contribute in no small measure to their ability to receive quality medications as at when due. The major human factors that may influence proper access to quality medications include:

• Physician’s opinions: Physician inertia to prescribe a more effective medicine as a result of perceived cost or a knowledge gap may result in the poor quality of care. On the flipside, due to a vested interest in certain medications or companies, physicians may over-prescribe certain medications for their gain. Patients wrong priorities: Patients often prioritise other activities over health-related issues. Even when they can afford quality medicines, they may decide to go for cheaper alternatives which may be substandard.

• Reduced Pharmacy involvement in Patient Care: The Pharmacist, as the custodian of medicines is meant to give unbiased advice to prescribing physicians on the quality and safety of medications. Unfortunately, more often than not, the Pharmacist is relegated to the role of mere drug dispenser in the hospital setting.

• The Patent Medicine stores: This group of medicine dispensers have a significant role to play in the dispensing of inadequate quality medications. Some of these patent stores offer consultation services to patients for chronic diseases like diabetes and hypertension. The unwitting Patients flock to these stores in hopes of getting affordable solutions for their ailments. A lot of times the patient ends up in far worse conditions after taking these substandard medications.

Brilliant Initiatives that have Improved Access to Quality Medicines in Africa

Several laudable initiatives have been rolled out across the various regions in Sub-Saharan Africa that have improved access to quality medicines. Some of these are: The National Health Insurance Scheme, Roll-back Malaria Initiative, Subsidized And Free Medicine schemes, Promoting The Quality of Medicines program.

• The National Health Insurance Scheme: Social health insurance schemes have been implemented in many countries in Sub-Saharan Africa to reduce the cost of medication to the poor. In Ghana, for instance, the health insurance scheme is designed to cover timpoverishedation costs for at least 50% of the impoverished population. In Nigeria, the National Health insurance scheme has distinct platforms for both the private and Government sectors. There is also a new insurance scheme in Nigeria for retirees and the elderly to reduce the impact of health cost to their caregivers. What these health schemes have in common is that they involve the pooling of funds by a majority. This central pool can then be used to provide adequate care for patients. Some of the challenges that the various Health insurance schemes have faced since their inception include: Inconsistent Government support. The Governing power may not have health care on its agenda. Mismanagement of the funds by corrupt administrators. The questionable Quality of some of the medications allowed on the NHIS scheme. The majority of the poor do not have access to these schemes either because they are not gainfully employed, or they live in remote and inaccessible areas.

• The Roll Back Malaria Initiative. The Abuja declaration in 2000 was a convening of 53 heads of state to specify some milestones they planned to achieve in the eradication of malaria in sub-Saharan Africa. It was declared that by 2010, at least 60% of the population would have access to Artemisinin-based the d anti-malarial therapies within 8 hours of onset of malaria symptoms. Several laudable objectives include free antimalarial treatment for 60% of the at-risk population, free mosquito nets for the prevention of malaria infection, and free preventive medications for expectant women. The challenges experienced by this multi-national project are beyond the scope of this article. Suffice it to say that human factors and poor management decision led to the failure to attain the desired outcome.

• Subsidized And Free Medicine Schemes. Some International bodies in partnership with State Governments provide access to free or highly subsidized medications for infectious diseases. The spread of diseases like HIV/AIDS, TB and Hepatitis has been checked as a result of the reduced burden of cost. In addition timmunisation by providing free vaccines and immunization for children, many infectious illnesses like polio and small-pox have been completely eradicated. The one-dollar access to medicine initiative by the Big Pharma companies aims to provide access to premium brands at a token cost to patients. This scheme is already in effect in certain Nations like Rwanda.

• The Promoting the Quality of Medicines (PQM) is an initiative funded by the US Agency for International Development. The objective of this program is to support the Quality control bodies in the sub-Saharan region by providing the equipment and reagents to conduct proper safety and quality assessments. These assays are performed primarily for essential medicines like antimalarials and anti-infective medications. This program has been implemented in 13 African countries and has aided in the detection of counterfeit, parallel imports and fake medications.

What Needs To be Improved Upon to Deliver Better Access to Quality Medicines

There have been several suggestions regarding what needs to be done to improve the quality of health care and especially access to medicines for the average patient. I have included here some of the more feasible solutions and added a few, which from my experience in the hospital and private pharmacy sector may prove invaluable.

The Government needs to make Health care a Priority.

• Without Government support, any medicine access scheme may not likely be sustainable. The ways in which the Government can help are: Partnering with the Big Pharma companies to subsidise the cost of chronic disease medications.

• Improving access to NHIS schemes for the poor through better collaboration with MDGs to reach the remote areas of Sub-Saharan Africa.

• Another method that may work is to create a disparity in contribution to the NHIS funds. The wealthier citizens could pay more than the stipulated percentage thus allowing the poor to access treatment at negligible costs.

• The Quality control sector should either be better funded or privatised to enable the purchase of better equipment for quality assessment of imported and locally produced drugs.

• There is also the need for constant quality checks at the pharmacy and patent medicine stores. Tightening up the borders and instigating stricter importation laws to check the illegal influx of medicines.

• The Government should also look into providing basic amenities that could entice the Big pharma corporations into investing in the production of drugs in sub-Saharan Afric

Pharmacists have a significant role to play in ensuring proper storage of medications.

The pharmacists may need to step up their game to assume their rightful role as advisers to physicians and patients on medication quality and safety.Rather than bicker about policies and politics, the pharmacists in sub-Saharan Africa should create value in the pharmacy practice.Let’s assume our rightful roles as the custodians of medicines and the go-to knowledge base on anything about drugs.

It is the duty of prescribing physicians to protect the patient’s interests at all times.

Regardless of whatever incentives to specify a particular brand, quality of a medication should be the primary consideration( affordability, cost-effectiveness, and availability). Also, as much as possible the patient must be carried along in the decision-making process.

Could investing in herbal medicines aid access to quality care?

Alternative medicine provides another possible source of quality medications for patients. The term Alternative medicine as used here refers to herbal supplements and potions used to treat or prevent disease.

The advantages of these non-conventional forms of drug therapy are:

They appeal to the patients’ cultural and social beliefs and thus may improve adherence.

They are usually more affordable in the long-run than orthodox medicines.

They are generally perceived to be more natural and therefore are less likely to be linked with adverse effects.

These alternative medicines claim to heal from the root and do not offer symptomatic management of diseases.

The disadvantages include:

The Regulatory Authorities do not regulate them and as such their safety and efficacy are questionable.

Their side effects and drug-drug interaction profiles are unknown, and there could be harmful interactions if they are administered concurrently with other medications.

Limited Scientific Research in the field of Alternative Medicine means that the correct dose of the active ingredient required to elicit the therapeutic effect is purely guesswork.

Perhaps one innovative idea by which Sub-Saharan Governments can improve access to quality medicines is by investing in Alternative medicine.

References https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1239960/ file:///C:/Users/user/Documents/sbitmart%20blogpost.pdf https://academic.oup.com/inthealth/article/10/1/1/4794744 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)66391-X/fulltext https://www.usp-pqm.org/sites/default/files/pqms/article/pqm-in-ssa-2015-02.pdf https://www.motherearthnews.com/natural-health/herbs-vs-drugs-facts-about-medicine-zmaz06djzraw