Nigeria: A Question of Political Will

Nigeria: A Question of Political Will
By Omololu Falobi

Patents are only one of many factors preventing widespread access to drugs
in Nigeria. Other obstacles include high cost, poor infrastructure,
government policy andcorruption.

Up to 30,000 Nigerians die of tuberculosis every year. Most of these lives
could be saved if Directly Observed Treatment, Short-course (DOTS),
involving a series of non-patented drugs was more widely available. At
market prices, DOTS costs 17,000 naira (US$130). Although DOTS is
theoretically free, government clinics often run out of the drugs, forcing
patients either to interrupt treatment - risking development of the
drug-resistant form of the disease - or to purchase the drugs themselves,
an option beyond the means of many citizens when the minimum wage is 7,000
naira (US$53) and most middle income workers earn N20,000 per month.

Cheaper options for treatment of tuberculosis include Streptomycin, but
its use is discouraged because the disposable needles and syringes needed
to inject it are not always available. Clinics therefore sometimes replace
streptomycin with ethamebutol, a much more expensive drug, stretching
already scarce resources.

Access to medical care

In the late 1980s, government health services were commercialised. Apart
from tuberculosis and malaria, free treatment facilities are no longer
provided.

Nigeria has one of the poorest doctor-to-patient ratios in Africa, with
one doctor per 3,500 people. In the last decade, less than four percent of
the government's annual budget has been allocated to health. In 1998
health
received four billion naira from a total budget of 164 billion naira (2.5
percent), while defence was given 16 billion naira.

Lack of modern, functioning facilities and lack of medical personnel mean
long waits for patients and inefficient service, including inappropriate
prescription or lack of prescription of necessary drugs. Patients also
have to pay for a registration card (about 50 cents) and transport to the
hospital, prescriptions have to be bought at pharmacies at prevailing
market prices and necessary laboratory tests are at the patient's cost.
These factors all discourage people from seeking health care.

Self-medication

Aside from tuberculosis, Nigeria faces many other health epidemics,
including malaria, cholera, HIV/AIDS, guinea worm and meningitis. Malaria
kills more Nigerians than any other disease despite the fact that
treatment is cheap, well-known and widely available.

"The main problem is drug resistance, caused by the wide practice of
self-medication, late diagnosis and early stoppage of treatment", says Dr.
Taiwo Adewole, one of Nigeria's top malaria experts. Self-medication is
common among low income earners. Walking to the nearest drug hawker to buy
a few tablets of chloroquine avoids the cost and time involved in visiting
public hospitals. "The result is that majority of malaria cases are
improperly treated and only report to hospitals when the parasite has
developed resistance to the cheaper, first-line treatment and
complications have set in", Adewole explains.

Industry collapse

Nigeria once hosted one of Africa's best pharmaceutical industries. "The
local pharmaceutical industry is at its worst ebb", says Mrs. Stella
Okoli, chair of the pharmaceutical manufacturing group of the
Manufacturers' Association of Nigeria

"In 1990, up to 137 indigenous and foreign-owned pharmaceutical firms were
operating; now,only 77 are". In the early 60s and 70s, a substantial share
of commonly-prescribed drugs such as paracetamol were produced by
state-owned manufacturers, many of which, due to alleged mismanagement and
poor funding, are now out of production. Recent efforts by one company to
start manufacture of a treatment for sickle cell, for which it has
proprietary
rights, have been stymied by non-release of capital voted by government.

Counterfeiting

Access to medicines is compounded by the problem of smuggling of
counterfeit or adulterated drugs into the local market. Dr. Niyi Ogundiran
of the World Health Organization estimates that up to 40 percent of all
drugs circulating in Nigeria are either smuggled in illegally or are
counterfeit versions of the original products.

The National Agency for Food and Drugs Administration and Control
(NAFDAC), claims that between April 2001 and April 2002, it seized and
destroyed over 2 billion naira worth of imported fake drugs. Local
pharmaceutical companies have also announced a yearly loss of 10 billion
naira to the adulterated drug market.

Many deaths have resulted from counterfeit drugs. In 1991, batches of
paracetamol syrup sold across the country contained poisonous substance;
196 children died after taking the "medicine". Such practices continue.
NAFDAC has recently identified seven different types of adulterated
paracetamol tablets and five different adulterated versions of chloroquine
circulating in Nigeria.

Distribution

Another factor restricting access to safe, effective and inexpensive drugs
is the poorly regulated distribution system. Most trained pharmacists set
up retail outlets in state capitals and urban centres, leaving wholesale
distribution and retailing in the rest of the country almost exclusively
in the hands of non-pharmacists.

Many distribution systems are controlled by cartels which in some cases
have been likened to mafias. "The drug distribution system is 'organised
chaos'," says Prince Julius Adelusi-Adeluyi, a pharmacist and past
Nigerian
health minister. "Organised because people still manage to get the drugs
they need by special legal or extra-legal means; chaotic because operators
have defied laid downrules and regulations".

The system of registering pharmacies is often ignored. A 2000 study by a
team of pharmacologists from the College of Medicine, University of Lagos
found that over 6 percent of drugs sold in drugstores in Lagos were past
their expiry dates. Of the 117 stores visited during the study, 54 were
unregistered.

Recently reformed and with a new management team, NAFDAC has taken steps
to re-organise the drug distribution system and stem the spate of
counterfeiting. It has embarked on strong promotional campaigns and taken
measures to stop the operations of cartels believed to be controlling the
fakedrug market.

Corruption

A key obstacle to efficient use of funds is corruption. Sharp practices by
unscrupulous medical personnel at state-owned pharmacies is a common
practice. Malaria or TB drugs clearly labelled 'not to be sold; for free
distribution only' have appeared at private pharmacies located next to the
gates of public hospitals. Patients who are supposed to receive these
drugs free at hospitals are told they are out of stock and referred to the
pharmacies outside, or quietly told they could be helped if some amount of
money is paid.

"There are clearly a lot of leakages in the system", says Dr. Dan
Onwujekwe, a clinician who has done extensive research on tuberculosis
treatment in Nigeria. "Pilfering goes on. Drugs are not well accounted
for".

Political Will

Experts believe many of the barriers listed above can be overcome.
Onwujekwe points out that although if TB treatment were procured using
bulk-purchase, the cost could be reduced by up to 70 percent (N5,000 or
US$38 perpatient). Local manufacture by state-owned companies of
commonly-prescribed off-patent drugs such as chloroquine, paracetamol and
tuberculosis drugs could significantly reduce prices and discourage
counterfeiting. Other developing countries with similar populations and
infrastructural challenges, such as Brazil, India and Thailand have
state-owned and private indigenous pharmaceutical companies producing a
high percentage of their nation's drug needs.

Boasting one of the best-trained workforces, technical capacity and
Africa's largest market, Nigeria already has the wherewithal to produce
off-patent drugs at cheap rates. "The one thing that we need is political
will", says Onwujekwe.

Another strong need is treatment advocacy and activism by civil society
actors. Current efforts by government to provide treatment literacy, stamp
out counterfeiting and corruption and reform the drug distribution system
needs to be strengthened; equally important is activism by civil society
to ensure that the reforms are sustained andinstitutionalised.

Omololu Falobi is project director of Journalists Against AIDS
(JAAIDS)Nigeria, a media-based non-governmental organisation that he
helped to establish in 1997.

Omololu Falobi
Email: [email protected]

A posting from AF-AIDS ([email protected])