“Can I dispense Floxapen (antibiotic) for Flucazole (antifungi)…?” asked a roadside drug vendor. This, and many others, are some of the poor practices Cameroonians are exposed to on a daily basis. What an untimely coincidence, at a time when countries are aligning themselves towards the 2030 Sustainable Development Goals (SDG) agenda and focusing on achieving Universal Health Coverage (UHC). Access to safe, effective and affordable essential medicines and vaccines, for all citizens without financial hardship, is a crucial component of UHC.
The issue of adequate access to essential medicines has (re)captured global interest as it increasingly affects both rich and poor countries. This was demonstrated by the recent UN High-Level Panel on Access to Medicines in which, among others, WTO member countries were reminded of the need to apply the TRIPS agreement/flexibilities enshrined in the Doha Declaration. In Cameroon however, access to essential medicines is still problematic; the fact that anti-retroviral drugs which are distributed free of charge in health facilities, are sold on the black market, illustrates this very well. Consequently, the vulnerable population continue to consume poor-quality medicines especially antibiotics and antimalarials, from unregulated roadside vendors.
The growing influence of private providers of healthcare, especially in LMICs, cannot be overemphasized. They range from low-quality/under-qualified, not-for-profit providers, to corporate commercial hospitals, and this heterogeneity makes the regulation and rating of service quality challenging.
In addition to the typical private providers, roadside medicine vendors also play a big role in the Cameroonian health system, because they are convenient, affordable, and socially and culturally preferred. These vendors however, usually have little or no medical training. As a result, the poor who are the major users, are often exposed to sub-therapeutic doses of medications and wrong prescriptions, which can lead to drug resistance (especially antibiotic drug resistance), renal failure or death from toxicity. In addition to this, they face the risk of catastrophic out-of-pocket spending, because of repeated sub-optimal treatment regimens.
Many institutions have been created and tasked with ensuring the safety of medicines in Cameroon. The National Drug Quality Control and Valuation Laboratory (LANACOME) for drug quality control and the National Central Supply of Essential Medicine agency (CENAME) for procurement and distribution of essential medicines with its regional network, are among the most important ones. Besides these, private-not-for-profit institutions like the Cameroon Baptist Health Services Board also procure, distribute and regulate medicines for their institutions.
The formal private-for-profit arm of the industry, dominated by large commercial pharmacies and pharmaceutical agencies, is regulated by official pharmacists’ associations, while the informal sector remains unrecognized and labelled ‘illicit’ by Cameroonian law. Consequently, for many years the policy has been to prohibit the existence of roadside medicine stores, with occasional raids to ‘seize and burn’ their products and seal the stores. These attempts can be likened to depriving the poor of their only source of medicines.
The fight against illicit medicines in Cameroon and her regional neighbors has proven futile because of many reasons. One is lack of political will, and the sub-optimal capacity of state agencies to control the quality, safety and efficacy of medicines circulating in Cameroon. For example there are undetected counterfeit medicines in both the informal market and health facilities, and regular stock outs of essential medicines in national drug warehouses due to poor planning and a low percentage of the government budget allocated to health (5.4%).
Another reason is the insufficient number of registered pharmacies which also often dispense mainly expensive branded medicines, and are seldom accessible at night when most health emergencies are experienced by the poor. Furthermore, there are many trained health workers without formal employment who, together with a vast number of lay businessmen, have availed themselves of a plethora of generics from Asian companies & local manufacturers. They fill the vacuum created by an inefficient public health sector and an expensive formal pharmacy sector in Cameroon, and in so doing, make a living through the seemingly lucrative medicine venture.
Experience from many LMICs has shown that the complete prohibition of actors from the informal sectors is an enormous challenge. Cameroon should therefore try to find a way of incorporating them into healthcare delivery, perhaps by partnering with them to the best extent possible, while regulating them as much as possible. The country should adopt measures to engage informal medicine vendors in the improvement of the quality and coverage of essential medicines.
Firstly, these vendors can be organized, trained and supervised to enhance the quality of medicines, as demonstrated with informal providers in India. Secondly, augmenting the existing community response via dialogue structures can adequately inform communities, make public facilities competitive and discourage unofficial vendors. Thirdly, CENAME can improve coverage by creating Generic Pharmacy Franchise outlets which are accessible to the poor and easy to regulate, as is the case in Mexico and the Philippines, rather than limiting medicine supplies to public health facilities alone.
There is a strong need for national, regional and multilateral collaboration to reinforce regulations on the importation & circulation of medicines in Cameroon territory. Increasing government spending on health (and aiming for the Abuja target ) would be a laudable first step, as it would help to reduce out-of-pocket payments and the currently frequent stock outs of medicines. However, the challenges outlined above illustrate the fact that there are no easy solutions to the problem. Still, the system must be reformed, because without change, UHC will remain a distant dream for Cameroon.