Access to medicines, vaccines and other health technologies is central to achieving universal health coverage (UHC) across Africa. UHC refers to access to high-quality health services for all with financial protection. It is a global health and development agenda which has received widespread attention and endorsement by global leaders, most notably in World Health Assembly resolutions, the 2019 United Nations political declaration and the Global Action Plan for Health and Wellbeing for All. Identifying and leveraging emerging opportunities to increase access to affordable, quality-assured medicines in Africa is crucial for UHC progress in this last decade of action before the 2030 deadline. With a 10-year experience in health service delivery and global health spanning key low and middle-income countries in Africa, I see three potential opportunities: the current UHC momentum at global and national levels, partnerships for local production and regulatory systems strengthening.
Universal health coverage is a global health and development agenda which has galvanized leaders across the world to commit to improving access to high-quality, equitable health services for citizens with financial protection. In September 2019, world leaders adopted the most comprehensive agreement ever on UHC, promising to fast track progress towards achieving UHC by 2030. In a similar fashion, the Inter-Parliamentary Union passed a landmark resolution to harness legislative and policy tools to make UHC a priority across countries. These laudable steps show high level political commitment towards UHC and offer the opportunity to hold political leaders accountable for UHC progress.
Leveraging this momentum to support countries to design or refine benefits packages is an important step on the journey towards UHC. The 2016 Lancet Commission on Essential Medicines Policies recommends review of essential medicines policies, adequate financing for medicines within benefits packages for UHC and appropriate use of medicines. A combination of technical expertise, contextual insights and apt management of political processes is important to guide the assessment, selection, and procurement of medicines, vaccines and other health technologies required for an essential package of health services. With the Astana Declaration’s emphasis on investment in primary health care (PHC), countries can ensure effective linkages across all levels of care with PHC as the foundation for UHC – and improve access to essential health services for all. While African governments have committed to raising more money for health, a focused investment in PHC and concerted efforts to reduce inefficiencies across health systems can help reduce inequities in access to health services.
In Nigeria, the government is financing primary care through the Basic Healthcare Provision Fund (BHCPF). Mainly tax-financed, the BHCPF seeks to facilitate effective collaboration across governments at national and subnational levels to ensure primary health centres have adequate resources to provide an essential package of priority health services for citizens, particularly the poor and vulnerable. It is also intended to be a vehicle to mobilize more domestic resources alongside external financing for sustainable risk-pooling mechanisms which provide effective coverage to the populace including the informal sector. Leveraging relevant experience from other low- and middle-income countries (LMICs), the BHCPF has the potential to boost access to medicines and enable Nigeria achieve universal primary care coverage.
Partnerships for Local Production
Africa is one of the fastest growing pharmaceutical markets in the world but the continent accounts for only 3% of global pharmaceutical production. The market is estimated to be worth $40 – 65 billion, a significant increase from its $4.7 billion size in 2003. An integrated continental market is crucial for building sustainable pharmaceutical manufacturing capacity and improving supply chain systems in Africa where over 70% of drugs consumed are imported and governments spend a third of their health budget on medical products. This can build on increased advocacy in recent years by governments, private sector players, civil society and multilateral institutions for needs-driven local production of medicines and other health technologies. A 2019 interagency statement by WHO, the United Nations Industrial Development Organization (UNIDO), United Nations Conference on Trade and Development, United Nations Children’s Fund, the Joint United Nations Programme on HIV/AIDS and the Global Fund called for ‘’multisectoral collaboration for sustainable local production’’. This convergence of multiple calls for increased production of medical products on the continent holds significant promise in view of ongoing reforms to integrate markets and economies for inclusive economic development.
A 2019 McKinsey report shows that Africa has less than 500 drug manufacturers compared to 5, 000 in China and 10, 500 in India: most manufacturing facilities are in North Africa. An expansion of production capacity which meets international standards is a noble objective that can create jobs, increase access to affordable medicines on the continent and facilitate progress towards achieving Agenda 2063 and the health-related sustainable development goals (SDGs). SDG targets 3.8 and 3b focus on needs-based production and access to essential medicines for all. Although there is ongoing discussion on developing industrial parks for local production of pharmaceutical products, there is ample opportunity for productive partnerships with key stakeholders in advanced and emerging economies that can stimulate human capital development, knowledge and technology transfer as well as increased investments in industrial pharmaceutical development and supply chain management that maximizes the opportunities of an integrated continental market.
In line with the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property and the African Union Pharmaceutical Manufacturing Plan for Africa, Ethiopia has developed its National Strategy and Plan of Action for Pharmaceutical Manufacturing in Ethiopia (2015 – 2025) to facilitate local production of quality-assured medicines. Implementation of the strategy and plan can galvanize the development of a sustainable pharmaceutical manufacturing system in Ethiopia which can be integrated with continental and international manufacturing systems and industry clusters. Besides, the recent agreement between UNIDO and the West African Health Organization for a similar objective is a timely development. Although evidence shows that local production does not immediately translate to access to more affordable medicines, it is a strategic choice on the access journey.
Regulatory Systems Strengthening
Poor quality medicines represent 10% of medical products used in LMICs. Evidence shows that 19% of antimalarial drugs and 12% of antibiotics used in LMICs are of poor quality. The London School of Hygiene and Tropical Medicine estimates that use of falsified and substandard antimalarials results in the preventable death of 116 000 people every year in sub-Saharan Africa. Most reports of poor quality medicine emanate from Africa where there is inadequate regulatory oversight and inefficient practices across the fragmented and complex national and continental supply chains. Despite efforts by national medicines regulatory agencies (NMRA) to tackle this challenge, the scope and impact of reforms are undermined by weak technical, institutional and collaboration capacities.
To address this challenge better, there is growing interest and investment in strengthening capacity of regulatory agencies to effectively manage sourcing, production, marketing, distribution and sale of pharmaceutical products in Africa. The 2019 Oxford statement acknowledged the public health and economic costs of substandard and falsified medicines, and called for urgent action to improve access to quality-assured medicines through effective collaborations for regulatory systems strengthening. Although the speed and impact of regulatory reforms differ in each country, the promise of functional regulatory agencies working efficiently in-country and across the region raises hope that quality medicines and drugs can be available at pharmacies and health facilities. Investing in human resource development for regulatory efficiency and quality management should be an urgent priority for African governments and development partners.
While there is a need to build functional NMRAs, the African Medicines Agency (AMA) is well-positioned to strengthen cross-country collaboration at regional and continental levels for research and development, marketing authorization and regulatory coherence. African leaders adopted the treaty for the establishment of the AMA at the 32nd Ordinary Session of the African Union Assembly in February 2019. The agency will become operational after fifteen member states of the African Union sign the treaty; seven countries had signed as of October 2019. It seeks to harmonize regulatory standards, frameworks and tools that can contribute to the growth of the pharmaceutical industry and improve access to safe, efficacious and quality-assured medicines on the continent. Building on the success of the African Medicines Regulatory Harmonization initiative, established in 2009, AMA will work closely with relevant national, regional and international institutions and partners to achieve its objectives.
The combination of a changing disease burden, UHC momentum at global and national levels with new partnerships for production and regulatory system reforms offers tremendous promise of significant improvement in access to medicines in this decade as innovations in distribution and procurement reforms work together towards affordable medicines for all. Although new evidence shows that this convergence will be a marathon, there are sufficient reasons to be optimistic that focused, collaborative actions of state and non-state actors can translate to better health outcomes.