In 2013, soon after Vivian Nwakah moved to Nigeria, a close friend died after taking a malaria pill he had bought at a local pharmacy in Lagos that turned out to be fake.
“One day he said he was feeling sick, he took a malaria pill and within a week he died,” she says. “That was a very traumatic experience but it made me really think about healthcare here.”
Tens of thousands of Africans die each year after taking fake drugs, usually manufactured in China, India, the UK, Paraguay or Pakistan, according to an EU-funded report released in June. Between 64,000 and 158,000 people die each year in sub-Saharan Africa from counterfeit antimalarial medication alone.
According to the World Health Organization, Africa accounts for 42 per cent of the world’s cases of distribution of fake or substandard medical products. Sham drugs are the world’s most lucrative counterfeit goods, with a global market worth roughly $200bn, according to WHO.
Fake medicine makes its way into African countries alongside other smuggled products — from cars to consumer goods — slipping past underfunded, often corrupt customs systems toward largely unregulated markets and distribution networks. But wide coalitions of governments, regulators, pharmaceutical companies, advocacy groups and tech start-ups are leading the continent’s fight against the scourge of fake medicine.
Ms Nwakah’s experience led her to found Medsaf, one of a number of start-ups across Africa working toward eliminating fake and substandard medicine.
Companies such as Medsaf — which has raised $1.4m and has 20 employees, mostly pharmacists — are using technology to try to clean up the supply chain. They connect manufacturers — ranging from big international players like Pfizer and Sanofi to small indigenous firms — that they have vetted directly to hospitals and pharmacies. Medsaf uses data and tracking to help its customers better plan which medicines they will need and when.
“What we realised is that this fake and substandard medicine issue is really a supply chain issue,” she says. “We’re cutting out all the middlemen, we’re getting it right from the manufacturer, doing quality control checks in our warehouse and shipping it out within 24-48 hours.”
Fakes slip past often corrupt customs to largely unregulated markets and distributors
Ghana-based Mpedigree has done something similar, on a larger scale, by working with government regulators. It has expanded operations to countries including Nigeria, Rwanda, Kenya, Tanzania and Uganda. As part of its system, manufacturers on the continent or in Europe uniquely identify each product, which can be tracked from factory to patient. It provides software to regulators and consumers for free — including an app that lets consumers scan the pills they buy to verify them — but charges pharma companies.
“We now have a network of apps talking to each other,” he says. The company has expanded into cosmetics and seeds, and operates in a dozen African countries.
The African pharma market is still relatively small in value, at just $14bn in 2017, compared with roughly $120bn in China, according to a recent McKinsey report. The continent has 375 drugmakers for 1.2bn people — mostly making generics, at least 100 companies simply doing packaging — compared with 5,000 for China. Africa imports 70-90 per cent of its drugs, according to the consultancy, compared to just 5 per cent for China and 20 per cent for India. The fragmentation and low income levels marking many African economies often leave countries with outdated drugs. This is because international drug manufacturers have little incentive to register and promote each new product for every small, low-value market.
The recently signed African Continental Free Trade Area agreement, meant to bolster intra-African trade, could change that. But the deal is years away from implementation.
In the meantime, the medical sector remains woefully underserved.
In Nigeria, more than half of child health products are distributed by so-called Patent and Proprietary Medicine Vendors, the local retail shops that were created to give remote and poor villages access to medicines, according to a 2015 research paper in the academic journal PLOS One. The paper calculated there were about one hundred times as many such outlets as licensed pharmacies in 2005.
PMVs do not require formal training, and they, alongside more informal salesmen, are the source of most of the country’s counterfeit drugs.
“When you look at that channel — particularly for products for kids under the age of five — that’s a big concern, the source that parents are getting these products from,” says Gregory Rockson, founder of Ghana-based Mpharma, which works with over 400 hospitals across Nigeria, Zimbabwe, Zambia, Kenya and Ghana, and has served over 1m patients.
But start-ups like Mr Rockson’s are trying to make licensed pharmacies more efficient and affordable. Their ambition is that Africans do not have to turn to more informal — and unreliable providers of medicine