Nigeria Races To Scale Up Its Production Of Medicines

When the NGO LiveWell Initiative (LWI) started its work in 2006, life expectancy in Nigeria was shockingly low, at under 50. It remains one of the lowest in the world, at around 53.

But Bisi Bright, the dynamic pharmacist who leads LWI, has an ambitious target: “Our goal is to take it to 70 by 2030.”

One of LWI’s activities is to provide vetted medicines, free of cost, to members of the officially unrecognized neighborhood Isale Ajoke, whose structures of wooden planks and metal roofs sit on stilts.

Having the assurance of high-quality, effective medicines has made a big difference for patients of the LWI health post like Evangelist Paul Asonde Adeyemi, a launderer who regularly obtains small packets of amlodipine from the health post to treat his high blood pressure.

Of course there are limits to what any single organization can do to improve health across a country of roughly 220 million people. And life expectancy involves a complex bundle of factors, including infant mortality, influenza, pneumonia, and respiratory diseases aggravated by air pollution. Poverty and limited access to healthcare are overlapping factors.

But one piece of the puzzle is low-quality medicines. An estimate from 2019 is that poor quality in just one category of medicines – antimalarials – leads to 12,300 deaths a year in Nigeria.

This is a tragic number of preventable deaths, in the country with by far the most deaths from malaria. But it used to be even higher.

While Nigeria once had a flourishing brand-name pharmaceutical sector, this market fell apart in the 1980s due in part to economic changes imposed by international institutions, as well as poor management. Poor-quality, difficult-to-trace medicines plugged the gap.

By the 1990s, the situation had reached crisis proportions. By the 2000s, other countries in West Africa had banned medicine imports from Nigeria, due to the country’s reputation for shoddy drugs.

In this decade a crusading pharmacist, Dora Akunyili, became the head of Nigeria’s food and drug regulator, NAFDAC, as well as a figurehead of the fight against bad medicines in Nigeria. The leader of a regulatory agency usually isn’t a household name, but Akunyili remains beloved, with biographies of her in bookshops and images of her on walls.

Under her helm, and despite arson and assassination attempts, NAFDAC instituted sweeping reforms to public awareness, technology, and enforcement of dodgy medicines. While nearly everyone knows someone who fell victim to a substandard medicine, sometimes with fatal results, they’re now more likely to talk of this as a problem in the past.

Yet the problem lingers – partly because medicines obtained and sold cheaply may have been produced under lax conditions. Nelly Okpako, a pharmacist at the upmarket pharmacy chain HealthPlus, is saddened to see unlicensed people selling loose medicines on the street. She believes that the Pharmacy Council of Nigeria and other authorities should crack down on such roadside vendors.

At the same time, according to Okpako, “People really, really need more sensitisation. A lot of people don’t know the health implications of roadside medications.”

Poor-quality medicines often reach Nigeria as imports from India and other Asian countries. Margaret Ilomuanya, a pharmacist at the University of Lagos, says that it would be easier to attack shipments of substandard medicines in the country of origin. She believes that heavy sanctions should be applied to companies found to be responsible.

Unfortunately, however, reform of India’s pharmaceutical regulations has been limited. This remains mired in a dizzying array of issues: weak and fragmented regulatory design, corruption, leniency, lack of scientific rigor, opaqueness, and conspiracy theories about other countries being threatened by India’s prowess as the world’s generic pharmacy.

Related to all of these is Indian authorities’ interest in bolstering the economic muscle of pharma manufacturing. In this climate, shortcuts and oversights are condoned or trivialized.

As Dinesh S. Thakur and T. Prashant Reddy write in The Truth Pill: The Myth of Drug Regulation in India, “In no other country in the world is the business of manufacturing pharmaceutical drugs such a low-risk enterprise.” Thus it’s hard for companies in Nigeria or elsewhere, if they’re following rigorous practices, to compete.

More generally, counterfeits crowd out legitimate drugs, and cutting corners with substandard drugs makes for cheaper products than medicines produced to good manufacturing practices.

One result has been dependence on imports from India, an important trading partner that Nigeria doesn’t want to alienate. Nigeria is an enormous market for medicines, but the trade has been imbalanced. According to the publication Nigeria Health Watch, the country imports $99 worth of pharmaceutical products for every $1 it exports.

Yet the capacity to scale up domestic production is there. “The local manufacturers don’t use up to 40% of their capacity. There’s a lot of importation that profits people who want to make money,” notes Cyril Usifoh, a professor of pharmaceutical chemistry at the University of Benin and the president of the Pharmaceutical Society of Nigeria.

Ilomuanya believes that expanded domestic manufacturing would be an opportunity to further investigate the active ingredients of herbal medicines, which she’s passionate about but may be little known outside of West Africa. She points to aspirin and antimalarials as examples of medicines with herbal origins.

More sweepingly, Ilomuanya says, “The pandemic was one of the best things to happen to the pharma industry in sub-Saharan Africa.”

It’s a bold statement, but Ilomuanya stands by it. Even when the funds were available during the Covid-19 pandemic, it was tough to obtain the active pharmaceutical ingredients and medicines that African countries badly needed. For instance, her aunt’s blood pressure medicine couldn’t be found for nearly three months.

This dependence on imports, which were choked by supply chain issues, meant that “we might as well put our money into our mouths and chew” in the absence of the medicines.

But it was a push toward stepping up production of medicines and active pharmaceutical ingredients within Nigeria, rather than continuing to depend on imports. At the same time, counterfeiting of medicines in India rose during the pandemic.

Of course, bringing production closer to home won’t be a cure-all. Substandard medicines are also produced within Africa.

But long, murky, international supply chains are more often involved in unreliable medicines, which can more easily hide beyond the reach of a national regulator. “Most of the time, when I’m taking medicines that are made in Nigeria, I don’t worry,” Ilomuanya says with a smile. For instance, she says she’s never heard of falsified paracetamol because it’s made in Nigeria.

Usifoh agrees that drugs produced within Nigeria would be easier to monitor. Yet some affluent people are under the impression that imported medicines – or more expensive medicines – are of better quality.

The Nigerian government has passed certain laws to encourage domestic pharma manufacturing. For instance, a 2017 executive order required at least 40% of pharmaceuticals procured by the government to be produced within Nigeria.

And an import ban on certain products has helped to spur domestic production. Paracetamol was #1 on the list, says Ibrahim Babashehu Ahmed, the registrar of the Pharmacy Council of Nigeria. “The tariff on importing those pills was so high that importers were no longer encouraged, and manufacturers took the opportunity to increase their capacity and contribute to the GDP,” Ahmed continues.

Yet an import ban is a heavy tool to wield – especially when it comes to essential items like medicines. “You can only bar imported medicines if you have a vibrant manufacturing sector,” Ilomuanya cautions.

One reason for the continued dominance of imports is that Nigeria’s electricity challenges can make it difficult for Nigerian manufacturers, which essentially have to generate their own backup power, to compete.

Usifoh says that Nigerian manufacturers need alternative sources of energy, so that they’re less reliant on the grid. Solar energy is one such alternative being expanded throughout the country, especially via minigrids.

But for now the infrastructure challenges make for higher prices. Ilomuanya gives the example of a particular Nigerian-made antibiotic, which costs 600 Nigerian naira (about $1.30 at the official exchange rate). An imported one can be as low as 150 naira (approx. $0.33).

As if to illustrate this point, when I speak with Ilomuanya, her Faculty of Pharmacy building is without electricity. The only lights in her office are powered by an inverter and a generator.

For Ilomuanya, the unstable electricity points to a bigger culprit that is limiting Nigeria’s potential as a pharma powerhouse: insecurity. Violence has hampered foreign investment, and insufficient power generation is related to that lack of funds, she believes. “Once you have security, then you have power.”

Of course, pharmaceutical manufacturing isn’t just about the physical production of medicines. It also encompasses pricing, marketing, and distribution.

Olugbenga Mokuolu, who leads malaria work in Nigeria for the global health nonprofit Management Sciences for Health, believes that “public-private partnerships are an untapped area for sustainable access to malaria commodities in Nigeria.” He gives some examples of how this could work to relieve pressure on the public purse:

“Developing a business case for malaria commodities, identifying local production capacities for some of the major items needed in the malaria control value chain, providing an assured or protected market, obtaining manufacturers’ commitment to keep prices affordable, and getting the private sector to use their mechanisms to make the products available in their protected markets. The idea is to increase product availability while keeping costs to consumers down and freeing up governments to deploy limited available resources to support the poorest of the poor through free distribution of malaria commodities.”

It’s hard to imagine when Nigeria will have this kind of business development – or full traceability of all medicines. One person who works in quality assurance for a pharma company based in Ogun State tells me that he hasn’t even heard of NAFDAC’s traceability goal. He believes it should be a gradual process, not occurring all at once. [NAFDAC did not respond to a list of questions.]

In the meantime, people like Titilayo Oke will continue exercising their own precautions. Oke, a former nurse, now works on the Medical Impact Team at Foursquare Gospel Church in Lagos. This team of doctors, nurses, and pharmacists runs medical missions in prisons, informal settlements, and other places with limited access to healthcare. Their work includes distributing medicines.

Oke is careful to check expiration dates and the quality of medicines, but says that not everyone does so. She says that improper production or packaging of medicine can lead to tablet defects like hardness, which affects the bioavailability of the drug. “It’s a lot of negligence,” she says. So people “have to be very vigilant,” particularly when it comes to imported medicines.

“It’s very good that there is caution of getting drugs,” Oke believes.

See also: a companion article on technology for combatting bad medicines in Nigeria.

This project was funded by the European Journalism Centre, through the Global Health Security Call. This program is supported by the Bill & Melinda Gates Foundation.