Olumide Akintayo is the immediate Past President of Pharmaceutical Society of Nigeria (PSN). In this interview with CHIOMA UMEHA, he takes a critical appraisal of drug distribution in Nigeria and posits that the drug handling laws have lost their applicability due to lack of updating. Excerpts:
Can you make a critical appraisal of drug distribution in Nigeria?
The drug distribution channels in Nigeria is in total chaos due to inadequate enforcement of relevant statutes, especially Act 91 of 1992 which established the Pharmacists Council of Nigeria and Act 25 of 1999 which established the various State and Federal Task Forces on fake and counterfeit drugs in Nigeria. This situation is the precursor to emergence of a plethora of open drug markets in almost all the state capitals and major cities in Nigeria. The open drug markets have evolved as the major sources of fake drugs in Nigeria.
For instance, an international workshop on fake drugs in 1988 revealed that 33 per cent of drugs which emanated from open drug markets were fake ones, while fatality rate on consumption was put at seven per cent. A review exercises by the Faculty of Pharmacy, University of Lagos in 1998, confirmed a rise in quantum of fake drugs from open markets to 49.6 per cent from 33 per cent; while fatality rate increased from seven per cent to 12.8 per cent.
Extreme government munificence continues to encourage the spread and growth of open markets which were few in 1988 when the first drug law against faking and counterfeiting was promulgated in the country. In 1988, the four thriving open markets were located in Idumota in Lagos, Ariaria in Aba, head bridge markets in Onitsha and Sabongeri in Kano.
New drug markets have since become realities in Agege, Mushin, Ikotun Egbe, Ajangbadi, Balogun in Lagos, Agbeni in Ibadan, Oja Oba in Akure, Oja Oba in Shagamu, Ogbete in Enugu, Gamboru in Maiduguri among others. Evolving drug markets have also been reported in Asaba, Kaduna, Owerri and Gombe all State capitals in the country.
The last scientifically documented report in 1998 by the Faculty of Pharmacy, University of Lagos, shows that therapeutic failure was as high as 10.8 per cent. More worrisome were revelations about consequences of encounters with fake drugs which led to increased resistance to drugs in 52.9 per cent of cases, increased severity in 48.2 per cent of cases and development of complications in 34.2 per cent of cases.
Further appraisals further showed that 29 per cent of physicians had life threatening encounters with substandard drugs. 9.1 per cent of those who shared their experiences said that the encounters ended in the death of patients. Antibiotics accounted for about 46 per cent, while six per cent were analgesics. The appraisals also showed that antibiotic counterfeiting accounted for death in 21 per cent of cases.
What then are the security implications of the fake drug syndrome?
The problems of drug distribution in Nigeria have grave security implications. Experience has shown that the peculiar nature of the network available in drug markets is very large and effective.
All that the enemies of Nigeria need to do is to lace cyanide or other toxic substance with active drug moieties and label such as any of our fast line drugs. On the delivery of these substances into the major drug markets, it would be distributed within 48 hours into the numerous open drug markets with the fall-out of substantial mortality.
A similar event in the ‘50s in the United States was the Tylenol episode where some aggrieved employees of a manufacturing company laced cyanide with paracetamol. The resulting disaster was easily checkmated because of the availability of a well-regulated drug distribution network, which facilitated a recall of the fatal batch of Tylenol. Such remains impossible in Nigeria as a result of chaotic distribution network.
What about the prescription and dispensing methods in the country?
Prescription and dispensing of medicines are regulated by laws of the federal government, some of which were enacted over 50 years ago and have lost their applicability due to lack of updating. Some efforts made by the federal government as regards prescription and supply of medicines in the recent past manifested through the birth of the National Drugs Policy 2005. There were existing recommendations that all medicines in the Nigerian drug market be classified before 2008 by NAFDAC
These lapses in dispensing and prescribing of drugs are major drawbacks in Nigeria’s version of social Health Insurance dubbed the National Health Insurance Scheme (NHIS).
The summations of issues are: The sale of drugs in Nigeria is ravaged by a departure from the global norm in many respects. In Nigeria today, there are only about 3,000 registered pharmacy facilities in the various cadres of practice including retailers, wholesalers, importers and manufacturers. Of this number, less than 2,000 are retailers who provide services directly to the consuming public. While there are less than 2,000 registered retail pharmacies, there exist over a million different drug sellers who are unregistered. It is this plethora of illegal drug sellers who are largely unregulated who perpetrate most of the obnoxious and dirty practices in drug distribution in the country.
Next, Nigerian doctors are particularly guilty of the phenomenon styled dispensing doctors in both the public and private sectors. Doctors are not trained to dispense drugs and therefore they are part of problems of drug abuse and misuse as well as the inherent complications of this unwholesome development.
The other dimension is that doctors through their hospital facilities purchase the drugs they use in practice from the open markets and unregistered wholesalers presumably because the drugs are cheaper. In this way, they sustain some of the illegalities associated with drug distribution in the country. Pharmacists are also guilty of prescription in pharmacies. This is also not lawful in many instances.
Nigerian doctors in the private sector are reputed to be the major promoters of quackery in the health sector as they ‘train’ auxiliary nurses, pharmacy and laboratory attendants, apart from plethora of other quack sub-health personnel in their hospital facilities.
It is the periodic dumping of these quacks that continues to be the stumbling block towards responsible healthcare delivery in the country. Surveys and data have confirmed that the brains behind the operation of illegal hospitals and care facilities in Lagos State are the graduates produced by private sector doctors in their hospitals across Nigeria.
What are specific local issues promoting hazardous drug prescription practices in the country?
They include what can be described as physician-patient ratio. For a country of about 160 million people, the population of doctors is only about 40,000, giving a doctor-patient ratio of 1:4000. Even then, there is a skewed distribution of the doctors who are predominantly in the urban areas, leaving the mass of Nigerians with a worse ratio.
The next is inadequate healthcare facilities: Our hospitals and healthcare centres are grossly inadequate in terms of number. Even when they exist, the out-of-stock syndrome of drugs and insufficient personnel often discourages patients from visiting them.
Another factor is that the number of Nigerians that are living below the poverty line continues to increase by the year. Therefore, many Nigerians are unable to pay consultation fees and many cannot afford prescribed drugs – even when they are available. The matter is worsened by our healthcare management system where up until today; most patients have to carry the full weight of their healthcare costs. The National Healthcare Insurance Scheme is yet to be effective because it is poorly designed and implemented.
Closely related to poverty is the high healthcare illiteracy rate among Nigerians. This makes it difficult for many of them to place the proper premium on their health. In their order of priority, healthcare maintenance expenses take a very low place in terms of priority, many times behind social functions, smoking or chewing and other sundry matters.
What then do you say about the quality of prescriptions in our hospitals?
All over Nigeria, it is known that a majority of prescriptions do not meet the required prescription standards. All manner of prescription ranging from pieces of paper to scrambling are noticed. Some prescriptions that may best be described as deadly are also constantly seen all over the place. The closest to prescriptions emanate from public health institutions, but the prescribers are usually unknown because the prescription formats are not standardised.
In the private sector, prescriptions are virtually non-existent. There is also no structure or line of communication between legitimate prescribers and dispensers in the private sector.
What is the way forward?
There is need for immediate dislodgement of open drug markets and other unregistered premises all over the country in line with the 2003 Presidential Committee on Drug Distribution. Another is strengthening the major regulatory agencies via PCN and NAFDAC to cope with the challenges of enforcement. The concept of mega wholesaling as viable alternative structure to open drug market phenomenon should be embraced. The federal government must ensure July 2017 deadline of the take-off of freshly approved amended Drug Distribution Guidelines.
Only health professionals who have a good knowledge of drug actions (medical doctors, dentists and veterinary surgeons) should be legally permitted to participate in prescribing for now in accordance with existing laws. Herbal practitioners should be allowed to prescribe only herbal medicines when integrated into orthodox healthcare practice. Patent medicine vendors and open drugs markets should strictly not be allowed to generate prescriptions of any sort for Nigerian patients.
The classifications recommended by the national drug policy should be legally ordered to be implemented with immediate effect. Prescriptions generated by `appropriate practitioners should be recognizable. Such practitioners may be legally required to use a standard prescription format, seals and phone numbers etc.
Prescription reviews and corrections by pharmacists should be encouraged in the interest of the health and safety of the Nigerian public. Only pharmacists should undertake dispensing of drugs in tandem with existing laws.
There should be a comprehensive survey of dispensing and prescription practices to identify gaps.
The International Pharmaceutical Federation (FIP) Guidelines on Good Pharmacy Practice should become the minimum standards for dispensing medication to Nigerians. Perhaps, it is strategic and imperative to call on the Federal Ministry of Health to release the draft National Prescription Policy document worked on by stakeholders between 2013 and 2014.
Obviously, the fundamental distortion remains unhindered access to medicines by consumers of health in the country. These challenges are not insurmountable. I believe that with all hands on deck and a strong resolve to ensure rational use of medicines like the rest of the decent world, we can normalise the situation.