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.
