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West Africa fights back against fake malaria medication

These are among the most common counterfeit drugs worldwide. Several promising interventions aim to combat the illegal trade.

Malaria infected 234 million people in Africa in 2021 – 593 000 of whom died, according to the World Health Organisation (WHO). Equally shocking is that counterfeit and substandard antimalarial medicines result in the deaths of as many as 267 000 people in sub-Saharan Africa annually.

Over the years, the antimalarial drugs that were widely recommended and supplied in West Africa – chloroquine and sulfadoxine-pyrimethamine – have lost their efficacy. ‘Something needed to be done,’ said Dr Sunday Olise at Abuja’s Orozo Medical Centre. ‘Many governments in the sub-region went with the recommendation of the WHO to shift to artemisinin-based combination therapies (ACT).’

However, because of their efficacy and widespread use, antimalarial medications, especially ACT, were among the most common counterfeit drugs in the world, he said. Globally, China and India are the main producers of ACTs and numerous other drugs. The United Arab Emirates, Singapore and Hong Kong serve as transit hubs in the global supply chain.

This market is constantly evolving. Dr Modu Sonkoh of the Edward Francis Small Teaching Hospital in The Gambia explained that fake malaria drugs were typically produced in illicit laboratories, often in African and Asian countries with weak regulatory systems.

A 2023 United Nations Office on Drugs and Crime report identifies West Africa, especially Guinea and Burkina Faso, as hotspots for the sale of fake medicines. According to the report, unauthorised importers in these two countries request legal and illegal laboratories in India to produce drugs with reduced active ingredients, to cut costs. The supply chain includes employees in authorised distribution centres, pharmacists, private depot sellers, government officials and people involved in healthcare sector corruption.

Malaria killed 593 000 people in Africa in 2021 – and fake antimalarials kill half that number every year

However, African governments are fighting back, including by making use of technological advancements and track-and-trace systems. James Ogoegbulem, Managing Director of Aid Emergency Consolidated Services in Abuja, told the ENACT project that the track-and-trace system required ‘a scan at each interaction with a medical product, spanning from its entry point to its [being dispensed].’

In the case of ACTs, he said, ‘All reputable pharmacies in Nigeria have signed up to the system. Nigeria is now adopting forensic techniques and systems that can embed unique authentication markers throughout the pharmaceutical distribution chain, ensuring the integrity of products up to the point of patient administration.’

Ifeoma Nnamuchi, a microbiologist at Vintage Pharmacy in Abuja, Nigeria, told ENACT that Nigeria’s government had started using medicine authentication technologies such as the Mobile Authentication Service. This text message-based initiative was introduced by the National Agency for Food and Drug Administration and Control. Using a code concealed under a scratch panel on drug packages, the authenticity of purchased medication can be confirmed through a free text message service.

Partnerships and information sharing among African countries are vital in combatting counterfeit ACT. According to Lansana Saccoh, a politician who campaigned in Sierra Leone’s 2023 elections on an anti-crime platform, ‘The effort to eliminate counterfeit ACTs in West Africa necessitates a comprehensive approach involving collaboration.’

He said although the Economic Community of West African States and the West Africa Health Organisation supported the region’s pharmaceutical industry, ‘more is needed to combat counterfeit ACTs through collaboration to ensure the operationalisation of Africa’s Pharmaceutical Manufacturing Plan.’

African governments are making use of technological advancements and track-and-trace systems

A 2021 joint law enforcement operation spanning 20 African countries coordinated by INTERPOL and AFRIPOL, identified hundreds of suspects. It led to the confiscation of over 12 million illicit health products and the imprisonment of seven executives from a multinational pharmaceutical distribution firm in Benin for their involvement in selling counterfeit medicine.

In February 2023, Nigeria and Cameroon signed a cooperation agreement to disrupt the manufacture and distribution of fake medicines by facilitating an exchange of experiences and technical expertise. Such collaboration needs to be supported by robust regulatory frameworks and enforcement mechanisms.

The African Union’s (AU) African Medicines Regulatory Harmonization programme is another worthwhile model. It works through regional economic communities to facilitate access to good-quality, safe and efficacious medical products. In support of the AU’s programme, The Gambia’s Medicines Control Agency is implementing stringent regulations for ACT, including licensing requirements for importers and quality testing of drugs.

The 2020 Lomé Initiative, a binding agreement to criminalise the trafficking of counterfeit and substandard drugs in Africa, is also proving useful. For the first time, leaders from the Republic of the Congo, Ghana, Niger, Senegal, Togo and Uganda have elevated fake and substandard medicines to a top-tier political priority.

Limited resources and inadequate techniques for identifying fake drugs are obstacles to tackling the trade

The initiative led to the development of a ‘comprehensive strategy to prevent, detect and respond to substandard and falsified medical products, including … actions from education to border control, from supply chain integrity to transparent legal processes,’ said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

‘More West African countries should join [the Lomé Initiative],’ says Sonkoh. He noted that education was key to preventing counterfeit ACT, citing the Fight the Fakes Alliance as an example of where information dissemination was working. Led by a coalition of international organisations, the campaign raises awareness among communities and healthcare providers about the risks of fake drugs. The campaign has been active in Ghana since 2020.

In Nigeria, the National Agency for Food and Drug Administration and Control spearheads public awareness initiatives, and since August 2021, has initiated campaigns in eight states. Dr Adebola Ajeye of Karshi General Hospital said they ‘educate the public through media campaigns, community dialogues and grassroots engagement to combat counterfeit ACT.’

Tackling counterfeit antimalarial drugs poses a significant challenge, primarily because of the limited resources and inadequate techniques available for detecting and identifying fake medicines. By using appropriate technologies, collaboration and information sharing, countries are moving towards ensuring the availability of authentic ACT. This not only protects consumers but contributes to global action against fake pharmaceuticals.

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Development partners
ENACT is funded by the European Union and implemented by the Institute for Security Studies in partnership with INTERPOL and the Global Initiative against Transnational Organized Crime. The ISS is also grateful for support from the members of the ISS Partnership Forum: the Hanns Seidel Foundation, the European Union, the Open Society Foundations and the governments of Denmark, Ireland, the Netherlands, Norway and Sweden.
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