Key messages

  • Africa’s poor local drug production and overreliance on other countries for its medical supplies worsened the impact of the COVID-19 pandemic.

  • Strengthening local manufacturing capacity in Africa's pharmaceutical sector is critical to building self-reliance in its public health system.

  • Building on lessons learned from the COVID-19 pandemic, African countries can ensure the uninterrupted supply of medicines and health technology during and post pandemics.

Introduction

The COVID-19 pandemic provoked serious social and economic changes [1], with the public health sector probably hit most severely, as it has placed a tremendous burden on even strong healthcare systems across the world [2]. The consequences have been most grave in low and middle-income countries (LMICs) like those in Africa where healthcare systems are fragile and largely overstretched [3]. In Nigeria, for example, confirmation of the index case on 27 February 2020 created an initial state of panic and confusion. It was clear that Nigeria's healthcare system was weak and unprepared for the huge challenge posed by the pandemic [4].

Several factors caused the enormous threat experienced in Africa’s health systems following the COVID-19 pandemic. A major factor was the continent's almost total reliance on other countries for the supply of its medical products and technologies (drugs, biological products, and medical devices) [5]. Indeed, many experts acknowledged Africa’s virtual reliance on medical products supply from other countries as a critical public health concern decades prior to the pandemic. According to the African Development Bank, African countries in 2022 relied on pharmaceutical manufacturing firms in China and India for over 70% of medicines prescribed. Governments have taken no concerted efforts for a long time, to address this challenge. African governments considered the global trade system to operate adequately, offering the medical products needed by their citizens at quite appealing costs [6]. However, Africa's negligence in the pursuit of a self-reliant public health supply system has dire consequences for the population of over 1 billion people living on the continent. Their access to essential medicines has been tremendously affected by the shock in the global health system caused by the COVID-19 pandemic [5].

The pandemic brought a global lockdown and severe travel restrictions that upset drug manufacturing and trade systems globally. As a result, both production and exportation of raw materials and finished products decreased across many countries [7]. Most high resource countries focused on their own healthcare needs and increased substantially their stockpiling of essential products, such as vaccines. This left Africa without any way to procure essential supplies [6]. Although substandard and falsified medicines have been traded for many centuries [8], system disturbances and shortages of medical products and devices caused by the COVID-19 pandemic exacerbated the influx – and created risk of a parallel pandemic of substandard and falsified products [9].

Uninterrupted supply of medical products across healthcare systems is critical to ensure availability and access to essential medicines for all patients when they need them [10]. A consistent supply of medical products strengthens the quality of care, produces better cost effectiveness and efficiency, and ensures greater positive impact of health programs [11]. Good medical supply chain management systems ensure that quality products are available, accessible, and affordable at all levels of the health system, and play vital roles in developing public health programs [11].

The World Health Organisation (WHO) affirms, as a critical element in achieving universal health coverage (UHC), that all individuals and communities should have easy access to quality healthcare without being burdened by the financial implications [12]. The United Nations has also adopted the 2030 Agenda for Sustainable Development “to ensure that all human beings can fulfil their potential in dignity and equality and in a healthy environment” [13]. The goal is to achieve health for all as a central tenet of the Sustainable Development Goals (SDGs), ensuring that “no one is left behind”. [13].

Africa’s population has increased significantly since the year 2000 when its population was 811 million—to over 1.4 billion in 2022 [14]. Forecasters expect the population of Africa to nearly reach that of Asia—of over 4 billion by 2100 [14]. As Africa’s population continues to rise, the demand for quality medical products will also rise. Africa must step up its capacity to cater for the healthcare needs of its population and should not rely entirely on the supply of medicines from other countries. [5]. Achieving more independent healthcare systems across the continent will play a critical role in advancing towards UHC [12].

Africa has the capacity to produce medicines for Africa with raw materials produced in Africa–and to move them to the bench and on to the bedside. An analysis by McKinsey & Company of the status of pharmaceutical market in Africa of 2019 assessed the costs, benefits, and public health impact of increasing local production of drugs in Africa and depicted opportunities that vary from country to country [15].

There are about 375 drug manufacturing companies serving the populations of all African countries. The majority of these are in the North Africa; those in sub-Saharan Africa (SSA) cluster in fewer than 10 of the 46 countries. Most countries in SSA import 70% to 90% of drugs consumed; comparable populations like China and India import about 5% and 20% respectively. These imports imply financial pressures on households and government given the already limited foreign exchange that has increased the cost of medical products and technologies.[15]. The value of SSA market is relatively small, about $14 billion, compared to that of China (over $120 billion) and of India (near $19 billion). In SSA, only Kenya, Nigeria and South Africa have relatively sizable industries and most of these local producers contribute small amounts to the value chain (research, development, production, and supply of pharmaceutical products to markets). Developing a more robust local pharmaceutical industry in SSA, according to the analysis, would require years of sustained and careful effort [13]. Increased local drug production in Africa would certainly make drugs more affordable. For example, the report noted that prices would be at least a 5% to 15% lower in Ethiopia and Nigeria compared to cost of drugs imported from India. Improved pharmaceutical manufacturing would enhance the quality and safety of medicines; and production in SSA would be easier for those countries to regulate. It would improve availability, awareness, and access to these products [15].

The workshop: Challenges in Africa to steady supplies of products for use in health care

How can Africa build capacity for a self-reliant public health system to ensure an uninterrupted supply of products and technologies for use in health care? The discussion at a virtual meeting (via zoom) early in the pandemic (3 June 2020) addressed this and we reflect on it. The group, comprised of global experts in medical products and supply chain (public and private sector, international development partners, the academia and public health media organisations) came from around the globe. It included the Director Generals of national medicine regulatory agencies and other regulators. Bloom Public Health, a leading public health think tank in Africa, organized the event. The agenda called for experts to present information and discuss effects of the COVID-19 pandemic on the medical products and technologies supply chain, especially the implications for LMICs. Participants focused on lessons learned from the pandemic by the time of the workshop, and the way forward for Africa to build and sustain a quality assured supply of medical products and technologies for use in health care. The key speakers shared their views on specified topics to generate discussion among participants. High points from the conversations generated the ‘Call to Action’.

The virtual meeting participants discussed that with the COVID-19 pandemic, Africa was hit hard with critical shortages in quality-assured, essential frontline medical devices and personal protective equipment [16]. Frontline health workers feared infection due to lack of protective covering and inadequate treatment once infected. The pandemic also created fundamental concerns about the sustainability of the health system: COVID-19 and shortages in supply of essential medicines interfered with addressing other high priority diseases including tuberculosis, malaria, and HIV [16]. Policymakers and all stakeholders must plan ways to mitigate direct and collateral negative consequences of the pandemic. Strategic interventions need to maintain the supply chain of quality-assured medical products (drugs, biological products, and medical devices) and technologies so critical to delivery systems [17, 18], and they need to build capacity to prepare for a future outbreak [15].

Even prior to the COVID-19 pandemic, Africa faced challenges in ensuring availability of medical products and technologies [19]. Factors included:

  • financial constraints on delivery of quality healthcare including underfunding of essential medicines and other health products;

  • poor national and sub-national health supply chain management systems with inadequate storage and warehousing infrastructure, transportation, and insecurity challenges(from wars and civil unrest) that affect the logistics and health supply chain system;

  • poor-quality assurance systems and weak regulatory framework [19, 20].

Persistent stock-outs of essential medicines have notably worsened during the COVID-19 pandemic.

Strengthening local manufacturing capacity in Africa's pharmaceutical sector can play a major role in building self-reliance in its public health system and help to ensure sustainable access to quality and affordable medicines. Local production could draw African countries closer to achieving our SDGs [21]. Such strengthening would also encourage economic diversification, growth of Gross Domestic Product in more countries, increase in foreign earnings through export, improving international relations, and job creation [15]. As of 2022, local manufacturing accounted for less than 30% of the medical products consumed in Africa. Improvement remains crippled by poor infrastructure, inadequate human resources, weak regulatory frameworks, and lack of protection from unfair international competition; all continue to limit Africa’s local manufacturing capacity [21]. In 2021, the Africa Union and Africa CDC launched a Partnership for African Vaccine Manufacturing (PAVM) including the framework to achieve this, an important advance.

Virtual meeting participants identified these key issues:

  • Negative consequences of the pandemic have limited tremendously Africa’s healthcare systems and the supply of essential medicines [22]. Medical products, vaccines and technologies together comprise one of WHO’s six building blocks of the health system [23] and WHO designated access to quality medicines and health products as an indicator to measure a countries’ progress towards universal health coverage (UHC) [12].

  • The effect of COVID-19 on products and technologies is comparable in most LMICs, even across Africa though the North and South Africa are world apart from the rest of sub-Saharan in terms of local production of medicines and supplies, yet COVID-19 disrupted the supply chain where the chain existed and interrupted production where production was taking place. Negative consequences flow from risks of shortages of products and the impacts of shortages on healthcare delivery and on the economy; diversion of drugs for other medical treatments to fight COVID-19, overdependence on imports, and poor patronage of the local industry [24].

  • The COVID-19 experience clarified the vulnerability of the supply chain, amplified inadequacies and constraints in the supply systems for products and technologies for health care in Africa [20].

  • Poor infrastructure, weak regulatory frameworks and inadequate compliance, lack of protection from unfair international competition, and poor patronage from buyers plague local manufacture of essential medical products and technologies(drugs, biological products, and medical devices) [21].

  • Influx and proliferation of falsified and substandard products increased with emergency efforts to find medical products to manage COVID-19 [25]. Without adequate quality assurance measures for medicines and vaccines, the world, especially Africa, risks a parallel pandemic of substandard and falsified products [25]. This poses a serious threat to the economy and health security of the continent, and even globally.

  • African countries and international development partners need to plan strategically to ensure manufacture, access, protection from substandard or falsified medical products), and monitoring of supply chains to deter inescapable shortages, price increases, and national hoarding [26].

Call to action

African countries need to study and build on lessons learned from the COVID-19 pandemic to ensure the uninterrupted supply of medicines and health technology during pandemics and post pandemics [26]. Africa needs to build alliances and capacity within and between its regions [27]. Participants proposed these actions:

  • Challenge governments and the private sector to prioritise Research and Development (R&D). Neglect, characterised by poor funding, inadequate grant funding, and high cost of research materials, hinders innovation.

  • Prepare early for future epidemics or pandemic by deliberate investment in R&D. As for wars, preparations cannot be undertaken only during a pandemic. Challenge the governments of African countries to change from import driven economies to a continent of indigenous R&D, local production, and export of technology and innovations.

  • Develop domestic pharmaceutical industry to reduce reliance on imported products. Preference for imports has led to underutilization of the industry. Create policies to protect the industry by increasing tariffs or banning imported products. Establish pharmaceutical manufacturing parks as a potent and effective model for revolutionising the pharmaceutical sector.

  • Secure an intervention loan from government and development banks for the pharmaceutical sector. Loans should be interest-free and continue post COVID-19 pandemic.

  • Reward quality by setting achievement of quality standards as a prerequisite for local procurement. Lack of quality standards operates as a disincentive for companies to improve quality.

  • Emphasize donations of know-how rather than donations of products. This will require changing attitudes about ‘Aids’ and ‘donations’ among governments and health systems in Africa.

  • Establish an African continental integrated market based on free trade agreements to create a large market and enhance buying power.

  • Strengthen risk based regulatory systems to expedite the issuance of Emergency Use Authorization of products to address emergencies such as pandemics.

  • Encourage governments to invest more on the digitalization of Medicines’ Regulatory systems and purchasing platforms to enhance ease of doing business.

  • Increase regulatory flexibility in times of emergencies. Act in a timely manner to deploy risk-based systems such as reliance and mutual recognition that is, regulatory bodies accepting the regulatory decisions made by other regulatory bodies in their own countries/regions to avoid spending a long time repeating the same process.

  • Prioritize focus on Herbal medicines’ research and development (an untapped potential) because this is Africa’s area of strength and comparative advantage. Governments must lead this.

Conclusions

COVID-19 has impacted the supply chain sector which in turn has led to inflation because demand far outweighs supply. Africa’s vulnerability has been greatly exposed. The question now is ‘what have we learnt so that we can do better next time?’ We should use this experience to plan a better future for equitable and affordable access to products for health care. People of Africa must think global but act locally. We must create policies and build capacity in Africa to protect the pharmaceutical industry so that it can become strong and vibrant to meet the challenges of a next pandemic. Taking the steps in this ‘Call to action’ proposed by experts during the workshop will move African countries in the right direction.