Access to safe, effective, affordable, and quality medicines is an essential component of the right to health and is also one of the targets in the global development agenda. However, access to medicines on the continent is not without issues and challenges. Africa faces a double burden of infectious and non‐communicable diseases and the need for effective universal access to medicines cannot be deemphasized.
Access to proper medicine is a major challenge for African countries. Many people living in Africa have a problem with accessing medicines and this undoubtedly contributes to the poor health metrics of most countries in the region. Access to medicine remains a major challenge in Africa with peculiar implications for the achievement of Universal Health Coverage on the continent.
Efforts to ensure access to medicines are mainly driven by an ethical imperative: people should not be denied access to life‐saving or health‐promoting interventions for unfair reasons, including economic or social causes. The need to have access to safe and effective medicines is so important that it has been designated as a basic human right by the World Health Organization.
Healthcare expenditures in many parts of Africa fall below what is required to achieve Universal Health Coverage (UHC) and many people have to resort to out‐of‐pocket payments for medicines. The African region also has the highest burden of communicable diseases (like tuberculosis, HIV/AIDS, malaria) and a significantly high burden of non‐communicable diseases such as diabetes and heart diseases.
This definition takes into consideration the basic components of access to medicines, that is, accessibility, affordability, availability, and acceptability. Access to medicines takes into account the effectiveness of the supply chain with respect to supply location and location of the end‐user. The methodological approach utilized in this narrative review is similar to what was used in some previous studies.
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We conducted narrative review with the inclusion of relevant papers published up to March 2022 and in English Language. Data reported in this study were gotten from published literature in African countries on topics pertaining access to medicines. The authors also snowballed further data to gather information for this review by reviewing the references of the included papers and narrative synthesis was conducted with theme of discussion identified across studies.
Challenges in Accessing Medicines in Africa
Despite the feeble healthcare systems, African countries are challenged with a double burden of infectious diseases and non‐infectious diseases. While communicable diseases still account for about two‐thirds of deaths in Africa, age‐specific death rates among men and women from chronic non‐communicable diseases are greater in sub-Saharan Africa than in any region globally. This has resulted in heavy demand for medicines for diseases treatment and prevention, making access to medicines on the continent considerably difficult for some patients, especially among the marginalized and vulnerable groups.
This situation is worrisome and concerning in Africa because of the presence of limited pharmaceutical manufacturing capacity to cater to the continent medicine's needs. More so, the emergence of the COVID‐19 pandemic has resulted in a shortage of medicines across the continent due to the global travel bans and lockdowns, which affect medicines manufacturing and importation. The urgent need to have access to medicines among the populace, due to the high diseases burden, is a potential route that can facilitate the circulation of fake and counterfeit medicines on the continent and the presence of porous supply chain systems worsen this further.
This implies that, as the efforts to curb diseases incidence and prevalence intensify, there is a need to invest in solutions and efforts aimed at ensuring uninterrupted access to effective, safe, quality, and affordable medicines. Here are some specific challenges:
Limited Local Production
The dearth of drug manufacturing industries in Africa vis‐à‐vis the exorbitant cost of raw materials constitutes a huge limitation to the ease of access to drugs. It is disheartening that Africa accounts for only 3% of global production of drugs despite bearing 24% of the global burden of disease and accounting for 11% of the world's population. Those in sub‐Saharan Africa are clustered in nine out of 46 countries.
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In 2005, a World Bank research identified that Nigeria, South Africa, Kenya, and Zimbabwe have the industrial capacity that can be channelled to the production of medicines for domestic consumption or export. However, they warned that if the economic cost of creating local production capacity is high or the quality of products is subliminal, this potential is prone to depleting. The cost of production and the quality of drugs manufactured are hugely dependent on the availability of raw materials, including active pharmaceutical ingredients (the primary components in the manufacture of drugs).
In Africa, raw materials and equipment needed for drug production are mostly imported, contributing significantly to the cost of production. Thus, industries are forced to rely heavily on imports and thereby incur excessive expenditures. This directly translates to a severe reduction in both the quantity and quality of drugs produced. The growth of local pharmaceutical industries also relies heavily on the availability of infrastructures such as transportation systems, communication networks, and constant power supply.
Combined with its fragile economy and ridiculous level of sustained poverty, indigenous drug production faces tedious constraints. The consequences thereof are suffered by the populace who have extremely limited access to essential and non‐essential drugs.
Over-Reliance on Imports
In most African countries, pharmaceutical imports comprise as much as 70-90% of drugs consumed. This overwhelming dependence on importation predisposes vulnerable citizens to shortages. This stems from two major reasons: firstly, there is an immense paucity of in‐country drug‐producing industries and secondly, there is a wide distrust in locally made drugs.
The consequence, therefore, is an enormous demand for overseas drugs which cannot match the importable quantities. The resulting shortages from lack of access to specific brands lead to deterioration of illness and an increase in mortality, signalling a poor health index. This jarring problem also signals ominous consequences on the economy of the Africa region. Overdependence on imported drugs pushes the economy to the edge of trade deficits.
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The entire process of drug manufacturing in a different country, the exportation of the final formulation, packaging, and repackaging of the drugs, and eventual sale of the packaged products can be complex. An efficient distribution system is, therefore, needed to ensure drug quality and ease of access.
Inefficient Distribution Systems
Despite the increased investment in the procurement of drugs, their availability in Africa remains extremely low. Inefficient drug distribution can drive up costs and cause drug stock‐out. The lack of a functioning drug supply chain has been observed to be one of the major causes of poor access to essential medicines.
Government Apathy and Poor Policy Implementation
The prevailing government apathy and lack of political will encapsulated by a consistent lack of investment in healthcare affect people's access to drugs. Additionally, there is an inadequate implementation of existing policies such as the Primary Health Care policy in many African regions. This policy aimed at ensuring equity in access to quality healthcare services has suffered severe setbacks due to poor implementation.
The primary healthcare systems are rife with fragmented services, a weak referral system, and a huge gap in access to basic healthcare. Government healthcare financing in Africa is critically low. There is abysmally poor coverage of insurance schemes with a significant number of the population unable to access the services. Thus, there is a disturbingly high un‐pooled source of payment for medical services and products including out-of-pocket spending by the populace which accounts for as high as 70% of total health expenditure in the region.
Low Manufacturing Capabilities
Drug production in Africa is typically done using small plants with low capacity and output. In the context of solid dosage forms, for instance, this limits the capacity to produce enough tablets to achieve economies of scale and lower overall production costs. According to a report by McKinsey, African manufacturers need to produce at least half a billion tablets per year to be cost‐competitive with India.
However, the prevailing low manufacturing capabilities often lead to high drug prices and discourages local drug production. Moreover, the utilization and efficiency of manufacturing plants are further exacerbated by high electricity costs, frequent power interruptions, and other infrastructural issues such as poor transportation and logistics systems. Unsurprisingly, these unfriendly manufacturing conditions are likely to outweigh any intended production‐cost advantages of local drug manufacturing.
As a result, the affordability of these medicines is adversely affected, as the overhead costs are ultimately transferred to patients and end‐users, obstructing access to affordable medicines.
Inadequate Healthcare Workers
Globally, the crisis of insufficient healthcare workers is most pronounced in Africa, particularly sub-Saharan Africa, thus limiting access to medicines. The region accounts for 36 out of the 57 countries with a critical shortage of health workers, having 2.3 healthcare personnel per 1000 population, a far cry compared to 18.9 and 24.8 in Europe and the Americas, respectively. Expectedly, this has remarkable consequences on healthcare delivery, including access to medicines.
Likewise, the unprecedented exodus of doctors, pharmacists, nurses, and other healthcare workers to developed countries also worsens the already frail health systems of African nations, further impairing access to medicines. Furthermore, there is evidence to show that this worrisome trend may further deteriorate if not addressed promptly and properly. A meta‐analysis revealed that the intention to leave among African nurses was approximately 52%, considerably higher compared to Israel (9%), Brazil (22.1%), and Europe (33%).
Poor Health Financing Frameworks
Many African countries lack proper health financing frameworks needed to achieve UHC, making access to affordable medicines challenging. Despite the 2001 Abuja Declaration in which African leaders agreed to allocate at least 15% of the general government expenditure to health, only five countries (Botswana, Togo, Madagascar, Rwanda, and Zambia) have kept to the commitment.
Moreover, twenty‐two (22) African countries do not meet the minimum health expenditure of $44 per capita as defined by the High‐Level Task Force on Innovative International Financing for Health Systems (HLTF), and only three countries (Botswana, Rwanda, Zambia) have met both the Abuja Declaration and the HLFT requirements.
Africa carries a heavy health burden. It accounts for 25% of the global disease burden despite having only 18% of the global population.Yet the continent produces only 3% of global medicines. It imports over 70% of its medicines.
Addressing the Challenges: Strategies and Solutions
To overcome these barriers, there is a need to:
- invest in local production of raw materials
- offer tax breaks and subsidies
- improve electricity supply
- expand training programmes.
Skills development is being driven through various initiatives. Examples include the Council for Scientific and Industrial Research Workforce Development Programme and the African STARS (Science, Technology and Research Scholars) Fellowship.
Promoting Local Production of Active Pharmaceutical Ingredients
At the heart of the challenge is the over-reliance on imports of active pharmaceutical ingredients. These are key components that make medicines work. Without them, there are no drugs. Africa imports over 95% of its active pharmaceutical ingredients, mainly from India and China. Importing them makes local production expensive and vulnerable to foreign pricing. This dependency has a severe impact on access to essential medicines.
Making active pharmaceutical ingredients locally would reduce costs by cutting out import fees and shipping delays. It would also boost local economies by creating jobs and encouraging innovation. One of these is continuous flow manufacturing, a production method where medicines are produced in a continuous stream rather than in batches. It enables faster, safer and more consistent production with less waste and cost. This could make African production more competitive and sustainable.
But no single technology is a silver bullet. A combination of traditional and modern methods, tailored to local needs, will be key to building a strong pharmaceutical sector.
Progress Underway
The good news is that momentum is growing. Several African companies are leading the way in producing local pharmaceutical ingredients. These include:
- Emzor Pharmaceuticals and Fidson Healthcare in Nigeria
- Aspen Pharmacare and Chemical Process Technologies in South Africa
- Eva Pharma in Egypt
- Dei BioPharma in Uganda.
The governments of Kenya, Ghana, South Africa and Nigeria are also investing in public-private partnerships to support this shift.
Investment and Financial Support
A great deal of investment is needed. A report by the African Development Bank said an estimated US$11 billion would be needed by 2030 to fund the growth of Africa’s local pharmaceutical industry. This includes manufacturing of active pharmaceutical ingredients and vaccines.
The vision is a continent where every country can produce its own affordable medicines and respond quickly to health crises. The South African government recently supported the establishment of FuturePharma. This is an open-access facility at the Council for Scientific and Industrial Research (CSIR). Its purpose is to assist pharmaceutical companies across Africa by providing research, development support and workforce training. It is also an investment in reducing the risk in modern active pharmaceutical ingredient manufacturing.
Enhancing the Role of Pharmacists
Across Africa, community pharmacies are often the first - and sometimes the only - accessible points of care, particularly in rural and underserved regions. In Nigeria, for example, pharmacies comprise ~50% of the primary healthcare facilities that cater to 70% of registered care visits.
Similar shifts are also underway in Africa, with Nigeria and South Africa having adopted task-sharing and task-shifting policies that empower pharmacists to administer contraceptives, support maternal and child health, and combat infectious and non-communicable diseases. However, the incorporation of pharmacies in healthcare delivery remains limited across Africa.
Like pharmacy schools in the US and UK, pharmacy schools across Africa can incorporate competencies in emerging technologies, multi-disciplinary patient care, and digital health technologies into the standard training curricula. Pharmacy compensation models should also evolve to cover an expanded set of public health services beyond dispensing.
Leveraging Digital Solutions
Pharmacies aren’t just uniquely positioned near patients - in some locations they’re also more likely to be digitally-enabled. Today, pharmacies mostly use digital platforms for payments and accounting. In the US, Saudi Arabia and South Africa, automated dispensing systems such as Right ePharmacy are streamlining medication dispensing, minimising human errors, and thus allowing pharmacists to focus more on patient care.
Pharmacy-based innovations are also emerging across Africa. Companies like Grinta (Egypt) and Remedial Health (Nigeria) use data-driven systems that enable pharmacies to monitor, restock and finance inventory, reducing fewer stock-outs.
The Need for Clinical Trials in Africa
Africa bears one-quarter of the global disease burden, but in 2023 only 1.1% of clinical trials carried out worldwide were hosted on the continent.Under-representation matters as clinical trials are a vital gateway to access, with implications also beyond Africa in terms of global health security.The global health community has long called for innovation that delivers impact where it is needed most. Yet the structure of medical research remains deeply unbalanced. When it comes to pivotal late-stage trials, which are typically conducted on a large scale and a worldwide basis, Africa also gets left behind. The 2024 Access to Medicine Index found only 27.5% of late-stage R&D projects - 89 of a total of 324 - from 20 top pharmaceutical companies analysed included one or more African country.
This under-representation matters because clinical trials are a critical gateway to access. They shape where treatments are approved first, how quickly they become available and whether products are tested for safety and efficacy across diverse populations. The missed opportunities are especially stark when it comes to high-burden diseases where Africans are on the frontline.
Africa accounts for more than 80% of all cases of sickle cell disease, for example, yet access to emerging therapies is extremely limited due to minimal trial activity in the region. Although sickle cell disease is one area where gene therapy has shown real potential, no gene therapy trials are under way for the condition across the continent. Similarly, modern long-acting injectables could dramatically improve treatment adherence and outcomes for a variety of diseases, but they are rarely trialled in Africa beyond those for HIV/AIDS.
As sponsors and asset owners of so many clinical trials, the pharmaceutical industry has a vital role to play, but the data shows it is falling short. As health threats grow more complex, with pandemics and antimicrobial resistance on the rise alongside climate change, building an inclusive research ecosystem is essential to prepare for what lies ahead.
Clinical Trials in Africa
The good news is that Africa already has some strong foundations. The WHO has also invested in a TDR network that spans several countries and has trained hundreds of clinical research staff. The availability and affordability of safe, effective, accessible, and high-quality essential medicines is a critical benchmark for achieving the right to good health, and it is also one of the goals of the global health development agenda.
The initial emphasis placed on the treatment of communicable diseases, the majority of which are acute, could explain the trend, which is similar to other low-income parts of the world. According to various studies, countries must urgently adapt and adapt their essential drugs. According to Kirigia and Barry, in Africa, there are serious leadership and governance challenges that include fragile public health leadership and management; inadequate health-related legislation and enforcement.
| Challenge | Impact | Potential Solution |
|---|---|---|
| Limited Local Production | High dependence on imports, increased costs | Invest in local manufacturing, provide incentives |
| Inefficient Distribution | Stockouts, increased costs | Improve supply chain management, invest in infrastructure |
| Inadequate Healthcare Workers | Limited access to medicines, poor healthcare delivery | Expand training programs, improve working conditions |
| Poor Health Financing | Unaffordable medicines, low insurance coverage | Increase government spending on healthcare, expand insurance coverage |
It has been demonstrated that access to availability and affordability of medicines in African countries present numerous challenges, and it is critical for the continent to address this situation. By addressing these challenges through strategic investments, policy reforms, and collaborative efforts, African nations can significantly improve access to essential medicines and enhance the health and well-being of their populations.
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