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Street-traded Drugs in Congo-Brazzaville
Staying quiet is as political an act as speaking out
Michel ODIKA
In matter of drug policy, the biggest challenge is to balance liberty and security. Why? Plausible answer: A society that substitutes liberty for security deserves neither. The health system, then, requires a critical mass of capacity for quality and safety. At the same time, committed and responsive stakeholders must not only carry out technical and organizational tasks, but they must equally build credibility and legitimacy… June 2009. Ms. O is a typical patient who lives in periurban Brazzaville, Republic of Cong (Central Africa). There are at least 10 “street-based drug sellers” and “around 5 mini-shops providing the lowest-income people with the cheapest pharmaceuticals around”, within a 15-minute walk from her house – and virtually any household in her city. Today she has decided to choose the “mini-shop” run by Mr. M.. Above this shop, however, no prominent sign says “Drugstore” or any other indicative label, suggesting that the shop is staffed by a… smuggler. In response to brief explanations, the shop owner takes different pills and asks Ms. O. – patient presenting with fever, coughing and a minor chest pain – to take them for two or three days. These pills include one antibiotic and one analgesic and anti-inflammatory drug (probably counterfeit drugs or pills unfit for use). Several lessons can be learnt from the example described above. First of all, things do not have to be that way: Staying quiet is as political an act as speaking out (Arundhati ROY). The incredibly striking example is a particularly important issue in the unregulated commercial settings of many African countries, such as Congo-Brazzaville, where people often get poor value for money. One way of tackling this situation is to fight unscrupulous drugs smugglers, who can capitalize on business opportunities arising from unmet health needs. They offer patients an
Can the “epidemic” be eradicated?
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appealing alternative (attractive fees are charged) certainly, but one that is often exploitative and harmful… Undoubtedly drugs smugglers disguised in care providers have an interest in selling what is most profitable, but not necessarily what is best for Ms. O.. In many respects, this patient lives in an environment where much health care is delivered by small-scale, largely unregulated and often unlicensed providers… Deteriorating health services in Congo-Brazzaville have made room for a thriving parallel market for drugs, many of them counterfeit, warn concerned health professionals. The sale of genuine as well as fake drugs on the streets are "big, booming business". Why? Mainly because the health system has been adversely affected by the poorly performing economy. There is a general shortage of drugs within the country and unscrupulous dealers are capitalizing on the situation by selling medical drugs on the streets." Among health professionals the overriding concern is that there is no quality control of the drugs available on the streets. Drugs are far cheaper in the parallel market – citizens in Brazzaville pay between five and eight times less than they would for any drug from a registered pharmacy. For example, a month's course of antiretroviral medication could cost anywhere from US$200 to $400 in the parallel market, against almost $1,200 from a legitimate source. But with the low prices comes high risk. In some of the cases, those who need the drugs are not even aware of the dangers that are posed by buying from the streets. Even where the drugs are genuine, they pose great danger to the sick because they are not stored under prescribed conditions and can cause side effects. Inflation tends to cripple the health sector, creating shortages of drugs, medical equipment and even medical personnel, who have migrated in search of better salaries and living conditions. There is also a growing trend whereby unregistered practitioners are opening surgeries and administering wrong injections on patients, in addition to prescribing incorrect drugs. But this is a very cruel and immoral way of trying to earn a living. Most of the drugs on the parallel market are smuggled from foreign countries, particularly from neighbouring DRC (the Democratic Republic of the Congo), Nigeria, China and India, where they are
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cheaper, but some employees of pharmaceutical companies and hospitals also steal drugs and sell them to street traders. A key lesson of experience with counterfeit or unsafe drugs is that a specific policy cannot exist as an island and expect to be effectively implemented. Its formulation must identify those other systems elements, be they financing, information, infrastructures and human resources, upon which its implementation is dependent. Procurement mechanisms for pharmaceuticals, for example, raise important considerations for systems financing policies: they are interdependent. Likewise, the education of citizens and their access to adequate information as well as the training and working conditions of services providers are likely to be key determinants of the rational and legal use of drugs. Experience across the world in promoting essential drugs policies is effective in making lower cost and safer drugs available and more rationally used. This specific approach offers lessons on how to handle cross-cutting challenges of scale efficiencies and systems co-dependence. Without such arrangements, the health costs are enormous: too many people die in Brazzaville from diseases that could easily have been treated if they had had access to essential drugs rather than to counterfeit or unsafe drugs. In response to street-traded counterfeit pharmaceuticals, drugs policies are also indicative of how efficiencies in the scale of organization can be tapped. Safety, efficacy and quality of care have universal properties that make them amenable to globally agreed international standards. Adoption and adaptation of these global standards by national authorities are much more efficient and effective than each country inventing its own standards. Ultimately, national decision-making and purchasing mechanisms can guide rational, legal, cost-effectiveness-based selection of drugs and reduce costs through bulk purchase. On a larger scale, transnational mechanisms afford considerable savings as well as quality assurances that Congo-Brazzaville on its own would be unlikely to negotiate… 1. References Measuring medicine prices, availability, affordability and prices components, 2nd ed. Geneva, health Action International and
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World Health Organization, 2008 (http://www.haiweb.org/medicineprices/). Matiru R, Ryan T. The global drug facility: a unique, holistic and pioneering approach to drug procurement and management. Bulletin of the World health organization, 2007, 85:348-353. Doctor Michel ODIKA Contact e-mail: michel_odika@hotmail.com