Personal tragedy has motivated a number of people to fight bad medicine in Nigeria. Jessica Osita, one of the Nigerian teens who developed an award-winning app called FD-Detector (Fake Drug Detector), lost her brother to a fake drug in an accident.
The founder of the online pharmaceutical marketplace Medsaf, Vivian Nwakah, was shocked when a friend died after taking a fake malaria pill.
Dora Akunyili was the respected head of NAFDAC, the Nigerian government agency responsible for overseeing the quality of food and medicines, during the height of the country’s counterfeit drug crisis. Akunyili lost her sister Nwogo at the age of 21 to a fake insulin injection. Akunyili would survive arson and assassination attempts in her work to stop the widespread proliferation of ineffective or harmful drugs.
And for John Okpe, it was a close friend’s sister who died after taking a tainted cough syrup. Okpe is the business development manager of health technology company Chekkit Technologies, a four-year-old drug authentication company. Okpe says Chekkit was the first traceability service provider in Nigeria to be approved by NAFDAC and GS1, a global non-profit organization that sets medical standards. And Chekkit allows verification in more ways than competitors – via a mobile app, SMS and USSD (another form of SMS that is faster than SMS).
Part of what Chekkit does is a more advanced version of an already mundane activity. Nigeria is the first country to mandate Mobile Authentication Service (MAS) on a large scale for medicines (particularly anti-malarials and antibiotics, although other medicines are now using it as well).
MAS is a system for telephone verification of goods. In Nigeria, it usually takes the form of self-adhesive labels with scratchable parts that reveal a code. Individuals can then send a text message with the code, which should quickly generate a message whether the drug is authentic.
“It’s really just a track-and-trace system,” explains Margaret Ilomuanya, the acting head of the Department of Pharmacy and Pharmaceutical Technology at the University of Lagos (who himself has had to advise people affected by poor quality drugs). In other words, MAS does not provide details about the biological composition of each controlled drug, but it allows some traceability through the supply chain.
It has been suggested that MAS may have been linked to the reduction of counterfeit medicinesalthough it was difficult to assess the exact impact.
For starters, it’s common practice not to use MAS, even if it’s available. Many people rely more on where the drugs are sold than on the technology. A 2016 study by Ilomuanya and Aisagbonhi Justine, from customers of licensed pharmacies, found that while more than ¾ were aware of the Mobile Authentication Service (MAS) for anti-malarials, just over ¼ used it regularly. And usage varied by part of the country and level of education.
Olusesan Makinde, a medical doctor and the CEO of the health and development consultancy Viable knowledge masters, says he would use MAS if he was unsure about a particular drug. But for the most part, “I prefer to rely on the kind of facilities I go to… That can also serve as security.”
Pharmacists are also not always enthusiastic about MAS. A survey of the perceptions of community pharmacists found, for example, that the ongoing power outages in Nigeria affected telecom networks, and therefore the speed and usability of the service.
Still, Nelly Okpako, a pharmacist at upscale pharmacy chain HealthPlus, says it makes good business sense to stock MAS-compatible products. Some of her clients have bad experiences with poor quality medicines. Those who get good results will come back. MAS helps with this because “when they can do this, they trust your brand and trust the authenticity.”
And even if people don’t use MAS regularly, it can still be worth it. “I think MAS is very useful,” says pharmacist Ilomuanya. “One of the things MAS has done is improve consumer acceptance of the products.”
So when someone sees that products have MAS, they have more confidence in the individual products and in the overall pharmaceutical system. That helps the pharmaceutical industry in Nigeria, even if people don’t check the labels.
Okpe says counterfeiters have started counterfeiting MAS labels, leading some companies to be interested in solutions that are more resistant to counterfeiting. Chekkit’s labels use security features such as taggants. This is a chemical coating, also used on some currencies, that manufacturers can scan with special devices to verify authenticity. The label lights up green for a verified product and red otherwise. So it provides some quality assurance before the drugs reach the consumers, who themselves can check the authenticity on their end.
Makinde and colleagues have that too developed an app where members of the public can report unlicensed medical facilities, including pharmacies and drug vendors. They are looking for investment and are working with the state government to roll it out, making sure the public reports are translated into action.
While useful, this kind of consumer technology remains out of reach for many. According to one estimate, about 35% of Nigerians do not have a mobile phone. Of those that do, only a small minority own smartphones, which are necessary to access apps.
Nor do all Nigerians have access to licensed pharmacies. Particularly in informal settlements or remote areas, there is a limited choice of medicines – if any, apart from herbal remedies and traditional remedies. Where medicines are available, it may be most convenient and economical to buy a few tablets or a sachet at a time, rather than buying a full pack. Yet it is the full package that would normally carry the MAS label.
Patent drug vendors can fill the gap in places without formal pharmacies. Points of sale for patent medicines are only allowed to sell over-the-counter medicines, but often sell other medicines as well. In reality, they operate in a legal vacuum as most places sell patent and proprietary drugs are not registered.
It would be easy to condemn the patent drug vendors who sell drugs illegally, without necessarily knowing about drug interactions. The quality of medicines in these outlets is often dubious. But with their convenience and availability, these largely informal businesses undeniably fill a gap. And some informal drug sellers want to be responsible, even if they don’t have a license.
But even people who have access to medications with MAS often don’t bother using it. And this is where Chekkit invented a way to instill the habit.
Its customers ask questions that Chekkit turns into optional surveys. These are simple two- or three-question surveys that customers can complete, even on feature phones or with an Android app. Completing a survey gives customers access to rewards such as points that can be converted into mobile airtime or bank transfers. These rewards are only linked to over-the-counter products.
The incentive is also a motivating factor for pharmaceutical manufacturers as they access the information through surveys. “Currently, we are the only company that offers this level of information and insight,” says Okpe. “We’ve had brands partner with us as a company because of the rewards.”
The company therefore has two sides: the authentication of medicines and the data generated thereby. Okpe believes that while Chekkit’s labels are slightly more expensive than standard labels, “manufacturers understand the added value.”
On the other hand, “Customers are starting to get into the habit,” notes Okpe. He says 60-80% of the time, customers authenticate the products they buy.
According to Chekkit CEO Dare Odumade, there have been more than 1 million consumer authentications and more than 30,000 users of the app, verifying an average of one product per week.
Ilomuanya recognizes that MAS is not perfect. She says there have been some cases where MAS falsely identified products as inauthentic, damaging the reputation of drug suppliers. And some of the less established tech companies that provide MAS services are having problems with their software, according to Ilomuanya.
Indeed, users sometimes complain that when they try to verify a message using MAS, nothing happens.
But given the benefits of MAS – which Nigeria has been at the forefront of and which other countries are eyeing – it is a promising tool for keeping out bad drugs. It can’t be the only tool, but it’s a useful part of the arsenal.
The end goal of such tools is full drug traceability in Nigeria. Okpe is extremely optimistic that when the goal is reached it will be a game changer. “Right now, the pharmaceutical industry in Nigeria is really fragmented,” he says. It will be very challenging, if not impossible, to eradicate all pharmaceutical crime and informality, but Okpe is shooting for the stars: “I think if this is implemented, counterfeiting will be essentially eliminated.”
In general, technology has limitations to achieve this goal. Good intentions have failed to stop a graveyard of apps and apps detection devices by polluting this field and eventually getting thrown out after having little effect.
“I’ve seen some very expensive detection devices sitting on a shelf just collecting dust,” noted Pernette Bourdillon Esteve, who leads a World Health Organization team working on counterfeit and substandard medical products, speaking at a Battle the Fakes Alliance event. “For a round hole you need a round peg.”
If Chekkit can indeed be a round peg to the round hole represented by the complex challenges of ensuring the quality of medicines in Nigeria, many lives will be saved.
Also see: a companion article on drug production in Nigeria.
This project was funded by the European Journalism Centre, through the Global Health Security Call. This program is supported by the Bill & Melinda Gates Foundation.