IBADAN, Nigeria — Pharmacist Atere-Akeukereke Hamidat knows that a problem exists in Nigeria’s medical ecosystem, in which citizens have easier access to drugs than they do to hospitals.
“From the main road to my house, there are dozens of patent and proprietary medicine vendors [basic drug stores] but no single hospital,” she told Devex.
Patent and proprietary medicine vendors, or PPMVs, have no formal education in health or pharmaceuticals and so, unlike pharmacies, are not allowed to sell prescription medicines. But with their proximity to citizens and lower cost of service, they have become the first point of care for most patients seeking health services in Nigeria. While official estimates are not available, a USAID report estimated that about 200,000 PPMVs operated in the country as of 2005, far outnumbering the 2,639 pharmacies that were registered that same year.
“It is easy to go on radio and ask people not to use drugs. [But] without providing them with a safer, more affordable and easily accessible option, they will not even listen to you.”— Monsurat Abayomi, owner, Nigerian patent and proprietary medicine store
PPMVs, however, are also poorly regulated. As a result, they often exceed the limits of their licenses. Although they are not permitted to sell antibiotics, many do — Devex was able to buy them from PPMVs across Ibadan, the sprawling metropolis where Hamidat works.
Antimicrobial resistance has become one of the biggest challenges in global health, driven by the overuse and misuse of antibiotics. Already accounting for 700,000 deaths each year, a report commissioned by the U.K. government estimated that figure will rise to 10 million within 35 years.
As a region, Africa is set to be worst affected because of the high burden of malaria, HIV, and tuberculosis. Yet many questions remain about how to tackle a health threat that often feels distant, and is complex to monitor and measure.
More on antimicrobial resistance
In Nigeria, the government launched a five-year national action plan on antimicrobial resistance in 2017. The plan noted “a pressing need to contain the problem,” and acknowledged that poor enforcement of regulations, a “chaotic” drug distribution system in the private sector, the prescription of antibiotics by people without licenses, and the sale of prescription medicines by PPMVs were all part of the problem — but little has been done to tackle those issues.
Money, myths, misconceptions
For store owners, the motivation for selling antibiotics without a license is clear. But what about the customers requesting drugs that might not be appropriate for their condition? Often, it comes down to misconceptions about what antibiotics can be used for.
Monsurat Abayomi has been running her patent and proprietary medicine store for six years. On weekends, it is common for young women to come into the store requesting a combination of the emergency contraceptive Postinor-2 and a branded antibiotic called Beecham Ampiclox. The combination is widely, though falsely, believed to enhance the efficacy of the emergency contraception — an idea often promoted by PPMVs themselves, who can then sell the drugs at inflated prices. Several PPMVs who spoke to Devex said they believed the combination to be highly effective.
The women who come in “are often desperate and are always willing to pay anything to get the drug combination that will prevent pregnancy,” Abayomi told Devex.
Pharmacist Habidat agreed. “Once they ask me for Postinor and Beecham Ampiclox, I know right away the purpose of the request and I refuse to sell to them, but I know they will see many PPMVs that will.”
Another issue is the financing system for health care in Nigeria, which is dominated by out-of-pocket payments. That discourages people from attending medical facilities for a proper diagnosis.
When Balogun Adeniji developed a fever, he paid 12,500 Nigerian nairas ($35) for a consultation and tests at his local private hospital. He was subsequently treated for malaria with Arthemeter and Lumefantrine tablets, which cost only N500 ($1.40).
“I felt cheated. How will I spend N12,500 for something that can be treated for just N500?” he asked. Nowadays, when he has similar symptoms, he visits a store to procure the drugs directly.
As a result of out-of-pocket payments, “many Nigerians don’t see lab tests and medical consultation as equally important as treatment in the management of health conditions,” explained private practitioner Dr. Ibikunle Adeyemi. Forced to pay, they would rather spend money on treatments than tests.
Lower-income patients who receive antibiotics from NGOs may also require follow-up doses that they can’t afford — further increasing the risk of drug resistance.
No simple solutions
In spite of the ambitions of Nigeria’s national plan for AMR control — including increasing awareness among Nigerians, building an AMR surveillance system, and investing in research and development — experts in the field said there is no quick-fix solution to the problem. Citizens will continue to seek out drugs indiscriminately as long as they are easier and cheaper to access than hospitals.
Hamidat added that health ministries at the state level are overwhelmed by the task of regulating drug stores.
“Oyo state [of which Ibadan is the capital] has tens of thousands of places where you can get drugs but only two people are saddled with the task of performing oversight functions on the drug outlets,” she told Devex.
The state government said it is revamping its health sector and strengthening its workforce.
Until the situation improves, some stakeholders are striving to engage with the channels of drug access. For example, Belgian health NGO the Damien Foundation is paying PPMVs to act as points of referral for TB screening, in order to reach patients that approach stores in search of drugs to treat an intermittent cough — a key symptom of TB.
Some say that because PPMVs have come to be trusted by the communities they serve as their main point of contact with the health system, they must be part of the solution.
“It is easy to go on radio and ask people not to use drugs. [But] without providing them with a safer, more affordable and easily accessible option, they will not even listen to you,” Abayomi said. “We may not be pharmacists, but we are saving lives in our communities. Instead of looking for ways to get rid of us ... what can be done is to help us improve our services while also rapidly improving the health system.”