Views and perceptions about locally manufactured medicines in Ethiopia: a qualitative study of physicians, patients and regulatory authorities

Assessment of Local Pharmaceutical Manufacturing Sector in a Low-income Country: A Descriptive Study

BACKGROUND

In high-income countries and emerging economies, pharmaceutical manufacturing is a driver for socioeconomic development. In sub-Saharan Africa, local pharmaceutical production is still fledgling largely because of historical economic and technological asymmetry. In Ethiopia alike, this environment has changed little despite six decades long operations and several support initiatives; access to essential medicines remained a persistent challenge. Despite a few fragmented reports on trends and profiles of the sector, in-depth investigations into underlying challenges remain limited. This study explores the perspectives and insights of upfront executives and technical personnel in the Ethiopian pharmaceutical industry on its current state, challenges and opportunities for enhancing local production capacity. The findings are triangulated with literature reports and provide valuable insights for developing intervention strategies and policy updates.

METHODS

A validated structured survey questionnaire was disseminated to professionals working in local pharmaceutical companies. Multiple regression analysis was conducted to study the effects of different factors on the performance of the local manufacturing sector.

RESULTS

Over half of the professionals (55.1%) rated the current production technology as advanced while 68% described it as semi-automated. Close to one-third (31.6%) reported that the companies are operating at acceptable level of performance, and 51.5% reported low-capacity utilization in their companies. Most professionals (67.8%) viewed export market activities as poor and many identified weak research and development activities. Unplanned operations downtimes, limited physical infrastructure, inadequate access to foreign currency, shortage and highstaff turnover of qualified experts, lack of commitment from top management, absence of merit-based support system and limitations in compliance with regulatory and quality requirements were reported as major challenges. Multiple linear regression analysis demonstrated that capacity utilization (α = 0.008), research and development capacity (α = 0.014) and export market activities (α = 0.027) have significant impact on the sector performance.

CONCLUSION

Despite commendable efforts by the industry and government, limitations in financing, infrastructure, qualified workforce, and quality system implementation are affecting capacity utilization and performance. Absence of reliable staff attraction and retention system, lack of effective leadership and non-favourable working environment were identified as missing elements. Enhancing economies of scale and capacity utilization, addressing policy and infrastructure bottlenecks, providing merit-based support for R&D and quality management, and implementing staff attraction and retention strategies are key steps towards developing competent local pharmaceutical manufacturing sector.

Parents' Medicine-Seeking Behavior and Their Beliefs About the Efficacy of Medicines

OBJECTIVES

Parents' medicine-seeking behavior is often influenced by their own experiences with illness. The purpose of this study was to investigate parents' medicine-seeking behavior and their beliefs regarding the efficacy of medicines.

METHODS

A cross-sectional study was conducted among parents in Mosul, Iraq. A convenience sampling method was used to select the parents who visited community pharmacies to buy medication for their ill children. A self-administered questionnaire was utilized to collect data from 380 parents who successfully completed the survey.

RESULTS

The majority of parents (83.4%) stated that they read the labels of medications before giving them to their children, and more than half of the parents (57.9%) did not buy medicines for their children without consulting a doctor. In addition, 65% of the participants asked about the possible side effects of the medicines. Additionally, the majority of parents (73.2%) believed that branded medicines were more effective than generic medicines, and 63.4% of them believed that the efficacy of medicines is not related to the manufacturing countries. Furthermore, 62.9% of the parents believed that the efficacy of medicines is not related to their price, while 35.2% of them believed that injections were more effective than other dosage forms. Parents' medicine-seeking behavior and their beliefs about the efficacy of medicines were significantly associated with parents' higher education level and higher family income.

CONCLUSION

There was inadequate information among parents concerning the use of medicines, including side effects, proper utilization, and the importance of seeking medical assistance. Furthermore, parents have false beliefs about the efficacy of medicines.

Health professionals' perceptions on local production and bioequivalence study of generic medicines: A cross-sectional survey of physicians and pharmacy professionals in Addis Ababa, Ethiopia

Local production of generic medicines in developing countries has a critical role to meet public health needs by ensuring the availability of essential medicines and providing patients' relief from the burden of unaffordable medical bills. Compliance with bioequivalence (BE) requirements increase the quality and competitiveness of generic drugs regardless of the source. In this regard, a regional BE center has been established in Addis Ababa, Ethiopia to serve the needs of Ethiopia and neighbouring countries. The present study aimed to assess the knowledge and perceptions of health professionals working in Addis Ababa regarding local production and BE studies of generic medicines. A cross-sectional survey was employed and physician participants working at public hospitals and pharmacists from various practice settings were selected using convenient sampling technique. Data was collected using self-administered structured questionnaire. Descriptive statistics was used to summarize the data and multinomial logistic regression analyses was used to assess predictors of health professionals' perception towards the source of drugs. Statistically significant association was declared at p-value < 0.05. A total of 416 participants responded and 272 (65.4%) of them were male. Nearly half of the study participants (n = 194) preferred the imported products. Compared to physicians, participants with diploma (AOR = 0.40; 95%CI: 0.18-0.91, p = 0.028) and bachelor degree and above holders (AOR = 0.32; 95%CI: 0.15-0.68, p = 0.003) in pharmacy were more likely to prefer locally produced products. Participants who practiced in pharmaceutical industries (AOR = 0.40, 95%CI: 0.22-0.77, p = 0.006) preferred locally manufactured products as compared to those practicing in the hospital. While a majority (321, 77.2%) believed in the advantages of doing BE studies locally, only 106 (25.5%) recognized that local pharmaceutical manufacturers did not implement BE studies for their generic products and lack of enforcement by the national regulatory body was raised as a reason for not conducting BE studies by most of the participants (67.9%). The present study revealed a modest preference by physicians and pharmacy professionals towards locally produced products. Majority of participants supported the idea of doing BE studies locally. However, manufacturers and regulators should devise ways to increase health professionals' confidence in local products. Strengthening local BE study capacity is also highly recommended.

Perceptions of generic medicines and medication adherence after percutaneous coronary intervention: a prospective multicentre cohort study

OBJECTIVE

To determine patient perceptions of generic medicines 2 and 6 months after percutaneous coronary intervention (PCI), and to determine whether these perceptions moderate medication adherence.

DESIGN

Prospective multicentre cohort study with repeated measures of perceptions of generic medicines and medication adherence.

SETTING

The CONCARDPCI study conducted at seven large referral PCI centres in Norway and Denmark between June 2017 and May 2020.

PARTICIPANTS

A total of 3417 adults (78% men), using both generic and brand name medicines, with a mean age of 66 years (SD 11) who underwent PCI were followed up 2 and 6 months after discharge from hospital.

MAIN OUTCOME MEASURES

Perceptions of generic medicines were the main outcome. The secondary outcome was medication adherence.

RESULTS

Perceptions of generic medicines were significantly more negative at 2 than at 6 months (1.10, 95% CI 0.41 to 1.79, p=0.002). Female sex (-4.21, 95% CI -6.75 to -1.71, p=0.001), older age (-0.12, 95% CI -0.23 to -0.02, p=0.020), lower education level (overall p<0.001), ethnicity (overall p=0.002), Norwegian nationality (10.27, 95% CI 8.19 to 12.40, p<0.001) and reduced self-reported health status (0.19, 95% CI 0.09 to 0.41, p=0.003) were significantly associated with negative perceptions of generic medicines. There was no evidence to suggest that perceptions of generic medicines moderate the association between sociodemographic and clinical variables and medication adherence (p≥0.077 for all covariates). Moreover, self-reported medication adherence was high, with 99% scoring at or above the Medication Adherence Report Scale midpoint at both time points. There were no substantial correlations between negative perceptions of generic medicines and medication non-adherence at 2 months (r=0.041, 95% CI 0.002 to 0.081, p=0.037) or 6 months (r=0.038, 95% CI -0.005 to 0.081, p=0.057).

CONCLUSIONS

Mistrust and uncertainty about the safety and efficacy of generic medicines remains in a sizeable proportion of patients after PCI. This applies especially to those of lower socioeconomic status, older age, female sex, immigrants and those with poorer mental health. However, this study demonstrated a shift towards more positive perceptions of generic medicines in the longer term.

Consumers' Perception of Generic Medicines and Evaluation of In Vitro Quality Control Parameters of Locally Manufactured Paracetamol Tablets in Asmara, Eritrea: A Cross-Sectional Study

Generic medicines are clinically equivalent and can be used interchangeably for their intended use. Globally, the usage of generic medicines is highly recommended because of their affordability and accessibility. However, consumers hold a negative perception and attitude of using generic medicine as they consider it poor and having inferior quality compared to branded medicines. This study was conducted to assess the consumers' general view of generic medicines and in vitro evaluation of a locally produced generic medicine, paracetamol. An analytical and cross-sectional study was conducted in three selected hospitals, and in vitro quality control evaluation was done in National Drug Quality Control Laboratory between October 26 and November 21, 2017, in Asmara, Eritrea. A systematic random sampling design was employed, and the data was collected using a questionnaire and a check-list for recording the quality control parameters of paracetamol tablets. A total of 403 respondents were included in the study. The majority of the study participants were females (61.8%). Generally, about half (49.1%) of the respondents choose locally manufactured paracetamol over the imported ones. More than half (68.5%) of the respondents did not believe expensive medicines are of better quality. The main reason consumers prefer the local paracetamol (Azemol) tablet to the imported one was due to their good experience (62.1%). About three-fourths (78.1%) of the consumers also believed that medicines manufactured abroad confer higher quality. At the multivariate level, having educational backgrounds such as elementary (AOR = 4.19, 95% CI: 1.251, 14.035) and junior (AOR = 2.4, 95% CI: 1.146, 5.028) was associated with preferability to local paracetamol as a pain killer over the brand ones. The in vitro test of the local paracetamol met the standard specification for the identification test, weight variation test, pharmacopeial test, friability test, disintegration test, and dissolution test. In conclusion, the majority of the consumers considered local paracetamol as having an inferior quality when compared with brand paracetamol. However, the reality revealed that the local paracetamol was of the same quality as the brand ones. To facilitate widespread use of generic medicines, healthcare professionals should educate consumers on the advantages of these medicines.

Acceptability and barriers to implementation of N-of-1 tests in Ethiopia - a qualitative study

Background

Locally produced generic drugs offer a cost–effective alternative to imported drugs to treat patients in Ethiopia. However, due to a lack of bioequivalence testing, additional assurance tests are needed to build trust in cheaper, locally made drugs. By testing bioequivalence of local drugs to gold standard, N-of-1 tests have the potential to promote patient centred quality use of medicines.

Method

We sought to assess the acceptability of, and explore barriers to, conducting N-of-1 tests to evaluate local medicines in a resource limited clinical setting. We conducted a descriptive qualitative study, analysing four focus group discussions and five key informant interviews. Participants were senior drug regulatory authority members, institutional review board members, physicians and patients. All interviews were audio taped and transcribed verbatim. Patient interviews were conducted in Amharic and translated to English prior to analysis. Data analysis used an inductive, thematic process.

Results

Five major themes were identified; (1) Appropriateness of N-of-1 tests to determine the therapeutic equivalence of local drugs, (2) N-of-1 therapeutic equivalence tests: clinical care or research? (3) Ethical and regulatory requirements (IRB), (4) Potential barriers to implementing N-of-1 tests and (5) Possible solutions to identified challenges. The study demonstrated considerable support for using N-of-1 tests for clinical equivalence studies between local and imported medicines, but important impediments were very likely to impact the feasibility of conducting N-of-1 tests in Ethiopia. Key informants from the regulatory authority did not support additional tests of local drugs. There were also mixed opinions regarding ethical requirements for conducting N-of-1 tests. The Institutional Review Board (IRB) members believed that IRB approval was sufficient to conduct N-of-1 tests, however, the regulatory authority members considered that N-of-1 tests constituted a clinical trial, and required approval at the regulatory level.

Conclusion

This study showed that there were key uncertainties that could impact the feasiblity of using N-of-1 testing local drugs in Ethiopia. Therefore, a number of protocol amendments to address contextual threats and regulatory challenges, would be needed before progressing to conducting these tests.