Keynote Address by Onyeka Onyeibor at Enugu



It is saddening that a 10am meeting is starting at midday. If there is Nigerian time, let’s create pharmacy time. Punctuality is the courtesy of kings and the graceful conduct of queens. Every beautiful person I know is punctual. Let’s clap for every beautiful person in this hall.

I find it very uncomfortable being in the same discussion panel with my teacher, Professor Ibezim. If I had any inkling he will be here, I would have found a thousand reasons not to show up.

I am deeply grateful to the Chairman PSN, Enugu State, my brother and friend, Dr. Egbuna Udeora for graciously inviting me to this event. When he asked me to be here, I said yes before he finished.

1. It is difficult to say no to a man as persuasive as Egbuna. His wife will agree with me.
2. It is imprudent to miss an opportunity, to be in Enugu. Residents of Enugu will agree with me
3. It is a great privilege to stand before distinguished men and women like you in an attempt to learn together as a community in advancement of our common voyage. Every man, every woman of goodwill will agree with me.

If you disagree with any of the reasons why I said yes, meet me after this speech for deliverance. I come from a religious background. I will lay hands on you.

I must confess my frustration with keynote speeches. Too much talk but too little action. I am convinced that the difference between one man and another is not in what they know but in what they do with what they know. It is good to know more. It is better to do more. I want to believe the organizers of this conference must have put together a framework to convert the word energy we expend today to work energy in the days ahead.
The theme of this conference is Medicines Availability and National Security – challenges and opportunities for an import dependent economy. Whoever chose this topic 'ma ebe ano'. If a

conference theme doesn’t sound heavy, it appears the selection committee did a poor job. I am glad that beyond the 'nnukwu bekee', we have a topic rich enough to excite and deep enough to inspire. We start by understanding what availability means and the factors that affect medicines availability.  We will then review the elements of national security and reflect on how the pharmacist is by role and function, a security officer.  We will discuss challenges, opportunities and then, close.

Adapting from the business dictionary, a resource is available if it is committable or usable upon demand to perform its designated or required function. An example will suffice here - you have a land cruiser and a landlord.  Both do not go together. From basic pharmacology you expect a land-land interaction. Its 5am! You need to drive out your land cruiser but your land lord packed behind you. You don’t need T. B. Joshua to tell you that your land cruiser is not available. Possession is not availability. The first measure of availability is accessibility. You have to reach the resource.

Let us assume your land lord was gracious enough to move his car but your land cruiser couldn’t start. Your battery has gone flat dead. You have accessibility but no functionality.

We stretch your luck a bit. Your neighbor jump starts your battery and off you go. You stopped at several points to top up water in your radiator. You eventually missed your meeting. You have accessibility, limited functionality and zero reliability.

My first submission this afternoon and I will make about 5 submissions is that availability is a composite of accessibility, functionality and reliability. Let this guide us as we discuss medicines availability.

Globally, availability of medicines is a challenge. The World Health Organization estimates that 1 in 3 persons lack access to essential medicines. In Africa, it is 47%. In a population of 1b people, 470m lack access to essential medicines. What is responsible for this?

Research & Development
This is a play of interest, technology, infrastructure, man and capital. Every disease will not generate the same level of research interest. The 17 neglected tropical diseases are not neglected because they are tropical. They are neglected because return on investment is poor. Leishmaniasis, filariasis, leprosy and river blindness will never attract as much interest as cardiovascular diseases. It is not about how many people are at risk but return on capital. African scientists must understand this and act accordingly. Oyibo will not find the cure to all our ailments. I have looked through the essential drug list. None was discovered by an African. We know of the celebrated work of Patricia Bath, but that is in devices for cataract.  If you have only six bottles of coke in a refrigerator, the probability of picking Fanta from that refrigerator is zero, because you did not put Fanta there. If we do not have molecules in R & D, availability is at best an illusion.

Closely related to this is funding for research. In the federal budget for 2017, the entire allocation to education is N540b. Revenue from all pharmaceutical companies in Nigeria in 2016 was slightly above that. If we combine the education budget and the pharmaceutical industry revenue we will have about $3b. Pfizer’s R & D budget in 2016 alone was two and a half times that - $7.8b.

Let us pretend we have the research pipeline adequately filled and the effort is optimally funded, focus then shifts to the manufacturing infrastructure. Do we have any comparative advantage in production? The raw materials are not ours. The bulk of the packaging material is not ours. The machines we use are imported, so also is the technology we copy shamelessly and paste haphazardly. Where then is the framework for achieving self-sufficiency in drug production? It is good that government policies favor local production. But government protection is not a globally competitive strategy. All it allows us is to shut our doors and remove whatever incentive there may be for internal efficiency.

I am from Nando. We have this saying – obulu na ego bu aja. It is a harmless indulgence in fairytale. What we conveniently forget is that if you have not done much with aja, you may not do more if ego becomes aja. We appear to have this conviction, poorly supported by facts, that if all essential medicines were made within the Nigerian geographical space, then availability is assured. Na lie. We have a big problem to contend with in distribution.

Every pharmacist knows of the WHO guidelines on good manufacturing practice (GMP). The same body also provided other guidelines – good pharmaceutical practice (GPP), good storage practice (GSP), good distribution practice (GDP), good trade and distribution practice (GTDP)
Good distribution practice sets out to define roles and functions and liabilities of all parties involved in the distribution of pharmaceutical products. The overarching aim is to ensure that the quality of pharmaceutical products and the integrity of the supply chain are maintained throughout the distribution process from the site of manufacture to the point of dispensing. The guideline covers regulation and licensing, management and organization, personnel and training, quality assurance and security. Distribution is a serious business. The new national drug distribution guideline is a necessary adaptation form the WHO – GDP guideline. Every pharmacist of goodwill must support the principle behind this.

My second submission this afternoon is that pharmacists must do better than the road safety commission. They look at the Tyres but they do not look at the road. They want cars that are road worthy but not roads that are car worthy. We cannot stop at enforcing GMP. We must ensure distribution follows good practices that protect the medicines, the patients and the integrity of the supply chain.

Price of medicines in Nigeria has become nwa agbo. Desiring to marry nwa agbo is not enough. You must be prepared for the maintenance. All of us involved in pharmaceutical practice at whatever level must understand that healthcare is a fundamental human right. This understanding is the basis for universal health coverage. Universal health coverage means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (WHO). Universal health coverage is built on 3 principles:
1.      Equity in access to health services - everyone who needs healthcare services should get them, not only those who can pay for them;
2.      The quality of health services should be good enough to improve the health of those receiving services; and
3.       The cost of using healthcare services does not put people at risk of financial harm.
There is a joint report by WHO, Federal Ministry of Health and Health Action International that claims that 90.2% of Nigerians cannot afford the medicines they need. Prices of medicines in Nigeria are 2 to 64 times the international reference prices. The manufacturer cries of diesel. The importer cries of tariff. Both cry of huge finance and redistribution costs, bad debts and endemic corruption in public procurement. Oga wants something. The PA to Oga wants something. The SA to the PA of the Oga wants something. The poor man groans under the weight of the grossly inefficient cycle that we run.

My third submission this afternoon is that government must begin to look seriously at the prices of medication by providing basic infrastructure, reducing tariff, making procurement more transparent and enforcing a national medicines pricing policy.

Brands vs. generic
Closely related to pricing is the selection of medicines by health professionals and care givers. The WHO report earlier referred to claimed that innovator brands in Nigeria are 2 to 7 times the prices of generics. At minimum wage of N18,000 a month, the daily disposable income of the Nigerian worker is N600. A doctor or pharmacist that gives to such a patient an innovator brand of an antibiotic at N3500 when a comparable generic is available at a fraction of the cost is not in touch with reality. We must begin to look at standardizing treatment guideline with a view to institutionalizing generic medication policy.

There is no universally acceptable definition for national security. The term has progressively evolved from military might and now includes economic, political, environmental and social considerations. To understand this evolution, we will take 2 definitions, one an earlier version and the latter a contemporary review. Walter Lippmann, an American writer, political commentator and arguably the most influential journalist of the 20th century believed there is national security when a nation does not have to sacrifice its legitimate interests to avoid war and is able, if challenged, to maintain them by war. Lippmann died in 1974. President Trump would have liked him as National Security Adviser. They speak the same language.

A more contemporary definition is provided by Charles S. Maier, a professor of history at Harvard. According to him, national security is best described as the capacity to control those domestic and foreign conditions that people in a given community consider necessary to enjoy self-determination or autonomy, prosperity and wellbeing.

Maier’s brilliant definition becomes a carte blanche, an open cheque. Anything a community considers necessary to enjoy prosperity and wellbeing falls under national security. You may now understand how Dasuki can allocate hundreds of millions of naira for spiritual support. His job description covered that. Many of us have no problem with how much Dasuki gave. Our problem is that he did not give us.

Today, if we talk of national security, we talk about military security, economic security, political security, environmental security, protection from narcotic cartels, information security, energy security, food security and health security. We look at health security from 2 aspects. The first deals with the knowledge, facilities and manpower to address adequately the prevention, diagnosis, treatment and management of diseases, illnesses or health impairment. A non-functional healthcare center at Nkanu becomes a national security concern. The second deals with the capacity to protect the nation state from bioterrorism and pandemics. Ebola is a case to remember. It could have been bioterrorism.
Imagine for a moment that Nigeria is at war with India and the supply of essential medicines dries up. More people may die from lack of medicines than from the enemy bullet.

My fourth submission this afternoon is that no nation is truly safe if it cannot guarantee the capacity to make and distribute the medicines it needs in sufficient quantity and quality within its geographical space. The operating word here is capacity not ability. Ability is what we can currently do. Capacity is what we can potentially do.

I have earlier said the pharmacist is by role and function a security officer. He exchanged the boots, baton and beret with prescription, pharmacopeia and pestle. A pharmacist makes drugs, stores drugs, distributes drugs, dispenses drugs, counsels patients on drugs, monitors drug use, protects patients from adverse drug reaction and drug abuse. If security is to protect and defend, to assure, maintain and keep safe, then the number 1 health security agent is the pharmacist. He safeguards the health of the nation. NAFDAC borrowed its slogan from the role of the pharmacist. I am happy the PSN Deputy National President is here. PSN should consider asking NAFDAC to pay royalties for the continued use of that slogan.

I can bet it is clear to everyone seated here that medicines availability in Nigeria is a big challenge and will remain so for as long as we are import dependent. Availability is a delicate balance of need and service. Mathematically, availability is only possible when service is equals to or greater than need. We basically have two options – increase service or decrease need. We increase service by discovering more drugs, producing more drugs, distributing them more efficiently and pricing them more competitively. We decrease needs by reducing disease burden and helping people make lifestyle choices that make more drugs unnecessary.

Let me share with you 4 things I think pharmacists can do differently to enhance medicines availability and by extension national security and then we close.

1. Compete less. Collaborate more.
Nothing worthwhile is ever the work of a single hand. We need each of us and all of us to build a vibrant and prosperous community. Think of something as small as a pencil. The wood comes from Nigeria. The eraser comes from Thailand. The lead comes from China. Medicines availability requires a multi-disciplinary collaboration. How much relief can I get from knowing I have done my job exceedingly well when the failure of the next man to do his part will compromise the result I set out to celebrate? Build the best manufacturing facility, if you do not spare a thought to how the product reaches the final consumer, the integrity of the product may be compromised along the supply chain. Silo thinking is dangerous and must give way to Systems thinking. Whether you manufacture or distribute; whether you teach or dispense; we have only one job – safe and effective medicines, available and affordable to the patient.

2. Think Health not Medicines.
We are having more drugs and less health, the same way we have more gadgets and less time. Chinua Achebe talked about the goal of charity not being kindness but creating a world where charity would be unnecessary. Similarly the goal of our practice should go beyond medicines availability to health availability. If a fraction of what we spend in manufacturing, promotion and distribution of anti-malaria products goes to cleaning sewage, we will reduce the malaria burden significantly. Start where you are. Create a desk on any public health issue and talk to your community on life choices that will make more drugs unnecessary. Working with the Catholic Archdiocese of Lagos and the Federal Road Safety Commission on prostate health brought me more joy than my other endeavors. We go from church to church and to motor parks to talk to people on how to sit, what to eat, how to exercise to improve prostate health. The aim is to not to sell PROSTAGEL. It is fantastic product by the way. The aim is to help as many as possible to escape the use and possible dependence on pills.

3. Ask more
I believe questions are man’s greatest resource, not answers. Answers freeze possibilities. Questions liberate thoughts. Ask and you shall receive. Those that ask more, receive more. Stop asking whether there is a pharmacy 100m away from you. Start asking whether there is an un-served or an underserved patient 1m or 1000m from you. Ask how technology can help you break geographical barriers and serve from Enugu a customer in Jos. If the world has become a global village, be a villager. Villagers in their simplicity ask. City dwellers in their sophistication assume. Assumption is the lowest form of knowledge.
I use every opportunity I have to talk with pharmacists to call attention to our faulty business model. We cannot serve the 21st century client with 19th century mindset. A patient that banks online, shops online, prays online, marries online needs an online pharmacy. We cannot remain insulated from the monstrous forces of technology. Amazon is one of the most valuable companies in the world. It is an E-market with revenue in excess of $90b per annum. If you are wondering how much that is, it is the accumulated earning of the Nigerian pharmaceutical industry every year for 60 years. Last year Amazon spent close to a billion dollars installing robotics to improve warehousing efficiency. Amazon appears far. Just at our backyard, Mpharma blossomed. Mpharma, headquartered in Ghana and with a technology hub in Israel is taking e-marketing and prescription management across Africa by storm. Perhaps Ghana also appears far. Drugstoc is an upstart in Lagos, created by 2 partners, one of them is a medical doctor. They run a B to B wholesale platform for pharmaceutical products. Think what you can do differently. Think patient safety and comfort. Think technology.

4. Do more
I am a believer. I believe in doing. It is the most reliable proof of interest. If everyone that is dissatisfied with the status quo does more than he or she is currently doing, we would make a remarkable progress. Commit to do good under every circumstance. Commit to do all the good you possibly can.
If there is ever a ‘better good’ or a ‘best good’ it will be found in service. The facts on ground do not suggest we serve enough as pharmacists. Within our own land we have created swathes of neglected communities. About 50% of Nigerians live in rural areas but our spread and service offer no consideration for demographics. Only 195 out of 774 Local Government Areas in Nigeria have a pharmacist and only Lagos, Rivers state, the FCT and possibly Ogun state have a pharmacist in all the local government areas. If we refuse to serve the rural communities do we really reserve the moral rights to complain when patent and proprietary medicines dealers take over? Have you wondered why in some places if inspectors go to shut them down, the man in the street rises to their defense? People respond to value not legislation. Our job is not to protect our turf. Our job is to serve. My fifth submission this afternoon is that when you make service an epidemic, people will line up before you to receive your service vaccine.

Our time is far spent. I did not come to Enugu to provide you answers and I hope I have not. Answers without a vigorous search are confined to what is. It is in the hunt of personal truth that we find the courage to ask ‘why not?’ The future we seek is in 'why not'. Why not safe medicines? Why not safe and effective medicines? Why not safe, effective and available medicines? Why not safe, effective, available and affordable medicines? Why not safe, effective, available, affordable and made-in-Nigeria medicines? When we find these answers we find medicines availability. We find health security.

Ladies and Gentlemen, my final submission this afternoon is that you have been an incredibly good audience, the best I have had in a long while.
Thank you. Thank you very much.



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