In the Sahel countries, the low affordability, availability, and access to healthcare create an environment in which formal channels do not meet the demand for medical products. This lack leaves room for trafficking, thus posing a threat to human and health security. Contrary to popular belief, terrorist groups and non-state armed groups are not the key actors responsible for the illicit pharmaceutical trade. Investigations have highlighted the involvement of a large number of opportunistic actors, from employees of pharmaceutical firms to law enforcement officials and health agency workers.
1. Filling the gaps
1.1 Weak healthcare system
Infectious diseases are among the leading cause of death in the Sahel (source). Yet, the accessibility and affordability of healthcare remain one of the lowest in the world. The weak governance of Sahel countries’ health systems as well as the insufficient healthcare provision has led to the emergence of a parallel informal and illegal market. Between January 2017 and December 2021, international authorities seized at least 605 tons of medical products in West Africa (source).
According to the World Health Organization, up to 50% of medicines in the Sahel are fake or substandard (source). At best, those counterfeit medical products are inefficient; at worst, they lead to toxic contaminations. Fake medicines are responsible of the death of at least 267,000 people each year; inefficient antibiotics used to cure pneumonia cause the death of around 170,000 children per year (source).
The reach of formal healthcare in the region is minimal, with healthcare infrastructure extremely scarce. For instance, in Chad, the density of pharmacies is 121 below the global average (source). Similarly, the health workforce density is significantly below the Sustainable Development Goal minimum density threshold (4.45 doctors, nurses, and midwives per 1,000 people). In 2018, the ratio was (source).
- Between one and two doctors for 1,000 people in Burkina Faso and Mali,
- Less than one doctor for 1,000 people in Chad and the Niger
1.2 Supply chain(s)
As Sahel countries import up to 90% of their medical products due to the lack of a developed pharmaceutical industry in the region (source), it leaves a gap for a significant illicit supply chain. The high interconnection between regulated (legal) and unregulated (illegal) chains renders the tracking of medical products complex and multi-layered (source). Allegedly, around 40% of fake medicines now make up the legal supply chain and are sold in licensed pharmacies (source).
Trafficked medical products, therefore, filled this disparity between the supply of and demand for medical care. This illicit pharmaceutical trade includes falsified medical products, substandard medical products, and unregistered/unlicensed medical products (source). The disruption of the legal supply chain can happen at various stages, including during the production, distribution, sales, and dispensing stages.
The trafficking in medical supply is fostered by both the inability of local governments to meet the demand and the lack of functioning healthcare infrastructures.
2. From where…and by whom?
2.1 Pharmaceutical trade routes
The limited traceability of medical products, partly related to poor infrastructures and poor cross-border tracking significantly facilitates mass illicit pharmaceutical trade. Most of the Sahel’s medical supply originates from Europe, more especially from France and Belgium. To a lesser extent, India and China also participate in the supply chain (source). Similarly, a small part of medicines is manufactured in Ghana and Guinea (source). Diasporas also smuggle medical products into the Sahel (source).
Medical supplies often reach their destination through mainstream international maritime trade channels. The following seaports have been identified as the main point of entry for both legal and illegal supply chains (source):
- Conakry, in Guinea
- Tema, in Ghana
- Lomé, in Togo
- Cotonou in Benin,
- Apapa in Nigeria.
Moreover, several cities have been identified as main points of transit (source).
- Bamako (Mali)
- Ouagadougou (Burkina Faso)
- Niamey (Niger)
- N’Djamena (Chad)
- Agadez (Niger)
2.2 Key actors of the illicit pharmaceutical trade
Contrary to popular belief, terrorist groups and non-state violent actors are not the key actors of the illicit pharmaceutical trade in the Sahel. Most reported cases in the region show that the involvement of such groups is limited. It mainly revolves around consuming medical products or collecting “taxes” on them in the areas they control (source). In northern parts of Mali and Niger, many terrorist groups have an influence on segments of the smuggling routes that fall within their territory. These groups usually levy “taxes” on different products trafficked in Mali (Gao and Timbuktu) and the Niger (Zinder), as well as on the border with Nigeria in the south and Libya in the north (source).
In reality, investigations have revealed the involvement of a wide range of opportunistic actors. Employees of pharmaceutical companies to public and law enforcement officials, and health agency workers are the principal actors of those criminal networks. The potential financial gain, because of the high demand and low supply, creates a significant incentive to take part in the illegal supply chain. Estimations evaluate the profit of illicit pharmaceutical trade to 75 billion USD (source).
Sahel has become the epicentre of a growing organised crime network. In July 2022, Niger’s Central Office for the Repression of Illicit Drug Trafficking (OCRTIS) dismantled a criminal network in Yaboni. Law enforcement officials seized 229,364 Royal 225 mg tramadol tablets, 8,000 exol tablets and traced the supply chain. The individuals arrested reportedly worked with India-based partners to export medical products through the seaport of Tema, in Ghana. Once transported to the Niger, some were dispatched in the country, especially to the Djado and Tchibarakaten gold-mining areas, where the prices tripled. They trafficked the rest to Libya (source).
2.3 An Endless Cycle
The high level of corruption creates a larger cyclical problem (source). The lack of public sector health delivery centres, as well as the lack of skilled staff leads to poor quality of the healthcare system. This results in the absence of adequate social security and meaningful commitment to welfare. In turn, it increases the incentive to take part in the trafficking networks, thus creating even more corruption.
The direct involvement of public and law enforcement officials raises political stakes, and questions trust in governments. The authorities convicted ten Chad nationals, including army officials and intelligence officers, for trafficking 246 boxes of Tramadol. The value of this shipment has been estimated to 12.3 billions CFA francs (18.8 million euros) (source).
Hence, political corruption needs to be tackled in order to curb trafficking in medical products in the Sahel.
3. So what?
Once diverted from the legal supply chain, oversight on how medicines are being used is complicated. Therefore, the systematized self-prescription contributes to antimicrobial resistance and toxic contaminations (source).
3.1 The Impact of COVID-19
The pandemic has brought a tremendous demand for medicine and medical products, over a relatively short period of time. It resulted in the amplification of weak regulatory and legal framework related to the prevention of the manufacturing and trafficking of substandard and falsified products (source). COVID-19 has been the catalyst for a hitherto global illegal market. Operation Pangea, coordinated by INTERPOL in 90 countries and targeting the online sale of pharmaceutical products, showed an increase of approximately 18% in seizures of unauthorized antivirals, while seizures of unauthorized chloroquine increased by 100% (source).
In the context of the pandemic, the absence of an effective and comprehensive regulatory framework constrained access and ineffective oversight to address substandard and falsified medical products (source).
3.2 Reinforcing the Existing Framework Against Pharmaceutical Trade.
The African Union established, in 2009, the African Medicine Regulatory Harmonization Initiative. It aims to improve access to safe and affordable medicines, as part of the AU Framework on Pharmaceutical Manufacturing Plan for Africa.
Strengthening the existing legal framework is thus necessary to tackle this global illegal market. Countries in the Sahel should aim at a more harmonized global approach to both the manufacturing and trafficking of medical products, thus enabling better individual, national, and regional security and safety (source).
Building governance improvements by addressing good practices in the procurement of medical products and the elimination of opportunities for corruption is an essential development to limit substandard and falsified medical products from entering the health system. Preventing, detecting and responding to medical product-related crime will require new or additional cross-skill training in the medical product sector and enhanced national coordination mechanisms by all relevant actors to address current and future challenges (source). Such policies also need to address the low availability and affordability of medical products. By aligning legal supply to demand could help limit illegal medicine trafficking in the region.
The weak healthcare system of the countries in the Sahel creates a suitable environment for the development of an extensive illicit pharmaceutical trade network. Falsified or substandard medicines pose a significant threat to human security and safety in the region, killing thousands each year. Worsened by the COVID-19 crisis, the situation requires structural governance improvements to curb illegal trafficking. Yet, contrary to popular opinion, terrorist groups and non-state armed groups are not the main actors of these criminal endeavours. Rather, investigations have highlighted the role of a wide scope of opportunistic actors, from employees of pharmaceutical firms to law enforcement officials and health agency workers.