The health department will not buy some medicine for cancer and rare diseases as they are not ‘essential’ but there are legal ways to get drugs unavailable here
You can’t buy medicine for a friend overseas and carry it into South Africa as easily as you’d bring them a keyring or a curio.
Pharmaceutical products, for people and animals, are strictly regulated – and for good reason.
In July, South Africa’s tourism minister Lindiwe Sisulu was quoted saying she’d brought back cancer medicine from Russia but she’d been too late to save her friend Jessie Duarte. The deputy secretary general of the ANC died of cancer on 17 July.
The South African Health Products Regulatory Authority (Sahpra) sent questions to Sisulu’s office to investigate and the minister has since said the media misinterpreted her statements. She was only speaking metaphorically, she told The Weekend Argus.
Before medicines are allowed to be sold in the country, Sahpra sifts through reams of evidence submitted by manufacturers. A team of experts then weigh the data against international quality standards and decide whether they can be put on the market.
This process applies to all medicines, and clinical trials, and is being expanded to cover medical devices. Sahpra also makes the rules to control the movement of medicines after they’ve been approved. That includes who can import, export, make, distribute, sell and prescribe them.
But many cancer patients do travel abroad and bring back medicines – literally – either because a drug is cheaper elsewhere or it’s not available in South Africa. It’s a risky move, however, and many people have burned their fingers trying to save money this way.
We answer five questions about the complex and highly regulated world of medicine imports.
- Who is allowed to import medicines?
No one can bring unregistered medicines into South Africa without approval from Sahpra and only licensed companies can do it. Those firms are subject to strict rules to make sure the medicines they import are safe to use.
For example, any vaccines brought into the country must pass quality checks at the National Control Laboratory for Biological Products in Bloemfontein before they can be sent to pharmacies and clinics.
But these rules don’t apply to those who enter or leave the country with medicines for personal use which have been registered in South Africa.
Travellers can have up to six months’ worth of medicines on them, as long as they have a letter from a doctor or pharmacist to prove they got the drugs legally. No approval is necessary from Sahpra. This applies to drugs such as cough syrup (schedule 2), antibiotics (schedule 4) and antidepressants (schedule 5).
Sahpra decides on a medicine’s scheduling based on safety factors such as how easily people can become dependent on it and how dangerous its active ingredient could be if it was taken incorrectly. The higher the schedule, the more restrictions there are on how the medicine can be sold.
For medicines scheduled 6 and higher (such as morphine), no more than 30 days’ supply is allowed, along with a doctor’s prescription.
- When does Sahpra allow individuals to import a drug?
Doctors can apply to Sahpra to bring an unregistered medicine into South Africa on behalf of an individual patient.
Such requests are only approved if there are no other drugs available in the country or if the other options haven’t worked.
For some rare diseases, the number of people in South Africa who would ever need a drug is so small that it doesn’t make sense for a company to pay the thousands it costs to register the medicine with Sahpra.
Or, a similar medicine might already be registered in South Africa and the second manufacturer might not think it’s worth competing.
The melanoma (the most serious form of skin cancer) and lung cancer drug Keytruda, for instance, is registered by Sahpra but Opdivo (also used to treat melanoma and lung cancer) isn’t.
Keytruda might not be the right medicine for every patient, though, in which case a doctor could apply to import Opdivo instead.
These requests are called “Section 21” authorisations (because that’s the section of the Medicines Act that allows it) and Sahpra usually responds to such queries within a day or two.
- How do Section 21 requests work?
There are three parties involved in a Section 21 request:
- The clinician
A doctor applies to Sahpra and explains why a patient needs access to the drug. If the request is approved, the physician must report on the person’s progress on the treatment. This includes any side effects they might experience while using the unregistered medicine.
- The company
The firm that will bring the drug into the country applies as a co-applicant with the doctor. A number of licensed pharmaceutical companies specialise in doing this.
- The patient
A patient must pay the admin fee (R350 for each application) and for the imported medicine. The state covers the cost for public sector patients. Medical aid members are reimbursed in certain cases.
- Are there any drawbacks?
Any medicine sold in the South African private sector is subject to a price control mechanism called the single exit price (SEP). Although the initial launch price is set by the manufacturer or importer, the SEP is the price paid by all buyers, regardless of volume. In addition, the health minister sets a maximum annual increase in the SEP. Retailers can still add a dispensing fee but there are caps on this amount as well.
The SEP doesn’t apply to drugs people get through a Section 21 request, so they could be exploited.
Since the patient is paying for the products that will be imported for their treatment, they also have a right to choose the most affordable option. Exercising that right, however, is by no means simple.
Doctors rarely have access to information about cheaper options and drug companies don’t advertise to patients.
There’s also nothing in South African law that obligates manufacturers to apply to register drugs that are often requested through Section 21, which would subject those drugs to the SEP and possibly bring down the price.
- Does the price problem disappear when a drug is registered?
No. When someone is getting access to a less expensive medicine through Section 21, it can be bad news when a similar medicine is registered by Sahpra, because it nullifies the motivation that there are no other options for this person. The registered medicine might be more expensive.
This is what happened with lenalidomide, which is used to treat a type of blood cancer called multiple myeloma.
The drug was approved for use in South Africa in 2016 under the name Revlimid, which cost R70 000 per month more than the generic previously imported in terms of Section 21.
Only nine patients got permission to keep using the cheaper generic version through Section 21.
The Cancer Alliance and patients challenged this to no avail, so sick people had to wait until a cheaper medicine came onto the market – which didn’t happen until four years later.
Most medicines that are needed to treat cancer and rare diseases will never be considered as essential medicines, so the health department won’t buy these medicines for the public sector.
That means they’ll be unavailable to people who use the state sector. For the fortunate few who belong to private medical schemes, such drugs might still be subject to out-of-pocket payments that can amount to thousands of rand a month.
Plus, it’s not clear what cancer care could look like under South Africa’s proposed National Health Insurance, a medical scheme that aims to buy the same package of health services for everyone. The health department’s Nicholas Crisp, who’s in charge of rolling out the scheme, told delegates at the Hospital Association of South Africa’s annual conference in August, the NHI would probably only be implemented in “years to decades, rather than months to years”.
In short, the possibility of equitable access to cancer drugs in South Africa remains elusive.
Salomé Meyer is an activist with the Cancer Alliance.
Andy Gray is a senior lecturer in pharmacology at the University of KwaZulu-Natal.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.