The medicine reached the patient. The label was correct. But it did not work.
No alarm went off. No investigation was opened. No one in the supply chain was notified. The patient, and the clinician, simply absorbed the outcome, and the chain moved on.
Variations of this story play out across East Africa every day, quietly, without attribution, and often without consequences for the system that produced them. A temperature excursion nobody caught. A product that passed release testing but later degraded on a truck that sat too long in the heat. A certificate completed in a poorly calibrated instrument. The medicine arrives. The system records a delivery. The patient receives something that looks like the right treatment.
WHO estimates have consistently suggested that up to one in ten medicines in LMIC settings are substandard or falsified, a figure that, while debated in its precision, is broadly corroborated by field evidence across the region. Studies on cold chain integrity paint an equally concerning picture. Research repeatedly shows that a significant proportion of temperature-sensitive products experience improper exposure at some point in the supply chain, with some estimates ranging from 19 to 38 percent. The question is not whether this is happening. What is worth asking is: Why, in a region full of actors who genuinely care about quality, does the system keep producing this outcome?
The answer, we believe, reframes everything about how solutions should be designed.
The System Is Not Broken. It Is Misaligned.
The instinct is to blame weak regulation, underfunded procurement, or manufacturers cutting corners. These are real, but they are symptoms. The root cause is structural: East Africa's medicine supply chain has been designed, not through malice, but through accumulated incentive misalignment, to reward the appearance of quality rather than its substance.
Every actor in the chain is behaving rationally within the system they operate in. Together, they produce a system that fails patients.
The manufacturer competing on a heavily price-driven tender has no commercial reason to invest in quality above the regulatory minimum. The logistics provider whose contract carries no penalty for a cold chain failure has little incentive to prevent one. The distributor paid purely on transaction margin has little stake in what happens after handoff. The procurement agency under budget pressure and time constraints, perceives thorough quality verification as a major delay.
Regulation sets the bar, and that bar matters. However, regulatory clearance tells us, at best, what a product was at the point of approval, not what it might be eighteen months later in a warehouse or dispensing facility no inspector has visited. While the approval was possibly valid, the guarantee expired somewhere along the journey.
This is not a compliance failure. It is a market design failure. And compliance-focused interventions alone will not suffice to address a challenge this systemic.
What the Ecosystem Is Already Doing
What gives us genuine optimism is not that the problem has shrunk, butthat the people closest to it are already responding with resourcefulness and conviction. Whilst the system has not yet found a way to reward their efforts, the technological tools to unlock transparency are taking root.
Manufacturers: are not indifferent to quality. Across our engagements with facilities across the region, we consistently find quality teams making the internal case for better systems. Tighter controls, stronger supplier qualification, genuine stability data: despite operating in a market that does not yet fully reward them for it. However, faced with persistently thin margins, many are walking away from complex, capital-intensive product categories altogether, in order to preserve quality. Sterile medicines for example are being deprioritised in favour of higher-margin oral formulations. The portfolio narrows; patients who depend on sterile products find supply thinner and increasingly import-dependent. The market incentive design failure is not only producing poor quality medicines. In some critical ranges, where investment behind quality is still a choice made, it is producing fewer medicines altogether.
Buyers: are not passive recipients. Some of the most striking conversations we have had so far have been with procurement teams who have established independent in-house testing laboratories, conducting their own quality assessments on top of supplier prequalification and certificates of analysis review, at their own cost, because the existing system has not given them the confidence they need. That is both admirable and telling. When buyers have to build their own laboratories to trust what they are purchasing, we find ourselves in a system that has not yet answered its most basic question.
Regulators: are operating in a more reform-oriented environment than is often acknowledged. Post-market surveillance remains the weakest link — the gap between what is approved and what actually moves through the supply chain is largely unmonitored. But the appetite for new approaches and real-time data is genuine. The WHO maturity level framework, the EAC harmonisation agenda or the African Medicines Agency latest efforts could represent meaningful momentum. The floor could be rising. What is needed now is the infrastructure that makes it hold.
The Missing Piece
The manufacturers are ready. The buyers are vigilant. The regulators are trying. So what is missing?
Connective tissue so that quality information does not die at every handoff. A buyer tests a product and only files the result internally. A manufacturer builds a strong track record that no buyer can see. A cold chain breach is logged in a compliance system no procurer ever reads. A patient reports an adverse event, no regulator will know about. Each actor generates quality intelligence. None of it flows to where it could support a systems change.
Technology closes this gap; not by replacing what the ecosystem is already doing, but by connecting it. By making quality performance visible, verifiable, and commercially consequential across the full journey from manufacturer to patient.
A logistics provider whose cold chain record feeds into their access to future contracts has a different incentive than one whose breach is simply filed. A manufacturer whose quality investment is visible to buyers has a different business case for making it. A procurer with access to verified supplier track records makes a different sourcing decision.
This is what Axmed is building — the infrastructure that redesigns the existing system to work the way it was intended to. Smarter accountability. A market where quality is not a burden each actor carries alone, but a shared standard which the infrastructure makes rational to meet and impossible to fake.
What Still Needs to Happen
The following shifts, though not conclusive, will determine whether this moment produces durable change or another cycle of well-intentioned interventions.
Post-market surveillance must become a priority, not an afterthought. The quality crisis lives in the gap between approval and administration. Closing it requires continuous data, not periodic snapshots.
Procurement must move beyond price. It is the hardest shift and the most leveraged one. A market that selects on verified quality performance changes the investment calculus for every manufacturer within it.
Regulatory and commercial systems must talk to each other. The performance data generated by technology-enabled supply chains is regulatory intelligence. Regulators who treat it as such extend their reach without expanding their inspection burden.
The cost of verification must be shared. Buyers who fund independent testing alone are solving a system problem with individual resources. Shared infrastructure distributes that cost and amplifies its value for everyone.
Quality must become a commercial asset, not a compliance obligation. The shift is from something actors perform for regulators, to something the market consistently rewards.
The Moment East Africa Is In
East Africa is at a genuine inflection point. Not because the problems are resolved, they are not. But because the conditions for resolving them are more aligned than they have been before. Several local and regional manufacturers are ready to meet a higher standard. Buyers investing in verification. Regulators open to new approaches. A regional architecture maturing toward harmonisation. Tech procurement platforms acting as connective tissue.
What has been missing is not commitment. It has been the infrastructure that turns individual commitment into collective outcome.
That infrastructure is being built. The momentum is real. And the standards East Africa's patients deserve is closer than many of us have been willing to admit.
The question now is whether the ecosystem moves together; or waits for the next visible failure to resurface a reality that should already be obvious
