The challenge
In Nigeria, blood pressure-lowering medication was unaffordable for many patients. Out-of-pocket fees were a primary barrier to accessing these life-saving medicines and keeping high blood pressure under control.
The solution
The Nigeria Hypertension Control Initiative (NHCI) established a self-sustaining drug revolving fund, supported by a nationally-endorsed treatment protocol and a tracking mechanism to accurately forecast purchasing needs, that reduced costs and improved availability of key drugs to control high blood pressure. Kano and Ogun state governments expanded impact by incorporating medicines from the treatment protocol into existing state-level drug revolving funds for the first time.
The impact
The price of amlodipine 5mg—the preferred first-line treatment for most uncomplicated high blood pressure—dropped by 30% in Kano state and the prices of amlodipine 5mg, amlodipine 10mg, and losartan 50mg decreased by approximately 49%, 47%, and 16%, respectively, in Ogun state. This vast improvement in medication affordability will help approximately 38,000 NHCI patients across 288 NHCI facilities access their life-saving medications.
THE CHALLENGE
Unaffordable drugs undermine blood pressure control
In Nigeria, 19.1 million adults have high blood pressure, the world’s leading cause of death. Yet only 11% have it under control, leaving millions vulnerable to disabling heart attacks, strokes and premature death.
In 2019, Nigeria’s Federal Ministry of Health and National Primary Health Care Development Agency, the World Health Organization, and Kano and Ogun State governments, supported by Resolve to Save Lives and Project Hope, launched the Nigerian Hypertension Control Initiative (NHCI) in 24 facilities throughout Kano and Ogun States to transform hypertension care. Modeled after WHO’s HEARTS technical package, the initiative sought to provide streamlined, affordable, sustainable care at the primary health care level.
But access to affordable, high-quality medicines remained a barrier to hypertension control. A 2022 report demonstrated that the prices of antihypertensive medicines included in Nigeria’s national treatment protocol were up to 7 times higher in the public sector than the target generic price of the same medicine.
THE SOLUTION
A steady, affordable drug supply with a drug revolving fund
Drug revolving funds (DRFs) are self-sustaining funding mechanisms that use a seed stock of medication provided through donation or purchase. Governments or programs sell those medications at a price that covers administrative costs only to maximize availability and affordability and reinvests revenue into buying more medications in a continuous cycle.
Though DRFs have shown to increase the accessibility of quality medications for other medical conditions, neither Kano nor Ogun State had incorporated medications included in the national protocol medications for treatment of hypertension at the primary health care level.
To make blood pressure-lowering medicines more available and cut costs to patients, the NHCI created a pilot drug revolving fund in November of 2020 to supply national protocol medicines for high blood pressure to all NHCI facilities throughout Kano and Ogun States.
Resolve to Save Lives provided an initial six-month seed stock of medications to get the DRF started, and the program sold those medications for no more than a 10-15% profit (compared to higher profits of 25-30% seen in the private sector). Within six months, the NHCI DRF was self-sustaining and supplying medicines at a reduced cost to more than 1912 registered patients.
Three key actions allowed the NHCI DRF to thrive:
1) A simple treatment protocol to aggregate demand
To streamline the procurement process, NHCI stakeholders developed a simple treatment protocol for treating hypertension. The protocol includes just three key antihypertensive medications at specific doses based on evidence-based best practices, so NHCI facilities could consolidate procurement to drive down costs.
2) National guidelines to improve drug availability
NHCI stakeholders developed a national hypertension treatment guideline that includes the NHCI simple treatment protocol and its three antihypertensive drugs. This facilitated the addition of losartan to the country’s essential medicines list, making it more widely available (the other two primary drugs, amlodipine and hydrochlorothiazide, were already included).
In 2024, the Federal Ministry of Health officially approved the Guideline for Prevention and Management of Hypertension, making Nigeria the first country in Africa to endorse a national hypertension treatment guideline and formally accepting and endorsing the NHCI hypertension treatment protocol for national implementation.
3) A system for monitoring drug supply to better forecast supply needs
To properly track drug availability and purchasing needs, the NHCI successfully advocated for the addition of their protocol medications into the National Health Logistics Management Information System, thus improving end-to end-visibility of NHCI commodities at all levels of the supply chain. This was the first time a chronic disease medication was added to the platform, which was originally established to monitor infectious diseases like tuberculosis, HIV and malaria.
The NHCI DRF was a learning experience. As with other industries, aggregating demand is key to driving down costs. So, the more clinicians you can get to follow the protocol and the more facilities you can gather into the purchases, the more power you have to negotiate the prices.
THE IMPACT
Driving down costs at the state level
The NHCI demonstrated that their DRF pilot was not only self-sustaining—it also led to more streamlined medication forecasting, efficiencies in transporting medicines, and reduced medication costs.
With that in mind, and with the support of the Clinton Health Action Initiative and Resolve to Save Lives, Kano and Ogun governments assessed their protocol antihypertensive medicine needs and added them to their existing DRFs. This boosted state-level purchasing power beyond NHCI pilot sites and further lowered medicine prices.
The negotiating power of Kano state’s DRF alone resulted in a 30% reduction in the price of amlodipine 5mg—the preferred first-line treatment for most uncomplicated high blood pressure—and the prices of amlodipine 5mg, amlodipine 10mg, and losartan 50mg decreased by approximately 49%, 47%, and 16% respectively in Ogun State. Pooled procurement across state lines further increased negotiating power leading to these dramatic improvements in affordability.
To date, approximately 38,000 patients are now registered in 288 NHCI facilities across Kano and Ogun states. Each facility uses the simplified treatment protocol and is supplied by the DRF. The initial 6-month seed stock has grown so much that all Ogun state NHCI facilities now have a minimum of 3-months stock available for patients at any given time.
Reducing medications costs will help improve access to the life-saving medicines people living with hypertension need to keep their blood pressure under control.
It became clear that the NHCI protocol that we developed made medicines more affordable for patients and controlled their blood pressure, which is a top killer in Nigeria. The ministry of health is committed to providing patients with what they need to live long healthy lives, so we adopted the protocol into the guidelines for all Nigerians.