Can public education campaigns equitably counter the use of substandard and falsified medical products in African countries?

Substandard and falsified (SF) medical products are a serious health and economic concern that disproportionately impact low- and middle-income countries and marginalized groups. Public education campaigns are demand-side interventions that may reduce the risk of SF exposure, but the effectiveness of such campaigns, and their likelihood of benefitting everybody, is unclear. Nationwide pilot risk communication campaigns, involving multiple media, were deployed in Ghana, Nigeria, Sierra Leone, and Uganda in 2020-21. Focus group discussions (n = 73 with n = 611 total participants) and key informant interviews (n = 80 individual interviews and n = 4 group interviews with n = 111 total informants) were conducted within each of the four countries to ascertain the reach and effectiveness of the campaign. Small proportions of focus group discussants (8.0-13.9%) and key informants (12.5-31.4%) had previously encountered the campaign materials. Understandability varied: the use of English and select local languages, combined with high rates of illiteracy, meant that some were not able to understand the campaign. The capacity for people to act on the messages was extremely limited: inaccessibility, unavailability, and unaffordability of quality-assured medicines from official sources, as well as illiteracy, constrained what people could realistically do in response to the campaign. Importantly, reach, understandability, and capacity to respond were especially limited among marginalized groups, who are already at the greatest risk of exposure to SF products. These findings suggest that there may be potential for public education campaigns to help combat the issue of SF medicines through prevention, but that the impact of public education is likely to be limited and may even inadvertently widen health inequities. This indicates that public education campaigns are not a single solution; they can only be properly effective if accompanied by health system strengthening and supply-side interventions that aim to increase the effectiveness of regulation.