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Root Cause Analysis of Counterfeit Medicines

RCA of Counterfeit Medicines

Counterfeit medicines remain one of the most pressing threats to global public health, especially in regions with limited oversight. These fake or substandard drugs, often containing incorrect or no active ingredients, can lead to treatment failure, increased antimicrobial resistance, or even death. Criminal networks exploit supply chain vulnerabilities. These include third-party logistics without verification, no background checks on vendors, and unsecured distribution channels lacking authentication mechanisms. The result is a dangerous ecosystem where counterfeiters thrive while patients are left exposed.

The rise of counterfeit medicines is fueled by a mix of regulatory gaps, technological deficiencies, and market pressures. Many regions suffer from weak penalties for counterfeiting and inconsistent enforcement across borders, leaving no deterrent for repeat offenders. On the technology front, the absence of digital verification tools, QR codes, serialization, and track and trace systems, combined with manual packaging, makes products highly vulnerable. Meanwhile, limited availability in rural areas and the high price of genuine medicines create demand that counterfeiters readily exploit. This is made worse by a lack of awareness, where pharmacists lack training on detection and consumers are unaware of the risks, due to insufficient public education.

When a counterfeit medicine incident is discovered, it becomes critical for pharmaceutical companies and supply chain stakeholders to conduct a structured, in-depth investigation. This is where ProSolvr brings clarity and control. As an AI-powered root cause analysis platform, ProSolvr enables teams to visually map the complex web of contributing factors, including illegal manufacturing, corruption, bribery of enforcement agencies, and gaps in distribution and education. Using frameworks like the Fishbone diagram and Six Sigma methodology, ProSolvr helps organizations identify true root causes, assign responsibilities, and track Corrective and Preventive Actions (CAPA), turning every counterfeit incident into an opportunity for systemic improvement, operational resilience, and future risk reduction.

Counterfeit Medicines

    • Supply Chain Vulnerabilities
      • Third-party logistics without verification
        • No background checks on vendors
      • Unsecured distribution channels
        • Lack of authentication mechanisms
    • Regulatory Gaps
      • Weak penalties for counterfeiting
        • No deterrent for repeat offenders
      • Inconsistent enforcement across regions
        • Lack of coordination among countries
    • Technological Deficiencies
      • No digital verification tools for customers
        • No QR code or mobile app support
      • Lack of serialization or track & trace
        • Manual packaging systems
    • Market Demand and Pricing
      • Limited availability in rural/remote areas
        • Counterfeiters exploit supply gaps
      • High price of genuine medicines
        • Patients seek cheaper alternatives
    • Lack of Awareness
      • Pharmacists lack training on detection
        • Untrained on visual identifiers and packaging clues
      • Consumers unaware of risks
        • No public education on counterfeit drugs
    • Corruption and Criminal Networks
      • Bribery of enforcement agencies
        • Officials ignore reported activities
      • Illegal manufacturing facilities
        • Operate without oversight

Suggested Actions Checklist

Here are some corrective actions, preventive actions and investigative actions that organizations may find useful:

    • Supply Chain Vulnerabilities
      • Third-party logistics without verification
        • Corrective Actions:
          • Immediately review and terminate contracts with unverified logistics partners.
        • Preventive Actions:
          • Implement a rigorous vendor onboarding process with verification protocols.
        • Investigative Actions:
          • Audit logistics partnerships over the past 12 months to identify gaps and risks.
      • Unsecured distribution channels
        • Corrective Actions:
          • Secure current distribution routes with physical and digital tracking mechanisms.
        • Preventive Actions:
          • Establish tamper-evident packaging and GPS tracking for high-risk zones.
        • Investigative Actions:
          • Map out and assess all distribution nodes for potential security breaches.
    • Regulatory Gaps
      • Weak penalties for counterfeiting
        • Corrective Actions:
          • Propose stronger penalties to relevant legislative bodies or regulatory agencies.
        • Preventive Actions:
          • Advocate for policy reforms through industry bodies and compliance associations.
        • Investigative Actions:
          • Benchmark existing penalty structures across comparable countries or industries.
      • Inconsistent enforcement across regions
        • Corrective Actions:
          • Engage regional regulatory offices for harmonized enforcement practices.
        • Preventive Actions:
          • Develop and implement standardized enforcement protocols across jurisdictions.
        • Investigative Actions:
          • Analyze enforcement records across regions to identify discrepancies and non-compliance patterns.
    • Technological Deficiencies
      • No digital verification tools for customers
        • Corrective Actions:
          • Launch digital tools (e.g., website or app) for consumers to verify product authenticity.
        • Preventive Actions:
          • Integrate product verification into the manufacturing and packaging process.
        • Investigative Actions:
          • Survey customers to determine technology adoption barriers and opportunities.
      • Lack of serialization or track & trace
        • Corrective Actions:
          • Initiate serialization for all products starting with high-risk SKUs.
        • Preventive Actions:
          • Implement a company-wide track & trace system linked to regulatory databases.
        • Investigative Actions:
          • Evaluate current packaging systems and traceability gaps.
    • Market Demand and Pricing
      • Limited availability in rural/remote areas
        • Corrective Actions:
          • Expand distribution network through rural medical outlets and mobile pharmacies.
        • Preventive Actions:
          • Partner with local NGOs and government health programs for outreach.
        • Investigative Actions:
          • Assess rural demand patterns and availability metrics for essential medicines.
      • High price of genuine medicines
        • Corrective Actions:
          • Review pricing structure and consider tiered pricing models.
        • Preventive Actions:
          • Launch affordability programs or subsidies for low-income patients.
        • Investigative Actions:
          • Conduct market research on price sensitivity and access barriers.
    • Lack of Awareness
      • Pharmacists lack training on detection
        • Corrective Actions:
          • Organize immediate training programs on counterfeit detection techniques.
        • Preventive Actions:
          • Mandate periodic certification and refresher courses for all licensed pharmacists.
        • Investigative Actions:
          • Evaluate training coverage and effectiveness through knowledge assessments.
      • Consumers unaware of risks
        • Corrective Actions:
          • Initiate awareness campaigns using print, digital, and community platforms.
        • Preventive Actions:
          • Collaborate with public health departments to include content in health outreach.
        • Investigative Actions:
          • Conduct surveys to measure public knowledge and misinformation levels.
    • Corruption and Criminal Networks
      • Bribery of enforcement agencies
        • Corrective Actions:
          • Report and escalate bribery incidents to higher regulatory authorities or anti-corruption units.
        • Preventive Actions:
          • Support whistleblower programs and anonymous reporting mechanisms.
        • Investigative Actions:
          • Review enforcement case histories for anomalies or abrupt closures.
      • Illegal manufacturing facilities
        • Corrective Actions:
          • Collaborate with law enforcement to identify and shut down unauthorized sites.
        • Preventive Actions:
          • Increase random inspections and registration compliance checks.
        • Investigative Actions:
          • Use intelligence networks to trace unregistered manufacturing operations.
 

Who can learn from the Counterfeit Medicines template?

  • Pharmaceutical Quality Assurance Teams: To understand how to conduct structured post-incident investigations and implement effective Corrective, Preventive, and Investigative Actions (CAPA) to avoid future quality lapses.
  • Regulatory and Compliance Officers: To learn how to identify systemic gaps in oversight, policy enforcement, and inter-agency coordination using structured root cause frameworks like fishbone diagrams.
  • Supply Chain and Distribution Managers: To grasp how vulnerabilities in procurement, vendor management, and logistics can be systematically analyzed and mitigated post-incident.
  • Healthcare Administrators and Hospital Pharmacists: To gain awareness of risks in medicine sourcing and handling, and how structured RCA can improve safety protocols and safeguard patients.
  • Forensic Auditors and Investigative Journalists: To explore how deep-dive analysis methods like RCA can be used to trace accountability and identify weak links in regulatory and commercial ecosystems.
  • Public Health Policy Makers and NGOs: To use the RCA template as a learning tool for designing awareness campaigns, policy reforms, and training programs aimed at preventing counterfeit drug circulation.

Why use this template?

The Counterfeit Medicines RCA template provides both a granular and holistic view of incidents, enabling teams to move beyond symptoms and identify true root causes. In a field where every error can have life-threatening consequences, structured and AI-powered RCA tools like ProSolvr are essential—not just for insight, but for systemic improvement.

ProSolvr transforms root cause investigations with speed, accuracy, and collaboration. By leveraging Gen-AI powered analysis, organizations can uncover failure patterns faster, prioritize actions intelligently, and eliminate recurring problems with confidence.

Use ProSolvr by smartQED to investigate critical issues, document findings, and implement CAPA that drives long-term change.

Curated from community experience and public sources:

  • https://www.fda.gov/drugs/buying-using-medicine-safely/counterfeit-medicine
  • https://www.ema.europa.eu/en/glossary-terms/counterfeit-medicine