Much analysis of the supply chain for essential medicines to Africa assumes broad sustainability of low cost generics supply from Indian manufacturers. We use Indian data and interviews to question that assumption. In a case study of Tanzania we then argue for the necessity and feasibility of enhanced local production of essential medicines. We identify key industrial policy interventions, including industrial protection and active government purchasing; public goods including legislative and regulatory frameworks and training; and encouragement and facilitation of joint ventures. We show that a basis has been laid for these activities, and identify the urgency and difficulty of the policy challenge. There are lessons for the Tanzanian case from Indian industrial history, and policy space is provided by Tanzania’s Least Developed Country status. Industrial and health policy can be further integrated to the benefit of Tanzania’s citizens. The Tanzanian case has broader implications for African policymakers.