There are plenty of people who would say that it may be a brave, foolhardy or perhaps overextended pharmaceutical manufacturer of diabetes drugs who fails to seize the potential opportunities afforded by the booming Chinese market.
China is home to the world’s largest population – close to 1.4 billion inhabitants, according to the World Health Organization (WHO) – of which around 113.9 million suffer from diabetes, according to a study recently published in the Journal of the American Medical Association (JAMA). This represents a sizeable chunk of the estimated 347 million sufferers worldwide and already a lure to pharmaceutical manufacturers on a philanthropic, as much as economic, basis.
Moreover, with WHO projecting that diabetes will be the 7th leading cause of death in 2030, China is set to remain a key challenge for the foreseeable future.
Diabetes has in fact been on the rise in China over the past thirty years and is already reaching epidemic proportions. The JAMA study reveals that less than 1 per cent of the Chinese population had diabetes in 1980, which rose to 2.5 per cent in 1994 and 5.5 per cent by 2000-2001. The most recent national survey, which was concluded in 2007, reported that the diabetes prevalence was around 9.7 per cent. JAMA also suggested that just over 50 per cent of the Chinese adult population could be pre-diabetic patients, while just over 30 per cent of current sufferers are aware of the state of their condition.
Add to these alarming figures the fact that China is one of world’s the fastest-growing economies, with the International Monetary Fund predicting growth to be around 7.5 per cent in 2014 (this may fall marginally to 7.3 per cent in 2015) and the attractiveness of the country grows for those wishing to invest in healthcare. China also charts the largest consumption increase in the world over the past three years and GDP is on the increase, meaning that the population has an expanding capacity to buy its way to a better, healthier life. Furthermore, according to consulting firm McKinsey, China is set to triple its investment in healthcare from $357bn in 2011 to $1tr by 2020.
The JAMA study, which was conducted by the Chinese Society of Diabetes (CDS) together with the International Diabetes Federation (IDF), suggested that the annual cost to the Chinese national health service for treating diabetes was 173.4bn Yuan ($28.5bn), which accounts for roughly 13 per cent of the nation’s total health spend.
The challenge
On the face of it, the unmet need in diabetes in China is significant now and only set to rise inexorably, in tandem with drivers of expanding society and mobility. However, healthcare businesses wishing to set up in the country, or even expand current levels of investment, are faced with several key challenges.
The growth and diagnosis rates of diabetes are so serious that healthcare systems will soon struggle to cope, Danish firm Novo Nordisk notes in its Changing Diabetes in China report: ‘Increasing childhood obesity in China is to diabetes and chronic diseases what melting glaciers are to climate change: a warning signal of times to come.’
Through its Together on Diabetes initiative, Bristol-Myers Squibb (Foundation) also cites a shortage of well-trained healthcare professionals, which has created barriers to preventing and controlling diabetes in China. Since doctors spend only around six hours with each diabetes patient each year, increasing awareness of and access to diabetes treatment are not enough, it argues. There is also a lack of millions of nursing home employees to care for its growing elderly population, which has a serious impact on the ageing diabetic population.
However, according to a report published by audit and consulting firm Deloitte, China’s Ministry of Civil Affairs has set an ambitious target to train six million caregivers by the end of 2020.
Helen Yan, head of communication, China and Asia for Sanofi in Shanghai, identifies a key challenge as an apparent imbalance of resources in healthcare system, which certainly favours the metropolitan over the rural population.
China has tried to address this issue, but disparity remains. In 2009, the government unveiled a three-year health reform plan, designed to lay a solid foundation for equitable and universal access to essential healthcare for all in China by 2020. At a cost of 850bn Yuan ($136bn), it aimed to provide universal access to basic health insurance, introduce an essential drug system, improve primary health facilities, reform state hospitals and ensure equitable access to basic public health services.
Yan cites additional serious barriers to proper diabetes care as being the low and late diagnosis and treatment of patients, poor glycaemic control and compliance among the populace, a huge pre-diabetes population and increasing diabetes-related complications.
However, part of the problem for innovative health companies looking to set up stall in the Chinese market is the fact it is already quite crowded, according to Stephanie Yu, senior vice president, head of healthcare practice, Weber Shandwick China. A number of pharma’s large diabetes players have been in the country already for several years, including Novo Nordisk, Lilly, AstraZeneca, Sanofi, Bayer and BMS.
Yu observes that this presence has created something of an information overload when added to the government’s drive to emphasise treatment as a means of reducing the overwhelming prevalence of diabetes in the population. “While there is a huge need for education in China’s healthcare sector, it is important for pharmas to consider specific demographics and channels to target for different stages of the product’s life cycle. This is not limited to patients – access to treatment knowledge, best practices and equipment can differ among healthcare professionals across different cities,” she says.
Practical barriers
Yet, while the government is clearly introducing reforms and education to tackle the diabetes epidemic, legislative barriers that impede drug manufacturers from helping to find real solutions remain firmly in place.
For example, as is the case in the EU, the advertising of prescription drugs direct to patients remains prohibited in the country, ostensibly for safety reasons. Stringent drug marketing regulations have meant that both patients and healthcare professionals are obliged to look elsewhere for information, which has placed more emphasis on the role of the media in conveying this information; and as a consequence a reliance on effective public relations to help build awareness of pharmaceutical products.
Yu notes that despite the huge number of social media users in China and the potential use of this medium to reach patients for educational purposes, it is relatively underexploited and has not really been assimilated into the core communications strategies of health businesses. “This is mainly due to regulations governing contact between healthcare companies and patients, and the internal legal constraints of many companies,” she adds.
Another problematic issue for manufacturers looking to engage with the public is that privately organised patient groups are also prohibited in China, although patient groups organised by doctors, within a hospital setting, are permitted.
This has not prevented the emergence of online patient forums, which are in effect thriving. Patients in China are using this media vehicle to satisfy their largely unmet need for support and interaction with other patients going through similar experiences.
Yet, companies seeking to interact with users through these channels should tread very carefully, because they are closely monitored and any references that may be construed as commercial activity might result in potential legal implications; as we’ve seen recently, pharma needs no further inference of undue influence over medicine promotion in China.
Chinese consumers are far more likely to trust information from friends or KOLs than media sources
None could have missed the problems experienced, for example, by GSK and Lilly in the Chinese market over the past two years. This has led most to be wary and even somewhat frightened to try anything adventurous in terms of business and marketing. The negative impact of these events on communications, particularly with healthcare professionals – which often has the potential to be misconstrued – cannot be underestimated.
There is one final barrier to overcome that is often underestimated, which is the role of traditional Chinese medicines. Most recently in January this year, a headline ran in the global press about Tianqi, a mixture of 10 herbs that showed signs of preventing people with pre-diabetes from developing the full-blown disease.
Even the British Medical Journal (BMJ) has acknowledged that traditional Chinese medicine and Western medicine ‘sit side-by-side’ in China; therefore convincing the populace to use innovative drugs may present an additional hurdle to effective marketing.
Emergence of media channels
Manufacturers looking to reach healthcare professionals must exploit interactive channels that allow these individuals to seek advice on specific clinical issues from experts. This type of media thrives in the cities, but there is also increasing evidence of its effectiveness in reaching rural communities.
Video streaming is starting to be used to access rural hospitals and encourage doctors to interact with top-level KOLs remotely. “This is an emerging channel with opportunities for simulating a ward visit by the KOL to help and coach doctors with clinical issues,” explains Patrick Nowlin, business operations director for Sanofi China’s Diabetes Business Unit. He added though that visits from company representatives continue to be important, enhancing visits with digital media, such as KOL video clips.
Novo Nordisk has also placed great emphasis on physician training in diabetes, focusing on prevention, screening, optimising treatment and patient communication. Specific initiatives included targeted training days where key opinion leaders have educated physicians directly.
Another leading player in China in the diabetes sector, Bayer, has also placed emphasis on physician education. A few years back it established the Bayer Health House programme, essentially creating a series of 400 individual platforms in hospitals and communities in 30 Chinese cities, which act as a platform for diabetes education, free doctor consultancy services and communication with patients. Later, Bayer HealthCare established the Go West Project to provide free training to physicians and hospital heads in poorer areas. The aim was to help develop the healthcare infrastructure, while promoting the brand.
Social and search
Reaching patients remains a more serious challenge. Sanofi’s Nowlin suggests that the use of a digital matrix on packaging that allows patients to access information portals through smart phones could help to drive a breakthrough. “The use of apps which allow for remote management and consultation for patients is also an important area of development,” he adds.
Leveraging China’s main social media platforms is essential in any communications campaign that aims to engage audiences across China. He points out that the most popular platforms, Sina Weibo and WeChat – often referred to as China’s Facebook and Twitter, which are banned along with YouTube – have over 500 million and 600 million users respectively from all over the country.
Yet while social platforms provide a means of communicating nationwide, Weber’s Yu cautions against a one size doesn’t fit all. “Multinational healthcare companies seeking to communicate in China must involve their China teams from the very first strategy discussions. This way they can ensure that all the relevant factors acting on China’s complex healthcare and socio-economic landscape are considered, and that global messages are tailored for specific Chinese audiences,” she advises.
Employing online influencers, or KOLs, is also vital in communication campaigns in China. “Surveys have revealed that Chinese consumers are far more likely to trust information received from friends or KOLs than traditional media sources.”
Trade shows are still significant means of expanding influence in the Chinese market, attended as they are by medical professionals, government officials at regional and national level, and academics. Last month’s ChinaBio Partnering Forum in Suzhou, for example, was sponsored by (among others) AstraZeneca, Bayer, Bristol-Myers Squibb, Johnson & Johnson, Lilly, Lundbeck, Novo Nordisk and Roche.
There are therefore a host of opportunities available to diabetes product manufacturers in China, but it is a complex set-up, and divers approaches will need to be taken if the intention is to expand nationwide. Foremost in company strategies should be the ability to understand various internal markets (leadership), provide an integrated portfolio and demonstrate a commitment to serving patients through partnerships with media, official health associations and the Chinese government.