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Consumers have access to more healthcare information than ever. Here’s how pharmaceutical companies can better understand the way people make decisions about their care.

Consider the following: a 25-year-old, healthy male notices he is developing itchy, scaly patches of skin. He has not experienced anything similar before, so he goes online to do some research. Soon, he finds photos and descriptions that seem to match his symptoms and decides he has psoriasis. He pores over content in patient forums and reads strong views on which medications work best. He then makes a doctor’s appointment, and when the physician prescribes a typical ointment, he asks to be prescribed an injectable biologic instead, even though the physician feels his case is mild and is unsure his insurance company will reimburse the biologic.

Most—if not all—physicians practicing today in an outpatient setting have had similar experiences. We live in a world in which people naturally turn to their smartphones to look for price comparisons while shopping for electronics. It is similarly natural for them to seek information about their health the same way. One in twenty Google searches is now for health-related information

For the pharmaceutical industry, this presents a challenge. The traditional commercial approach based on mass-media advertising, hefty sales forces, ready access to physicians, and relatively uninformed patients is falling short. In particular, companies are failing to engage with patients in the early stages, when they look for information about symptoms. For example, a recent YouTube search for “psoriasis” produced among its top 100 results not a single branded video made by a pharmaceutical company. The first two videos had close to 500,000 views each. To connect with patients when they are looking for answers, pharma companies need to design a new approach based on an understanding of patients’ experiences and how they make decisions.

The healthcare decision journey, or CareFlow

Most pharmaceutical marketers are familiar with the concept of conducting market research to create a “sales funnel” as a guide for marketing programs, where patients move in stages from product awareness to product purchase. Often, these use a linear or sequential logic to represent patient behavior. In the retail industry, that linear journey has been augmented in recent years by the consumer decision journey (CDJ), which recognizes that in a world where consumers are empowered by information, the process involved in making a purchase is much more iterative (for more, see the article which revealed the concept, “The consumer decision journey,” McKinsey Quarterly, June 2009).

For pharma companies seeking to understand how consumers make healthcare decisions, the CDJ is enlightening. We now see consumers undertaking what we call a CareFlow (exhibit). A CareFlow maps a patient’s journey from the first awareness of a problem to treatment, examining the factors guiding their decisions at each stage. These insights enable pharma marketers to engage with patients in ways that feel natural and personal. That may mean providing information to help an important choice to be made, supporting the execution of that choice, or simply empathizing. For while the moment a prescription is filled at the pharmacy is the “success event” commercially, it’s just one of many points of influence in the CareFlow, alongside patients’ own research, their consultations with others, considerations of the cost of treatment, scheduling of appointments, responses to side effects, or remembering to take medications. Some may be far more important than the fulfilling of the prescription, such as the moment before the first time the patient self-injects a biologic (or the moment before the second time, when the patient remembers how much the first injection hurt). Every point in the CareFlow is potentially a vital point of interaction; by understanding it, the marketer can understand the relative importance of points and (re)allocate investment and attention accordingly

The CareFlow also vividly illustrates the considerable branching and looping that can happen within each of the five stages of a typical patient journey. The first group of instances relates to a patient’s recognition of a problem (what we call the external trigger). The second is the process the patient goes through to gather information. The third represents the patient beginning to evaluate treatment options (which can be iterative). The fourth is the beginning of treatment. And the fifth is the ongoing treatment. Patient behaviors and experiences at each point differ by disease, and even by the patient, of course, so the CareFlow has to be disease-specific. For example, a CareFlow analysis of a sample of psoriasis patients in the United States found that 58 percent had requested a specific brand of medication from their physician in the past year. This is twice as high as would be expected in the general patient population and illustrates the importance of communicating with certain segments of psoriasis patients before they visit a physician.

A CareFlow for depression built from a survey of more than 1,200 patients revealed how long it took for them to seek care. Although a diagnosis for depression can be made after 2 weeks of symptoms, 71 percent of respondents took more than a month to receive a diagnosis after first sensing something was wrong, and 38 percent took more than six months. The time lag represents an opportunity for pharma companies to accelerate the patient path to care. The CareFlow also revealed how better management of patients’ expectations—perhaps before as well as when they visit a physician—could improve adherence to treatment. Although the literature suggests that changes may be considered after 2 to 4 weeks of treatment, it also states that antidepressants can take 6 to 12 weeks to take full effect; providers typically wait this extended period before making a determination of a medication’s effectiveness.<a “=”” class=”link-footnote” rel=”#footnote2″ role=”tooltip” tabindex=”0″ aria-label=”Open tooltip”>² The survey, however, showed that 18 percent of prescribed medications were discontinued in less than one month and, in these cases, 52 percent cited perceived lack of efficacy as a reason.

CareFlows can be constructed using surveys of patients and physicians, and analysis of the data available on social media and from web-engine search trends, for example. Pharmacy claims, electronic medical records, and consumer data can also help build a comprehensive and more quantitative view of the patient flow. Data sets can include factors directly related to specific health conditions, as well as demographics, consumer behavior, and communications preferences. Lack of data will not be an issue.

CareFlows are an important new concept for helping pharma companies play a meaningful role in the decisions patients and healthcare providers make about care, ensuring their marketing tactics and offers are targeted, dynamic, and effective. Once companies are committed to understanding them, the next imperative is to reshape their commercial approach accordingly—something that is likely to require a reallocation of marketing focus and investment. In a digital world, they will be a crucial element of any successful commercial strategy.

Amid the country’s downturn, should companies still be looking here for growth? Yes—and we can learn five lessons from players getting it right today.

Five years ago, Nigeria’s strong economic growth sparked a burst of enthusiasm about opportunities in its pharmaceutical market. Yet capturing that promise has proved harder than expected, with many multinationals struggling to find a recipe for success. More recently, the economic downturn has cast an altogether different light on the industry’s prospects. But Nigeria still offers attractive opportunities for companies with realistic expectations and the ability to tailor creative strategies to the Nigerian context and local patient journeys.

As leaders have learned in the past few years, growth must be earned, not taken for granted. To capture Nigeria’s potential, they need to take a long view, weather economic headwinds, and overcome structural obstacles. To tap into pockets of growth and to improve patients’ access to medicines, they should conduct a granular analysis by city, therapeutic area (TA), and channel, and develop innovative offerings that drive penetration in the growing middle class. They need to get closer to healthcare providers, build skills at handling complex sales-and-distribution networks, and invest in local talent.

Putting growth in perspective

As Africa’s largest economy, most highly populated country, and biggest consumer market, Nigeria has been hailed as the next frontier for pharma after South Africa and the hotspots of Northern Africa. But its recent slide into recession has made some companies wonder whether robust growth is still attainable. In July 2016, the International Monetary Fund cut Nigeria’s GDP growth forecast to –1.8 percent, the lowest since 1987. Yet despite the worsening economic outlook, we believe the prospects for pharma remain sound.

As more people join the ranks of the middle classes, household consumption is expected to grow by $94 billion over the next ten years. As out-of-pocket spending accounts for the bulk of healthcare expenditure, growth in consumption should translate into higher healthcare spending. Meanwhile, the rise in noncommunicable diseases (such as diabetes and heart disease) presents opportunities for pharma companies to position themselves as long-term partners to the government by providing access to much-needed medicines. Our analysis indicates that the value of the Nigerian pharma market could rise by as much as 9 percent a year over the next ten years to reach $3.6 billion by 2026 (exhibit), making it as large as the South African market today. Over the same period, Nigeria could contribute between $1.9 billion and $2.2 billion to pharma sales growth, 55 percent of it from prescription drugs.

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However, Nigeria is a complex market, and companies will need to address short-term economic setbacks and deep-rooted structural challenges before they can take advantage of growth in the longer term.

Diagnosing healthcare in Nigeria: Persistent symptoms to address

Pharma companies seeking to capture opportunities in Nigeria will need to develop local solutions to three obstacles to market access.

Healthcare infrastructure is not fully developed

Nigeria’s healthcare infrastructure varies considerably between cities and rural areas, and between public and private provision. Overall, the country lacks the medical facilities, equipment, and capabilities it needs to tackle the considerable healthcare challenges it faces. For example, its ratio of 0.9 hospital beds per 1,000 people is less than half the global average of 2.3, and its 0.07 intensive-care beds per 100,000 people is a fraction of Kenya’s 0.3. Because of this lack of infrastructure, an estimated 5,000 patients a month travel abroad for healthcare, with 60 percent needing treatment in cardiology, musculoskeletal, hematology, or oncology. This medical tourism—much of it to India and South Africa—cost more than $1 billion in 2013.¹

Healthcare financing is a barrier to market access

Healthcare spending in Nigeria is predominantly a private affair, with out-of-pocket spending accounting for 70 percent of total health expenditure in 2015, compared with just 7 percent in South Africa, for example. Private health insurance accounts for about 5 percent of this expenditure, compared with 45 percent in South Africa, while the government’s contribution is an estimated 25 percent, little more than a third of the 72 percent average for countries in the Organisation for Economic Co-operation and Development. As a result, patients face high out-of-pocket costs, and affordability is an issue for all but the richest, with less than 5 percent of households able to cover the full cost of ethical drugs through out-of-pocket spending or private health insurance. Making matters worse, distribution, wholesale, and retail markups can be very high: a drug’s manufacturing price can double or triple by the time it reaches patients.

Counterfeits and parallel imports compete with registered drugs

In Nigeria’s predominantly informal distribution and retail networks, counterfeit and parallel medicines are often difficult to distinguish from the genuine article. Estimates suggest that informal retail accounts for more than three-quarters of the value of the pharma market, and parallel imports for up to half of drugs sold in some TAs. Several generics companies that have no commercial activities registered in Nigeria still have statin variants that are widely distributed and sold there, for instance. “The competition is beyond fierce and highly fragmented. You always have to be on your toes,” one local executive warned.

Five lessons for pharma companies pursuing opportunities in Nigeria

Drawing on our experience of supporting companies with market entry in this and other African markets, we have identified five lessons that should inform any pharma strategy in Nigeria:

Focus first on cities and then on commercially attractive districts

As their share of consumption increases, cities are becoming ever more important as sources of growth. Forty-five percent of consumption is concentrated in the top five Nigerian cities, and per capita spending in big cities can reach almost twice the national average. Cities are important for another reason too: their superior logistics, infrastructure, and healthcare capabilities make them an engine for structural changes in Nigeria’s health system. A targeted approach to major cities and urban districts will be a necessary condition for commercial success and will involve developing a grassroots view of local potential using household purchasing power as the metric. For instance, among the ten commercial centers and 20 local government areas in Lagos, attractive areas could include Eti-Osa, Ojo, and Surulere, which have the highest number of upper-class households with annual incomes above $70,000.

Create a granular view of the opportunity by TA and channel

Drilling down into opportunities at the level of TAs and sales-and-marketing channels enables a company to make smart choices about where to allocate resources. Many multinationals are realizing that their traditional model—using a clinical sales force to serve hospitals and account managers to serve government tenders and large accounts—is not well suited to overcoming barriers in patient access and infrastructure. An approach geared to specific products, channels, and healthcare providers is likely to prove more effective. Companies also need a product portfolio that meets the contrasting needs of affluent patients, who face a growing burden of noncommunicable illnesses such as heart disease, and poorer patients, who disproportionately suffer from infectious diseases such as typhoid. In addition, market-entry strategies need to be tailored to the roles played by the main healthcare providers. For instance, some multinationals have overemphasized detailing in hospitals while underserving retailers, which can represent more than 70 percent of revenues in major TAs such as cardiovascular and musculoskeletal. To strike the right balance, companies need a detailed knowledge of the stakeholders and dynamics that shape the most attractive TAs across the private, public, and donor markets.

Understand the reality of patient journeys for priority TAs

Traditional market-entry models are unlikely to prove effective against the hurdles presented by awareness, access to primary healthcare, generics substitution by retail pharmacists, and product availability and affordability in Nigeria. Multinationals should instead study local patient journeys and develop bespoke solutions. Take the patient journey for hypertension in Lagos, for example. More than four-fifths of patients are unaware of their condition, while among the one-fifth with a diagnosis, fewer than half regularly check their blood pressure. Two-thirds of patients visit a retail pharmacist rather than a medical professional as their first port of call, but three-quarters of Lagos’s retail pharmacies and proprietary and patent medicine vendors are unregistered and are often staffed by technicians lacking the knowledge, skills, and tools for effective diagnosis. Hypertension is frequently misdiagnosed as typhoid or malaria, with serious consequences for patients. Multinationals entering this TA could start by carrying out focused detailing with retail pharmacists, providing blood-pressure kits, training staff in diagnostic methods, and hosting screening sessions in priority cities.

Improve ability to handle sales-and-distribution networks

One of the difficulties multinationals face in penetrating Nigeria’s retail pharmacy and hospital networks is their limited influence over sales and distribution. Products are imported and distributed through two main distributors, which are licensed to sell only to registered pharmacies, hospitals, and other institutions. However, just 4,500 out of 80,000 retailers are registered pharmacies, and more than 70 percent of revenue potential lies in unregistered and informal outlets served by some 200 wholesalers. Nimble companies could try to capture a first-mover opportunity by identifying the wholesalers with the largest distribution shares in target territories, partnering with them, and establishing clear trade terms. These should include stringent metrics for compliance and performance; well-defined priorities for markets, TAs, channels, and customers; attractive financial and nonfinancial incentives; and adequate marketing resources. Such steps could help companies extend their reach in underserved cities, TAs, and customer segments.

Build a strong local leadership team

To succeed in Nigeria, companies need a committed leadership team with a country head who has deep knowledge of both industry and local context. Novartis, and Sanofi have hired seasoned African country leads to run their Nigeria operations. Once leaders are in place, they need dedicated investment budgets, autonomy to make routine day-to-day decisions, and local support for critical functions such as marketing and finance. Local talent is available, but in high demand. For broad middle-management skills, companies will find themselves competing for talent against other rising sectors such as telecommunications, so a creative approach and a compelling people proposition will be essential. Specialist regulatory, pharmacy, medical, and commercial skills will be harder to come by, so companies should research global and local talent markets and consider less obvious candidates who cost less to hire but need extensive training and development. Leading multinationals attract local talent by promoting a meritocratic culture with global career tracks, investing in diversity, building trusting local relationships, and offering globally competitive financial packages. Nigeria’s top executives come from the world’s leading universities and expect their compensation to match their experience and aspirations.

What to do next: Developing a successful commercial model

As pharma leaders revisit their commercial models and devise innovative entry strategies for Nigeria, they can ensure they cover all the bases by addressing ten questions:

• Aspiration setting. What is our ambition, given our global priorities and the conditions in Nigeria?
• Geographic focus. Which cities and districts should we prioritize?
• Health providers. Who are the key buyers, and how much value do they drive?
• Product portfolio. Which TAs are the most attractive to target, given our products and pipeline?
• Patient journey. How can we address the pain points that limit patient access to healthcare and medicines in each disease area?
• Route to market. What sales-and-distribution model would best open up our path to the patient?
• Innovative partnerships. What are the big ideas and stakeholder partnerships that will drive step-change growth?
• Business case. What sales growth and returns can we expect from our investment?
• Organization and talent. What organization and skill gaps exist, and how can we fill them rapidly?
• Road map. What tactical levers can we pull to capture quick wins, and what key performance indicators, targets, and milestones should we use to measure success?

Nigeria still offers exciting growth opportunities for multinational pharma companies, but short-term success is by no means assured. Gaining market share requires a clear grasp of city potential, government context, distributor landscape, and healthcare providers. Those companies that master local dynamics and devise bespoke solutions will be best placed to develop winning strategies.

By Tania Holt, Laura Millroy, and Matthews Mmopi

Although I was born in the UK, I attended secondary school and university in Nigeria, as my family moved to Nigeria when I was young.

I got into pharmacy because I loved chemistry. I came across the profession when I was about 13, before hearing about clinical pharmacy, which was in its infancy in the US – and not even known about in Nigeria. So, I decided I would become a clinical pharmacist. But to do that, I had to move to the UK as I realized that I wouldn’t be able to achieve my dream of being a clinical pharmacist as the pharmacy wasn’t, and still isn’t, practiced in the same way in Nigeria.

Culture shocks

In those days, pharmacy technicians were not regulated in the UK. In addition, then, as of now, there was a shortage. I easily gained worked as a locum pharmacy technician in various London hospitals, but the role was considerably underdeveloped then, although clearly a vital one. The concept of medicines management or ward-based pharmacy technicians did not exist. We were also definitely second-class citizens, after pharmacists. Even though I had regular work and had no dependents, money was very tight as I was saving up to pay for my conversion course and associated living expenses. After an interview at the Royal Pharmaceutical Society, and a review of my university transcript, I was allowed to enroll in the overseas conversion course, which was then only available in Sunderland as a year-long residential course. For someone who had moved from Nigeria to multicultural London, living in the North-East in the 1980s was certainly a culture shock. There was a big divide between the university and its students, and the local community at that time, so I had a significant socio-political learning curve. Black students were advised not to walk around the town alone at night and physical assaults were not unknown. As a black student in Sunderland, there was no chance of getting a part-time job, so I was always broke. Although the practice of pharmacy was different, the academic knowledge from my Nigerian pharmacy degree was the same, which gave me a great grounding for my studies.

Embedded discrimination

I completed my pre-registration training year at Greenwich Hospital in London, helped very much by my pharmacy technician training. I remember being congratulated by my tutor on my excellent Controlled Drug dispensing and documentation skills! The pre-registration examination had not been invented when I registered in 1989, so we had just had to achieve the competencies. On receiving my registration certificate, I was struck that my registration number was very different from my colleagues, being shorter and preceded by ‘F’. I have never found out what the ‘F’ stands for, but possibly: foreign? This will always mark me out as ‘other’ – although the only element that is different is that I have a pharmacy degree from another country. I think this practice has now stopped, but it is just one example of the embedded discrimination that we overseas pharmacists regularly encountered.

Changing the image of pharmacy

There is still an issue in academia with a lack of diversity and representation, not that it is limited to the pharmacy. Pharmacy is not particularly different to any other healthcare professional. If you are in an industry where you have to climb the ladder to be successful, you are disadvantaged if you’re black. When I first moved back to the UK, I didn’t see senior black people working as lecturers or in practice. I did meet some black pharmacists in London, but they were either in community practice or they remained in very junior roles in the hospital, certainly not in senior leadership roles. That has changed, but it remains a struggle. There are black pharmacist student associations across the country, that are doing impressive work. But at a strategic level, the Pharmacy Schools Council needs to be radical about appropriate representation. We need to ensure that, if you run a pharmacy course, students see themselves reflected in the lecturer workforce. If you do not have that diverse representation, we have to ask, ‘how can we put that into practice?’ Senior black pharmacists are often asked to give talks to pharmacy students, but if, as a university, you don’t have any senior black lecturers, then you need to go and get them or develop them.

It’s vital that diversity of culture and ethnicity, which helps with diversity of thought and the removal of systemic barriers, is seen as normal business.

What is Medicines Optimisation?

Healthcare costs are rising worldwide, due to the combination of an aging population, increasing burden of chronic diseases, technological advances, the prevalence of medication errors, and increasing yearly spending of medicines, often attributed to polypharmacy and medical waste.  In 2019/20, the NHS spent £20.9 billion on medicines  – this was the second-highest area of spending in the NHS, after staffing costs. The increased cost of medicines has intensified the pressure on NHS organizations to identify and implement cost-control measures as a means to establish and maintain the financial sustainability of the NHS.

The bridge between Clinical Commissioning Groups (CCGs) and Medicine Optimisation (MO) is formed by the requirements for CCGs to commission the right services to improve the lives of those living within their local population. CCGs are required to ensure that services and pathways in which medicines are used to deliver cost-effective use of resources, reduce risks associated with medicines use, and improve the health, safety, and wellbeing of the population.

My day-to-day role

As a Medicines Optimisation pharmacist, working within Devon CCG, my main aim is to utilize the principles of medicine optimization – getting the right medicine to the right person at the right time – to ensure the best possible health outcomes from appropriate investment in medicines. The optimization of medicines not only produces savings for the NHS but can also be used to have greater beneficial impacts to our social and healthcare system, such as:

• Supporting the Climate Change Agenda, by reviewing our formulary to support prescribing of Dry Powder Inhalers over Pressurised Metered Dose Inhalers in asthma and COPD.
• Tackling polypharmacy and medicine waste by providing clinical support to care homes.
• Addressing health inequalities by working collaboratively with healthcare providers such as mental health, drug, and alcohol addiction services, and pain management specialists, to reduce prescribing of drugs associated with dependence and withdrawal.
• Reducing GP workload by supporting the implementation of national and local medicines management initiatives such as electronic prescribing, repeat dispensing, Pharmacy First scheme, and GP Community Pharmacist Consultation Service (CPCS).
• Working closely in a multidisciplinary team to reduce the prevalence of medicines-related safety incidents that often contribute to poorer health outcomes and patient experience, prolonged and expensive hospital admissions, and increased GP and emergency department visits.

• Reviewing variance in local and national prescribing data, to drive changes in prescribing behaviors and encourage high-quality, safe, evidence-based prescribing.

The impact of COVID-19

However, like many, the pandemic has altered my usual day-to-day role, and I have had to adapt both the ways in which I work and the work activities I now undertake. I have felt privileged to be able to play such an important role in supporting and coordinating the NHS response to the COVID-19 pandemic. Over the past 22 months, I have been involved in the following activities:

• Trained and worked as a dilutor for vaccination sites, and housebound patients
• Providing clinical support to care homes in Devon
• Delivering legal, clinical, and pharmaceutical advice to COVID vaccination service providers
• Visiting non-NHS sites to complete site assurance and reviewing virtual assurances of sites to ensure vaccine integrity is maintained
• Interpreting the latest national and local guidance and providing updates to vaccination sites and internal colleagues
• Reviewing and organizing the transfers of COVID vaccines between sites in Devon in order to increase vaccine uptake
• Liaising with Regional Vaccine Operations Centre (RVOC) and/or Immunisation Clinical Advice Response Service (iCARS) regarding vaccine-related queries, where appropriate

In summary, the MO team has a significant role in supporting the CCG to ensure that appropriate investment in medicines leads to improved health outcomes and patients’ experiences with their medicine. However, the landscape of the CCG is changing, and its functions and staff will soon become absorbed into the Integrated Care System (ICS) NHS body. There is also the possibility that some of the commissioning responsibilities of NHS England will be passed down to ICSs. This exciting change in the way NHS commissions services could mean that the MO team will have the opportunity to further stretch and challenge our current roles and responsibilities