Developing health, developing profits

pharmafile | April 30, 2009 | Feature | Research and Development, Sales and Marketing |  Pfizer, healthcare, working poor 

Pfizer's Dr Ponni Subbiah is at the forefront of a revolution in the way the pharma industry views its business, who it believes its customers are, and how it can be socially responsible.

There is currently much talk of pharma's emerging markets – China, India, Brazil, Russia – but this expanded world view still excludes most countries, and billions of the world's population.

The most potent symbol of global poverty – and dire health needs that go with it – is sub-Saharan Africa. The pharma industry has traditionally seen its role in this region and others like it as social responsibility rather than commercial activity.

But the pharma's reputation has been badly damaged by its inflexible approach to patents and prices in these areas, most notably a humbling defeat over access to HIV drugs in South Africa in 2001.

Despite considerable progress on these issues since then, access to medicines remains a major problem, with low incomes being one of the biggest hurdles. Put simply, poverty and ill-health go hand in hand in the poorest regions, and without a welfare or healthcare system to help out, many millions find themselves unable to pull themselves out of poverty.

But now Dr Subbiah's team at Pfizer is latching on to the latest thinking on how corporations can help the 'working poor' build a better life for themselves and at the same time establish a viable business in these areas.

The seminal work in this area is CK Prahalad's book The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits, published in 2002.

The 'Bottom of the Pyramid' refers to the world's largest, but poorest socio-economic group – the four billion people who live on less than $3,000 a year, mostly in developing countries.

So when Dr Subbiah talks of 'access' for developing countries it is not charity or philanthropy. Pfizer believes if it helps support these people through access to quality, affordable medicines, it can lead to improvement in their health and, in the long-term, earn revenues and help build a solid economic base to the benefit of all.

Dr Subbiah sums up her mission by saying it is to develop "a socially responsible, commercially viable and sustainable business model for Pfizer to reach the 'working poor' in the world who currently don't have access to our medicines".

But this goes beyond the normal practice of pharma companies in the developed world, and requires fresh approaches and 'joined up thinking' including long-term partnerships with governments and NGOs.

Less than a year since Pfizer's global access strategy was formed, it is already forging some promising new partnerships. Subbiah's team is now working with the Clinton Foundation to bring down the price of one of its drugs, has set up an R&D collaboration to tackle malaria, and entered a collaboration in Bangladesh with an organisation that has developed an exciting new approach called 'micro-finance'.

Socially responsible and commercially viable?

The concept seems to present obvious tensions – the needs of the world's poorest people and one of the world's biggest corporations seem to be very difficult to align. But Subbiah believes it is possible to make a breakthrough by getting the right partners around the table and negotiating a project which all sides can believe in.

She says: "If we are doing the right thing for the patient, we will be commercially viable."

Ponni says the developed world often thinks of Africa and other regions as "people in ragged clothes getting handouts" but these preconceptions, often fuelled by media coverage of humanitarian disasters, are not representative of many people in these areas, especially the 'working poor'.

Subbiah says the working poor have the innate creativity and skills but do not always have the external support (e.g. financial credit, insurance, affordable and quality goods) to become successful and independent. Therefore, the philosophy is to help these people help themselves. In the area of healthcare, statistics suggest that small-scale spending on healthcare by millions of individuals can add up to a worthwhile market for the pharma industry.

A 2005 World Bank report showed the Bottom of the Pyramid group spent $30 billion on medicines, a total made up of hundreds of millions of people spending just a few dollars each. This spending figure is expected to double in the next ten years, opening up an opportunity to accelerate health improvement.

As head of Pfizer's Global Access team, it is Subbiah's job to seize these opportunities. The team, only established last year, will use Pfizer's scale to extend its reach in developing markets and improve the health of the poor through innovative projects.

"I really view pharma companies as healthcare companies. We have to play a role in improving the health of people at all levels of the socioeconomic sector. We need to think about the healthcare infrastructure and our role in being a partner with governments and other stakeholders. We'll bring our medicines but also look at what other things need to be there, to make sure that ultimately there is an impact on health and overall wellness. Hopefully, this will contribute to economic well-being also."

She says effective collaboration between NGOs, multilateral organisations, governments and the private sector will be critical in overcoming the challenges and improving the healthcare for these traditionally underserved populations.

"There is commercial potential, but there are also healthcare needs that have been neglected. So I think there is a great opportunity in both respects."

Global access at work

Subbiah says if Pfizer has a compound to treat a major disease in an area that is not commercially viable, but there is no alternative treatment, it will establish a partnership with an NGO to bring it to market together.

Many patients in Africa who are HIV positive also have TB and the World Health Organisation (WHO) has identified the need for greater access to Pfizer's tuberculosis treatment Mycobutin (rifabutin) – the only drug licensed for this group.

Generic manufacturers have launched low-cost versions of the drug but access to it is still limited.

Pfizer is currently looking at how it can make its rifabutin available more widely in the developing world.

The company is also applying its formidable marketing capability and expertise to a new malaria collaboration. In December last year it formed a partnership with Italian company Sigma-Tau to market a new malaria combination.

Eurartesim (dihydroartemisinin plus piperaquine) is a phase III candidate for resistant malaria developed jointly by Sigma-Tau and the Medicines for Malaria Venture (MMV).

Ponni says this is an example of how Pfizer will increasingly look to market drugs for the developing world. When the medicine is approved, the companies plan to ensure access to it in Africa by collaborating with local stakeholders.

Subbiah adds that more evidence of Pfizer's willingness to learn and understand the needs of the working poor can be seen by Pfizer's work with the Grameen Bank – the pioneering micro-financing organisation in Bangladesh that shared the Nobel Peace Prize in 2006 for its work to alleviate poverty. This method of micro-finance is designed to serve low-income people and businesses that are not served by typical social or commercial insurance schemes. The bank offers small loans to people to start or expand a small business or for things like housing and education.

Professor Muhammad Yunus, who founded the Grameen Bank, said: "In Bangladesh, we have found that only an economically viable solution can create the infrastructure needed to enable people to sustain themselves, alleviating the poverty cycle. We believe our knowledge and expertise in micro-financing can be applied toward the development of a sustainable health care system."

If successful the model could then be transferable to other healthcare systems.

These are just some of the projects scattered around the world that the global access team are working on. Ponni and her colleagues travel the globe, and are now establishing relationships with Pfizer colleagues in markets in every continent, most recently visiting Russia, China, Philippines, Costa Rica, Venezuela, and Colombia, with the aim of replicating successful ideas for access.

A personal mission

Subbiah moved from India to Minnesota in the US when she was young, then returned to study and receive her medical degree in Chennai. But while on the face of it her Indian heritage gives her affinity with the task, she ranks it behind her experience in public health.

She says: "To have a good commercial strategy, you need to understand what it is like stand in your customer's shoes.

"I do have some of that insight, but at the same time it's important I don't believe I know exactly what these areas need. Just because I'm Indian doesn't mean I automatically know what the population there needs, for example."

She says her clinical experience, especially in the developing world, as well as her understanding of public health needs are most important to her work, perhaps over and above her business experience.

"I have a public health background, and that allows me to keep that bigger picture in mind for all of our work."

Ponni has also established quite clearly her business savvy, on top of her clinical excellence, having been joint winner of the US 2008 Asian Women in Business Award.

Her skills are enhanced by that of her team, which includes a member experienced in developing products, one with a background of business planning, one with market analytic commercial skills and another with a business technology background.

But despite her faith in win-win partnerships Subbiah, says she is personally aware that social responsibility and commercial viability are not the most natural bedfellows.

She felt the tension personally in 2004, when having worked at Pfizer for eight years she went to Uganda as a Pfizer Global Health Fellow (a company volunteer programme), to work in a tertiary hospital as well as a community HIV clinic.

That trip opened her eyes to the vast amount of work needed to alleviate the healthcare problems of developing populations.

"We didn't have an access team at the time, but when I came back from Uganda I knew that I wanted to play a role in trying to figure out a solution for this patient population."

She returned to New York to undertake a Masters in public health as a step towards achieving her goal, but was unsure exactly how to take it forward.

"I was struggling – should I leave Pfizer or should I stay? And then I thought, if I worked for the car industry that would be different – I couldn't provide direct help through my job – but I'm part of an industry that makes something this population needs. So why can't I be part of something within Pfizer?"

Subbiah says she was fortunate that when she completed her Masters in 2008, Pfizer's leaders were thinking in the same way and looking at how to improve access to its medicines in emerging markets.

She grasped the opportunity to help shape Pfizer's approach, and make it about public health as well as business. "I convinced them it should be me, rather than a marketer or a pure business person."

The Access to Medicines Index

As in all other areas of its work, Pfizer is competing with its big pharma rivals in access to medicines.

But despite its pre-eminence globally, Pfizer is not seen as a leader in improving access in developing countries.

GSK is grabbing headlines with its drive towards new patent pools, while Novartis has established co-payment schemes with local governments or patients in some countries to share the cost of medication, linked to ability to pay.

The newly-launched Access to Medicines Index (created by the Netherlands-based NGO Access to Medicine Foundation) is a league table of pharma companies, ranking their performance in the field.

GSK, Novo Nordisk and Merck head the table, with Pfizer languishing in seventeenth place.

The measurement is not a science, but is coming to the fore of the industry conscience, and its advocates say it will soon be consulted by investors.

Understandably, those at the top of the index value its importance, including GSK at number one and Sanofi-Aventis at number five.

But Subbiah regards the index as a blunt tool, saying that access is a lot more complex, but that it is a beginning. She adds that it fails to take account important issues such as actual reach and impact of specific programmes as well as sustainability. She is also cautious about its role, saying companies shouldn't be behaving just for the good PR.

"It can be window dressing if it is not used appropriately. It's all very well companies wanting to be number one, but for me as a clinician, I want to know what that actually does for patients' lives."

For Subbiah, healthcare should be about the patient and public private partnerships, "I think we can learn from each other," she says. But as ever, those outside the industry may need more persuasion.

BIOGRAPHY: Ponni Subbiah emigrated from India to Minnesota in the US with her parents when she was seven. She returned to India to study and received her medical degree from Madras Medical College in Chennai.

She returned to the US to complete her training in Neurology at the Mayo Clinic and with a fellowship in AIDS Neurolgy at the Johns Hopkins University School of Medicine.

She then joined the staff at the VA Medical Center and the University of California, San Francisco, and the Fresno Medical Education Program in Fresno, California. She also worked at the Alzheimer's disease Centre of Central California in Fresno.

Subbiah joined Pfizer in 1996 and worked on bringing an Alzheimer's medicine to the market. Her experience spans neuroscience, urology, respiratory, arthritis, pain, metabolic and established products.

In 2004, she was a Pfizer global health fellow in Uganda, where she educated medical students and residents in neurology and worked at a community HIV clinic.

In September 2008, she became vice president of the global access strategy team at Pfizer.

She has a Masters in public health degree from the Johns Hopkins Bloomberg School of Public Health, and is a member of the American Academy of Neurology.

She is the author or co-author of 19 works in neurology and has been awarded several honours in her career, including the Pfizer W.E. Upjohn Award in 2005 and a grant from the National Institutes of Health for an AIDS Neurology Fellowship at Johns Hopkins University School of Medicine in 1993.