Roundtable: The Business Of Delivering Health In India

The business of delivering health is undergoing a significant transformation globally, and nowhere more so than in India. On the one hand, technology is reshaping the sector's approach to innovation, while on the other, the challenges of multiple stakeholders with different information needs is only exacerbated by such issues as the lack of a predictable policy environment, trust issues and pricing pressure.

To understand this transformation in greater detail, the Holmes Report convened a roundtable of senior in-house communicators in Mumbai, in collaboration with SPAG Asia. The event featured the following participants:

Aman Gupta, Managing Partner & Founder, SPAG Asia
Aparna Thomas, Senior Director, Communications & Public Affairs, Sanofi (India & South Asia)
Atish Majumdar, VP and Cluster Head, Lupin
Bhavna Singh, Director of Communications, OPPI
Sarthak Ranade, VP - Mass Markets, Dermatology & Immunology, Janssen India   
Vaishali Iyer, Head – Communications & Patient Advocacy, Novartis India      

Moderator: Arun Sudhaman, CEO & Editor-in-Chief, The Holmes Report

What follows is an edited transcript of the conversation that took place in mid-July in Mumbai. Gupta started things off by exploring how healthcare firms are being asked to "deliver more than a product to the market."

Beyond product communications

Technological disruptions are forcing India's healthcare industry to not only deliver drugs and devices but also play a much clearer role when it comes to delivering more value to various stakeholders, whether that involves building systems for better compliance or delivering information to HCPs in a personalized ecosystem. 

Those changes, furthermore, are leading to an evolution in the way healthcare marketers communicate with various stakeholders – consumers (patients), customers (HCPs), and medical marketing teams, civil society and policymakers. Against a backdrop of declining trust, healthcare communicators are being challenged like never before.

Arun Sudhaman: "To get things started, I'm curious to know, how do you all see your roles changing, given the transformation that is underway?"

Aman Gupta: "So it’s an ask from a pharma company, it’s an ask from an industry association, it’s an ask even from communications people that you are not just delivering a medicine and therefore it changes completely the way you define your stakeholders, you define the sort of channels you want to use, you define your overall strategic direction of the part of the campaign."

Vaishali Iyer: "I think there are multiple factors which have influenced this change. One is the way the consumer today is consuming content. The second piece is around the fact that within the healthcare space we are moving off therapy areas from acute to chronic. Indians suffering from non-communicable diseases are far higher and therefore the way we engage with them has to change dramatically. And the core piece is of course around digital, in terms of digital technology and down to social media which has become a part and parcel of our life. So if we look at channel optimisation and the way we consume channels is very different, so the consumption of television is reducing dramatically. I think it’s very important as an industry that we regain trust with what we communicate because what we’ve seen over a period of time is there’s a trust deficit and therefore credible information is going to be very critical as we move ahead." 

Aparna Thomas: "I wouldn’t say it’s a new trend, ensuring that communication is based on the truth. Unfortunately, the rising frequency of fake news going viral, has made the industry’s efforts to become more transparent much more complex." 

Sarthak Ranade: "20 years back, we just had one stakeholder who was a physician, and we used to centre everything around them. We are all seeing the rise of different stakeholders, the patients also want to be an equal partner in decision making, which is good, I personally feel it’s a very important thing to happen. We’ve also seen the rise of other stakeholders like regulators and activists. It’s pretty much technology and I think the healthcare industry has not been insulated. I mean it’s good as innovators, but bad also because fake news travels much faster. Now, we need to step in, and provide that credible information that is required. We’re not living in the same world now."

Atish Majumdar: "I think the evolution we have seen in the environment today, especially in pharmaceutical healthcare, has got to do with one big issue: our healthcare system today is geared for 'sick care', not healthcare. So you know everything that we do is if a person falls sick. We look after him. But digital brings in the concept of healthcare. It’s how you manage patient data and how you communicate to them before they become a patient. Pre-diabetes and pre-hypertension, since you mention chronic disease, is a bigger segment than diabetes and hypertension per se. So I think a large part of communication today evolves because the lenses through which you look at your industry and the work that you do has drastically changed. The other thing here is digital. The challenge is to build communication which will direct the patient towards, or make him lean in perhaps, to what you want him to do. I think the mindset itself is getting shaped by the changes in the macro environment and the lenses through which your patients, your various stakeholders, are looking at healthcare today." 
 
Gupta related an anecdote involving a politician who would prefer to open a hospital rather than spending on prevention. And he broadened that example to note that civil society often thinks the pharma industry's business is illness, rather than wellness. "So when you have different stakeholders looking at it from different lens,  I think this is the role of a communicator — bringing everybody together on the same platform and driving them towards a common goal. I think that’s the kind of a challenge we are having right now."

SR: "So I have the pleasure of working with Johnson & Johnson and some of the work which is happening in our headquarters is quite interesting. There is something called a disease interception module, which actually puts scientists behind this and their whole job is basically to find out if there is a possibility to prevent a disease from happening. I think that has stemmed from the fact that the healthcare world is one that has changed very dramatically. I keep on hearing this from our senior leaders globally that what keeps them awake is, if we don’t disrupt ourselves, companies like Google will. So I think there is a realisation that the business of selling pills is not going to take us for long and we need to be ready for that world."

"The message is more important than the product"

OPPI's Bhavna Singh noted that, as a relative newcomer to the healthcare industry, she has seen some critical changes in terms of how the healthcare industry is thinking about communication. Most notably, she pointed out that the product is taking a backseat to the message, which is only complicated by the regulatory landscape in India.

Bhavna Singh: "So we have to start from there as communicators. You are already barred from talking so much, then what do you say? How do you empower the patient? How do you educate the patient? Where does he go and look for material? How credible are those sources?" 

AT: "I don’t think the trust deficit is as high as we position it to be, because maybe it’s the more evolved patients who have read a lot who might have that trust deficit. The bigger problem is the ratio of doctors to patients. Doctors simply don’t have the time to explain and listen, they just give instructions and say this is your medicine, have it for three days, two tablets, and come back. The education is therefore required to help the patient manage the ailment and the disease better. Also things like compliance. If I’ve been told to have the medication for three days X number of times a day and after two days I feel better, then I tend to stop, and then obviously this will re-occur and then I say 'that medicine didn’t work' and I go looking for an alternate treatment. I also might look for another doctor because this doctor’s treatment didn’t work so I’m going to another one. So it serves the purpose of overall management to be able to educate the patient and talk to them on all these different points."

SR: "That’s where I think we need to step in. But one thing which I keep on telling my communications team also is, how do we make this whole area of disease education or awareness less technical. We tend to get more jargonistic and then that puts the patient off. So I keep pushing my staff that let’s try to communicate in the way the patient can understand. In a very simple manner — use more pictures, use less scientific words."

VI: "There are simple insights to do this. A patient who is suffering from an eye problem — the best colours to communicate with them is yellow and black. Which you would never think. All of our communication was white and all sorts of colours but not yellow and black. You really don’t get into those insights of colour, size, simplicity of messaging, which I think are so important, especially when you are talking to patients. We love to use jargon."

The power of influence

Discussion of the trust deficit as it pertains to the healthcare industry underscores the need for credible influencers, said Gupta. That can often add up to a complicated equation for healthcare communicators that are aiming to build sustainable advocacy campaigns amid a climate of increasing scepticism.

Singh pointed out that OPPI prioritises influencers in its communications work, collaborating with government, with other industry groups, with patient groups and with independent bodies. "Every advocacy effort that OPPI takes is through influencers, through collaboration, through others talking more about the issue than OPPI. And we have found tremendous amount of success when more minds think of the issue and there are, of course, differences of opinions but ultimately there is some point that comes out from the discussions."

Meanwhile, Ranade pointed how Janssen is supporting India in its effort to eradicate Tuberculosis. In particular, Ranade noted that "by working closely with government & NGO, the company learned of the importance of nutrition in the treatment and recovery from TB.  The company has supported the nutrition needs of 5000 patients in India. This is a great example of aligning everyone towards doing something for the greater common good."

AT: "Influencers also bring in the authenticity and emotion. Because the industry is an industry, right. So the assumption is that there is no emotion in the industry. Complementing the scientific knowledge and information that we have, the emotion comes sometimes from the influencers. You bring that together, it makes it the right package for better consumption and acceptance of data."

Campaigns require collaboration 

Of course, influence is required to drive multifaceted campaigns that result in positive behavioural change. Many of the panellists, accordingly, shared details of successful campaigns, and the unique communications blend that underpinned them.

Iyer, for example, pointed to Novartis' impressive work around heart failure, which began with the insight that "patients didn’t know the difference between heart failure and heart attack so anybody who said heart failure thought heart attack."

VI: "So our campaign is basically talking to other stakeholders and creating advocates — it started right from engaging with our doctors associations, bringing them on board, creating influencers in that forum first because that is where the credibility starts from. We did talk to patient advocacy groups. The third piece is that we are talking to patients through social media to basically educate them, and I think the most important piece that we did is converting media or journalists into advocates. And, more importantly, is to eventually talk about heart failure as a public health priority. We have already initiated that process with the government to see how we can bring in heart failure as a national health priority and therefore influence policy. We’ve reached out to academia to see how heart failure can be included as a separate subject whilst students are studying about cardiovascular diseases. So I think all these things put together is creating a robust, positive eco-system for the disease condition and awareness. It’s all about all the things, right from academia to government and everybody who comes in between."

Meanwhile, Singh used the example of OPPI's 'Red Line' effort, which means that all prescription drugs now have a red strip on their packaging, to ensure that antibiotics are correctly identified in rural areas. 

BS: "All that we said was that when you are buying a medicine or when the doctor tells you that this is the medicine and you go and pick it up and you see a red line on the strip, that means that you need to be cautious about what you are eating because that’s an antibiotic. So the doctors prescribed you two doses a day for five days, stick to that, don’t cut your dose. We collaborated with patient groups, we collaborated with the Indian Medical Association, the doctors, we collaborated with the nurses training association, and we told them why it’s important for patients to understand that they need to consume antibiotics cautiously, it is also important for the medical fraternity to understand that you need to prescribe antibiotics also rationally. The Ministry of Health ran this campaign for us and it was one perfect example of how all the stakeholders actually came together to collaborate and how each person played their role. Our campaign is now part of the superbugs collection which is in the National Science Museum in London. They have actually displayed this campaign, saying that this is how people should be educated."

AT: "The one which is really top of my head at the moment is what we did for rare diseases and it’s also interesting because we did not approach it from a communications point of view only, but from a public affairs point of view. Typically we look at media and towards the general public. Here we were looking at the media and the readers really in terms of readers being the government, the readers being doctors, and not just the general public. So we were using the media to reach out to these specific audience groups whom we wanted to influence. We, of course, collaborated with patient advocacy groups and they provided the emotion, like I said, and the conviction about really trying to explain why rare diseases is also an area in which the government needs to be responsive." 

AG:  "In each of these campaigns the media is an audience and they need to be seen as how you can work them and then they run with your messages for the long term. The emotional angle is very significant. It becomes an essential. So it’s not just the influencers outside. The media has to be seen as an influencer and an ambassador and work along with them in that spirit. It also takes a much longer time from when you start — you are initially talking and educating them that why this subject is important, because once they understand the subject then they are able to run with it on their own." 

BS: "Most often, the media is also in the dark. They don’t know as much as we think that they know so it’s very important to educate the media. So as an industry association we do regular roundtables for the media, if there is something new like the intellectual property rights policy. You know for us, OPPI, to get stories is even tougher than the member companies because we have nothing new. So we don’t even start our conversations at what’s new. So that is the role of the communicator also. That’s when the media starts working with you — it’s not really the number of stories or the quality, it’s more to work with them as one of our audience as well. Educate them, explain to them what is happening, because not many times will they cover that as beats, there would probably be different levels of knowledge, and if they are going to write it they will influence something so it’s I think also our responsibility to educate them, give them information."

AT: "I think what really helps is that what’s very common between all of us is the commitment, the passion and the fact that we are all really doing this from our hearts and not just from our minds. That is very visible in the kind of work we are doing, the kind of outreach programmes, the kind of communication campaigns, and that really makes it much more impactful and tangible in terms of outcome than what we have done in the past."

Reputation & trust

AS: "At a global level, healthcare companies have reputation challenges. It’s an industry that perhaps has more reputation challenges than most. Some of that is possibly down to pricing issues, some of that is down to rogue operators. But how much of an issue is it for all of you to deal with that kind of scepticism, and do you see that becoming more of a challenge for you?"

SR: "Having worked in Japan, I can see the stark difference between Japan and India is the appreciation for innovation, or reward for innovation. People don’t mind paying for an iPhone but they will think twice before spending on medicine. One needs to understand what this innovation is doing in terms of the patient outcome. There has to be some reward for that innovation that has gone in but the whole story gets hijacked by price. So I find that challenging, that in India actually no one talks about quality, about innovation / patient outcome but it’s only about price."

BS: "There are two areas which are very emotional: health and wealth. So when you are talking about your health and your wealth you are talking about very intimate things. So it becomes that much more personal. So that is where ethics, being trustworthy, transparency play a really big role. That is why OPPI as an organisation has been championing the need for uniform code of pharmaceutical marketing practices. That’s what we do as an association when it comes to these kind of ethics and reputation at stake. I think the first step is to have regulations and then that’s one battle won." 

Gupta added that the industry needs to invest in market access campaigns earlier in the product lifecycle if it hopes to genuinely convince hearts and minds. He pointed to an HIV vaccine campaign which spent two years educating stakeholders before successfully launching the phase one clinical trial, and also incorporate a strong policy angle.

"When you have to go for a human trial in India you have this whole cynicism that Indians are being used as the guinea pigs," he said.  "One element is, how soon you start priming the market and understanding the issues which exist. I think that’s something which has started to happen in India. (various agreement) It’s started and more and more of it will happen and that will start to therefore reduce those challenges." 

AT: "Unless we get into that very vigorously as an industry I don’t think we will be able to drive the value that innovation and innovative medicines bring to the table. Otherwise it will always be a fight against the generics. Always it will be a fight against alternative therapy. For example, our heart failure drug — it very clearly has benefits around reducing hospitalisation by 25%. It improves productivity. Ask me how much work have we done on real world evidence. Not as much. You haven’t moved the needle there. These are very, very important pieces." 

AM: "Our industry itself is a branded generic industry and I think the shift that the government is trying to make, in many ways driven by the bodies, is trying to separate what is common and what is innovative. In the US you pay a price for innovation, right? In India you really don’t. And the communication that we devise has been very, very restricted or the reputation of a company has been very restricted to the doctor. Hence, communication never evolved. So you saw corporate communications departments in big Indian companies, coming in somewhere around 2002. And the need to communicate and build a reputation on quality, on innovation, identifying yourself with therapy areas, reaching out to the consumer, or to the patient — I think that is imperative today with the new market dynamics that are evolving. Reputation is going to be a big play as the market shifts and the branded and the generics separate out."

AS: "Do you feel as communicators that you are ready for that shift?"

AM: "It’s a tough one but we are progressing. We are all leaning in towards that. We all understand that this is the horizon and I think every company is today trying to go that way. You see you have newer departments. Digital marketing was never there. We just launched a branded drug in the US, and I spent quite some time with the market access team. They spend a lot of time listening in to patients’ responses. Response is also an influence in many ways. It’s how you respond….and we don’t see that in India so much."

Digital...strategy or tactic?

AS: "You have described these complex multi-stakeholder campaigns and we see them winning awards, but surely those can’t succeed without some level of insight into the various stakeholders."

AG: "[Previously] you would see the marketing department doing all the communication.  That shift is definitely happening because today digital opens you up to the whole world, the opinions, the legal consequences, everything. So I think a large part of it today is driven by insights but, I think we have a long way to go." 

AM: "And I think it’s a good thing because, from a digital perspective, it’s an area which is right now a must-have on the radar for almost every healthcare company, from a pharma to medical devices, to healthcare delivery people. Now whether it is strategic in nature or tactical, I think that differentiates two sets of organisation you will find." 

AT: "Any communication or anything we do with the brand has to be primarily based on a strong insight. It’s a central idea that you are looking at. Digital to me is just a channel. That’s it."

AM: "If you look at what digital has done, it has brought the consumer and the brand together. Today, why healthcare is so interested in digital is not because of the tactical reasons that we see in India a lot – Facebook and PR calls — the real reason is that healthcare IT is going to drive growth. With three growth drivers. They are looking at data, big data. They are looking at artificial intelligence and they are looking Internet of Things. When you look at this on healthcare, digital is a strategy for branding action. And when it becomes a strategy for branding, your communication must also be driven from all of this. You make your communication so very transparent that from the factory to the consumption of the drug the patient knows everything. You end up building communication around all these things, and data will essentially drive everything that you do."

VI: "So that is how we are consuming information, it does not change my insight, nor does it change my brand strategy. Therefore the idea for anything, whether that is a disease campaign, is central and then everything just draws out of that."

AG: "We talked about listening. One of the elements for us will be to look at the conversations and start from offline first. You will talk to a couple of doctors to understand the patient journey. You talk to the patients to understand the challenges which they face. And in that conversation, in certain cases you will hear about the role of digital because you will hear doctors saying the person has done a lot of online research. And then you think, if they have done online research can I see what kind of research pattern this is. Based on the search patterns and sentiment, what kind of conversations are happening. Is there a kind of a trend you can see? Now, that in itself is an exercise which will tell you how your world looks."

VI: "And that feeds then into your strategy."

AG: "Exactly. So I think that is an area which is increasingly being explored by the pharma industry. But, again, I won’t say that is the majority. A few companies are doing it. In a larger context, you still get calls saying 'we want a website'. Now, why do you want a website, what is it going to do for you? A year back the flavour was ‘can you guys do it on a mobile app?’ (various agreement). Now what did that app do?"

VI: "So I don’t even think marketers are really tuned to how do we integrate [digital] it beautifully and seamlessly into our brand strategy. I think very few people would have that understanding."

Artificial intelligence

The discussion also considered how the rise of AI will impact healthcare communicators. Most of the panellists admitted that big changes are afoot, and that the industry has a very important role to play when it comes to concerns that AI might trigger.

BS: "We all understand that technology is a positive disruptor and that it's going to happen whether we like it or not. Now whether people believe in AI, whether there are misnomers around various facets of technology, that’s the future and that’s what everything is going to lead into. So we as an industry and the government are not turning a blind eye to it, and people’s perceptions about that may play a role, may not play a role. But if that’s the future, I think as an industry and the government, that’s the reality for us. So it’s more productive to start planning for that reality rather than wishing it away because that’s not going to happen." 

SR: "I think my opinion on this is we need to be a bit careful in terms of the applications of artificial intelligence. Just two weeks back, one vendor came up to me and he was talking to me about this chatbot for depression, schizophrenia. And I found it a bit scary. I was not very comfortable exposing some of our patients to that. We don’t know how this algorithm would work. So there are certain areas where I feel comfortable, but there are certain I would not pitch my hand into."

Agility takes centre stage

Finally, the panel concluded with their key learnings from the discussion, which included the importance of internal alignment, balancing agility and responsibility, and remaining relevant. 

AG: "On the one we talked about educating the media and the other stakeholders at different levels. I think there is also an equal need to educate internal stakeholders because as an industry we find people at different stages of learning. I think that is an area where we do need to invest."

VI: " I think as an industry, given the way environment is changing especially with regards to technology, one of the things that we need to really work on is agility. Given all the 300 approvals and everything that we need to do, it’s a fact, our agility actually becomes very restricted. So in our minds all of us want to go out there and respond ASAP but our response time takes really long."

AT: "Because it has to be responsible." 

VI: "Correct, it has to be responsible. But how do we create the environment to respond faster with responsible communication? There is enough research that says that most of us want responses within an hour and so on and so forth. So the challenge is how do we really make our internal environment far more responsive and agile? I think that is very, very critical." 

AS: "How do you become more agile?"

AT: "Given the fact that every year there is a new wave of price cuts, the unpredictable is now predictable. When you know that, it helps you become more agile because you are now thinking more on your feet. From a communication point of view, therefore, it’s about envisaging scenarios, it’s about trying to prevent those scenarios from taking place if possible, and if they do, to be in the state of alert so that you can quickly get your crisis team to deliver whatever is required to be done." 

BS: "For me I think communicators need to be relevant and topical."

AM: "Internally, the question is critical. Interpretation is very important. Does the company understand these regulations? My take is that the regulations are there, so that’s a culture which you’re building. You have to be responsible, but this process of making the communication responsible in many companies takes very, very long."

VI: "That’s what I’m saying. So you need to sharpen and simplify that process."

SR: "We should think like a surfer. The whole idea is that you surf only when the sea is choppy. Think like a surfer until everyone in our organisation also thinks like a surfer. I really like that — how do you live in the world where the sea is going to be choppy every day and you still need to stay on top?"