Understanding the Chronic Disease Patient Journey in Emerging Markets
How can pharma companies make a positive intervention to improve sub-optimal patient journeys in emerging markets?
The benefits of understanding the patient journey are well documented in mature markets. But in emerging markets, the patient journey is less understood. We recently presented a webinar where we addressed the changing emerging market healthcare environment and explored the challenges and differences in the patient journey. In many emerging markets the days of the relatively uninformed patient are coming to an end. Increasingly patients are becoming more engaged in their own health decisions. We expect this will disrupt the traditional pharma sales model and increase the influence of the patient as a stakeholder. Patients have increased access to information on disease areas and associated treatments. In many markets, patients pay a significant proportion out of their own pocket. Patients are already involved in many crucial decisions in their own chronic disease but face many obstacles in their quest for optimal treatment.
Traditionally, emerging markets have been associated with communicable disease but over the last decade, the prevalence of chronic disease has risen significantly amongst the urban population. The rise can be attributed to 3 factors:
- Aging population - Chronic diseases become more common with age as risk factors accumulate over time and the impact of risk factors increases over life course. By 2025, for the first time in history, those aged over 65 will outnumber children under five years old
- Sedentary lifestyles - Technological advances, such as cars and elevators, combined with a shift away from manual labor, mean that people’s level of physical activity has declined
- Westernized diet – Over the last decade, people’s diets in developing economies have changed – generally for the worse. Driven by globalization and urbanization, there is less dependence on locally grown natural produce, and an increased consumption of processed food and sugar
Highlighting just how significant the impact has been of these 3 factors, the World Health Organization estimates that 80% of chronic disease deaths occur in low- and middle-income countries. Sub-optimal patient journeys can lead to preventable deaths. We ask, where are the inflection points which have the greatest negative impact on treatment outcomes?
Presentation
The first challenge is getting patients suffering from a chronic disease to actually present to the correct healthcare professional. Poorly developed primary care systems mean wellness and prevention are often not central to healthcare strategy or a focus of public health investment. This means that options that could potentially prevent chronic diseases, such as vaccines, weight management or nutrition, may be lacking. Established routine screening programs are often also lacking, which can be especially problematic for asymptomatic conditions, as patients may not be aware they are suffering from a chronic disease until they experience symptoms.
Patients can choose to put off presentation for a variety of reasons including:
1. Lack of awareness/understanding of condition
2. Inconvenience of seeking treatment e.g. long waiting times in hospital
3. The cost of treatment and the potential financial burden on the family
4. Stigma associated with certain conditions.
This delay can result in patients presenting at late stages, limiting the treatment options available. Even when a patient presents, it does not mean they’ll be accurately diagnosed. In many markets, there is a lack of established primary care systems and so a patient may present to a healthcare professional who is not well versed in a condition. Consequently, the HCP may refer them inappropriately or not refer them at all.
Diagnostic techniques used can also be more limited, as many institutions may lack access to the latest technology or expect patients to pay for them out of pocket. Where diagnostic tests are used, diagnosis can be a more time-consuming process due to longer turnaround time for lab tests given the infrastructure in many emerging economies.
Consultation
Another potential obstacle occurs during consultation between the patient and physician. In many markets, the HCPs workload is very high so the length of a consultation is limited. This can result in the patient getting a prescription but not being able to ask questions. Given that HCPs might be the primary information source for patients, this short consultation can result in poor understanding which can in turn impact on fulfillment, adherence and persistence behaviors later down the line.
On the subject of ffulfillment one of the associated challenges is generic substitution. For example in Brazil, where prescribing and dispensing is separated, generic substitution within class is allowed. So when the HCP writes the script and the patient goes to the pharmacy to have it filled, pharmacists will frequently suggest a generic alternative to patients. This can occur even if the doctor had written the originator brand.
Persistence
The final challenge is persistence. In many countries, patients pay at least some of their healthcare costs out of pocket. This definitely does have a limiting impact on the duration of therapy. However, it is not only about the costs. Many patients, especially in Asia, are concerned about the potential negative impact caused by taking strong medicines for a sustained period. Typical concerns center on fear of addiction and loss of efficacy which translates into shorter treatment periods than seen in the EU and USA.
So, we have seen that challenges can be encountered at any point in the chronic disease journey and that roadblocks can be caused by the patient, the HCP, the healthcare system, payers and even society at large. There is rarely one single cause.
In response, the pharma industry has come up with a number of novel strategies specifically focused on unblocking these obstacles. Here are two examples:
1. Addressing breast cancer diagnosis roadblocks in MENA
In many growth markets accurate diagnosis is a challenge especially for those living outside the Tier One cities. This was a problem faced by women at risk of breast cancer in MENA. Without timely, accurate diagnosis treatment options were severely limited for women diagnosed with breast cancer. Early diagnosis provides the opportunity for surgical intervention and radiography and improved outcomes. However, many women are diagnosed at Stage 3, which drastically reduces treatment options and outcomes. In response, Roche developed a program to provide mobile mammography screening across MENA. Each truck was fully equipped and staffed with trained nurses, radiologists, other healthcare workers. The benefit of this approach was two-fold, serving to provide mobile mammography screening to remote regions but also to raise awareness and encourage participation.
2. Improving the management of diabetes in China
The second example comes from China. Sanofi partnered with a number of governmental and NGOs with the aim of delivering a unique, patient-centric model to improve the management of diabetes. The initiative focused on educating and training different stakeholders, from KOLs to community level HCPs all the way through to patients. The program sought to improve many aspects of the patient journey, from the very early stages of presentation all the way through to adherence and long term patient management. What is interesting about this program is that Sanofi took a truly 360 degree view, identifying many different inflection points and targeting all relevant stakeholders.
So, in summary, how can pharma companies make a positive intervention to improve sub-optimal patient journeys in emerging markets? Essentially, there are 3 distinct steps. First, identify all relevant stakeholders. Determine which stakeholders are involved in the patient journey and identify where they interact in the journey. Secondly, work out which points in the patient journey can be improved and which stakeholders hold the key to unlocking the potential. It is likely that a thorough analysis will uncover a number of potential opportunities where positive interventions can be made. Thirdly, prioritize and focus on those factors which will provide the greatest return on investment.
In a forthcoming white paper, I will be exploring these steps in greater detail. For a copy email me at marcy@researchpartnership.com.