The Opportunity for Women’s Health in Emerging Markets
Challenging awareness, attitudes and access barriers.
In this month’s article, I explore issues relating to the health of women in emerging markets. I will recommend that pharma companies wishing to maximize the opportunity in women’s health need to start from an understanding of how women are viewed by society in these markets and challenge awareness, attitudes and access barriers that can lead to their health outcomes being sub-optimal. As a starting point, it is necessary to establish a working definition of women’s health. This isn’t as straightforward as it might seem, as women’s health can be considered at multiple levels.
The conditions which most obviously fall under the ‘women’s health’ umbrella relate to women’s sex, their female biological characteristics. This branch of medicine is known as gynecology, derived from the Greek word for woman, “gyneco”. Typically the remit of gynecologists/OBGYNs, this includes reproductive medicine (in terms of either fertility or contraception) and the menopause, along with diseases of organs specific to the female anatomy, such as uterine, cervical and ovarian cancer. Although breast cancer technically affects men, too, it is approximately 100 times more common in women and therefore also typically considered a women’s health issue. Female sexual dysfunction is a growing, if controversial, area of interest for pharma. Hoping to follow in the footsteps of the mass erectile dysfunction market created by Viagra, this has acquired its own acronym: FSD. Drugs in this category range from libido enhancers to hormone-based treatments intended to alleviate pain during intercourse.
When thinking about women’s health, we can also expand our outlook to consider diseases that are linked to female biology, and therefore more prevalent in women. An example is osteoporosis. While also occurring in men, this is associated with bone loss as oestrogen levels decline when women reach menopause. Urinary incontinence, which is often caused or worsened by pregnancy, is another example of this.
Taking a broader view, women’s health outcomes are also influenced by gender - the cultural or learned significances of sex. Specific gender-based behavioural, social and cultural factors can influence health in women. An obvious example of this is aesthetic medicine, from breast implants to dermal fillers. While male spending in this domain has increased, this is a market dominated by women, linked to the cultural value assigned to female beauty. A darker facet of the beauty industry, eating disorders such as bulimia and anorexia are also closely linked to cultural ideals of the body, and about 90% of sufferers are women (although interestingly, as with aesthetic medicine, as male gender archetypes evolve, the prevalence of eating disorders in men is on the rise).
Gendered cultural and behavioral norms in society, such as smoking and drinking behaviors, also impact women’s chronic disease burden. Although women currently smoke much less than men in many emerging markets (in contrast to high income countries where rates are similar between the sexes), the female-to-male smoking prevalence is predicted to rise as attitudes become more tolerant and women’s purchasing power increase.
There are also grey areas where sex and gender interact to influence healthcare outcomes. Many diseases that affect both women and men are more common in one gender than the other. For example, women have higher prevalence of gallstones, migraine headaches, depression, irritable bowel syndrome and multiple sclerosis. The reasons for such differences between the sexes are not always well understood – often partly due to hormones/other biological characteristics and partly the result of the way women live their lives, linked to their gendered roles in society. In every country in the world throughout history, women have consistently greater average longevity than men. Attributed to both biological and socio-cultural factors, this means diseases of old age, such as Alzheimer’s disease, are also more common in women.
I find women’s health to be particularly interesting because however broadly we define it, the opportunity for pharma/healthcare in this space is deeply influenced by gender roles and societal attitudes to sex and reproduction. It is also dynamic, as these roles and attitudes are going through dramatic changes. They are also highly globally uneven, which means the opportunity for women’s health varies widely from one country to another. Understanding gender roles and attitudes to sex and reproduction and how and where they are changing is therefore fundamental to understanding women’s health, and to identifying the opportunities and challenges for pharmaceutical companies in this area.
Focusing in on emerging markets, two key demographic trends have hugely impacted women’s health in recent years.
The first is the rapid decline in fertility rates many emerging markets have experienced over the last 50 years. In a striking statistic I came across recently, the average Brazilian woman in the early 1960s had more than six children, and currently has less than two – even fewer than women in the United States. Brazilian women are also having their children later in life, with over 30% of children born in 2012 having mothers aged 30 or over compared to only 22% in 2000. This is a complex phenomenon driven by factors such as improved education for women and increased female participation in the work force, as well as changing societal lifestyle ideals. While a similar trend is evident in many other emerging markets, the rate of decline in fertility rates varies between countries, and is less pronounced throughout much of the Latin American region than it is in Brazil. It is also very much an urban trend – fertility rates remain high in rural areas throughout many emerging markets.
This demographic transition is important for pharma and healthcare in general, as it has major ramifications on the overall population structure. It impacts the size of the market for drugs suitable for different age groups, as well as the proportion of working-age population able to contribute to the economy (and fund their country’s healthcare system). Specifically in terms of women’s health, decline in fertility rate impacts the opportunity for contraception and fertility treatments. Family planning techniques are extremely variable around the world due to a range of factors, including culture, religion, medical attitudes and women’s position in society, as well as practical price and access issues. The contraceptive market in Sub-Saharan Africa, for example, is dominated by injectable contraceptives and implants, alongside ‘traditional’ methods of contraception such as withdrawal. On the other hand, China, with its one child policy, has been described as the ‘world leader’ in contraception. However while it has a high rate of sterilization and use of IUDs is widespread; oral contraceptives play almost no role and awareness of the pill among Chinese women is low. Concerns about the birth control pill causing lasting infertility, potential for interactions with Traditional Chinese Medicines and widespread confusion between regular once-daily pills and emergency contraception (i.e. the morning after pill) all present barriers to its wider adoption. The strong taboos associated with pre-marital sex in some emerging markets not only lead to challenges for unmarried women to access effective contraceptives, they can also make the market challenging for other women’s health products. An example is resistance to HPV vaccination for school-age girls due to the connection between HPV and sexual activity.
In many Asian cultures, for example, it is considered to be ‘fate’ if a woman has difficulty conceiving, rather than a natural effect of getting older that can be remedied by fertility treatment. Further market shaping and awareness raising is required to maximize the potential of this industry.
At the other end of the spectrum, with women in emerging markets increasingly putting off having children until they are older, fertility treatments are also in higher demand. IVF clinics are increasing in number in emerging markets, particularly in South and South East Asia. Reproductive tourism also represents a growing industry in countries such as Thailand and India, with clinics in Thailand attracting a broader audience by offering parents the opportunity to select their child’s gender. However, there are barriers restricting domestic growth in this market. In many Asian cultures, for example, it is considered to be ‘fate’ if a woman has difficulty conceiving, rather than a natural effect of getting older that can be remedied by fertility treatment. Further market shaping and awareness raising is required to maximize the potential of this industry.
The second demographic trend we see impacting women’s health in emerging markets relates mainly to the broader definition of women’s health: increasing life expectancy. This is leading to an increase in women suffering diseases of old age.
Depression among women in the Middle East and North Africa was recently described as a ‘silent epidemic’.
However, the healthcare market for women is suppressed in many emerging markets, especially when it comes to the elderly. Elderly women in low and middle-income countries suffer a disproportionate level of financial hardship as a result of persisting gender inequalities. Although women’s access to healthcare is improving overall, healthcare systems’ lack of an adequate safety net mean the needs of an aging female population are often not being fully met. This is particularly marked in patriarchal societies where the male is the decision maker for his family’s health and women’s freedom of movement is restricted. For example, in many Middle Eastern countries, women with breast cancer often present to a doctor for the first time only when their cancer is at an advanced stage, at which point treatment options are limited. Female mental health issues are even less well catered for in many emerging markets. Depression among women in the Middle East and North Africa was recently described as a ‘silent epidemic’. The acute stigma associated with mental health in general, coupled with women’s position in society and the family, can make it particularly difficult for women in the region who are suffering from depression to speak up and seek treatment.
Implementing widespread prevention and screening programs aimed at women and developing strategies to inform and empower women to take ownership of their healthcare choices are critical first steps many emerging markets need to take in order to improve women’s health outcomes. The scope for pharma and healthcare companies active in this area to support them is vast, due to the huge awareness, attitudinal and access barriers that need to be tackled. In the meantime, women’s health offerings, and the ‘beyond-the-pill’ services they offer to support women and the healthcare professionals who treat them, need to be sensitive to the local cultural context of emerging markets while also keeping up with the rapidly changing environment.
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