What the critics call “big pharma” has had an image problem in recent years, and Andrew Miles, the executive in charge of the global health care company GlaxoSmithKline’s (GSK) business in the Gulf, thinks he knows how to resolve it.
“Choice of medication should be a clinical choice, rather than being based on some potential conflict of interest,” said Miles when we met at the UAE offices of GSK in Dubai.
For the last four years, GSK has been at the forefront of a transformation of the drugs industry. Barraged by allegations of inappropriate payments to doctors and other health care professionals, especially in the hyper-litigious US, GSK took the decision to halt all payments to health care providers (HCPs), and to cease rewarding its sales force according to the number of prescriptions issued for its products.
The initiative grew out of GSK’s “corporate integrity agreement” in 2012, which settled lawsuits in the US, and involved a multibillion-dollar payment to the authorities, but it has become something more for GSK.
“GSK was the first big pharma company to stop payments to HCPs to promote our products. It was a big decision for us, and nobody else has done it, though maybe other pharma groups will follow. Overall, it has had a net positive impact. Governments love it. They want all pharma companies to stop payments and we are advising them how to do it. It is a policy for the long term, good for patients and good for shareholders,” he said.
That initiative is set to have repercussions in the Middle East, where GSK has been involved for 65 years. Miles revealed that GSK is in advisory discussions with the Saudi health authorities to draw up new legislation to better regulate the medical and pharmaceutical industry in the Kingdom.
“We are in dialogue with the Saudi Food and Drug Administration (SFDA) in an advisory capacity, and I don’t think we’re far off some kind of enactment of major legislation on standards of transparency and engagement with the health care industry,” he said.
Saudi Arabia has been a focus of the company long before the 2000 merger between UK firm Glaxo Wellcome and American SmithKline Beecham that produced the sixth biggest drugs company in the world.
In different guises, GSK has had a manufacturing facility in Jeddah since 1992, currently employing 427 people. Between that facility, a distribution hub in Dubai’s Jebel Ali, and sales offices throughout the region, GSK covers a region of increasing interest.
“The GSK footprint in the region has a big heritage and has been expanding over the years,” he said.
Its regional operation mirrors the three-sector global corporate structure: Consumer products like household drugs Panadol and Sensodyne; pharmaceutical and prescriptions products like its blockbuster respiratory drug Advair; and vaccines, ranging from the full-spectrum of children’s vaccines — over half the pediatric vaccines delivered in the UAE are made by GSK — to anti-HIV and anti-malarial treatments.
“We have an integrated strategy in the Gulf Cooperation Council (GCC) markets. The region does not have a lot of intra-GCC trade, but is very similar in terms of language, culture and business practices,” he said.
“We will be able to supply Kuwait and Oman via the UAE and Saudi Arabia. The UAE has a good position as a re-export hub for the rest of the region and Africa via our facilities at Jebel Ali. In Saudi Arabia, 80 percent of the portfolio is locally manufactured in Jeddah. That operation has been there for a long time, but it is now part of the Vision 2030 strategy to expand localization and local employment,” he added.
A major expansion is also planned in the UAE, with manufacturing facilities in Dubai due to be opened next year, making the full range of GSK products. The standoff between Qatar and the four countries of the Anti-Terror Quartet (ATQ) prompted some urgent changes to distribution channels earlier in the summer.
“Products are now going straight from Europe to Qatar, which used to come direct from the UAE, and we believe supply continuity is going well. We saw an increase in demand when the measures (blocking land, sea and air links with Qatar) were first announced, and some stockpiling of medicines,” he said.
“We are monitoring the situation. We think it could either escalate or de-escalate rapidly, but we don’t see it getting resolved quickly. It could be one or two years on the current status. But really it’s anybody’s guess,” he added.
Even without the distribution changes forced on GSK by the Qatar crisis, other factors are changing the shape of the industry and the traditional marketing methods used by companies.
“The channels of communication with sales reps are all digital now. You might not be able to physically see a sales rep but you can always get experts online,” he said.
And, of course, marketing is being transformed by the decision to stop payments to HCPs. “Before, there were two ways to drive performance. You could pay HCPs to speak on behalf of the science, but this was expensive and problematic. The main concern, however, was the potential conflict of interest involved. So in 2016 we took the decision to stop it completely. Now promotion is purely based on the science. We do still hire HCPs to work for us, to go out and talk about the products, but it is clear they are our employees,” he said.
“The second way was to pay sales representatives by the number of prescriptions issued for a product. We don’t do that anymore either, so again the potential conflict of interest is removed,” Miles added.
Health care is a major pre-occupation in the Gulf and a top priority for policymakers, which has led to a boom in medical-related industries, from the physical provision of hospital and clinic facilities to the expansion of obligatory medical insurance and the growth of pharmaceutical retailers across the region.
But it has not been without its controversies. How does Miles, as a career executive in the “big pharma” sector, see the big issues in health care in the Middle East?
One perennial is the increasing use of antibiotics. Some critics allege that doctors and pharmacists are too ready to prescribe or sell antibiotic treatments for even the most trivial of complaints. The scientific evidence suggests that this is leading to a new generation of “super bugs” that are resistant to traditional penicillin antibiotics, storing up big health problems ahead worldwide.
One of GSK’s biggest products in the region is the ubiquitous antibiotic Augmentin, and Miles concedes that the industry must do more, in conjunction with governments, to curb excessive selling or prescribing.
“There is a risk that the last line of therapy is no longer effective, but there are things that can be done about that. We can invest in new research and development to tackle the superbugs, and we are doing this. But it also revolves around the indiscriminate use of antibiotics. So we need to do more research to monitor the effectiveness and appropriateness of the existing drugs,” he said.
“We must also educate people on the use of antibiotics via prescription. Most illnesses are viral so they are no good anyway. There is a job of education to be done here with the health service providers. We need government support for regulation for the over-the-counter dispensation of antibiotics. The government is taking some steps but more needs to be done,” he added.
The other big issue for the region is in the related field of allergies and respiratory complaints, which have been chronic problems for many in the desert climate.
“We have a big presence in asthma treatment and have a new medicine which presents double the opportunity for asthma control, with a short-acting element to open the respiratory channels and a long-term part to maintain that.
“Maybe because of climate and environment, we’re also looking closely into chronic obstructive pulmonary disease (COPD) at the moment. We’re looking to unveil a ‘blockbuster’ in this area soon. It’s possible now to alleviate the rate of increase in COPD symptoms, and hopefully keep patients out of hospital for longer,” he said.
“COPD and asthma are closely connected, and around 5 percent of asthma patients get acute symptoms. There are around 50,000 people in the GCC with severe asthma who are not currently getting treated. Our new drugs, Relvar and Nucala, tackle this problem and the response has been incredible,” Miles said.
Other blockbusters are also in the pipeline. “Our big new product Shingrix, which will be launched in 2019, is to treat shingles, with an 80 percent prevention rate,” Miles said.
GSK has also been at the forefront of treatment for HIV. “We’ve launched HIV products across the world and the region, to dramatic effect. In the 1980s, it was a death sentence, now it’s under control in all areas, with the possible exception of sub-Saharan Africa. You’re more likely to die of old age even if you have contracted HIV. But we have to emphasize that healthy lifestyles should not be relaxed,” he said.
In Africa and India, GSK has given up its license rights for anti-HIV products to local producers. In many cases, patients and hospitals in those countries could not afford advanced HIV treatments, so GSK in partnership with the Bill & Melinda Gates Foundation waived its right to license fees.
Meningitis is another area where GSK is active. Its incidence always increases during the Hajj season, when pilgrims are in close proximity to each other. “We have developed several vaccines to treat meningitis,” he said.
Other diseases like malaria and polio are also on GSK’s target board, but again there are other factors at play. On malaria, he said: “It’s the biggest killer in the world, but was not well researched because the commercial opportunities are not there. We have a vaccine, which is 50 percent effective, which we are supplying to some countries at cost. But it needs other measures — like water quality control and preventive netting — to make it more effective,” he said.
“Polio too is a problem with a regional resonance. It has largely been eradicated in most of the world, with the exception of some cases in Afghanistan, Pakistan and (now) Syria, as well as a few cases in West Africa. There is still a cultural problem with polio vaccination in some parts of the Middle East and Asia,” Miles said.
Willingness to bend traditional commercial imperatives to the medical needs of communities, in cooperation with governments, is a sign of what some industry analysts have called “new pharma.”
GSK has consciously set out to take a lead in promoting the more progressive, compassionate side of the industry.
At GSK, that change is likely to be accelerated by the arrival of a new British chief executive of the group, Emma Walmsley, who plans to visit the Middle East soon. “The old model couldn’t continue to exist, it had outlived its purpose,” said Miles.