Brand positioning in Indias prescription drug market

In the first of a series of articles, Dr Rajeshwar Singh, head, Scriptamedica Farmaceutica, gives insights on brand positioning from his forthcoming book What is positioning of a brand? Once upon a time, two expressions dominated the diffuse world of marketing the word marketing itself being hard to define, except by shouting at a housewife that shopping is NOT marketing. The two phrases were: Unique Selling Proposition (USP) in the domain of consumer marketing, and Unique Prescribing Proposition (UPP) in the restricted field of pharmaceutical marketing of prescription (Rx) brands. USP and to a lesser extent UPP are still in use but are no more vogue words. Perhaps Unique Differentiating Proposition (UDP) fits better in the prevailing brand overlap in India. Over to Al Ries Positioning, first vocalised in 1970s by Al Ries and Jack Trout in the columns of American journal Advertising Age, rapidly snowballed into a cult. A book under the same title, published in 1981, elevated Al Ries and Jack Trout to the status of new age marketing gurus. Ries and Trout emphasised that positioning is battle for the consumers mind, and not the market place. The concept caught up rapidly: Pharma marketers smelled gold in the concept, knowing well that different doctors formed their own opinion about a drug because the drug itself behaved differently in different patients having the same problem. The emphasis in the marketing of prescription-only-medicines started shifting from productcentric to patient-centric promotion, as more and more prescribing options started flooding the market five drugs for constipation, 10 for hyperacidity, 15 for pain relief, 25 for high blood pressure The time was ripe, and the ground fertile, for positioning to take root in the promotion of Rx brands. Positioning may be the best thing that could have ever happened to Indias pharma market. 1.b Positioning in US-EU vis-a-vis India

In the west, where one-molecule-one-brand is the norm, the brand manager of Prozac (fluoxetine) has to strategise the brands positioning vis-a-vis similar antidepressant brands having as their active ingredient either fluvoxamine or paroxetine or sertraline, all SSRIs or selective serotonin reuptake inhibitors. The Indian counterpart faces a nearparalysing situation: 20 brands of fluoxetine, 15 of sertraline, and 10 of paroxetine25 of alprazolamthe obstacles keep mounting, whatever the therapy area.
The author currently heads Scriptamedica Farmaceutica, a Consultancy Service specialising in pharma and medical communications. He can be contacted at scriptamedica@gmail.com

The brand-positioning exercise in India truly incredible India - thus morphs at best into minimising brand-blurring, because many organisations, in their basket-enlarging wisdom, decide to market more than one SSRI, more that two PPIs (proton-pump inhibitors). Thus, under the same marquee. omeprazole, lansoprazole, pantoprazole and rabeprazole can, and do, originate from the same stable. Without creating a credible brand differential, the brand manager doubling as a medical copywriter, on forced into writing such asinine line. my circle is more circular than yours my mango-flavoured formulation is more mango-ish than yours my tablet is triple-coated: others are double-coated my brand is three-and-a-half paise cheaper One absurdity deserves another and thus the visualisers of pharma literature have a whale of a time, depicting more mango-ish mangoes, more squarish squares or, visualising economy of a brand by showing melting coins, chopped currency notes, bar charts of piledup coins. The outstandingly outlandish visuals are those which illustrate mixed-strawberrycherry-pineapple flavours. Can some semblance of brand positioning be achieved in this cacophony of pseudo product claims? The answer is a guarded YES. David Ogilvy the first positioner For those PMT people who are keen on finding some differentiating feature in a me-too brand, an advertising sage, the late David Ogilvy had shown the way several decades ago. His often-told story is worth repeating (the details vary from one raconteur to another the essence is as follows). Ogilvy, in his first job as a cub-copywriter in a UK agency, was assigned to a brand of beer about to be launched in the British market. Agency rules did not allow copywriters to be meeting with the client directly; an account executive acted as a go-between.

The ever-curious, irrepressible Ogilvy pleaded that he wanted to visit the brewery where the new brand was being brewed and bottled. The account executive finally conceded, and arranged Ogilvys weekend visit to the brewery, In accordance with the protocol for visitors, Ogilvy, escorted by the manager, was taken to all sections and departments storage area, the fermentation chamber, the finished goods warehouse. While taking a tour of the brewery, the cub copywriter heard a loud, repetitive hissing noise. He asked about the sounds origin. Oh! thats our bottle washing area the manager told him dismissively, Can I have a look? Ogilvy persisted. Sure, the manager continued, and explained on reaching the area you see it is a practice in the beer industry to get back empty bottles, clean them up, and refill, recork, relabel and pass on the savings to the customer hence this in-house washing plant. Curious as ever but whats this hissing about? Well, its like this; the left over few drops of beer in a bottle dry up, form an obstinate tartar, which can be dislodged only with steam. Thats what you are witnessing a nozzle injects high-pressure steam into each bottle on the revolving platform. Oh! I see: you actually sterilise each bottle with live steam, remarked Ogilvy. The manager responded casually thats nothing new; everyone is doing that! To which Ogilvys historic response was but everyone is NOT saying that The rest, as they say, is historyOgilvy goes back to the creative director of agency, convinces him about the Unique Selling Proposition (USP) for the new brand, and creates a campaign with the headline: Drink So-&-So Beer: it comes to you in bottles sterilised by live steam! The brand was a hit: and Ogilvys career had hit the skies. Small wonder that the Indian branch of Ogilvys agency, O & M, has been keeping the flame of creativity alive, garnering the highest number of Oscar-equivalent Cleo and similar national awards, year after year And countless copywriters (this copywriter included) acknowledge, with a profound gratitude, their careers to Ogilvy. Ogilvys recipe is simple, though demanding: dig deeper, keep asking questions, keep afire the flame of curiosity you WILL succeed in differentiating me-too products. The New Thinking Tools First, consider these market dynamics...

Dynamic I - ONE DRUG: SEVEN USES 1. 2. 3. 4. 5. 6. 7. As Antipyretic As Analgesic As Antiarthritic / Anti-inflammatory For Angina Prophylaxis (as an Antiplatelet agent) For Transient Ischemic Attacks (TIA) Prophylaxis For Pregnancy Toxemia Prophylaxis For Alzheimers Disease

THESE ARE CURRENTLY THE SEVEN POSSIBLE USES OF ASPIRIN ALONE more on the way Dynamic II Eight Different Classes of Drugs; Eight Different Modes of Action BUT SAME INDICATION: HYPERTENSION 1. 2. 3. 4. 5. 6. 7. 8. Calcium Blockers Beta Blockers Alpha Blockers Diuretics ACE Inhibitors Peripheral Vasodilators Angiotensin Receptor Blockers (ARBs) Nitrates

(ACE = Angiontensin Converting Enzyme) Positioning so many options for the same disease-entity poses clinical challenges of a different kind; the brand manager must learn the nuances of hypertension as well as be a master of the minutiae of antihypertensive pharmacology. Mercifully, positioning is somewhat helped by the fact that no two persons with high blood pressure have the same clinical picture even when they are twins. Patient Stratification and Disease Stratification the two practicable positioning strategies for Rx brands in India Historically, the splitting of patients into subgroups (subsets or cohorts in technical jargon) has been the standard approach in positioning of various medicines, including household remedies as well as of prescription-only medicines. Evolution of Patient Subsets / Cohorts over the centuries reveals the following chronology FROM One nostrum for Human and Animal ailments (in 19th century) TO One panacea for all human ills TO One medicine for each disease TO One medication for each symptom

TO One drug each for the same symptom (21st century) in men and women in infants and children in adults and elderly in poor patients and rich patients in dark skinned and light skinned persons Coping with overlapping molecules using new tools and novel approaches There's a way, and though hard-to-believe at first, an honourable and a scientific way for fine-tuning the promotional message of overlapping molecules - thanks to three converging developments, two in the field of medicine, and third in the domain of Creative Thinking. These have led to the availability of sharper tools for disease stratification. The three convergent developments can be summarised as follows 1. Advances in Diagnostic Technology Firstly, clinical medicine has been getting more logical, precise and predictable as a result of improved diagnostic techniques and instrumentation. Some of these techniques help in diagnosing a given illness, others serve as predictors, yet others as early markers of impending worsening of a disease. 2. Formal guidelines and algorithms for disease management A second development in medical science, occurring in tandem with diagnostic precision, is the compilation of clinical guidelines and algorithms for the management of most major clinical conditions: Diabetes, Asthma, Stroke, Heart Failure, Hypertension, Infertility Stratification based on algorithms translates into different and differing patient-subsets under the same disease segment. Indeed, patient stratification may be the new key to brand differentiation. 3. Tony Buzan and his Mind Mapping tool for stratification In the 1970s, Tony Buzan, a UK- based learning consultant, had developed a revolutionary yet disarmingly simple approach to handle complex situations that required clear-headed thinking. Buzan's technique, a thinking tool called 'Mind Mapping', is a brilliantly conceived system for capturing and differentiating ideas and insights on any given problem. All aspects of the problem are scribbled on the same page, as and when they radiate from the mind. How does Mind Mapping operate? Just take a piece of paper, have same coloured pens around, put your problem in the centre, and start plotting all the attributes and aspects of the problem on lines radiating from the centre. By doing this, you are actually 'mapping' your responses, thoughts, ideas,

and reactions across the page, rather than listing these in a linear fashion one below the other. This linear mode cuts off each idea from the ones preceding and following it, disassociating an idea on page 1 from an idea as page 3. Mind Mapping as a Tool for positioning : A Demo Tony Buzan's thinking tool for pharma brand managers can come handy when the need is to achieve a brand differential between apparently conflicting or overlapping brands. Hypertension' is the disease that has been selected for this demonstration because of three considerations: a) antihypertensive drugs constitute one of the largest and growing market segments. b) hypertension with its wide-spread prevalence provides probably the widest number of patient-subsets than any other medical condition. c) hypertension offers maximum therapeutic options that work in different ways in different patient subgroups The utility of this tool, however, hinges on a lucid and deep understanding the disease and its treatment modalities. Remember, all Thinking Tools are the equivalent of mining equipment: gold, diamonds or oil must be there to be mined and extracted. By the same analogy, there must exist a rich matrix of knowledge that can be scooped by Mind Mapping to deliver tangible stratification. The exercise starts with the Mapping of Hypertension as depicted below. Next the setting, a large pharma organisation let's call it LPO Labs - has in its antihypertensive range the following entities: Two beta-blockers, say atenolol and metoprolol - two ACE inhibitors, say ramipril and lisinopril; two ARBs, say candesartan and losartan ; two diuretics, say hydrochlorothiazide and furosemide; two calcium-channel blockers say amlodipine and diltiazem; two statins, say atorvastatin and simvastatin; and two antithrombotics, say aspirin and clopidogrel; and as if this were not enough, two nitrates as well - isosorbide mononitrate and isosorbide dinitrate! That's a mind-boggling even for the likes of Al Ries and Jack Trout, or even for the positioning wizards, Tony Buzan and David Ogilvy. To start the exercise, keep your attention glued to the 'Hypertension Map'. Here we go

Positioning Challenge 1 : Slotting Atenolol / Metoprolol for LPO Labs But first, a quick recap of current medical background Of late, beta-blockers have been loosing their long-held primacy in Hypertension, and are therefore undergoing a clinical shift, being preferred in POST-MI patients where their antianginal / antiarrhythmic as well as antihypertensive benefits can be put to good use. As if through a back door, beta-blockers are also staging a comeback in Heart Failure (particularly Metoprolol). Atenolol is hydrophilic and eliminated renally; metoprolol is lipophilic, and undergoes hepatic elimination. The controversy regarding the relevance of beta-blockers in Diabetes also stands resolved as diabetics are now perceived as 'Coronary Equivalents', requiring antianginal cover. While diabetics have nephropathic changes, even non-diabetics have an age-related decline in kidney function, starting at age 40. Now, re-focus on the map (Mapping Hypertension), and explore the possibilities for positioning / repositioning Atenolol and Metoprolol. The following options, among others, may occur to a knowledge-primed brand manager doing this exercise. Metoprolol, alongwith a suitable regimen of an ACE-I and a Diuretic for patients of Heart Failure Atenolol, as the preferred antihypertensive for post-MI patients with evidence of diabetes OR Atenolol in post-MI patients with impaired liver-function Metoprolol as an antianginal/ anti-hypertensive / antiarrhythmic cover in elderly post-MI patients with impaired renal function Metoprolol in women patients with hypertension who also have a history of migraine

Positioning Challenge 2 : Slotting Losartan / Candesartan in LPO labs Again, first a quick survey of the clinical considerations Faced with a) increasing incidence of hypertension in younger population b) people marrying or remarrying late - in their 40's or 50's c) beta-blockers, diuretics, and even calcium-blockers, inducing impotence (now 'erectile dysfunction') because all three can affect cardiac output. d) young, educated male patients with hypertension complaining of 'reduced quality of life' a euphemism for erectile dysfunction (which itself is a euphemism for impotence) the pharmacologists were been forced into looking for alternatives to bring down BP without affecting cardiac output directly. The focus thus shifted to the Renin-AngiotensinSystem (RAS), and Angiotensin Converting Enzyme Inhibitors (ACE-Is) were the outcome (captopril to quinapril, and counting ). ACE-Is however were found to induce irritant cough in up to 20 per cent patients. Pharmacologists therefore had another look at RAS, and came up with Angiotensin Receptor Blockers (ARBs), which are largely devoid of the side-effect of cough. Initially, the official positioning of ARBs (losartan being the prototype), was only for those patients who were well-controlled with an ACE-I, but found their cough troublesome. 'LIFE' and 'CHARMS' studies firmly established the newer roles of Losartan and Candesartan in many patient subsets such as diabetic hypertensives and chronic hypertensives with left ventricular hypertrophy. Candesartan, because of its placebo-like side-effect profile and its predictable kinetics, has probably a slight edge over Losartan. Cast now another focussed look on the 'Map' to trigger some positioning ideas for Losartan /Candesartan... you are likely to come up with: Candesartan for the newly-diagnosed, young male hypertensives who may not like to exchange their raised BP (hypertension has no symptoms) for cough or impotence. Losartan for chronic middle-aged hypertensives with diabetes, who may also be having microalbuminuria.

THAT'S MIND MAPPING IN ACTION it facilitates disease stratification into patient subsets it facilitates positioning or repositioning of brands and at the very least it minimises brand blurring

Positioning statements for other molecules in the Antihypertensive Range of LPO Labs may read as: Atorvastatin for all young, male hypertensives as routine prophylaxis against lifestyle dyslipidemia

Atorvastatin for all post-menopausal hypertensives to reduce the risk of coronary disease Simvastatin as the ideal add-on with Ezetimibe for hypertensives with an adverse lipid profile Isosorbide mononitrate in ischemic hypertensives with chronic stable angina, for prophylaxis of effort-induced angina

Isosorbide dinitrate for chronic hypertensives with Chronic Stable Heart Failure and similiarly for other molecules or even their fixed-dose combinations. The more 'radiant' the mapping, and deeper your knowledge of drugs and disease, the more the possibilities of arriving at a well-demarcated brand positioning. Some Tangential Benefits of Mind Mapping Benefits of precise brand positioning Target audience gets sharply segmented Appropriate indication gets duly emphasised Product message becomes succinct. Supporting visuals become relevant and evocative Detailing becomes crisp and brief

Precisely targeted brand positioning resolves many issues, some at the corporate level. THUS Along the TrainerDetailperson-Prescriber Axis, positioning achieves or fosters Clarity in Training Inputs Clarity in Training Objectives Clarity in a Detailpersons mindset Credibility in the Prescribers Mind

Along Medical DepartmentBrand ManagerArt Department Axis, positioning facilitates or inspires Pin-pointed Information Search Relevant Inputs from the Medical Team Unambiguous Promotional Themes Memorable and Clinically-evocative Visuals

Further reading Mind Maps in Pathology Peter Dervan & Michele Harrison, 2002, Churchill Livingstone Mind Maps in Medicine P. McDermott & D. N. Clarke, 1998, Churchill Livingstone Useful Websites for Patient Stratification/Evidence-based Medicine

1. Clinical Guidelines <www.ngc.org> 2. Medical Algorithms <www.medal.org> 3. The Cochrane Collaboration (http://www.cochrane.org) Mind Manager and FreeMind (its really free!)