Jean-François Courtet, who has been leading the Tunisian affiliate of Novo Nordisk as general manager for three years, discusses the prevalence of diabetes and lack of awareness thereof in Tunisia, the company’s ambition to launch a series of new products to the market, and Novo Nordisk’s continuing dedication to the Libyan market and its patients.
What defines the Tunisian market for Novo Nordisk and what place does the company occupy in it?
“I am very satisfied with how far we have come in Tunisia, and I was able to implement all changes and reforms in order to bring the affiliate back on a sustainable growth track.”
Going back to the beginnings of this affiliate: Novo Nordisk has a history of 35 years in Tunisia and was long the sole supplier of insulin to the Tunisian patients. So, our history with Tunisia and dedication to its patients reaches far beyond the opening of our affiliate in 2004. We grew our affiliate from about 20 employees in 2014 to 70 today and are planning to grow further, by launching a series of products to the market as we have been facing difficulties to do so of late.
In 2013, we suddenly had a competitor for our human insulin product in Tunisia and we lost the tender call that year. This was a wake-up call for us and we restructured our affiliate in order to ensure our future in the country by focusing on better treatments for our patients: Modern Insulins. Thus, even though we have won the tender again, it does not account for a large share in our revenues anymore. We were successful in outperforming competition and have today 84 percent of market share in the area of insulin in Tunisia.
It pains me to say that while there is a rate of up to 90 percent of modern insulin in Algeria or Morocco, in Tunisia it is of only 30 percent today, Tunisian patients are then still treated in majority with outdated human insulins. Moreover Tunisian patients are still not having access to the new molecules for diabetes management while Algerian & Libyan patients for instance have this kind of access. We have been struggling to bring Liraglutide – a breakthrough GLP1 Receptor Analog to the market since 2009 but are now confident we will succeed in seeing it approved soon. Our pending and soon to be submitted market authorizations in Tunisia constitute a large pile, on top of which are products such as Degludec, a New Generation Insulin.
What challenges does Novo Nordisk encounter in the launch of its products in the country?
The main challenge we encounter is that of pricing and reimbursement. In Tunisia, when you apply for a market registration you apply for a price at the same time. Often, the product will be approved to be launched but the authorities will ask for a dramatic price decrease. No single new molecule was reimbursed for diabetes for more than 10 years making it impossible for us to perform launches in Tunisia.
It is a challenge for us, as authorities in Tunisia focus solely on the price, and not on the long-term economic burden a disease such as diabetes represents for society. In order to address this hurdles we invest a lot on generating and sharing epidemiological data & pharmaco-economics evidence to help authorities and practitioners understand the need to invest on efficacious early treatments to prevent costly & dramatic diabetes complications such us amputations, myocardial infarction, stroke, blindness… In many cases, Novo Nordisk is still not having access to drugs that address unmet medical needs.
Another dimension that needs to be addressed is that of a system with two paces, by which some doctors in Tunisia are chocked. Novo Nordisk invented the insulin pen several decades ago, but while some patients can afford it or can be reimbursed for, the majority of the population in Tunisia notably in the public system has to continue using insulin in vials which is cheaper but not as safe and efficacious. There still is this logic in Tunisia where many think that what is cheaper is better, although many products that are more cost-competitive have long been fast-tracked by newer and more efficient solutions, just as human insulin replaced animal insulin. Many more modern products have significantly fewer side effects. Meanwhile, patients are not under control and thus diabetes is the second cause of death in Tunisia and is accountable for almost 10 % of the lives lost every single year. Those are realities the authorities should take into consideration when deciding on approvals for new products.
Novo Nordisk’s activity is closely linked to the disease of diabetes. How do you assess the awareness of the Tunisian public towards this condition?
It is extremely low, especially regarding the factors that lead to diabetes. The numbers however do not lie, as 16 percent of the adult population are estimated to live with the disease, i.e. 1.1 m persons. While only the half is diagnosed, only 22% reach glycemic control and less than 1% reach full cardio-metabolic control.
This disease landscape positions Tunisia as having high potential for clinical trials for Novo Nordisk, which we did in the past and consider conducting in the future.
Further, we are also very active in hemophilia, mostly fighting for awareness with parents of children who are touched by this rare disease. We estimate there are about 500 people living with the disease in Tunisia, and the same number of people in need of our growth hormone treatments. In hemophilia we currently treat factor 7 but will soon have registered products for factors 8 and 9 as well.
Whatever the disease, the issue is the lack of awareness. Hemophilia and growth issues are rare diseases so to speak and partly because of that not systematically diagnosed in Tunisia. Moreover, once the diagnostic done, rolling out the treatment is a long procedure here and we spend a lot of time explaining its functioning.
Novo Nordisk is—as in every country we have a presence in—very active with campaigns, trying to communicate about risk factors while taking away unnecessary fears. Our Changing Diabetes® campaigns are the main focus point therein. In the past year we conducted a campaign in Tunis, as the epidemiology of diabetes is very much more prevalent in the big cities than in rural areas. The Tunisian authorities have also made an effort to raise awareness, they had a decisive campaign that battled for the reduction of salt compounds in bread. Those efforts seem small but can have an important impact.
What more can Novo Nordisk do to raise awareness?
Our main responsibility is to identify the barriers and then work to surpass them. We bring products to the market that have a certain price, but we also accompany them by patient support services that ensure they can be exploited to their full potential for the benefit of the patients. Novo Nordisk constantly strives to reinforce its discussion with the authorities and address the notion of pharmacoeconomics, through Sephire (association for innovators of the pharmaceutical industry in Tunisia) for instance. We also stress the importance of education and have just deployed a team entirely dedicated to the education of patients in the use of insulin pens and including nutritionists. For two years now, we have also been taking doctors to American and European conferences, which has been a good way for them to visualize in which ways Tunisia can still evolve to catch up with solution standards offered elsewhere.
Mr. Courtet, after a very successful position as national sales manager in France, you have now been general manager of Novo Nordisk in Tunisia and Libya for three years. What would you define as the main learning points since 2014?
I believe it is good for a general manager to come to a new country and position without prejudices. Novo Nordisk of course provides a training to its general managers it sends out throughout the world so that they may have a few notions of the cultural particularities of a country they are being sent to. However, I really think that the best way to succeed is to forge your own opinion by seeing by yourself.
I am very satisfied with how far we have come in Tunisia, and I was able to implement all changes and reforms in order to bring the affiliate back on a sustainable growth track. This also implied for me to take decisions, whether good or not, but to act.
Last year then, Novo Nordisk Tunisia was the group’s best performing affiliate in Africa with 38 percent growth and the only African affiliate to reach its sales targets. How did you achieve such distinction?
We have indeed achieved an impressive growth figure within two years. Part of it was due to global economic or political trends. For instance, our forced exit from the tender business for one of our main insulin products was a blessing in the end as it rendered us entirely independent from the public tender in terms of finance and allowed us to focus on our core know-how and master our fundamentals better by reviewing our way of doing things while explaining to our employees why we were doing things a certain way and reinforcing collaboration between our teams. We further developed our market access team as well as the team in charge of partnerships and reviewed our marketing, mainly in the field of diabetes which accounts for 80 to 90 percent of our revenues.
This is how we became the best performing affiliate in diabetes in 2015 and the only African affiliate to present positive figures in 2016. Of course, those numbers are only true in Tunisia, in Libya where we kept on providing the market during almost the whole of the aftermath of the revolution, we are focused on reducing the debt. It has already been divided by three.
Within the next five years we plan on doubling our revenues & investment and launch at least three more products to the Tunisian market. These ameliorated profits will allow us to finance new projects such as a mobile clinic for Diabetes, an itinerant diabetes clinic that will cover all the country and screen 100 000 people for diabetes.
Speaking of Libya, can you elaborate on Novo Nordisk’s commitment to Tunisia’s neighbor?
While we did not maintain a proper affiliate in Libya throughout the civil war, we constantly remained present and never stopped providing the market with our products. There was in fact never a discussion about the depth of our commitment to Libya. Actually, we have more innovative drugs in Libya than in Tunisia. Over the coming years, Novo Nordisk will maintain its presence in Libya and be an active support for the practitioners there.