Positioning a new indication of a drug in a
highly competitive market
Positioning a New Indication of a Drug in a
Highly Competitive Market
A. H. Kaplan
Groningen, The Netherlands, 02 December 2019
Advanced International Business Management and Marketing Student number: S3824322 / B9016073
University supervisors Company supervisor dr. Pennink
Management Summary
Studies show that the quality of pharmaceutical marketing strategies are variable, and mostly of a lower quality (Smith, 2003). While there has been some support on the quality of current pharmaceutical marketing strategies (Black, 2005), others claim that strategies are far from excellent (Stuart-Kregor, 2006). This difference might be due to the fact that theories describing steps within the marketing process cannot always be used effectively in practice (Cui and Xiao, 2019; Dibb, 1998; Warner, 2010; Zain and Subramaniam, 2007). Additionally, it could be due to the fact that pharmaceutical companies are using similar methodologies to draft a pharmaceutical marketing plan (Calkins, 2019), leading to a lower level of uniqueness that is needed to achieve a marketing plan of high quality (Smith, 2003).
The goal of this research is to study whether current theory can still be used to write a qualitatively high marketing plan for the pharmaceutical industry. Against this background, the purpose of this research is to answer the following research question:
How useable are current pharmaceutical marketing strategies aimed at positioning a new indication of a drug in a highly competitive market?
Methodology
This research will conduct a case study at the pharmaceutical company Eli Lilly to draft a pharmaceutical marketing plan. The theory behind this plan will be based on the framework of Lidstone et al. (1999), and on the Lilly Marketing Framework, combining literature and practice. Visschers and Fisschers’ (2007) Coloured Diamond Approach is used to combine the two methodologies.
The marketing plan is assessed on four criteria’s set by Smith (2003), which are the target market definition, proposition differentiation, the SWOT alignment, and the strategy uniqueness. Conclusion and contributions
Preface
Being close to completing my studies “Advanced International Business Management and Marketing”, I wrote my dissertation at a pharmaceutical company. The interest for this industry derived ever since my time in Singapore, where I analyzed the characteristics of researchers inventing breakthrough drugs. At that time, I noticed that while this industry receives much critique, it also gives so much good to the world. The pharmaceutical industry provides the world with innovative drugs which heal people effectively, giving them a chance to enjoy life to the fullest again. I wanted to be part of the innovation process within a pharmaceutical industry and that is why I chose this innovative company to perform my research at.
First of all, I want to thank my supervisor at the company, Ingrid Clement. She is the one that made this all possible by offering me this research place at Eli Lilly. I am thankful to have learned from you as a supervisor, and I want to thank you for your enthusiasm, flexibility, efficient meetings, and valuable feedback.
Secondly, I want to thank my supervisors from the University of Groningen and Newcastle University, Dr. Pennink and Dr. Haist. It is not easy to combine a project like this with writing a dissertation, especially in a short time, but they have been supportive from the start. Firstly, Dr. Pennink, thank you for the enthusiasm regarding a company based project, and for visiting me at the company in Utrecht. Secondly, Dr. Haist, thank you for the pleasant Skype meetings and all the positivity you brought along with them. I am truly thankful to have learned from the both of you!
Lastly, I want to thank my colleagues at Eli Lilly for the warm welcome I received at the company and all the positivity they carried along. Special regards go to Manolya Demirkaya and Jose Hoffman who helped me get this internship, and Naomi van der Linde, for the wonderful cooperation.
Ali Kaplan
Abbreviations
AS Ankylosing Spondyloarthritis
ASAS Assessment of Spondyloarthritis International Society
AxSpa Axial Spondyloarthritis
CME Continuing Medical Education
CGR Code for Pharmaceutical Advertising
CRP C-reactive Protein
DMARD Disease-Modifying Anti-Rheumatic Drug
DTC Direct-to-Consumer
EHCI Euro Health Consumer Index
GP General Practitioner
GVS Dutch National Reimbursement System
HCP Healthcare Professional
HLA Human Leukocyte Antigen
IL-17 Interleukin-17
JAK Janus Kinase
NVR Dutch Society for Rheumatology
Nr-AxSpA Non Radiographic
NSAID Non-Steroidal Anti-Inflammatory Drugs
OTSW Opportunities-Threats-Strengths-Weaknesses
PESTLE Political, Economic, Social, Technological, Legal, Environmental
PsO Plague Psoriasis
PsA Psoriatic Arthritis
SI Strategic Initiative
SWOT Strengths-Weaknesses-Opportunities-Threats
TL Thought Leader
TNF Tumor Necrose Factor
1. Introduction
This chapter introduces the research. It will start in section 1.1 with explaining the research context and how the outcomes can be relevant to the academic literature. Additionally, the main research question driving this research will be presented. Next, in section 1.2, the scope of the research and the research approach will be described briefly. This part of the report will conclude by presenting the sub questions guiding the research and the research framework in section 1.3.
1.1. Study Background and Main Research Question
The pharmaceutical industry is risky and challenging (Couzin, 2005; Ladha, 2007; Munos et al., 2011). Developing a drug takes on average 12 years. Additionally, the process of developing and testing a drug, and eventually bringing it to the patient costs on average 2.2 billion euros (AIM, 2019). Pharmaceutical marketing is a key component for pharmaceutical companies to see risk, time and effort back in profits (Applbaum, 2006).
In literature, much can be found on the principles of pharmaceutical marketing (McFadden et al, 2007; Ladha, 2007; Spielmans and Parry, 2010) and positioning a product in this specific niche (Lidstone et al., 2017; Siegal and Shah, 2019; Spielmans and Parry, 2010). However, since the pharmaceutical market is continuously changing (Bukuta, 2002), and pharmaceutical companies have to embrace marketing strategies even more than in the past (Ladha, 2007), new marketing research and strategies are needed to successfully launch new drugs and new indications of drugs into the market.
The Netherlands is one of these countries (Windmeijer et al., 2006), and the country used in the case study of this research, and therefore of special interest in this study.
The literature on potential pharmaceutical marketing strategies is scarce (Buckley, 2004; Grenada and Mancuso, 2011). A reason for this could be that pharmaceutical companies do not want their competitors to know how they handle or have handled drafting a marketing plan and strategies in the past, since this could give away future tactics. Another reason is the fact that pharmaceutical companies are limited in some countries in their marketing tactics (Windmeijer et al., 2006). However, there are some marketing strategies known (Bukuta, 2002; Moyniha et al., 2002). Giving free sampling of drugs have been proven to be highly successful (Bukuta, 2002). Another example is providing medical education in the form of for example educational events, teaching conferences, and seminars. At these events, practitioners, medical students and other medical parties are invited to listen to a variety of speakers and offered free meals and other amenities. In literature, these events have been highly criticized because of their accusations to bias physicians (Relman, 2001), but also highly appreciated by the medical industry (Holmer, 2001). Lastly, pharmaceutical companies could publish stories linked to their medicine. Merck, a large pharmaceutical company, targeted news media to write stories designed to create fears about certain conditions or diseases. For example, Merck used Australian newspapers to write articles about hair loss and the emotional trauma that could come along with the medical condition. Merck published this story at the time their hair growth drug Finasteride (Propecia) was recently approved in Australia. While in Australia pharmaceutical companies are prevented from direct to consumers marketing, Merck released a statement that these articles were merely to create awareness of scientifically proved options to stop hair loss (Moyniha et al., 2002).
pharmaceutical industry. Against this background, the purpose of this research is to answer the following research question:
How useable are current pharmaceutical marketing strategies for positioning a new indication of a drug in a highly competitive market?
1.2. Research approach and scope
Where traditional methods struggle to answer complex phenomenon for marketers, case studies have been claimed to be effective (Johnston et al., 1999). Therefore, the research question will be answered by a review of current literature on pharmaceutical marketing tactics, and by conducting a case study.
This case study takes place at a pharmaceutical company with one of the largest market cap in the world, called Eli Lilly (Forbes, 2019). Eli Lilly successfully developed and positioned the drug Taltz in the market. Taltz is a biologic injection, which currently can be used to treat patients with moderate to severe plaque psoriasis (PsO) or active psoriatic arthritis (PsA). Eli Lilly will expand their drug Taltz in 2020 on the Dutch market with a new indication for Axial Spondyloarthritis (Lilly, 2019). Axial Spondyloarthritis (AxSpA) is a chronic form of arthritis that causes significant inflammatory low back and/or buttock pain, stiffness and fatique (Mease et al., 2018).
The research scope is limited to the Dutch market. Eli Lilly has developed a global strategy, but there is currently an incomplete picture on how to position this new indication in the Dutch market. The Dutch market is competitive with different types of medications available to treat Axial Spondyloarthritis.
1.3. Sub questions and research framework
Firstly, it is important to know in what way marketing pharmaceutical products within the Dutch is different from other markets. Therefore, the first set of sub questions driving this research are as followed:
What distinguishes marketing pharmaceutical products from regular products in the Netherlands?
a) What distinguishes pharmaceutical marketing from regular marketing? b) What are the rules and regulations regarding pharmaceutical marketing in the
Netherlands?
c) How is the Dutch health care system with regard to prescribing medicines organized?
To deliver the marketing plan successfully, previous successful strategies will be analyzed as well, foreseeing future successes. In addition, a case will be described to get a clear picture of a pharmaceutical marketing strategy. Lastly, since the pharmaceutical industry is highly criticized (Leefland and Wieringa, 2010), the ethical considerations that has to be taken into account in study will be described. The sub questions driving this part are:
What can be learned from previous pharmaceutical marketing strategies?
a) Which strategies are available to put a new medicine in the pharmaceutical market?
b) How did Cialis take over market leader Viagra within the market?
c) What ethical considerations should be taken into account in this highly criticized industry?
Eli Lilly already uses a particular method to draft a marketing plan. However, additional literature will be studied, to check whether it can complement their current methodology. Moreover, a way to assess the marketing plan in the end will be studied and used to assess marketing plan developed. This section is guided by the following questions:
How are pharmaceutical marketing plans drafted in theory and practice, and how can these plans be assessed?
b) Which method does a pharmaceutical company use to draft their marketing plans?
c) How can we evaluate the quality of the marketing plan?
Before the company can be provided with a marketing plan and strategies, the case and the clinical picture has to be outlined as well. Additionally, the key strengths of the medicine should be known. Therefore, the following sub questions are designed:
What are the best options for possible strategies to launch Taltz in the Dutch market to treat Axial Spondyloarthritis?
a) What is Axial Spondyloarthritis? What is Taltz?
b) What competitors does Taltz have in the Dutch market?
c) What are the strengths, weaknesses, opportunities and threats of Taltz? d) What are the unique selling points of Taltz over its competitors?
This is research is structured as followed: Firstly, a review on the current literature will be provided in Chapter 2. Next, the research methods to conduct this research will be given in Chapter 3. Then, the context of the case will be described in Chapter 4. Since a large portion of pharmaceutical marketing strategies have been of lower quality (Smith, 2003), Chapter 5 analyzes the drafted marketing plan. Lastly, this study will end by giving its concluding remarks, limitations and future recommendations in Chapter 6. Figure 1.1 gives an overview of the this report.
Figure 1.1: Overview of the report
Pharmaceutical marketing in Dutch market Pharmaceutical marketing strategies Drafting pharmaceutical marketing plans Literature review Research Design Data collection Data analysis Methodology
Context case study
Case study
Result analysis
Conclusion
Recommendations
2. Literature Review
The following section focuses on a review of literature and has the objective to answer sub research questions. Firstly, it provides information that can answer the research question on pharmaceutical marketing in the Dutch market, which will be described in section 2.1. Secondly, it will outline the strategies available in pharmaceutical marketing, with an example of a previous case and the ethical considerations, which can be found in section 2.2. Lastly, section 2.3 describes the theory on drafting a pharmaceutical marketing plan, how this is currently handled at Eli Lilly, and how these methodologies are combined.
2.1. Pharmaceutical Marketing in the Dutch Market
Since the main task of the project is to write and analyze a marketing plan, the first research question drawn is:
What distinguishes marketing pharmaceutical products from regular products in the Netherlands?
This main question will be answered by first explaining the key concepts of pharmaceutical marketing and by distinguishing the differences between pharmaceutical marketing and regular marketing. Since this research is conducting a case study for the Dutch market, the rules and regulations for the Dutch market with regard to pharmaceutical marketing will be described. Lastly, the way the Dutch health care system is organized regarding the prescription of medicines will be explained. This is described, since the pharmaceutical industry uses indirect selling, and therefore has a less obvious target group (Grenada and Mancuso, 2011).
2.1.1. An Introduction to Pharmaceutical Marketing
Pharmaceutical marketing can be defined as “Activities focused on making physicians as well as the general public aware of new and existing pharmaceutical brands. Pharmaceutical marketing can include giveaway samples, detailed product literature, disease management programs, and support material for patients, internet initiatives, and events/meetings for physicians” (Masood et al., 2009, p. 1942).
Pharmaceutical marketing is different from generic consumer marketing. One of the main differences is the extent of marketing during the patent life cycle. A patent life cycle shows the patent’s value at each step of the way, until it reaches maturity (Hikkerova et al., 2014). The patent period on medicines is 20 years. However, because the development of these medicines takes on average 8 years, pharmaceutical companies therefore have on average 12 years to gain profits back (Dietvorst, 2017). For a consumer-focused company like Coca Cola, branding is one of the most powerful intellectual property. Therefore, marketing Coca Cola products and the overall Coca Cola brand lasts relatively long (Smith, 1991). However, a pharmaceutical company have to use all its resources to get the most out of the patent value just before and in the beginning of the product life cycle (Smith, 1991). Realizing quick sales levels and marketing efficiency in the first period after the product launch is therefore more important in the pharmaceutical market than other mainstream markets, because of two reasons, in addition to the remaining patent period. Firstly, because others companies may introduce a better drug, which can give companies a better position within a market, and secondly, because the first on the market has the possibility to ask ‘’’premium’’ prices for their product which could lead to more profit (Karagozoglu and Brown, 1993). After the term of the patent ended, other companies are allowed to recreate the medicine and introduce biosimilars. These biosimilars are drugs with the same characteristics, but offered for a much lower price, since they do not have to pay for the high risks of possibly developing a weak product (Windmeijer et al., 2006).
Another difference is that pharmaceutical marketing uses indirect selling. In most cases, a company seeks to have a good relationship with the end-user to gain marketing advantage (Cristopher and Peck, 2012). However, even though in some countries pharmaceutical companies target consumers, the prescribing physicians are overall the most targeted group, who in the end make the purchase decision for patients (Grenada and Mancuso, 2011).
Budweiser beer, and almost as high as Coca Cola classic, which is well known for their marketing spending’s (Bukata, 2002). The reason for these high spendings are explained in Schwartz and Molowin (2019). They argue that “Increased medical marketing reflects a convergence of scientific, economic, legal, and social forces. As more drugs and devices and medical advances convert once-fatal diseases into chronic illnesses and with renewed interest in prevention for some diseases, the marketing of tests, treatments, and services has expanded” (Schwartz and Molowin, 2019, p. 87). These spending can especially be seen in the US, where they estimate that for marketing and advertising to physicians, pharmaceutical companies spend on average between $8000 and $13000 per physician (Haaijer-Ruskamp and Denig, 2001).
Lastly, the rules and regulations regarding pharmaceutical marketing is more restricted than in other markets. This will be explained more comprehensively in the next section (KNOV, 2016). The reason for a more comprehensive explanation of this point, is the high influence it can have on the marketing decisions (Dijkgraaf et al., 2006; Windmeijer et al., 2006).
2.1.2. Rules regarding Pharmaceutical Marketing in The Netherlands
2015 Celgene agreed to settle for a payment of $280 million for false claims (United Stated Department of Justice, 2017).
2.1.3. The Dutch Healthcare System
The Dutch healthcare system is similar to most other countries in Europe. Citizens are free to choose their healthcare providers, and individuals who feel sick first go to a general practitioner before being referred to a specialist (Van Mil, 2005). The drug prescribing decision in the Netherlands is either made by a general practitioner or a specialist (Windmeijer et al., 2006). When doctors or specialists require information regarding pharmaceutical products, the Farmacotherapeutisch Kompas is commonly used, which is the Dutch National Drug Formulary. The framework contains information about treatment guidance, warnings, dosage, and side effects (CVZ, 2010).
Healthcare in the Netherlands is one of the best in Europe, consistently ranking in top of the Euro Health Consumer Index (EHCI), which assess healthcare in different European countries based on waiting times, results, and generosity. The Netherlands is unique in EHCI study, being the only country consistently appearing among the top three, regardless what aspects of healthcare are studied (EHCI, 2019).
Health care to individuals in the Netherlands is funded both publicly and privately, depending on the income of the individuals. When the income of an individual falls below a certain threshold, public funding covers this individual. When the individual earns above the threshold, the individual can choose a private insurer if he or she likes (Windmeijer et al., 2006).
Market access for pharmaceutical companies in the Netherlands is linked to the pricing and reimbursement of medicines (Jommi et al., 2012). There are maximum prices set for medicines. This is based on the Medicines Pricing Act (WGP), which has been introduced in 1997. Since the introduction of the act, the price of medicines have decreased over the years (AIM, 2015). The maximum prices for medicines is determined based on the average prices of similar medicines in four referential countries, which previously were Germany, Belgium, France and the United Kingdom. However, since the prices of medicines are consistently much higher in Germany, the Act has substituted Germany with Norway (Rijksoverheid, 2014).
want to cover, and normally choose to cover the cheapest version of a certain active substance (Rijksoverheid, 2019).
2.1.4. Answering the First Sub Question
To summarize the first part of the literature search, which reviewed pharmaceutical marketing practices within the Dutch market, the main following question was drawn:
What distinguishes pharmaceutical marketing in the Netherlands from regular marketing?
What has been found in literature regarding pharmaceutical marketing is that the patent life is of most importance. Especially in the beginning and at launch, a pharmaceutical company must use all it resources to get the most out of the patent life remaining (Smith, 1991). Additionally, the Netherlands distinguishes itself with the excellent health care (EHCI, 2019), and the rules and regulations set in the country. A Code for Pharmaceutical Adverting (CGR) is active in the Netherlands, limiting pharmaceutical marketing strategies to offer a fair system. When pharmaceutical companies disregard these rules, they can obtain high fines from the Dutch Health and Youth Care Inspectorate (Reijn,, 2015).
2.2. Pharmaceutical Marketing Strategies
The second part of the literature review has the objective to study the available literature on pharmaceutical marketing strategies. Possible targets within the pharmaceutical market are evaluated, and possible ways to position a medicine in the market are discussed in the first section. After this, a pharmaceutical marketing case that Eli Lilly has handled previously will be discussed briefly, since this case was highly successful (Dawar, 2013). Since the industry has received many critiques, this part will conclude in section three by listing the ethical considerations that has to be taken into account within this study.
The goal of this part of the literature review is to answer the following question:
What can be learned from previous pharmaceutical marketing strategies?
2.2.1. Targeting and Positioning
Targeting within pharmaceutical marketing can be divided in marketing to physicians and marketing to consumer. The latter is often referred to as direct-to-consumer (DTC) marketing and contains advertising appears in a variety of media platforms, such as newspapers, television, and billboards (Bukata, 2002). Furthermore, marketing appearance online have increased as well for direct-to-consumer marketing (Sweet, 2009). Marketing to consumer is not allowed in all countries because of local laws (Windmeijer et al., 2006). While the U.S. pharmaceutical industry spends $5 billion annually on marketing to consumers, there have been questions around the effectivity of this marketing strategy. A study by a group of Harvard Medical School researchers compared the effectivity of direct-to-consumer marketing, and found little difference in the potential of prescriptions generated between potential patients targeted with the ad campaigns and the control group (Winer and Ravi, 2013).
market was the provision of free samples, which had an increase of budget from 4.9 billion US dollars to 7.9 billion US dollars in four years (Bukuta, 2002). Additionally, pharmaceutical companies buy space in medical journals to advertise the effectivity of their drugs. Furthermore, physicians can be sponsored by pharmaceutical companies to attend professional events for educational purposes. In addition, some pharmaceutical companies offer physicians medical education to obtain their continuing medical education (CME) credits (Grenada and Mancuso, 2011). Moreover, pharmaceutical companies use a push strategy creating goodwill by sponsoring patient organizations. Lastly, pharmaceutical companies use key opinion leaders, for example medical educators and senior clinicians, for promotion purposes (Buckley, 2004).
In addition to sending a sales representative, pharmaceutical companies in North America and Europe are increasingly using E-detailing as a strategy to get the message through to the physicians. By E-detailing, pharmaceutical companies promote their products via online channels and information technology (Trucco and Amirkhanova, 2006). It includes various strategies, such as the previously mentioned educational modules, the use of e-mails with information about the medicine, and videoconferencing. E-detailing is especially popular for pharmaceutical companies to use for disease-awareness campaigns, and for customer relationship management (Sweet, 2009).
The study of Turcco and Amirkhanova (2006) showed that in multiple cases, e-detailing has been less costly and more effective for pharmaceutical companies. In addition, and possibly interesting for the case study, they showed that even though doctors do not have much time during the day to talk to sales representatives to obtain information, they do try to find more information later in the day through e-detailing. More specifically, 86% of the European physicians searched for medical information in the evening and 71% in weekends. In addition, considering the physicians in the United States, 60% search for information between eight and twelve post meridiem, implying pharmaceutical companies can use this opportunity to get their message through, even though it seems that physicians are not interested in the information during the day.
price influences the positioning of a drug in a market. Especially biosimilars with much lower prices can disrupt the market place.
Lidstone et al. (2017) listed additional pharmaceutical positioning factors that can be used for measurement comparing pharmaceutical products. Firstly, the dosage needed and the convenience of use can make a difference positioning a drug. Next, the price versus the severity of the medical condition can be used as parameters. Thirdly, the speed to activity and the duration of action are listed as positioning tactics. Fourthly, the side-effect profile versus the efficacy of the drug can be important parameters. Lastly, the packaging convenience and the availability of the drug can be used as differentiating tactics.
Firms do not compete in just one pharmaceutical market, but within therapeutic markets. When there is competition, the quality of the drug is an important decision factor, which can have multiple characteristics. Important characteristics are the efficacy, safety, ease of use and side effects of the medicines (Windmeijer et al., 2006).
2.2.2. A Pharmaceutical Marketing Case: Cialis versus Viagra
A case that Eli Lilly handled previously was the positioning of the drug Cialis (Tadalafil), which also entered a competitive market. Cialis is a drug that treat men with erectile dysfunction and had two main competitors in the market, market leader Viagra (Pfizer) and Levitra (Bayer). Viagra was the first set into the market in April 1998. With a price of $10, the launch was a success, leading to a $1.5 billion dollar in annual sales in 2001. Other pharmaceutical companies took notice of the success and Bayer introduced Levitra in 2003 to compete with Viagra. Levitra’s drug profile was comparable to Viagra, which left Bayer with the choice how to strategically position this product in the market. Bayer chose a price differentiation strategy, putting Levitra cheaper in the market than Viagra in the hope to win the market. Later in 2003, Eli Lilly put together with ICO, a biotech firm, introduced Cialis into the market. Again, the question was raised how to position Cialis in the market (Wienke, 2005).
research showed that the drug prescribing behavior of physicians and urologists were most influenced by the efficacy of the medicine, followed by its safety. This accounted for 70% of prescribing importance, whereas duration just accounted for 10%. While the market research showed that physicians rather see improvements in safety, the marketing team of Eli Lilly after heavily debating the strategy, ended up choosing to focus on the duration. Eli Lilly priced Cialis higher than Viagra, to show that the product is ‘’better’’. Additionally, with the possible duration of the product, they focused on intimacy instead of sex. Cialis turned out to be a success, taking over market leader Viagra, and passed their annual sales in 2012 (Dawar, 2013; Wienke, 2005). The learning point of this case is that it shows how marketing outside the preferences of the physicians still can have a positive impact. It shows that while physicians might like to see a certain effect of a drug, the consumer might like other treatment goals (Dawar, 2013).
2.2.3. Ethical considerations
The pharmaceutical industry gained a negative image, both in politics and in the media (Buckley, 2004; Dietvorst and Geerts, 2019; Parker and PettiJohn, 2006; Relman). In the Netherlands, the main critique on pharmaceutical companies are the “high’’ prices asked, once the medicines have been developed (Dietvorst and Geerts, 2019). An example of a case that caused discussion in Dutch politics and media, is the case with the Italian pharmaceutical company Leadiant. Leadiant increased the price of their drug 500-fold, resulting in an increase in treatment from €300 to €150,000 per year (Jack, 2018; Dietvorst and Geerts, 2019).
indication of drug are the ones most heavily promoted, while they are the least clear on future safety profiles.
Nonetheless, while there are many negativity pointed at the strategies, there are also positive voices on pharmaceutical marketing strategies. Holmer (2001) discusses the benefits with regard to pharmaceutical companies stimulating medical education.
2.2.4. Answering the Second Sub Question
To summarize the second part of the literature search, reviewing pharmaceutical marketing strategies, the question drawn was set as followed:
What can be learned from previous pharmaceutical marketing strategies?
Different options for pharmaceutical marketing strategies are listed within the literature. The strategies can broadly be divided in (1) gifts in the form of, for example, samples, (2) sponsorship of educational events and conferences, (3) the use of key opinion leaders for promotional activities, (4) funding of medical journals to publish relevant medical data on drug or clinical picture, and (5) sponsorship of patient organizations (Buckley, 2004; Grenada and Mancuso, 2011).
Pharmaceutical companies can distinguish their drug on the market either by (1) clinically strong data, (2) beyond clinical aspects like the administrative ease, or (3) by a price advantage compared to their competitors (Siegal and Shah, 2019).
The Cialis case shows the possibility that marketing outside the preferences of the physicians can have a positive impact. Considering the Taltz case, this means that while physicians might like to see a certain effect of the drug, the consumer might have different treatment goals.
2.3. Drafting a Pharmaceutical Marketing Plan
2.3.1. Theory on drafting a pharmaceutical marketing plan
A marketing plan is ‘’a written document containing the guidelines for the products marketing program and allocations over the planning period’’ (Winer and Ravi, 2013, p. 33). Overall, the objective of a marketing plan is to assist a marketing manager in three key factors of success within the business environment, which are the customers, competitors and factors outside both the customers and competitors, like governmental restrictions (Winer and Ravi, 2013). A strategic marketing plan supports a company with foreseeing future successes and putting itself in a tactical position. In addition, selecting the right objectives and strategies within the plans lead to an increase in revenue (Nykiel, 2003).
The literature discusses multiple marketing strategy frameworks for marketing planning (Winer and Ravi, 2013; Nykiel, 2003; Lidstone et al. 1999). Since many of the frameworks in literature are not specifically drawn for the pharmaceutical industry, which section 2.1 has shown to be of importance, a framework made for the pharmaceutical industry will be studied, developed by Lidstone et al. (1999). This framework can broadly be divided in eight steps and is shown in Table 2.1 below.
Table 2.1: Pharmaceutical marketing planning process (Lidstone et al. 1999)
Section 1 Market Segmentation Section 2 Market Analysis
Section 3 Environmental Analysis Section 4 Product Audit
Section 5 Company Audit Section 6 Strategic Options Section 7 Action Plan
Section 8 Performance Management
the market differently than their competitors (Lidstone et al. 1999; Payne and Frow, 2013). However, while the literature states that this could give a firm a competitive advantage, segmenting strategically have been shown to not be as easy in practice (Dibb, 1998)
Secondly, a market analysis should be made, consisting of the different customer segments and the reason why they are attractive. Additionally, the competitors have to be listed with their strengths and weaknesses (Lidstone et al. 1999). While this is step is key in many marketing processes (Ottum and Moore, 1997; Winer and Ravi, 2013 ), others show that this step is not always that beneficial in practice, when for example obtaining the market information is too costly (Cui and Xiao, 2019).
Thirdly, an environmental analysis should be drawn. This analysis can be known as the PESTLE analysis, and involves a review of political, economic, social, technological, legal, and environmental issues (Payne and Frow, 2013). However, within the pharmaceutical industry, the legal and environmental review is substituted by review of competitive and ecological issues. The analysis should consist of the drivers of change within the market environment, and the segments they can effect (Lidstone et al. 1999). While this step is described within the pharmaceutical marketing planning framework, executives in business settings have shown their critiques on the practical side, where the analysis turned out to be ineffective (Warner, 2010).
Next, a product and company audit should be performed, which shows all the strengths and weaknesses of the product and the company compared to the competitors in the market (Lidstone et al. 1999). Once the product audit is performed, the task is to differentiate from competitors. Section 2.2.1 can be used as a guideline, which describes different ways to position a pharmaceutical drug are listed (Siegal and Shah; 2019). A company audit has the additional benefit of better managing key stakeholders expectations (Feizizadeh, 2012). However, since company audits also need to be well-timed to be effective (Feizizadeh, 2012), and are performed usually in corporation with higher levels of management, it can create a wrong picture of the situation that the higher level of management like to see (Zain and Subramaniam, 2007).
The analyses made results in a SWOT analysis, which outlines the internal and external environment (Lidstone et al. 1999).
correct role of top management, the market orientation, and the quality of the execution (Cooper, 1996).
Lastly, the performance management of this particular marketing plan should be measured. This should monitor under- and over performance of the product, and the financial objectives (Lidstone et al. 1999). Monitoring the performance have shown to increase the effectivity of the product development (Sarin and McDermott, 2013).
2.3.2. Drafting a Marketing Plan at Eli Lilly
The marketing plan in the case study will be developed based on the company’s preferences, which is added to Appendix C.
2.3.3. Combining literature and practice
Van Aken and Berends (2018) distinguish two main research paradigms, which are the explanatory research paradigm and design science research paradigm. Explanatory research, which is for instance the key paradigm in physics, are driven by pure knowledge problems and considers the case study from the observers’ perspective. The design science research paradigm, on the other hand, is driven by field problems and considered from the actors’ perspective. Furthermore, this view is the key paradigm in medicine and engineering. This study can be categorized within this last view, since it is interested in solving a field problem, which is the case study at Eli Lilly, and considers the study from the actors point of view, in this case the patients and physicians.
3. Methodology
In this chapter, the methods used to conduct this study are described. Section 3.1 will start by introducing the research approach. Next, the research design of the case study will be discussed, using the framework of Van Aken (2007). After this, the data collection method will be presented in section 3.3, based on theory on pharmaceutical marketing planning (Lidstone et al., 1999). Lastly, the analysis method used to assess the marketing plan will be described in section 3.4.
3.1. Research Approach
Traditional methods can lack in answering complex phenomenon for marketers, whereas case studies have been claimed to be effective in these complex circumstances (Johnston et al., 1999). This is the reason that this research is approached by a case study, since this research is set in a complex environment (Jommi, 2012). In addition of the practical side, which is the case study, theory will be used to support the marketing planning (Lidstone et al., 1999).
Qualitative research can produce insights that other types of research cannot (Winer and Ravi, 2013). In addition, within pharmaceutical marketing planning, it is argued that qualitative research is tactical for this type of research, since qualitative research fits the search for needs or opportunities, product positioning, advertising, and new product concepts. Since this research needs further insights when drafting the marketing plan on the clinical picture and the current market overview, which is data that is not analyzed statistically, this research can be categorized as qualitative (Lidstone et al., 1999).
Subjective data is used, to gain knowledge on how patients express themselves on the clinical picture. Studies showed that blogs and forums can be viable for research purposes. These groups and forums could open up new views and thoughts when trying to understand what the consumer wants (Wilkinson and Thelwall, 2011).
3.2. Research Design Marketing Plan
The basic activities in a business problem-solving project are analysis and design (Van Aken et al., 2007). The case study can broadly speaking also be divided in these two parts: an analysis of the available literature and the design of the marketing plan for Eli Lilly.
Key activities taking place in the analysis part can be divided in developing a problem analysis and developing a specifications part. The initial one is the analysis and diagnosis of the problem, and the latter is the definition of the specifications to which the solutions should conform (Van Aken et al., 2007). In the context of this case study, this can be categorized as the literature review and a market research on the clinical picture, which will result in different objectives for the plan. After this, designing will take place, which consists of a synthesis part and an evaluation, done in an iterative matter. The synthesis part is the creative part, where the solutions are assessed and compared with the specifications. Within the evaluation part, the contribution is assessed (Van Aken et al., 2007). In the context of this case study, this is the development of the marketing plan for Eli Lilly. After the iterations needed until approval received from Eli Lilly, the case study is successfully performed for this research. Figure 3.1 shows the outline of the case study.
Figure 3.1: Research design marketing plan, drawing on Van Aken et al. (2007)
Problem analysis Developing specifications Synthesis Evaluation Analysis
Literature review and market research Design
Develop marketing plan
Y
OK
?
3.3. Data collection
Grounded theory allows for a wide range of data, as long as the information has relevance and fit to the study. It allows for company reports and secondary data to be used (Glaser and Strauss, 1968), what this study will do. In addition, literature on pharmaceutical marketing planning advices desk research to be performed to obtain quickly overall awareness of the situation, and discusses different sources which can be used to obtain information (Lidstone et al. 1999). This research uses three of these sources. Firstly, published sources are used to get a view on the clinical picture, pharmaceutical marketing strategies and a methodology to assess the data in the end, which will be described in section 3.4. Secondly, company sources are used to assess the market and obtain a picture of the benefits and the disadvantages of the drug. Thirdly, information obtained from public organizations are used within this research. An example of a public organization used, is the Dutch Society for Rheumatology, which is used to understand the current guidelines on prescribing drugs within the clinical picture.
3.4. Data Analysis
Studies have shown that theories on the marketing process cannot always be used effectively in practice (Cui and Xiao, 2019; Dibb, 1998; Warner, 2010; Zain and Subramaniam, 2007). In addition, studies show that the quality of pharmaceutical marketing strategies are very variable, and mostly of a lower quality (Smith, 2003). Therefore, the eventual marketing plan has to be evaluated to see if methods used in literature and practice are still applicable.
The plan can be assessed by Smith’s (2003) properties of an effective strategy. The study describes four different criteria by which the quality of a pharmaceutical marketing plan can be assessed.
propositions differed from that of the competition. The criteria’s are defined comprehensively in Table 3.2 below.
Table 3.2: Properties of a strong strategy (Smith, 2003)
Strategy properties examined, in terms of idealized
description from the literature
Characteristics of strong strategies found in this study
Characteristics of moderate strategies found in this study
Characteristics of weak strategies found in this study
The target market(s) are defined as groups of customers that are broadly homogeneous in their needs
Target markets are defined by a tight product
definition, but with additional focusing according to behavior and attitudes.
Target markets are defined by product, but systematic targeting of resource is according to sales potential
Target markets are defined by a product definition and no sub targeting is visible within that.
The value proposition(s) are tailored to the specific needs of the target(s), across the breadth of the marketing mix
A core product proposition is clearly ‘tiered’ by levels of augmented product such as service and support. Alternatively, target customers allowed to ‘tailor’ propositions individually. There is clear evidence of alliances or other means of enabling the augmented product.
There is crude ‘rationing’ of a fairly standard service and support offer according to potential, usually carried out at sales team level.
The proposition is largely standard across the customer base, with minimal tailoring of price at sales team level.
The choice of target(s) and proposition(s) allows leverage of organizational strengths and minimization of organizational weaknesses.
There is tightly defined focus, based on a combination of tangible and ‘cultural’ strengths, combined with de facto avoidance of less attractive segments
Accidental’ alignment is caused by the de facto selection by customers in the context of
differentiated competitors
There is poor appreciation of relative strengths and weaknesses, with alignment only at sales level.
The choice of target(s) and proposition(s) is significantly different from that of the competition.
Initial targeting is similar to that of the competition, but with sub-targeting on different motivational criteria. There are similar core product propositions but with distinctly different augmented products.
Very similar explicit targeting and propositions to the competition is improved by targeting and proposition refinement, within narrow limits, at sales team level.
Target description is identical to that of the competition and there is little proposition
4. Context of the Case Study
In this section, the context of the case study at Eli Lilly will be described. It will start with the background of the company. Next, the clinical picture ‘’Axial Spondyloarthritis” will be described and an outlook of the competitive overview with the biologicals in this field will be given. After this, the medicine Taltz designed by Eli Lilly for the disease will be described shortly, and assessed briefly based on the current market.
4.1. Background of the Company
Eli Lilly and Company is an innovative pharmaceutical company, founded in 1876. Products developed by Eli Lilly are sold in approximately 125 countries and the company has offices in 18 countries. They have over 40,000 employees working for the company worldwide, of which approximately 100 work in the Netherlands (Lilly Nederland, 2019).
They currently focus their internal research efforts primarily in core therapeutic areas like diabetes, oncology, immunology, neurodegeneration and pain. The company got famous for their mass-produce of the polio vaccine and for their remarkable insulin productions (Lilly, 2019). Eli Lilly is one of the top pharmaceutical companies in the world based on market share, and consistently ranked one of the best companies to work at. They claim to sustain a culture that values excellence, integrity and respect for people (Lilly Nederland, 2019).
4.2. Axial Spondylarthritis
4.2.1. Symptoms
Months of inflammatory back pain is the key symptom of AxSpa. Since chronic back pain is common in general practice, the disease can be hard to diagnose (Rudwaleit, 2004). It can take up to multiple years to obtain the right diagnoses (Feldtkeller et al., 2003). The back pain occurs mostly at nighttime, which wakes up the patients, and results in stiffness in the morning. The stiffness can be decreased by physical activity. Additionally, waking up in the night due to the pain leads to fatigue during the day. The general patron of the disease is that the pain decreases during the day, where patients have the least pain in the evening (Landewé and Van Der Heijde, 2011). Figure 4.1 displays quotes of how patients experience the symptoms.
4.2.2. Diagnosis
5. Result Analysis
Now that the marketing plan has been drafted, this chapter will analyze the plan. This will be done, based on the four criteria’s discussed by Smith (2003). This chapter will conclude by evaluating the theory of Smith (2003).
5.1. Assessing the marketing plan
Smith (2003) discussed four properties that can distinguish a high quality marketing strategy. Firstly, the target market within the plan need to be checked to see whether this is defined as a groups of customers that are broadly homogeneous in their needs. Secondly, the value proposition is assessed based on how this is tailored to the needs of the target market. Thirdly, the SWOT analysis will be assessed based on its fit with the choice of targets and proposition. Both tangible aspects, for example the product features, and intangible aspects, for example cultural issues, should be taken into consideration. Lastly, the uniqueness of the strategy will be assessed based on the differentiation of the targets and propositions set compared to the competitors.
5.1.1. Target market definition
The target groups of Eli Lilly’s are defined in Appendix C. Reflecting this back to the property of Smith (2003), the marketing strategy covers a tight product definition, with additional focus on both attitude and their buyer readiness stage, implying this is a strong property of the strategy. 5.1.2. Value proposition
The value proposition in this marketing case can be found in Appendix C as well, where the action plan on how to reach the target groups is described.
The first two value proposition can be classified as strong characteristics of the plan, since they tailor propositions (Smith; 2003). The third value proposition can be classified as moderate, since this is a standard activity that all pharmaceutical companies have to carry out (Jommi et al., 2012). Taken the three value propositions in consideration, the overall conclusion is that this is again a strong property of the marketing plan.
5.1.3. SWOT alignment
Ignorance of company weaknesses are a common aspect of weak pharmaceutical strategies (Smith, 2003). Furthermore, intangible points are taken into account as well, for example with regard to the cultural aspects.
The SWOT analysis links the strengths and weaknesses of the organization to the choice of the target groups and the value propositions. Therefore, this property should be regarded as a strong strategy as well.
5.1.4. Strategy uniqueness
The uniqueness of the marketing strategy can be put in doubt. Nevertheless, this property is not weak, since steps are taken to differentiate from competitors, and therefore not to be categorized as market follower (Smith, 2003). This can be seen, for example in section 5.4.
This property has shown both strengths and weaknesses. The strategy is comparable to what competitors have done in the past. Therefore, this property has been categorized as a moderate strategy.
5.2. What can be learned from the case
Overall, the quality of the written marketing strategy has been shown to be fairly high, based on the fact that it scored three times strong and one time moderate on the four criteria’s. This refutes the theory of Smith (2003), but also Stuart-Kregor (2006), who claimed that pharmaceutical marketing strategies are far from excellent. Three points of evaluation on the theories (Smith 2003; Stuart-Kregor; 2006) are discussed below.
Firstly, one of the criteria’s of Smith (2003) required differentiation in services. This can be put to question, since the availability to offer services as pharmaceutical company is very restricted in some countries, which does not give the pharmaceutical company much choice in differentiation (Dijkgraaf et al., 2006; Wanyama, 2012; Windmeijer et al., 2006).
6. Conclusion, Limitations and Recommendations
In this chapter, the main research question will be answered in Section 6.1, where also the contribution to the academic literature and practice are described. Then, the limitations of this study will be discussed. This chapter will conclude in section 6.3, by providing recommendations, both for literature and for practice.
6.1. Main Findings
After analyzing the results in Chapter 5, this study goes back to the main research question:
How useable are current pharmaceutical marketing strategies for positioning a new indication of a drug in a highly competitive market?
As described more comprehensively in Section 5.1, this study showed that the current pharmaceutical marketing strategies are still usable and of a fairly high quality. The marketing plan has shown to have a high level of quality on three criteria’s, and a moderate level on the remaining one.
6.1.1. Contribution to the literature
The contribution to the literature that results from this research, is that it refutes the theories of Smith (2003) and Stuart-Kregor (2006), showing that current pharmaceutical marketing strategies are still applicable and of a fairly high quality.
6.1.2. Managerial contributions
The first contribution to practice is the analysis of the methodology used by Eli Lilly. With more certainty can be claimed now within the company that the used methodology is of a fairly high quality (Smith, 2003).
The second contribution can be found in Appendix C.
6.2. Limitations
As mentioned in the Chapter 3, this study followed the Coloured Diamond approach of Visscher and Fisscher (2009), implying that a part of the theoretical suggestions made by Lidstone et al. (1999) have not been put in practice, because this fell outside the preferences of the company. This is the case for the extensive company audit, which studies already questioned regarding its effectiveness (Zain and Subramaniam, 2007). However, the high quality of the SWOT analysis showed that limitations of the company are still covered to a certain extent.
Secondly, this research performed a single case study, which has the benefit of being less time-consuming. However, studies conducting a multiple case study have shown to provide stronger and more reliable data (Gustafsson, 2017; Heale and Twycross, 2018)
6.3. Recommendations
6.3.1. Recommendations for literature
The main recommendation for literature is to test the quality of pharmaceutical marketing strategies in a multiple case study instead of this single case study, since multiple case studies are known to provide strong and reliable data (Gustafsson, 2017; Heale and Twycross, 2018).
Secondly, this research performed a marketing study for the Dutch market. This is a very restricted market and has multiple differences compared to organization to other countries, as discussed in Section 2.1 (Grenada and Mancuso, 2011; Windmeijer et al., 2006). The
References
AIM (2015). [online] Vereniginginnovatievegeneesmiddelen.nl. Available at:
https://www.vereniginginnovatievegeneesmiddelen.nl/stream/com-brochure-farmafeiten-2015-engelse-versie-pharma-facts-2015.pdf [Accessed 18 Nov. 2019].
AIM (2019). MEDICIJN MONITOR 2019-2020 - Vereniging Innovatieve Geneesmiddelen. [online] Vereniging Innovatieve Geneesmiddelen. Available at:
https://publicaties.vereniginginnovatievegeneesmiddelen.nl/magazine/mm2019/cover/ [Accessed 2 Sep. 2019]. ASAS (2009). ASAS Handbook. [online] ASAS. Available at: https://www.asas-group.org/education/asas-handbook/ [Accessed 29 Aug. 2019].
Black, I., 2005. Pharmaceutical marketing strategy: Lessons from the medical literature. Journal of Medical Marketing, 5(2), pp.119-125.
Brandt, H.C., Spiller, I., Song, I.H., Vahldiek, J.L., Rudwaleit, M. and Sieper, J., 2007. Performance of referral recommendations in patients with chronic back pain and suspected axial spondyloarthritis. Annals of the rheumatic diseases, 66(11), pp.1479-1484.
Buckley, J., 2004. Pharmaceutical marketing-time for change. EJBO-Electronic Journal of Business Ethics and Organization Studies.
Bukata, W.R., 2002. Pharmaceutical Marketing: The Facts Speak for ThemselvesPart I in a Two-Part Series. Calkins (2019). Timothy Calkins - Faculty - Kellogg School of Management. [online] Kellogg.northwestern.edu. Available at: https://www.kellogg.northwestern.edu/faculty/directory/calkins_timothy.aspx [Accessed 30 Nov. 2019].
CBS (2019). [online] Centraal Bureau voor de Statistiek. Available at: https://www.cbs.nl/nl-nl/visualisaties/bevolkingsteller [Accessed May 2019].
CVZ (2010). [online] English.zorginstituutnederland.nl. Available at:
https://english.zorginstituutnederland.nl/binaries/zinl-eng/documents/reports/2010/03/01/dutch-assessment-
procedures-for-the-reimbursement-of-outpatient-medicines/Dutch+Assessment+Procedures+for+the+Reimbursement+of+Outpatient+Medicines.pdf [Accessed 30 Nov. 2019].
Cooper, R.G., 1996. What separates the winners from the losers. The PDMA handbook of New Product Development.
Couzin, J., 2005. The brains behind blockbusters. Science, 309(5735), pp.728-728.
Cui, A. S. and Xiao, Y. (2019) “The Role of Market and Technical Information Generation in New Product Development,” Journal of Product Innovation Management, 36(3), pp. 305–330. doi: 10.1111/jpim.12479. Dawar, N., 2013. Tilt: Shifting your strategy from products to customers. Harvard Business Review Press.
Dietvorst, G. (2017). Geharrewar over geneesmiddelen, maar zijn ze nou echt zo duur?. [online] Nos.nl. Available at: https://nos.nl/artikel/2203961-geharrewar-over-geneesmiddelen-maar-zijn-ze-nou-echt-zo-duur.html [Accessed 18 Nov. 2019].
Feizizadeh, A., 2012. Strengthening internal audit effectiveness. Indian Journal of Science and Technology, 5(5), pp.2777-2778.
Feldtkeller, E., Khan, M., van der Heijde, D., van der Linden, S. and Braun, J., 2003. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatology international,
23(2), pp.61-66.
Forbes (2019). [online] Available at:
https://www.forbes.com/global2000/list/#header:marketValue_sortreverse:true_industry:Pharmaceuticals [Accessed 27 Nov. 2019].
Haaijer-Ruskamp, F.M. and Denig, P., 2001. Invloeden bij het kiezen van geneesmiddelen. Dutch: Influences on the choice of pharmaceuticals]. Geneesmiddelenbulletin, 35, pp.37-42
Hikkerova, L., Kammoun, N. and Lantz, J.S., 2014. Patent life cycle: new evidence. Technological Forecasting and Social Change, 88, pp.313-324.
Hunter, T., Deodhar, A.A., Bolce, R., Schroeder, K. and Calderon, D.S., 2018, September. Predicting Treatment Persistence and Non-Persistence of Newly Initiated TNF Inhibitor Therapy in Ankylosing Spondylitis Patients: A Gender Comparison. In ARTHRITIS & RHEUMATOLOGY (Vol. 70). 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY.
Johnston, W.J., Leach, M.P. and Liu, A.H., 1999. Theory testing using case studies in business-to-business research. Industrial marketing management, 28(3), pp.201-213.
Jommi, C., Otto, M., Armeni, P. and De Luca, C., 2012. Market access management by pharmaceutical companies in a complex environment: The Italian case study. Journal of Medical Marketing, 12(2), pp.93-103.
Karagozoglu, N. and Brown, W.B., 1993. Time-based management of the new product development process. Journal of product innovation management, 10(3), pp.204-215.
Keefe, L.M., 2004. What is the meaning of ‘marketing’. Marketing News, 38(15), pp.17-18. KNOV (2016). [online] Knov.nl. Available at:
https://www.knov.nl/serve/file/knov.nl/knov_downloads/2639/file/Gedragscode_Geneesmiddelenreclame_1_dece mber_2016.pdf [Accessed 18 Nov. 2019].
Ladha, Z., 2007. Marketing strategy: are consumers really influenced by brands when purchasing pharmaceutical products?. Journal of Medical Marketing, 7(2), pp.146-151.
Landewé, R.B.M. & van der Heijde, D.M.F.M. (2011). Het herkennen van patiënten met spondyloartritis.
Nederlands Tijdschrift voor Geneeskunde, 155:A3680.
Leeflang, P. S., & Wieringa, J. E. (2010). Modeling the effects of pharmaceutical marketing. Marketing Letters, 21(2), 121-133.
Lilly (2019). Scientific Areas of Interest. [online] Lilly.com. Available at: https://www.lilly.com/partners/scientific-areas-of-interest [Accessed 1 Dec. 2019].
Lilly Nederland (2019). Kernwaarden. [online] Lilly.nl. Available at: https://www.lilly.nl/nl/about/kernwaarden.aspx [Accessed 1 Dec. 2019].
Mease, P. J., Heijde, D. V., Karki, C., Palmer, J. B., Liu, M., Pandurengan, R., … Greenberg, J. D. (2018). Characterization of Patients With Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis in the US-Based Corrona Registry. Arthritis care & research, 70(11), 1661–1670. doi:10.1002/acr.23534
Munos, B.H. and Chin, W.W., 2011. How to revive breakthrough innovation in the pharmaceutical industry.
Science translational medicine, 3(89), pp.89cm16-89cm16.
NVR (2014). [online] Nvr.nl. Available at: https://www.nvr.nl/wp-content/uploads/2018/09/NVR-Reumatische-ziekten-richtlijn-axiale-SpA-2014.pdf [Accessed 1 Dec. 2019].
Nykiel, R.A., 2003. Marketing your business: a guide to developing a strategic marketing plan.
Ottum, B. D. and Moore, W. L. (1997) “The Role of Market Information in New Product Success/failure,” The Journal of Product Innovation Management, 14(4), pp. 258–273. doi: 10.1016/S0737-6782(97)00013-1.
Payne, A. and Frow, P., 2013. Strategic customer management: Integrating relationship marketing and CRM. Cambridge University Press.
Rasmussen (2017). NJ to Get $287K Share of Boehringer's $13.5M Off-Label Marketing Settlement | New Jersey Law Journal. [online] New Jersey Law Journal. Available at:
https://www.law.com/njlawjournal/sites/njlawjournal/2017/12/21/boehringer-to-pay-13-5m-to-settle-states-off-label-marketing-claims/?slreturn=20191020043800 [Accessed 20 Nov. 2019].
Reijn, G. (2015). Recordboetes voor verboden reclame farmaceuten. [online] Volkskrant.nl. Available at: https://www.volkskrant.nl/nieuws-achtergrond/recordboetes-voor-verboden-reclame-farmaceuten~b51b2215/ [Accessed 20 Nov. 2019].
Rife, S.C., Cate, K.L., Kosinski, M. and Stillwell, D., 2016. Participant recruitment and data collection through Facebook: The role of personality factors. International Journal of Social Research Methodology, 19(1), pp.69-83. Rowley, J., 2012. Conducting research interviews. Management research review, 35(3/4), pp.260-271.
Sarin, S. and McDermott, C., 2003. The effect of team leader characteristics on learning, knowledge application, a nd performance of cross‐functional new product development teams. Decision sciences, 34(4), pp.707-739. Schwartz LM and Woloshin S (2019) “Medical Marketing in the United States, 1997-2016,” JAMA, 321(1), pp. 8 0–96. doi: 10.1001/jama.2018.19320.
SEO (2014). [online] Vereniginginnovatievegeneesmiddelen.nl. Available at:
https://www.vereniginginnovatievegeneesmiddelen.nl/stream/com-rapport-seo-de-farmaceutische-industrie-in-het-maatschappelijk-debat [Accessed 18 Nov. 2019].
Sheehan, N.J., 2004. The ramifications of HLA-B27. Journal of the Royal Society of Medicine, 97(1), pp.10-14. Siegal and Shah (2019). Optimizing market access. [online] Deloitte Insights. Available at:
https://www2.deloitte.com/us/en/insights/industry/life-sciences/pharmaceutical-pricing-market-access.html [Accessed 20 Nov. 2019].
Slobodin, G., & Eshed, I. (2015). Non-radiographic axial spondyloarthritis. IMAJ, 17, 770-776.
Smith, B., 2003. An empirical investigation of marketing strategy quality in medical markets. Journal of Medical Marketing, 3(2), pp.153-162.
Smith, B., 2004. Making marketing happen: How great medical companies make strategic marketing planning work for them. Journal of Medical Marketing, 4(2), pp.129-142.
Spielmans, G.I. and Parry, P.I., 2010. From evidence-based medicine to marketing-based medicine: evidence from internal industry documents. Journal of Bioethical Inquiry, 7(1), pp.13-29.
Stolwijk, C., van Onna, M., Boonen, A., & van Tubergen, A. (2016). Global prevalence of spondyloarthritis: a systematic review and meta‐regression analysis. Arthritis care & research, 68(9), 1320-1331.
Stuart-Kregor, P., 2006. Are Pharmaceutical (or Healthcare) Companies Achieving True ‘Marketing Excellence’?. Journal of Medical Marketing, 6(1), pp.19-30.
Sweet, M., 2009. Pharmaceutical marketing and the internet. Australian prescriber, 32(1), pp.1-4.
United States Department of Justice (2017). Celgene Agrees to Pay $280 Million to Resolve Fraud Allegations Related to Promotion of Cancer Drugs For Uses Not Approved by FDA. [online] Justice.gov. Available at: https://www.justice.gov/usao-cdca/pr/celgene-agrees-pay-280-million-resolve-fraud-allegations-related-promotion-cancer-drugs [Accessed 20 Nov. 2019].
Van Aken, J. E., & Berends, H. (2018). Problem solving in organizations. Cambridge University Press. Van Mil, J.F., 2005. Pharmaceutical care in community pharmacy: practice and research in the Netherlands. Annals of Pharmacotherapy, 39(10), pp.1720-1725.
Visscher, K., & Fisscher, O. A. (2009). Cycles and diamonds: How management consultants diverge and converge in organization design processes. Creativity and Innovation Management, 18(2), 121-131.
Wanyama, M.I.L.D.R.E.D., 2012. Differentiation strategy of pharmaceutical companies manufacturing human medicine in Kenya.
Warner, A. G. and Business Expert Press (2010) Strategic analysis and choice : a structured approach. 1st edn. Ne w York: Business Expert Press (Business Expert Press Strategic Management collection). doi: 10.4128/978160649 1768.
Wilkinson, D. and Thelwall, M., 2011. Researching personal information on the public web: Methods and ethics. Social science computer review, 29(4), pp.387-401.
Windmeijer, F., De Laat, E., Douven, R., & Mot, E. (2006). Pharmaceutical promotion and GP prescription behaviour. Health economics, 15(1), 5-18.
