1.1 INDUSTRY PROFILE

1.1.1 Pharmaceutical industry in India:

The Indian pharmaceutical industry today is in the front rank of India’s science-based industries with wide-ranging capabilities in the complex field of drug manufacture and technology. It is a highly organized sector growing rapidly. It ranks very high in the third world, in terms of technology, quality and range of medicines manufactured. Playing a key role in promoting and sustaining development in the vital field of medicines, Indian pharmaceutical industry boasts of quality producers and many units approved by regulatory authorities in USA and UK. International companies associated with this sector have stimulated, assisted and spearheaded this dynamic development in the past 53 years and have helped to put India on the pharmaceutical map of the world.1

It is an extremely fragmented market with severe price competition and government price control. However, the span of price control has been on the front of steady decrease. The first formal drug price control was introduced in 1979, effected under the essential commodities act. Since then, there have been two price revisions, the first being in 1987 and the second in 1995. Administrative and rigid price control has certainly retarded the development of this essential industry. More and more products are being withdrawn from DPCO and in such a situation, serious questions arise towards health for all quote but from the intellectual property point of view, it gives support to the industry towards R&D development.2

1.1.2 Overview of Diagnostic Imaging Industry:

The ever-advancing field of radiology has seen tremendous growth since the discovery of X-ray by Roentgen in 1895. In fact, it is one of the most powerful diagnostic approaches in clinical medicine today. Moreover, in the past 30 years, the field has seen accelerated growth in technology with the dawn of interventional radiology and nuclear medicine and the introduction of cross-sectional imaging. Indeed, the technologies used today in the arena either did not exist a decade ago or were only at a nascent stage. About 34 per cent of radiological imaging procedures and 73 per cent of the relative value units involved in radiological imaging namely, computed tomography (CT), magnetic resonance (MR) imaging, Ultrasonography (US), interventional radiology, or nuclear medicine were only in the embryonic stage a generation earlier.3

Although diagnostic imaging has made dramatic progress in the last few decades, it’s expected to make a more dramatic turnaround in the foreseeable future. For one, medical imaging is increasing in sensitivity and in specificity moving towards optimum precision; it is acquiring and displaying data in three a four dimensions, on the verge of providing virtual presentations. What’s more? Functional and metabolic imaging has become a reality, and one can expect that genetic and molecular marker imaging is going to explode in the scenario in the near future. Additionally, novel, more biologically specific contrast media for all medical imaging modalities and especially for MR imaging are in various stages of testing. Consequently, new techniques are also resulting in rapid throughput of patients, which even makes examinations performed on very expensive instruments more affordable as high

1 Gerster R. “ (N.A.) “Indian Pharmaceutical Industry”, Available from: http://www.pharmaceutical-drug-manufacturers.com/pharmaceutical-industry/ (Accessed on: 30/June/10)2 Rane Y., Shah P., Mashru R. (2006)“Intellectual property rights for Indian pharmaceutical firms: What needs to be corrected?” Pharma Times, Vol. 38 (6), Available from: http://www.ipapharma.org/pdf/Yogesh%20Rane_Article.pdf (Accessed on: 9/July/10)

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volume results in reduced costs. Of course, we do not know for sure how many of these potential advances will prove worthwhile in everyday clinical practice, but the possibilities are enormous. 3

This remarkable progress in the field can be mainly attributed to advances in electronics and computing. There has been a tremendous growth in computer function, and according to industry experts, this growth would be a continuous process. Further, diagnostic imaging has leveraged the benefits of this growth in many applications. Although, much of the advancement in diagnostic imaging is attributed to the shrinking size of equipment, the improvements in detectors; the revolution in image acquisition, resolution, transmission, and manipulation have also contributed to the leap in medical imaging in the past two decades.3

Incidentally, most of the research that fueled this growth has been conducted in the West. Very few investigators in India are working on discovering new contrast media or working on innovations in diagnostic imaging equipment. Interestingly, till date, government bodies or even the ever growing venture capitalist firms have not opened their eyes to the benefits of investing in such research. As a result, financial crunch remains one of the most crippling burdens of researchers in India. 3

1.1.3 Trends in Indian Diagnostic Imaging Market:

Future developments promise to make the progress of radiology as dramatic, exciting, and expansive as it has been for the past 25 years. The most promising of these likely advances would be seen in conventional radiology and picture archiving and communication systems (PACS), CT, MRI, interventional radiology, and nuclear medicine. In days to come, radiology will move towards filmless environment with streamlined, lower cost, and physician-friendly workstations. With the advances in flat-surface digital detectors, even bedside radiography will become directly digitalized and all of it will feed into PACS.3

In India, most hospitals are at some stage of PACS planning or implementation and the field is expected to grow by leaps and bounds. PACS in India would grow both in institutions and hospitals in corporate as well as government sectors. PACS integration is more likely in new hospitals where an online system is easy to start with, rather than one where the process will be over phases. Furthermore, PACS will soon be imperative in order to manage the exploding volumes of images created by the newest technologies like CT and MRI and to provide enhanced quality and service. At nearly 10 years old, PACS can validly be considered mature. Its technology is well-understood, its clinical usefulness universally acknowledged, and ongoing research reveals new secondary benefits-from faster diagnosing and easier consultations to systemic cost savings. 3

 Right now, most specialized modalities are already digitalized: angiography, ultrasound, CT, MRI, and nuclear medicine. However, general radiography and mammography are slowly moving in this direction. In future, computer assisted diagnosis (CAD) will become prominent as an adjunct, providing a second read for screening mammography. TomosIndo-US Healthcare is launching virtual radiology network (VRN) for Indian radiologists to collects digital imaging studies from multiple, geographically-dispersed locations and delivers them securely, reliably and efficiently to physicians using broadband internet connectivity. The virtual radiology network would enable radiologists to perform remote

3 Tiwari A. , Kishore L.T. , Naiyer Imam (2010) “Medical Imaging Industry in India” ; Healthcare IT solutions, Indo-Us Healthcare, Available from: http://www.indoushealthcare.com/html/medical-imaging.html (Accessed on: 4/July/10)

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reading across geographic boundaries with greater control over report turnaround times and distribution to referring doctors and even patients and their families. The virtual radiology network will also help radiologists manage image-related workflow across distributed sites, providing productivity-enhancing tools and capabilities that include universal work lists, automatic routing, workload balancing and management control dashboards. It would also provide an outsourced clinical image management service that can increase the productivity of multi-site groups, helping them achieve growth without the pain, cost and risk typically associated with traditional PACS solutions. Synthesis will provide 3D breast images from digital mammography.In lieu of this development, teleradiology will get a huge impetus to spread its roots globally. Today, though it is not an alien term, teleradiology is not actually flourishing in India. The road ahead does promise the benefits of low costs and second opinion, it would be imperative to wait and watch for the results. 3   

Refer Appendix VI

1.1.4 Radiology in India:

Though Prof. W.C. Roentgen discovered the mysterious X-rays on 8th November, 1895, it is difficult to be sure as to when and where the first X-ray machine was installed in India. The late Dr. K. P. Mody had mentioned, in his editorial in the Indian Journal of Radiology & Imaging, in 1956 that the first X-ray machine was imported by a chemist in 1902 into India; that was only 7 years after the discovery. New Delhi became the capital of India in 1912. It appears that, in Delhi the first X-ray machine was installed at Lady Hardinge Hospital in 1918, and a chair in radiology was established in 1923 at the Lady Hardinge Medical College & Hospital. After World War I, the government established a dispensary with X-ray facilities somewhere near Jama Masjid. Rai Bahadur Hari Ram started private practice in radiology along with his general practice in 1932, but exclusive radiology practice was started by Dr. S C Sen in 1933 that later became a founder member of the Indian Radiological Association (IRA). He had a 150 mA unit. Dr. Sen claimed two other "firsts" to his credit. He started deep X-ray therapy in New Delhi in 1935 with a 180 kV machine and also started group practice.9

Radiology in North India further evolved at the time of partition in 1947, when a large number of medical practitioners including radiologists migrated to Delhi from Pakistan. Some of the prominent radiologists among them were Dr. Diwan Chand Agarwal, Dr. R K Handa, Dr. R C Goulatia, Dr. R M Sharma and Dr. Roshan Lal. Dr. D C Agarwal had been one of the leading radiologists in Lahore since 1927. This remarkable man laid down the foundation of a modern X-ray clinic in Delhi. Similar advancements were taking place in the southern, western and eastern parts of India and Madras (now Chennai), Bombay (now Mumbai) and Calcutta grew in stature. The Barnard Institute of Radiology was established in Chennai and many radiologists who could not go abroad for training, went to Madras for their post-graduate studies.9

As for the “Equipments”, earlier machines were single phase self rectified x-ray machines with air-cooled rectified valves with cones and cylinders. The tables were mechanically or manually operated with crude spot film devices, etc. One was lucky to get access to a 200 or 300 mA unit. In Delhi, upto 1952, Irwin Hospital and Lady Hardinge Medical college had the only well-equipped radiology departments while Safdarjung Hospital languished with only one 100 mA unit. At present, there are scores of well-equipped departments in Government and public institutions and there are over a 100 private clinics. Similarly, all the metropolitan cities have scores of well-equipped centres.9

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It appears that there are about ten thousand 500 mA units in India today; 100-500 mA units are about 30,000 and less than 100 mA units may be about 20,000. The annual demand for conventional x-ray machines is in the vicinity of 1500 (though it appears that demand is going down). There are about 350 CT scanners all over the country with a demand of about 50 per annum. There are about 50 MRI scanners and the anticipated demand is 20 per year. 4

1.1.5 Radiologist and cardiologist societies:

Though Prof. W.C. Roentgen discovered the mysterious X-rays on 8th November, 1895, it is difficult to be sure as to when and where the first X-ray machine was installed in India. The late Dr. K. P. Mody had mentioned, in his editorial in the Indian Journal of Radiology & Imaging, in 1956 that the first X-ray machine was imported by a chemist in 1902 into India; that was only 7 years after the discovery.

New Delhi became the capital of India in 1912. It appears that, in Delhi the first X-ray machine was installed at Lady Hardinge Hospital in 1918, and a chair in radiology was established in 1923 at the Lady Hardinge Medical College & Hospital. After World War I, the government established a dispensary with X-ray facilities somewhere near Jama Masjid. Rai Bahadur Hari Ram started private practice in radiology along with his general practice in 1932, but exclusive radiology practice was started by Dr. S C Sen in 1933 that later became a founder member of the Indian Radiological Association (IRA). He had a 150 mA unit. Dr. Sen claimed two other "firsts" to his credit. He started deep X-ray therapy in New Delhi in 1935 with a 180 kV machine and also started group practice.

Radiology in North India further evolved at the time of partition in 1947, when a large number of medical practitioners including radiologists migrated to Delhi from Pakistan. Some of the prominent radiologists among them were Dr. Diwan Chand Agarwal, Dr. R K Handa, Dr. R C Goulatia, Dr. R M Sharma and Dr. Roshan Lal. Dr. D C Agarwal had been one of the leading radiologists in Lahore since 1927. This remarkable man laid down the foundation of a modern X-ray clinic in Delhi.

Similar advancements were taking place in the southern, western and eastern parts of India and Madras (now Chennai), Bombay (now Mumbai) and Calcutta grew in stature. The Barnard Institute of Radiology was established in Chennai and many radiologists, who could not go abroad for training, went to Madras for their post-graduate studies.

As for the “Equipments”, earlier machines were single phase self rectified x-ray machines with air-cooled rectified valves with cones and cylinders. The tables were mechanically or manually operated with crude spot film devices, etc. One was lucky to get access to a 200 or 300 mA unit. In Delhi, upto 1952, Irwin Hospital and Lady Hardinge Medical college had the only well-equipped radiology departments while Safdarjung Hospital languished with only one 100 mA unit. At present, there are scores of well-equipped departments in Government and public institutions and there are over a 100 private clinics. Similarly, all the metropolitan cities have scores of well-equipped centres.4

It appears that there are about ten thousand 500 mA units in India today; 100-500 mA units are about 30,000 and less than 100 mA units may be about 20,000. The annual demand for conventional x-ray machines is in the vicinity of 1500 (though it appears that demand is

4 Dhawan S K(N.A.) “A brief history of Indian Radiology” ; Radiology Education FoundationAvailable from: http://www.refindia.net/rindia/history.htm (Accessed on: 5/July/10)

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going down). There are about 350 CT scanners all over the country with a demand of about 50 per annum. There are about 50 MRI scanners and the anticipated demand is 20 per year.4

India currently has five national Associations in the field of Radiology:

National Radiologist Societies

IRIA - Indian Radiology & Imaging Association (IRIA)

ICRI - Indian College of Radiology & Imaging (ICRI)

ISVIR - Indian Society of Vascular & Interventional Radiology (ISVIR)

IFUMB - Indian Federation of Ultra Sound in Medicines & Biology (IFUMB)

ISNR - Indian Society of Neuroradiology 5

IRIA - INDIAN RADIOLOGY & IMAGING ASSOCIATION (IRIA) 5

Name Indian Radiology & Imaging Association (IRIA)

Corresponding Address

IRIA House, C-5, Qutab Institutional Area, New Delhi 110 016.Tel: 011-2696-5598, Fax: - 011-265 65391

INTERNET www.iria.in

EMAIL iria@bol.net.in

President - Dr. S S Doda

Secretary - Dr. Prabhakar Reddy

Scope - Represents Indian Radiology

Membership Fees - Rs. 4,000/- + Rs. 200/- (Admission Fees)

Membership Criteria

- Qualified and practicing radiologist

Next Conference http://www.iria.in/news_list.php

5 REF (2009)“India Radiology Institutions” Available from: http://www.refindia.net/rindia/associations.htm (Accessed on: 9/July/10)

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ICRI - INDIAN COLLEGE OF RADIOLOGY & IMAGING (ICRI) 5

Name Indian College of Radiology & Imaging (ICRI)

Corresponding Address

IRIA House, C-5, Qutab Institutional Area, New Delhi 110 016.Tel: 011-2696-5598, Fax: - 011-265 65391

INTERNET www.iria.in

EMAIL iria@bol.net.in

Chairman - Dr. Samarjit Bhadury

Secretary - Dr. O.P. Sharma

Scope - Radiology education in India

Membership Fees - Rs. 3,000/- + Rs. 500/- (Admission Fees)

Membership Criteria

- Continuous member of IRIA for 3 years or more and life members

Next Conference http://www.iria.in/news_list.php

ISVIR- INDIAN SOCIETY OF VASCULAR & INTERVENTIONAL RADIOLOGY (ISVIR)5

Name Indian Society of Vascular & Interventional Radiology (ISVIR)

Corresponding Address

Dr. Sanjiv Sharma Dept. of Cardiac Radiology, Cardiothoracic Centre All India Institute of Medical Science New Delhi - 110 029 E-mail : meetisv@yahoo.com

Dr. A. K. Gupta Dept. of Neuro Radiology Sree Chitra Tirunal Institute of Medical Sciences & Technology

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Thiruvananthapuram, Kerala Email: GUPTA@SCTIMST.ker.nic.in

INTERNET www.isvir.in

President Dr. Sanjiv Sharma

Secretary Dr. Shailesh B. Gaikwad

Scope Vascular & Interventional Radiology

Membership Fees Rs. 3,000/-

Membership Criteria

Specializing in Vascular & Interventional Radiology

Next Conference http://www.isvir.in/events.php

ISNR - INDIAN SOCIETY OF NEURORADIOLOGY (ISNR) 5

Name Indian Society of Neuroradiology (ISNR)

Corresponding Address

ISNR Secretariat, C/O Dept of Radiodiagnosis, Institute of Neurological Sciences, Dispur, 781006. Assam, INDIA.

INTERNET www.isnrindia.org

EMAIL info@isnrindia.org

President Dr. N.K. Mishra

Secretary DR. S.K. Handique

Scope Neuroradiology

Regular Fees Rs. 1,000/- + Rs. 200/- (Admission Fees)

Membership Fees Rs. 3,000/- + Rs. 200/- (Admission Fees)

Membership Post-graduate qualification from

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Criteria recognized university

Next Conference http://www.isnrindia.org/pages/annual-conference.php#

Regional Radiological Societies

ISRT- THE INDIAN SOCIETY OF RADIOGRAPHERS & TECHNOLOGISTS (ISRT)5

IART- INDIAN ASSOCIATION OF RADIOLOGICAL TECHNOLOGISTS (IART)5

Name IART- INDIAN ASSOCIATION OF

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Name INDIAN SOCIETY OF RADIOGRAPHERS & TECHNOLOGISTS (ISRT)

Corresponding Address

ISRTDept. Of  Radiodiagnosis P.B.No:1508 Medical College.P.O. Calicut -673 008 Kerala, India

Phone:-     +91 9846433944     +91 9731564323     +91 9496804998

Email: info@isrt.org.in

INTERNET http://www.isrt.org.in/

President Dr. Sanjiv Sharma

Scope Interventional Radiology

Membership Fees Not disclosed

Membership Criteria

Specializing in Radiology

Next Conference http://www.isrt.org.in/php/ourActivities.php

RADIOLOGICAL TECHNOLOGISTS (IART)

Corresponding Address

Indian Association of Radiological Technologists,

Department of Radiodiagnosis & Imaging,

P.G.I.M.E.R, Sector 12,

Chandigarh (India) - 160012

INTERNET http://www.iart.org.in

EMAIL mail@iart.org.in

President Mohan Lal Bhagwat

Secretary S. C. Bansal

Scope Represents Indian Radiology

Membership Fees Not Disclosed

Membership Criteria

Qualified and practicing radiologist

Next Conference http://www.iart.org.in/news.php

Refer Appendix V

1.2 PEST ANALYSIS OF THE INDIAN PHARMACEUTICAL INDUSTRY

As part of qualitative analysis, PEST analysis is done to understand the industry environment and its influences on business. The acronym stands for the Political, Economic, Social and Technological issues that could affect the strategic development of a business. Identifying PEST factors is a useful way of summarizing the external environment in which a business operates International and national regulations, perpetual demand and changing technologies that have made pharmaceutical industry environment very competitive and tough.

Political

1. The Drug pricing control orders (DPCO), and NPPA nullifies the market forces from encouraging competitive pricing of goods dictated by market. Now the pricing is

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determined by the Government based on approved cost and irrespective of actual cost incurred. 6

2. Since the implementation of product patent, small Indian companies are finding it hard to survive. The law requires them to put capital for R & D and innovate their own drugs. They can no more follow reverse engineering route to develop alternate methods of manufacturing already patented drugs. This led to acquisition of small Indian pharmaceutical firms by big firms.7

3. The subsidy provided by government to manufacturing units located in some specified areas is unfair to rest of the industry. For e.g. Tax exemptions provided on SEZ in state of Himachal Pradesh and Gujarat for pharmaceutical companies. This brings skewed development of industry making it unsuitable for a best cost manufacturing activity.2

4. Effective the January, 2005 the Government has shifted from charging the Excise Duty on the cost of manufacturing to the MRP thereby making the finished products more costly.2

5. Effective the January, 2005 the country got in for the IPR (Intellectual Property Rights) regime, known as the Patent Act. India amended its patent legislation to allow product patents for pharmaceutical and agricultural products that were not previously permitted. After 2005, the globally harmonized patent system prohibited the production and marketing of patent-protected new drugs. TRIPS(Trade related aspects of intellectual property rights) allows patenting of pharmaceuticals for 20 years from the date of filing, grants exclusive marketing rights until patent expiry and doesn’t permit patent discrimination for imported products. Since 2005 India began recognizing global patents. After recognizing the global patent regime the Indian pharmaceutical market became a sought after destination for foreign players. The patent expiry of Magnevist by Bayer Schering in 2007 in India has also affected Bayer Schering Pharma’s performance in the Indian market. The generic brands will thus rise and Bayer will face stiff competition from the domestic Indian Pharmaceuticals. For e.g. JB chemicals of India has already started producing contrast agents for MRI called Magnelink which has “gadopentetate” compounds of Magnevist. 8

Refer Appendix I, II

Economic

1. India spends a very small proportion of its GDP on healthcare (a mere 1%). This has stunted the demand and therefore the growth of the industry.2

6 Rao P., Tiwari P., (2006 )“Impact of TRIPS on Pharmaceutical prices “ Available from: http://www.whoindia.org/LinkFiles/Trade_Agreement_Impact_of_TRIPS_on_Pharmaceutical_Prices.pdf (Accessed on: 20/July/10)7 Satyanarayana T. , Reddy D., Swarnalatha D., Purushothaman M. (2010)“Enforcement of Intellectual Property Rights: International and National Obligations and Practical Challenges in Pharmaceuticals Sector”, JITPS, Vol.1 (4), pp. 186-190, Available from: http://www.itpsonline.net/Documents/Volumes/Vol1Issue4/jitps_01041005.pdf (Accessed on: 9/July/10)8 Sharma A. (2005) “New amendments to Patents Act, 1970 to affect farm sector “ Available from: http://www.financialexpress.com/fe_archive_full_story.php?content_id=78652 (Accessed on: 30/June /10)

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2. Low per capita of average Indians makes them to spend even less on their healthcare, making unauthorized practitioners popular and prevalence of substandard products, which hit the sales of genuine manufacturers.2

3. The various taxes paid by drug manufacturers(Excise duty, custom duty, Service tax, Professional tax, License fees, Royalty pollution clearance, Hazardous substance license, Stamp duty and Income tax etc.) increase the cost of drugs by 40-50%. 2

4. Rising demand for cheaper generic products amid cost-containment pressures would affect the demand for contrast media of Bayer Schering Pharma.2

5. Price sensitiveness of Indian consumers would impact the buying pattern of contrast media by the hospitals and diagnostic centers.2

6. High corporate income tax of 33.3% compared to other south Asian countries also deters many MNC’s to do investment in this Industry.2

7. Inadequate transportation and storage facilities for special drugs, causes deterioration in quality of drugs administered and add costs to companies. Due to poor road infrastructure in India, transportation time is higher. This calls for higher inventory carrying costs and longer delivery time. All this adds to the invisible costs.

Social

1. High incidence of illiteracy and lack of adequate knowledge of people make them believe in unauthorized medical practitioners. Hence large proportion of Indian population doesn’t go for effective and expensive drugs and formulations.

2. Other forms of drugs and treatments like Homeopathy, Reiki, Yoga and Ayurveda take away share of sales from pharmaceutical manufacturers. A larger part of the population prefer treating and curing common ailments using household treatments handed down for generations rather than visiting a specialist or doctor.

3. Lack of health insurance, adequate knowledge and awareness about the latest diagnostic imaging facilities holds them back from going to specialized diagnostic centers for treatments and check up.

Technological

1. Acquisition of advanced technology by Indian firms has increased the output and decreased the cost of drugs and formulations by increasing operational efficiency. 9

2. More and more companies are investing for research and development after implementation of product patent.

3. High unemployment in India prevents companies from going fully automatic as government and labor unions voice complaints against such establishments.14

9 Kumara G., Mitra P., Pasricha C (2009 )“Indian Pharma 2015: Unlocking the Potential of the Indian Pharmaceuticals Market” McKinsey & Company Available from: http://www.mckinsey.com/locations/india/mckinseyonindia/pdf/India_Pharma_2015.pdf (Accessed on: 4/July/10)

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4. After 2005 many Indian companies merged with or were acquired by Global pharmaceutical companies to gain competitive advantage through new technology. Bayer Schering is already in a co-operative alliance with Zydus-Cadilla for distribution of its contrast media so it can look for further potential partners to leverage their competencies in gaining a foothold in the market.14

5. Newer medication, molecules and active ingredients are being discovered. As of January 2005, the Government of India has more than 10,000 substances for patenting.14

6. Bayer Schering is a worldwide leading specialty pharmaceutical company and world leader in developing and manufacturing contrast media for use in X-ray, computed tomography (CT) and magnetic resonance imaging (MRI). Of all the companies supplying contrast media, Bayer Schering Pharma is the one with the strongest in-house therapeutic expertise. The Diagnostic Imaging business unit collaborates with Bayer’s subsidiary MEDRAD, the market leader in contrast media injectors and a supplier of other state-of-the-art technical accessories.

7. A significant number of breakthrough products like contrast media for use in X-ray, computed tomography (CT) and magnetic resonance imaging (MRI).14

8. Bayer Schering Pharma is ahead in adapting contrast media applications to cutting-edge technologies such as the Dual Source CT, and strives to be one of the first companies to bring specific tracers for molecular imaging to clinical practice.15

9. Bayer Schering Pharma has strong manufacturing capacity and plans to expand through acquisition of international facilities like Schering AG Possis medical Inc,a minority stake in Aventis Crop Science from Sanofi-Aventis 10,11

1.3 COMPANY PROFILE

1.3.1 Bayer Schering Pharma:

Bayer Schering Pharma is one of the ten largest specialty pharmaceutical companies in the world. We market our products in more than 100 countries, and in 2009 generated sales of almost € 10.5 billion.17

More than 36,000 members of staff currently work for Bayer Schering Pharma worldwide – more than 5,800 in research and development alone. We aim to improve people’s quality of life with our products. To achieve this, we concentrate on the research and development of innovative drugs and novel therapeutic approaches. At the same time, we are constantly improving established products. In this context, Bayer Schering Pharma uses experience it has gained from over a century in the business.12

10Bayer Schering Pharma (2009) “Contrast Media “ Available from: http://www.bayerscheringpharma.de/scripts/pages/en/therapeutic_areas/imaging_techniques/contrast_media/index.php (Accessed on: 9/July/10)

11Bayer Schering Pharma (2009) “Pioneer in Diagnostic Imaging” Available from: https://www.diagnosticimaging.bayerscheringpharma.de/scripts/pages/en/public/about_us/the_business_unit/index.php (ACcessed on: 12/July/10)12 Bayer Schering (2009) “Corporate Profile” Available from: http://www.bayerscheringpharma.de/scripts/pages/en/company/about_us/corporate_profile/index.php

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In addition to the classic X-ray procedure, various diagnostic methods are available to medicine today, such as computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. It is a global market leader in the field of in-vivo diagnostic agents with our X-ray and magnetic resonance imaging (MRI) products.

1.3.2 Contrast Media:

Contrast media improve the quality of images of the body's structures and functions in X-ray diagnostics, magnetic resonance imaging, and sonography. Bayer Schering is one of the pioneering developers of these substances, launching the first iodine-containing X-ray contrast medium as early as 1931.18

It remained the standard for X-rays of the kidney, bladder and blood vessels for decades. Since then, countless innovative contrast media have been developed for all routine X-ray and CT examinations. They are now used all over the world in millions of examinations. When used in combination with novel CT procedures, contrast media from Bayer Schering Pharma open up many advantages over conventional systems – e.g. sharper images and higher resolutions. This technology sets new standards for non-invasive examinations of the heart and coronary arteries. It enables a rapid diagnosis based on optimum image quality to be made when examining acute patients. Bayer Schering Pharma and Siemens Medical Solutions are jointly exploring the potential of this novel technique, which is known as dual-source CT technology.13

1.3.3 SWOT Analysis of Bayer Schering:

SWOT Analysis is a tool that enables a subjective assessment of a given situation or subject in order to make critical decisions that are related to planning and risk management. It was used to gauge the degree of “fit” between Bayer Schering’s strategies and the environment, and to suggest ways in which it can profit from strengths and opportunities and shield itself against weaknesses and threats.

Strengths

1. It is the worldwide leading specialty pharmaceutical company, innovator and world leader in developing and manufacturing contrast media for use in X-ray, computed tomography (CT) and magnetic resonance imaging (MRI).17

2. It is ahead in adapting contrast media applications to cutting-edge technologies such as the Dual Source CT, and strives to be one of the first companies to bring specific tracers for molecular imaging to clinical practice.15

3. It is the Innovator of first X-ray contrast media in 1930 and the world’s first contrast medium for magnetic resonance imaging in 1988. 17

4. It introduced breakthrough product -Gadovist, a special contrast agent for liver imaging. 17

(Accessed on: 28/June/10)13Bayer Schering (2009) “Imaging Techniques “ Available from: http://www.bayerscheringpharma.de/scripts/pages/en/therapeutic_areas/imaging_techniques/contrast_media/index.php (Accessed on: 27/June/10)

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5. It is the producer of Asprin, having a subsidiary in India (Bayer Corp Science)17

6. It has strong manufacturing and strongest in-house therapeutic expertise through Medrad, the market leader in contrast media injectors and a supplier of other state-of-the-art technical accessories. 17

7. It has global presence through acquisition of international facilities like Schering AG Possis medical Inc,a minority stake in Aventis Crop Science from Sanofi-Aventis. 17

Weaknesses

1. It was earlier present in India (15 years back) but due to poor performance sold out to Zydus Cadilla. 17

2. There would be implications of new Patent Act 2005 in India which allows patent for 20 years.

3. The expiry of patent of its major products (Magnevist and Ultravist’s patent expired in 2007) would impact the sale of its products. 17

4. Tough generic competition as its products are slightly expensive than the other players in the market like GE, Bracco, Mallinckrodt, Guerbet.

5. India spends a very small proportion of its GDP on healthcare and other facilities.

6. The low per capita of average Indians makes them to spend even less on their healthcare, making unauthorized practitioners popular and prevalence of substandard products, which hit the sales of genuine manufacturers.

7. The rising demand for cheaper generic products amid cost-containment pressures would affect the demand for branded contrast media.

8. Price sensitiveness of Indian consumers would impact the buying pattern of contrast media by the hospitals and diagnostic centers.

Opportunities

1. The Indian health care infrastructure is developing boosted by the new ANDA financing. 2

2. Bayer Schering can merge with or acquired Global pharmaceutical companies to gain competitive advantage through new technology. It is already in a co-operative alliance with Zydus-Cadilla for distribution of its contrast media so it can look for further potential partners to leverage their competencies in gaining a foothold in the market. 14

3. It can tie up with equipment manufacturers and offer the contrast agents along with the equipment to hospitals and diagnostic centers (e.g. Siemens, Philips, Toshiba)

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4. The CT and MRI markets are growing due to technology evolution, fusion imaging and co-existing modalities.

Threats

1. The regulatory and legal pressures from government and authorities regarding control on pricing, stringent patent laws, duties, taxes and licensing.2

2. The competing companies (GE, Bracco, Guerbet, and Mallinckrodt) are already well established in the market and their brand names are recognized as opposed to products of Bayer Schering thus giving tough competition.

The distribution rights of Bayer Schering’s contrast agents presently are with Zydus Cadila, which also has its own range of contrast agents, thus it is less motivated in pushing Bayer Schering’s products.

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CHAPTER 2

PROJECT PROFILE

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2.1 PROJECT PROFILE

Bayer Schering Pharma is one of the ten largest specialty pharmaceutical companies in the world. We market our products in more than 100 countries, and in 2009 generated sales of almost € 10.5 billion. Bayer Schering is one of the pioneering developers of contrast media, launching the first iodine-containing X-ray contrast medium as early as 1931.It is planning to venture into the Indian Contrast Media Market to take advantage of the booming pharmaceutical industry. The aim of the study was to understand the contrast media market situation in the Indian market and discover feasible marketing opportunities for Bayer Schering Pharma to enter the Indian market. The purpose of the project is to offer background and recommendations for Bayer Schering’s Indian marketing strategy development. It was done through analyzing the Indian Pharmaceutical Industry, examining the diagnostic imaging market, analyzing the major competitors and their strategies and studying the behavior of the Hospitals, Diagnostic centers and other buyers of contrast media like the medical colleges, etc. The survey was restricted to only 3 diagnostic centers being surveyed in India (Gujrat, Kolkata, and Madhya Pradesh).

The scope of this project is to analyse Indian pharmaceutical industry and assess the contrast media market.The focus was to study the working of the diagnostic imaging industry and understand the working environment as a whole. The study involved examining the diagnostic imaging market, analyzing the major competitors and their strategies and study the behavior of the Hospitals, Diagnostic centers.

2.2 OBJECTIVES

The objectives for the project undertaken are:

1. To identify a viable segment for Bayer Schering Pharma and discover feasible marketing opportunities to explore its outlook in the Indian market with specific reference to the regulatory environment.

2. To profile the key competitors and suppliers of contrast media and their product offerings.

3. To examine the distribution pattern and distribution partners, agents and wholesalers of the key players

4. To investigate the diagnostic imaging market in India and get an insight into the markets for CT Scan, MRI, Ultrasound and Interventional Cardiology in India

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CHAPTER 3RESEARCH METHODOLOGY,

OBSERVATIONS

AND

FINDINGS

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3.1 RESEARCH METHODOLOGY

The project is primarily a market research project of collecting data about the contrast media market in India with specific referrence to Bayer Schering Pharma. The data would be obtained mainly from industry trade publications, academic journals, news and research articles, press releases on the web and corporate websites and Indian governmental sites. Secondly, questionnaires would be sent to diagnostic imaging hospitals and centres to gain primary data which was essential to understand the basic pricing, distribution, buying pattern and channel flows.

The project was started by back getting an insight into the Indian pharmaceutical industry and understanding the regulatory environment and the basic patent system for pharmaceuticals in India and further exploring the contrast agents authorized and patented in India.

The PEST analysis and SWOT analysis was done to identify a viable market segment for Bayer Schering in the Indian market. The PEST analysis identifies the factors that might in turn affect a number of vital variables that are likely to influence the organization’s supply and demand levels and its costs. The SWOT analysis was used to gauge the degree of “fit” between Bayer Schering’s strategies and the environment, and to suggest ways in which it can profit from strengths and opportunities and shield itself against weaknesses and threats. The Porters’ five forces elaborated on the industry competitiveness and was done to understand the dynamics of the industry and markets in order for Bayer Schering to compete effectively in the contrast media market. The marketing mix analysis was done to understand the strategies of the competing companies as the 4 P’s are the four wheels of the vehicle on which the path of an organization's marketing success is actually dependent. The focus was to investigate the diagnostic imaging market in India with specific reference to X-ray, CT-Scan and MRI and the contrast media market situation. The major players in the medical imaging equipment manufacturing and contrast media were studied and their distribution and buying pattern were analyzed. Information was gathered on the major buyers- Hospitals, Diagnostic Centers and Medical Colleges. All the observations made after analyzing the data gathered from primary and secondary research lead to the recommendations on the entry of Bayer Schering Pharma in Indian contrast media market.

3.2 PROJECT IMPLEMENTATION AND OBSERVATION

The investigation required to study the Diagnostic Imaging Industry with specific reference to the Contrast Media Market and major players in the market for contrast media and examining their profiles and marketing mix.

Porter’s Five Forces & Structural Industry Analysis Model was used to discover feasible marketing opportunities for Bayer Schering to explore its outlook in the Indian market.

3.2.1 Porter’s Five Forces & Structural Industry Analysis: The Porters’ five forces elaborated on the industry competitiveness and was done to understand the dynamics of the industry and markets in order for Bayer Schering to compete effectively in the contrast media market.

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Industry Competition: High

Competition within the industry is very high. It can be gauged from the fact that there are well established players like GE who is the leader in the Indian Contrast Media Market, yet even GE faces tough generic competition and is looking for alternative ways to maintain its market share. GE has signed a strategic deal with Wipro, where it would use its strong distribution network to increase its penetration in the market, especially in the tier I and tier II cities and semi-urban areas. The other major players are Bracco, Mallinkcrodt, Guerbet and Amersham. These companies are also significant players and have a range of contrast media available at reasonable prices. The Patent act 2005 has increased the rivalry in the Indian pharmaceutical industry as it allows patent only for 20 years. The patent expiry of Bayer Schering’s Magnevist and Ultravist in 2007 has increased the rivalry as it has led to the generic contrast media being sold by domestic pharmaceutical companies.

Barrier to entry: Medium

The Indian Pharmaceutical industry is one of the most easily accessible industries. The capital requirement for the contrast media manufacturing is not that high. But creating brand awareness and establishing the brand amongst hospitals, radiologists, and diagnostic centres is the key for long-term survival. There may be quality regulations by the government which may put some hindrance for establishing new manufacturing operations. The barriers to entry will increase in the future with specific reference to regulatory pressures from DCGI (Director Controller General of India) and MOHFW (Ministry of health and family welfare) NPPA (National pharmaceutical pricing agency) for licenses, patents, quality and prices. Moreover, changes in the patent regime as it will see new proprietary contrast media coming up, making imitation difficult. Going forward, the impending new patent regime will raise the barriers to entry. But it is unlikely to discourage new entrants, as market for generics will be

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as huge. The players with huge capacity will be able to influence substantial power on the domestic players by their aggressive pricing which will create hindrance for the smaller players. There is huge market potential for contrast media for ultrasound in India and Bayer was the innovator and the market leader of ultrasound contrast media called “Ultravist” thus it can leverage its first mover advantage and economies of scale while entering the Indian market. The other barrier to entry is the distribution network. Bayer Schering needs to develop a strong distribution network to establish itself in the market. 2

Bargaining power of suppliers: High

The diagnostic imaging industry (especially contrast media) depends on the suppliers, especially suppliers of active chemicals. Therefore the chemical industry needs to be considered as well. The Chemical industry is highly competitive and the suppliers have high bargaining power and the companies buying from them would have to switch from their suppliers at a higher cost. The bargaining power of suppliers is high. The contrast manufacturers are striving to produce at lower costs in order to target the Indian consumers who are price sensitive. The local suppliers of active ingredients like iodine, injectors, and special components for MRI contrast media would also have high bargaining power. These suppliers may also pose to be a threat in cases where they go for forward integration.

Bargaining power of buyers: Medium-High

The unique feature of pharmaceutical industry is that the end user of the product is different from the influencer (doctor). In case of diagnostic imaging and use of contrast media, the end consumer has no choice of the contrast media as it is solely dependent on the diagnostic imaging centre or the hospital. Considering the buyer’s power, we can say the only influence they have is on the price of the product. Considering the Radiologists, Cardiologists and Medical Doctors, they act as an agent of the final consumer. The Hospitals and diagnostic centers’ choice is often influenced by the price, quality and the brands that are used by others in the industry. They can easily switch to other brands in case they find better deals, and as their switching cost is low, the bargaining power ranges from medium to high.14

Threat of substitute products: Low to Medium

One of the great advantages of the pharmaceutical industry is that whatever happens, demand for pharmaceutical products continues and the industry thrives but the disadvantage is that the advances made in the field of technology, can prove to be a threat to the pharmaceutical industry as it gives rise to product imitation and generic products. Moreover, the threat from indirect competition is also prevalent. Considering the Indian healthcare market, it is developing rapidly and becoming an attractive place for medical treatments through Reiki, Yoga, Ayurveda and Homeopathy. These are indirect competitors for the contrast media manufacturers as they result in people opting for natural or household treatments rather than visiting a radiologist, cardiologist or medical centre for diagnostic imaging. However, there is no such direct substitute for contrast media so there is still untapped market potential that Bayer Schering can leverage upon.

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The Marketing Mix analysis was undertaken to profile the key competitors and suppliers of contrast media with their product offerings and examine the distribution pattern and distribution partners, agents and wholesalers of the key players.

3.2.2 Marketing Mix: The marketing mix analysis was done to understand the strategies of the competing companies as the 4 P’s are the four wheels of the vehicle on which the path of an organization's marketing success is actually dependent.

Product

Contrast agents, also known as contrast media, often are used during medical imaging examinations to highlight specific parts of the body and make them easier to see. Contrast agents can be used with many types of imaging examinations, including x-ray exams, computed tomography scans and magnetic resonance imaging. It is used to highlight specific areas so that the organs, blood vessels, or tissues are more visible. By increasing the visibility of all surfaces of the organ or tissue being studied, they can help the radiologist determine the presence and extent of disease or injury. Contrast media can be categorized under monomers or dimers, ionic or non-ionic, low osmolar contrast media (LOCM) or high osmolar contrast media (HOCM) and low viscous contrast media (LVCM) or high viscous contrast media (HVCM). This classification is on the basis of difference in structure, ionicity, osmolality and viscosity.14

Fig a) Product Hierarchy

Schering is the world market leader and regarded as a trendsetter in particular for MRI contrast media. It introduced Magnevist®, the world's first MRI contrast medium in 1988. The contras media approved (January 1988-August 2006) to be marketed by the Drugs Controller General (India) :

Table 1:

14 Radiology Info (2010) “Contrast Materials” Available from: http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_contrast (Accessed on: 22/July/10)

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Serial no

Name of Drug PharmacologicalClassification

Date ofApproval

1. Iopromide (Ultravist) Contrast Media Jul-90

2. Gadopentetic acid Dimeglumine salt Contrast Media  May-92

3. Itrolan (Isovist)   Contrast Media   Oct-92

4. Ioversol injection Contrast Media Dec-93

5. Gadodiamide I.V.Injection Contrast Media Jan 94

6. Levovist   Contrast Media   Nov-97

7. Iomeprol Contrast medium 05.10.2000

8. Iobitridol Contrast Medium 17.10.2001

9. Meglumine gadoteric Contrast media 16.10.2002

10. Gadobenate (Dimeglumine IV Injection) MRI Contrast Medium 7.3.2003

11. Gadoversetamide Injection MRI Contrast Medium 04.06.2003

Source: Author compiled from various government sites

http://www.cdsco.nic.in/list_of_drugs_approved_during_2001.htm

Price

Price offered by the authorized Indian distributor of the major contrast media players:

Table 2:

Product Company/ Authorised distributor

Maximum

Retail price in Rupees

Offer price to the institute in Indian Rupees

In terms of Euros

Omnipaque

50 ml (350 mg)

Chayagraphics 750 500 8.43

Omnipaque

50 ml (300 mg)

Chayagraphics 625 450 7.59

Omnipaque

100 ml (350 mg)

Chayagraphics 1500 1000 16.87

Omnipaque Chayagraphics 1250 900 15.18

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100 ml (300 mg)

Omniscan

10 ml (0.5 mmol)

Chayagraphics 1450 1000 16.87

Visipaque

50 ml (320 mg)

Chayagraphics 1080 895 15.10

Visipaque

100 ml (320 mg)

Chayagraphics 2160 1785 30.11

Magnevist Inj

10 ml

Cadilla 1757.86 950 16.02

Ultravist

100 ml (370 mg)

Cadilla 1655.95 950 16.02

Ultravist

50 ml (370 mg)

Cadilla 1006.31 650 10.96

Ultravist

100 ml (300 mg)

Cadilla 1579.52 850 14.34

Ultravist

50 ml (300 mg)

Cadilla 853.45 475 8.01

Source : Survey (Refer Appendix IV, VI)

The above mentioned prices are in refernce to the questionnaire sent to Bellvue Hospital, Kolkata, a major medical care hospital. The prices are offered by one of the authorized distributors- Chayagraphics (GE healthcare) and Cadilla (Bayer Schering). The parameters seen before buying were understood through the survey. The centre buys the contrast agent on the basis of price and quality of material, product specifications (chemical names). Sometimes references and online directories are also used.

The survey was also conducted in Gujrat (Surat) and aMadhya Pradesh (Satna). It revealed that in tier I and tier II cities, the buying centres are more price conscious due to their price sensitive customers and thus companies sell at lower prices in such places.The survey was done based on convenient sampling.

Place

The distribution of contrast medium is done through distributors, wholesalers and retailers which reflects a 2-level marketing channel. The retailers are usually used to penetrate the Tier I and Tier II cities and the semi-urban areas. Companies also use co-promotion as a tool to make their products more accessible like GE and Wipro deal, Lantheus and J.B Chemicals deal. In such cases companies leverage on to the co-promoters’ strong distribution network.

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In metropolitain cities, the companies introduce their product offering through their authorised dealers and the institute then negotiates with the dealers regarding the pricing and term of delivery of contrast medium. In case of Tier II and Teir III cities the authorised dealers are supplemented by Medical Representative who contact the local doctors and diagnostic centres and offer them the products. The following table shows the distribution pattern by the major contrast media manufacturers.

Table 3:

Origin-ator

Compound

Brand Manufacturer

Market Authorization holder

Marketer Distributor, Agent

Local Supplier

Guerbet Iobitridol Xenetix Guerbet Guerbet - Choksi Bro. Ltd

-

Guerbet Gadoterate

Dotarem Guerbet Guerbet - Choksi Bro. Ltd

-

Bracco Iomero Lomenpr-ol

Bracco - - Imaging Products India

Imaging Products India

Bracco Gadobe-nate

Gadobe-nate

Patheon Italia

- - Imaging Products India

Imaging Products India

GE Iohexol Omni-paque

GE Health Care

GE Health Care

GE Wipro

Chaya-graphics

-

GE - Vistavu - - - Chaya-graphics

-

GE - Iohexol Komorawsh, CZ

- - Dabur -

GE - Iohexol Xinhua, China

- - United Agencies

-

GE - Iohexol Ningbo,China

- - RS Pharma

-

GE - MaxView

- - - Zen Life Sciences

-

GE Iodixanol Visi-paque

GE Health Care

GE Health Care

GE Wipro

Chaya -Graphics

-

GE Gadodan-mide

Omni-scan

GE Health Care

GE Health Care

GE Wipro

Chaya-Graphics

-

Bracco Iopimi-dol

Lopa-midol

Bracco - - Imaging Products India

-

Bracco Iopimi-dol

Dynavu Bracco - - Choksi Bro. Ltd

Covi-den Ioversol Optiray Tyco Canada

Tyco India

Tyco India

Adithi Med X

Atlas

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Covi-den Gadover-set

Optimark Mallinkcrodt, USA

Tyco India

Tyco India

Adithi Med X

Atlas

Bayer Schering

Gadopen-tetate

Gadovu - - - Choksi Bro. Ltd

-

Bayer Schering

Gadopen-Tetate

Magne-vist

Bayer Bayer Cadilla - AMS

Bayer Schering

Iopro-mide

Ultravist Bayer Bayer Cadilla - -

Lantheus Gadofio-reset

Magnelik JB Chemical

- JB Chemical

- -

Lantheus Perflu-tren

- Lantheus - JB Chemical

- -

Source: Author Compiled from Various sources

Promotion

The contrast media are marketed to:

1. Private hospitals managed by big business corporations

2. Medical Colleges managed and funded by the central government, state governments, or municipal corporations

3. Government Hospitals run by the central government, state government or municipal corporations

4. Private diagnostic imaging centers managed by a single radiologist or cardiologists or a group of radiologists/cardiologists

The companies promote their products by increasing their visibility via sponsoring and participating in the events and conferences of the Radilogical and Cardilogy societies, like:

 National Radiologist societies:

IRIA - Indian Radiology & Imaging Association (IRIA)

ICRI - Indian College of Radiology & Imaging (ICRI)

ISVIR - Indian Society of Vascular & Interventional Radiology (ISVIR)

IFUMB - Indian Federation of Ultra Sound in Medicines & Biology (IFUMB)

ISNR - Indian Society of Neuroradiology

National Cardiologist societies

CSI- Cardiological Society of India

 Furthermore promotion of the product is also done by co-branding with the diagnostic imaging equipments and by forming strategic alliance with the local Indian Pharmaceutical companies and distributers .The radiology solution offering companies also sponsor and advertise in the journal radiology and cardiology.

Refer Appendix III

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3.2.3 Indian Market for Diagnostic Imaging:

The following is the detailed investigation of the diagnostic imaging market in India and an insight into the markets for CT Scan, MRI, Ultrasound and Interventional Cardiology in India

The Indian market for diagnostic imaging systems grew rapidly in 2008. The deepening of the global economic crisis, however, is strongly limiting facilities' ability to raise capital for the purchase of advanced imaging systems such as computed tomography (CT) and magnetic resonance imaging (MRI). Additionally, the Indian rupee has weakened against the US dollar since September 2008; this is also limiting the market because advanced diagnostic imaging systems used in the country are imported. Sales of more powerful ultrasound, higher-frequency analog x-ray, and digital x-ray solutions to improve image resolution and diagnostic confidence will, however, drive the Indian market for diagnostic imaging systems. Additionally, the adoption of higher-slice CT and high-field MRI systems will remain strong as imaging facilities compete for patients and referrals. Consequently, the Indian market for diagnostic imaging systems will expand over the forecast period.15

Computed Tomography in India

CT was introduced 30 years back and has undergone numerous advances, but no time period has seen changes as rapid and profound as the last few years and will continue to do so for the next ten years. In addition to much faster throughput, three-dimensional reformatting and rotation of images, this technique is becoming increasingly popular with plastic surgeons, vascular surgeons, and neurosurgeons. Moreover, procedure volumes have been growing at the rate of 10 per cent per year, a trend that is expected to accelerate in the next five years. Actually, Multi-Slice CT (MSCT) was introduced in 1998 and has rapidly evolved from 2>4>8>16>32>64 slices with 128 and 256 debuting on the horizon. In fact, new equipment called ‘Adaptive Spiral CT’ has debuted on the block.  With this technology, radiologists can do perfusion study of several body regions as large as 27 centimeters. Even a CT scanner with 320 detectors cannot offer the capability of time resolved perfusion studies of regions as large as 27 centimeters.   However, the end point would be flat panel detectors which provide infinite slices. Additionally, the reduction of the risk of radiation overexposure for patients and operators is currently being seriously addressed by the imaging industry. CT has nearly peaked itself in its capacity and the one beat, three beat cardiac CT have reached their potential. The stress now will be on cost reduction and radiation protection. Decrease in radiation exposure will be the direction technology will drive us to.16

 The cost of the equipment is another pressing matter waiting addressee. Focus is definitely towards making cheaper CT scanners. Apparently, these will appear as refurbished models, with no frills and they will be needed in large numbers for rural and interior India.3

Cardiac applications of CT scanners are driving the high-end urban CT market whereas; huge base of oncology patients is leading to growth in the tier 2 and 3 cities.6

15 Research and Markets (2009) “Indian Markets for Diagnostic Imaging Systems” Available from: http://www.medicexchange.com/Radiology/indian-markets-for-diagnostic-imaging-systems.html (Accessed on: 4/July/10)16 TehcnoClin Consulting (2009)“Trends in Diagnostic Imaging”Available from: http://technoclin.com/articles/trends-in-diagnostic-imaging (Accessed on: 9/July/10)

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The advent of computed tomography (CT) has revolutionized the face of radiological diagnosis. CT continues to be a central modality in both inpatient and outpatient care. It is one of the few modalities that have undergone transformation in terms of technological advancement and product innovation since its inception in the 1970s. The recent past has seen a transition from low-end 16 slice systems to high-end 320 slice systems.6

While hospitals started out as the original care site where scanning was done, independent imaging centers offering scanning have become widespread over the last decade. Recent advances in CT technology particularly in the multiple-row detector scanners have presented new opportunities for improved patient imaging and throughput. Data acquisition in the order of few hundreds of a milli-seconds and rapid image reconstruction has made real-time imaging a possibility.6

Market Dynamics

Source: Medical Buyer (2010)

2009 saw the CT scanner segment back at the Rs. 315 crore level of 2007 and is poised for 5-7 percent growth in 2010. With higher adoption of cardiac scanners (64 slices and above) in private hospitals in urban areas and increasing purchase of radiological scanners (16-32 slices) in tier 2 and 3 cities, the high-end CT scanners dominated with a combined value-wise market share of 60 percent, at Rs. 190 crore (80 units). The value segment declined from Rs. 90 crore in 2008 to Rs. 45 crore in 2009. An estimated 50 units were sold in 2009. Entry level CT scanners remained stagnant at Rs. 30 crore with an estimated sale of 40 units. With an estimated sales of 130 units valued at Rs. 50 crore, refurbished CT scanners saw an increase in demand for tier 2 and 3 cities, especially in secondary care, diagnostic centers, and nursing homes. CT scanners market is dominated by the four brands, GE, Philips, Siemens, and Toshiba. Other players include Blue Star Limited (representing Hitachi), Cura Medical, Electromedicals, First Medical, Gabri International, Mars Medical, Masters Medical, Sanrad Medical, and Shimadzu. 6

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Growth Drivers

Source: Medical Buyer (2010)

Computed tomography (CT) has undergone dramatic developments since its first introduction into clinical practice. The drivers behind this reformation are advancements in technology and new clinical applications for CT. Awareness and demand for healthcare in India and increasing ability of patient population to spend on improved health services are some of the major factors behind the growth in CT segment.6

Growing popularity of CT scanners as a common diagnostic tool coupled with the reduction in prices are factors expected to drive its growth. Cardiac applications of CT scanner are driving the high-end market, whereas, huge base of oncology patients is leading to growth in the mid-range segment.6

Despite competition with magnetic resonance imaging (MRI), CT remains the modality of choice for many diagnostic problems in the area of neck and trunk. The advent of new scanning techniques such as spiral or helical CT and more recently multi detector row CT (MDCT) has even reversed the trend toward MRI with a return to CT. At the same time, integration of CT with nuclear medicine technologies (PET/CT and SPECT/CT) and also the superior diagnostic capabilities of 256-slice CT, may end up replacing some of the traditional modalities.6

Growing Refurbished Market

The market for refurbished equipment is growing owing to low cost of the equipment. Refurbished equipment propels the end users to purchase latest technology products for their hospitals. Refurbished medical imaging equipment is likely to be the most viable and cheap alternative to high-end equipment. As private healthcare institutions are key end-users of refurbished equipment, anticipated growth in their number is likely to strengthen the market for refurbished CT scanners.6

Slice War

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The CT market has witnessed the introduction of technologically advanced higher-slice scanners, which improve image quality and enhance diagnostic capabilities. Facilities seeking to enhance patient care are fueling growth in the higher-slice segment of the CT system market. Adding extra number of slices to the existing capabilities of CT scanners has not only served as a boon for the patient population but also been a mode of demonstrating the technological superiority of vendors. This trend of technological advancements that eventually took the form of an intense slice war amongst the CT vendors now seems to be on the verge of fading out. 6

Although several cardiologists are quite excited about the concept of high slice configurations, the radiologist community doesn't seem too convinced. Some radiologists are of the opinion that 256 and 320 slice CT scanners can do little more than the 64 slice scanners while encountering non-moving organs. This is one of the common attitudes that the vendors would like to change in the market. In case they fail to do so, the scope of these CT scanners with very high slice configurations might be reduced mostly to cardiac applications thereby reducing their sales opportunities. 6

Workflow Technologies

Thinner slices allow clinicians to view the anatomy in such precise detail it has to be seen to be believed. However, it has its drawbacks; thinner slices are doubling or tripling the volumes of image data - putting extra strain on already stretched workflow processes. But, advanced solutions aim to solve these issues. These technologies provide a revolutionary productivity platform that delivers unparalleled workflow in CT examinations. A new CT operator console with software advancements is capable of reconstructing and transferring clinical image data at record speed.6

Impact of Radiation Risks on CT Market

CT involves larger radiation dosages as compared to conventional X-ray imaging procedures. Radiation exposure from CT scans is highly variable and often exceeds recommended limits. Studies conducted in the recent past suggest that this might have adverse effects in the long run posing a potential threat. Whether CT radiation exposure might be responsible for cancers in the future has become a debatable issue.6

With the increase in awareness about radiation exposure and its effects in the long run, the market is shifting toward a trend where vendors are looking at radiation dose reduction technologies and reconstruction software. The battle of the slices has drawn to a close with the focus now being on sharper images that involve lower radiation dosage and reduced examination time. CT scanners with lower dosage and greater image clarity ensuring better diagnosis and treatment, is likely to be the order of the day. The idea is not to confuse coverage with temporal resolution as physicians are not looking for more slices with same resolution but rather clinically relevant pathology, structure, and better temporal resolution. The factors considered during a purchase are radiation dosage, throughput, and speed of the exam. The market can expect cost efficient CT technologies in the coming years. What is certain however, is that the endeavor toward reducing radiation dosage shall continue in the market Vendors may also look to come up with technologies and protocols allowing myocardial perfusion studies to counter the subtle yet certain threat from other modalities. In 2009, the overall CT market was approximately Rs. 315 crore (revenue wise) which constitutes of approximately 300 units. 6

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During 2009, 43 percent of the total CT scanners (revenue wise) bought in India are 64 slice and above, indicating a significant shift from value segment CT scanners in private hospitals in urban India. 16 slice CT scanners (20 percent) are being purchased increasingly in tier II and III cities. The CT market in India is expected to grow at a rate of 5-7 percent per year.6

Growing popularity of CT scanners as a common diagnostic tool, coupled with the reduction in prices, are factors expected to drive this growth, future. The cardiac applications of the CT scanners are driving the high-end market, whereas, huge base of oncology patients is leading to growth in the mid-range segment. A prevalent trend being noticed in the CT scanners market is the increase in sales of refurbished equipment in tier II and tier III cities, especially in secondary care, diagnostic centers, and nursing homes. CT has nearly peaked itself in its capacity as far as standard applications are concerned. The stress now will be on cost reduction and radiation protection. Companies will be driven to decrease the radiation exposure. Integration of CT with nuclear medicine technologies (PET/CT) and also the superior diagnosis capabilities of 256-slice CT may end up replacing some of the traditional modalities like dedicated angiography machines.17

Magnetic Resonance Imaging in India

About 25 years back, a diagnostic technique in which radio waves generated in a strong magnetic field were used to provide information about the hydrogen atoms in different tissues within the body was introduced. It was MRI. Since then, the field has experienced rapid growth at rates of 8-12 per cent per year. This trend will continue due to new applications resulting from magnet and gantry design, coils and greatly increased computing speed. Modalities like parallel imaging have come up, which are faster and have higher strength magnets for imaging body organs. Nowadays, open magnet diagnostic MRI is preferred by the radiologists, which are patient friendly. The clinical areas that are currently most significant for MRI are neurosciences, orthopedics, oncology, and ENT. Newer areas of growth in the next 5-10 years are breast, cardiology, vascular, and interventional/minimally invasive procedures. Experts believe that breast MRI will become prominent; it will guide breast interventions for lesions that can only be detected by MRI. In future, MRI will complement CT in assessing brain function post-stroke and will be a standard of care for all white matter brain diseases. Additionally, MRI will complement CT for plaque and characterization of wall. Development of 3T scanners has provided the MRI industry with an edge over 1.5T scanners, and is likely to be the gold standard going forward.3

Magnetic resonance imaging is a ubiquitous diagnostic tool in modern healthcare. Even while growing in sophistication, MRI has considerably simplified the scanning procedure for the patient-the reason for the rapid growth of the segment. Both the technology and market are continuously evolving. In the MRI market, innovation and service quality are the mantra for success.

One of the greatest strengths of MRI is the ability to change the contrast of the images. Small changes in radio waves and the magnetic fields can completely change the image contrast. Different contrast settings highlight different types of tissues. Another big plus of MRI is its ability to change the imaging plane without moving the patient. Most MRI machines can produce images in any plane.

17Medical Buyer (2010), “CT scanners” http://www.medicalbuyer.co.in/2007/ct-scanners-discerning-procurement-2704-41.html (Accessed on: 13/July/10)

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Source: Medical Buyer (2010)

Market Dynamics

With the total market in 2009 at Rs. 500 crore, from Rs. 425 crore in 2008, the Indian MRI market is witnessing an average growth of 17 percent per annum. Superconducting systems remain the key segment, driving growth within the MRI systems market. This segment accounted for 85 percent of the overall MRI systems revenue in 2009. 1.5 tesla equipment continues to dominate the superconducting magnet MRI segment, with 74 percent market share value-wise, and 85 percent market share quantity-wise. The permanent magnet MRI continues to have a presence in the market, albeit witnessing a decline. The refurbished/re-engineered equipment which accounted for Rs. 20 crore in 2008 has almost doubled to Rs. 38.5 crore in 2009.7

The MRI equipment market is dominated by GE Healthcare, Philips Healthcare, and Siemens. The other aggressive players are Blue Star (representing Hitachi Medical Corporation), Erbis (representing Toshiba Medical Systems), Esaote India, Gemini Medical Networks (representing XGY), and Sanrad Medical Systems. Bhram Systems, Cura Medical, Electromed, Mars Medical Systems, and Masters Medical Equipment, have made their mark in the refurbished and re-engineered MRI equipment segment.

Growth Drivers

Demand for effective diagnosis has given rise to the need for enhanced data images provided by MRI imaging systems, especially in cardiovascular diseases, thereby increasing market revenues. MRI has been propelled by improved image quality, facilitated by higher field strength magnets, and the development of new techniques for evaluating specific portions of the complex structures in the brain. The increasing applications of the MRI equipment in the field of angiography, cancer screening, breast screening, and neurosurgery planning have provided the requisite impetus. Functional MRI remains a significant market, due to increasing number of research to study the human brain across universities. The quest for speedier imaging has been the impetus for the development of new sequences, improved coil design, and significant hardware advances. Advent of automation and power-saving features in MRI equipment has also been growth drivers. 7

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The need for sophisticated technologies and enhanced capabilities is driving the healthcare providers to upgrade and replace existing equipment. Continuous enhancement in tesla strength of the MRIs is demanded. High tesla MR systems are mainly sold in metros and big cities whereas permanent MR systems are sold mainly in medium and small cities and also as secondary units in big institutions. Various institutions are now interested in an additional MR unit, mostly a permanent MR model. On the other hand, refurbished segment attracts price conscious customers for whom cost is a concern. Refurbished 1.5T systems are quite popular as compared to refurbished permanent MR models among customers.7

Advancements in Technology

With its ability to image both anatomically and functionally, MRI has found its way into surgical planning and navigation as well as diffusion and perfusion imaging. It is being combined with other modalities to achieve new heights of image clarity. For instance, once considered unreliable in imaging cartilage, it is being considered for assessing chondral damage and repair. Three dimensional (3D) MRI is sensitive enough to replace arthroscopy.7

Functional MRI is an imaging technique to map the functional status of an organ, which sets it apart from the routine radiological imaging studies. Functional MRI not only points out functional abnormalities, but also improves our understanding of various organs, their physiological status and furthermore, helps in therapeutic decision making. Even though it is commonly used in imaging of the brain, it has found wide application in other parts of body such as lungs, liver, pancreas and heart.

Development of 3T scanners has provided the MRI industry an edge over 1.5T scanners, much touted as the industry's Gold Standard. 3T MRI systems have come of age and are a success story in the MRI market today. Lower examination costs complimented by improved image quality and lesser scan times highlight the benefits of 3T scanners.7

Yet, while 3T MRI is quickly becoming the standard for neurological and musculoskeletal imaging, the challenge presented by dielectric shading effects, can make it difficult for radiologists to harness its full power for body imaging. In particular, dielectric shading can lead to reduced signal in the liver and left-right differences in breast imaging. This limits the usefulness of 3T systems for these clinical applications.

Parallel RF (radiofrequency) transmission has been introduced to address these challenges. This technology uses multiple RF transmission signals that automatically adjust to each patient's unique size and shape. Doing so directly addresses the challenges presented by dielectric shading. Just as two lamps, one on either side of an object, reduce the shadow cast by the object, each RF source is individually adapted to the patient's anatomy and optimized to cancel out the dielectric shading of the other source. The use of parallel RF transmission also allows the system to reduce local SAR levels, which enables faster scanning. With the introduction of automated scanning technology which enables patient position identification, consistent planning, scanning, and processing of images automatically-advanced scanning of a patient is possible at the touch of a single button. This technology delivers consistency in scan quality, in each and every patient, without delaying any of the scans. Scanning through MRI is a time taking process which requires the patient to remain under the magnet tunnel while being stable and calm. But, now MRI systems are available which perform scanning 16-32 times faster than the conventional systems. It also offers better imaging, higher throughput, and patient comfort. The future advancements in MRI seem to be moving toward

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improving the speed of scanning and enabling the magnet to capture real-time images for dynamic MRI.18

Statistics about CT and MRI in India

India definitely faces a dearth of radiologists. At present, there are about 8,000 radiologists in India, catering to the needs of the sub-continent and about 300 are expected to be added each year. Also, this figure could go up if the National Board of Radio-diagnostics would come through and diagnostic centers are given more DNB seats. Currently, there are around 5,000 radio-diagnostic centers in India, mainly concentrated in the tier I and II cities. The Indian population at large, and people not living in large cities in particular, is grossly underserved for diagnostic radiology.3

Table 4:

Modality Total Installations in India (Jan 2010)

Per Million Population

India China Japan Korea

CT 3000 3 6 92 32

MRI 600 0.6 2 >35 >11

Source: Indo-US Healthcare

Indian Equipment Market for Diagnostic Imaging

The Indian medical devices and equipment industry was estimated at $1.82 billion in 2007 according to Frost & Sullivan, Healthcare Practice, Economic Research and Analytics Group. 19The Indian health imaging market contributes approximately 50 per cent of this market and by 2010 is expected to swell to $700 million. The demand for hi-tech medical devices alone constitutes nearly 80 per cent of the overall market in India and involvement of foreign companies in sourcing hi-tech devices is higher since domestic production is primarily skewed towards low-tech devices. Currently, nearly 90 per cent of the demand for imaging devices and equipment in India is being met by imports from countries such as the US, Germany, and Japan. The medical devices and equipment market is becoming increasingly competitive for multinational companies (MNCs) due to the low entry barriers, increasing number of participants, and a huge consumer base. Moreover, most of the imported medical devices and equipment products have high gross margins too. Currently, some of the products such as medical imaging equipment, ultrasonic scanning equipment, and cancer diagnostic equipment have greater sales prospects. The market is dominated by MNCs, where GE Healthcare and Siemens Medical Solutions are neck to neck in market share with Philips Healthcare closing on. Other significant players are L&T Medical, Trivitron, Toshiba Medical System, BPL India Ltd., Esaote India Ltd. and Sonosite Pvt. Itd. New entrants like Mindray are also gaining attention.8

18Medical Buyer (2010) “Gold Standard Diagnosis” Available from: http://www.medicalbuyer.co.in/2007/mri-equipment-gold-standard-diagnosis-2697-41.html (Accesseed on: 27/July/10)

19 Kachhap M., (2008)“Imaging Industry in India ” Available from: http://www.modernmedicare.in/article/Leaping-forward-diagnostic-imaging/page5.html (Accessed on: 27/July/10)

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India is reported to be one of the largest markets for diagnostic imaging and therefore a lot of movement is seen in this arena. The main concern for India is to have technology that reaches the mass population who are currently excluded from receiving quality healthcare because they are in remote locations or there is not enough equipment to service their demand. Technology that makes healthcare highly portable and cost effective will very quickly gain acceptance. The focus of innovation has always been on one hand to help doctors to diagnose more confidently while at the same time make the technologies more patient-friendly.3

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CHAPTER 4

RECOMMENDATIONS & CONCLUSION

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4.1 RECOMMENDATIONS

After analyzing the PEST analysis, the results show that Bayer Schering can take advantage of opportunities in the Indian market and make contingency plans for threats when preparing business and strategic plans. It can understand the market growth rate and accordingly plan its business position, potential and direction for operations. Bayer Schering Pharma can develop its strategic planning, marketing planning, business and product development. The Porter 5 forces analysis would break Bayer Schering’s unconscious assumptions, and help to effectively adapt to the realities of the new environment in the Indian Market. There were many facts revealed like it was observed in the survey that GE sells its contrast media (Omnipaque-100ml) at a lower price (Rs.850) in the semi urban area (Madhya Pradesh- Satna) but at a higher price (Rs.1000) in the metropolitan city (Kolkata). Therfore Bayer Schering can understand GE’s pricing policy and thus formulate its own strategy like selling cheaper in the metropolitan cities too, in order to target a larger number of customer base and increase its market share by following penetration pricing.

The SWOT analysis showed that Bayer Schering has the resource advantage relative to competitors as it has always been the worldwide leader in the contrast media market, being the Innovator and developer of world’s first contrast media. This is a distinctive competence as it gives Bayer Schering a comparative advantage in the marketplace. It can use this to leverage its brand image in the new market and increase its customer base. But it should also be aware of the fact that other existing players already have an established base with strong distribution network and established clientele base. To overcome this Bayer Schering can merge with or acquired Global pharmaceutical companies to gain competitive advantage through new technology or take advantage of their distribution network. It is already in a co-operative alliance with Zydus-Cadilla for distribution of its contrast media so it can look for further potential partners to leverage their competencies in gaining a foothold in the market. It can also tie up with equipment manufacturers and offer the contrast agents along with the equipment to hospitals and diagnostic centers (e.g. Siemens, Philips, and Toshiba). It can also identify a previously overlooked market segment like the rural areas and thus contact the government hospitals present in these local areas to offer contrast media at a lower rate than the competitors. Moreover, it can focus on improved buyer relationships to build on customer loyalty, unlike the competitors. In most cases, the buyers are not loyal as they buy products which are available at cheaper rates. Since its customers are fragmented, it can try to bring them into a cluster by providing contrast media in bulk to group of hospitals or chain of hospitals.

4.2 CONCLUSION

The Indian pharmaceutical Industry is fast growing and lucrative because of the vast population, ageing societies but it is also highly fragmented and vulnerable with many players and low per capita healthcare spending, complex regulatory requirments, government interventions on prices and patents and tough competition from local and international firms. The market will triple to US$20 billion by 2015 and move into the world’s top 10 pharmaceutical markets. It is expected to face many challenges ahead but growth prospects are also encouraging.The Indian diagnostic market has been growing fast, at 15-20 percent growth. The research findings reveal that GE is the unparalleled leader in the contrast media market amongst the multinational players like Bracco, Mallinckrodt, Guerbet, and Amersham. In order to tap the Indian Market and compete with a player like GE, Bayer Schering should enter the market with strong distribution network, better quality and focus on improved buyer relationships to build on customer loyalty, unlike the competitors. It should

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leverage its core competencies and overcome the weaknesses and threats. Bayer Schering can surely succeed in the Indian contrast media market when it develops its strategies based on the PEST and SWOT analysis and keeping in mind the intense rivalry in the industry

4.3 LEARNING OUTCOME

1. Insight into the working dynamics of the Indian Pharmaceutical Industry and more specifically about the contrast media situation in the Indian Market.

2. Able to relate the theories and concepts studied (in marketing) to what is being practised in the industry

3. Understand the purchasing process of contrast media by the diagnostic centres like details about the brands purchased, pricing, distribution channel.

4. Understand the medical and diagnostic imaging market in India.

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REFERENCE LIST:

1. Gerster R. “ (N.A.) “Indian Pharmaceutical Industry”, Available from: http://www.pharmaceutical-drug-manufacturers.com/pharmaceutical-industry/ (Accessed on: 30/June/10)

2. Rane Y., Shah P., Mashru R. (2006)“Intellectual property rights for Indian pharmaceutical firms: What needs to be corrected?” Pharma Times, Vol. 38 (6), Available from: http://www.ipapharma.org/pdf/Yogesh%20Rane_Article.pdf (Accessed on: 9/July/10)

3. Tiwari A. , Kishore L.T. , Naiyer Imam (2010) “Medical Imaging Industry in India” ; Healthcare IT solutions, Indo-Us Healthcare, Available from: http://www.indoushealthcare.com/html/medical-imaging.html (Accessed on: 4/July/10)

4. Dhawan S K(N.A.) “A brief history of Indian Radiology” ; Radiology Education Foundation, Available from: http://www.refindia.net/rindia/history.htm (Accessed on: 5/July/10)

5. REF (2009)“India Radiology Institutions”, Available from: http://www.refindia.net/rindia/associations.htm (Accessed on: 9/July/10)

6. Rao P., Tiwari P., (2006 )“Impact of TRIPS on Pharmaceutical prices “ Available from: http://www.whoindia.org/LinkFiles/Trade_Agreement_Impact_of_TRIPS_on_Pharmaceutical_Prices.pdf (Accessed on: 20/July/10)

7. Satyanarayana T. , Reddy D., Swarnalatha D., Purushothaman M. (2010)“Enforcement of Intellectual Property Rights: International and National Obligations and Practical Challenges in Pharmaceuticals Sector”, JITPS, Vol.1 (4), pp. 186-190, Available from: http://www.itpsonline.net/Documents/Volumes/Vol1Issue4/jitps_01041005.pdf (Accessed on: 9/July/10)

8. Sharma A. (2005) “New amendments to Patents Act, 1970 to affect farm sector “ Available from: http://www.financialexpress.com/fe_archive_full_story.php?content_id=78652 (Accessed on: 30/June /10)

9. Kumara G., Mitra P., Pasricha C (2009 )“Indian Pharma 2015: Unlocking the Potential of the Indian Pharmaceuticals Market” McKinsey & Company Available from: http://www.mckinsey.com/locations/india/mckinseyonindia/pdf/India_Pharma_2015.pdf (Accessed on: 4/July/10)

10. 10. Bayer Schering Pharma (2009) “Contrast Media “ Available from: http://www.bayerscheringpharma.de/scripts/pages/en/therapeutic_areas/imaging_techniques/contrast_media/index.php (Accessed on: 9/July/10)

11. Bayer Schering Pharma (2009) “Pioneer in Diagnostic Imaging” Available from: https://www.diagnosticimaging.bayerscheringpharma.de/scripts/pages/en/public/about_us/the_business_unit/index.php (Accessed on: 12/July/10)

12. Bayer Schering (2009) “Corporate Profile” Available from: http://www.bayerscheringpharma.de/scripts/pages/en/company/about_us/corporate_profile/index.php (Accessed on: 28/June/10)

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13. Bayer Schering (2009) “Imaging Techniques “ Available from: http://www.bayerscheringpharma.de/scripts/pages/en/therapeutic_areas/imaging_techniques/contrast_media/index.php (Accessed on: 27/June/10)

14. Radiology Info (2010) “Contrast Materials” Available from: http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_contrast (Accessed on: 22/July/10)

15. Research and Markets (2009) “Indian Markets for Diagnostic Imaging Systems” Available from: http://www.medicexchange.com/Radiology/indian-markets-for-diagnostic-imaging-systems.html (Accessed on: 4/July/10)

16. TehcnoClin Consulting (2009)“Trends in Diagnostic Imaging”Available from: http://technoclin.com/articles/trends-in-diagnostic-imaging (Accessed on: 9/July/10)

17. Medical Buyer (2010), “CT scanners” http://www.medicalbuyer.co.in/2007/ct-scanners-discerning-procurement-2704-41.html (Accessed on: 13/July/10)

18. Medical Buyer (2010) “Gold Standard Diagnosis” Available from: http://www.medicalbuyer.co.in/2007/mri-equipment-gold-standard-diagnosis-2697-41.html (Accesseed on: 27/July/10)

19. Kachhap M., (2008)“Imaging Industry in India ” Available from: http://www.modernmedicare.in/article/Leaping-forward-diagnostic-imaging/page5.html (Accessed on: 27/July/10)

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