‌9

‌Making value off-patent: India’s pharmaceutical globalisation

‌Yves-Marie Rault-Chodankar

‘In the Western world, if you make something for 1 dollar and you can’t sell it for more than 25 dollars, it is not viable’ (ARTE Reportage 2019). Talking about India’s role as a primary supplier of generic medicines in the developing world, the executive director of the Serum Institute India – the largest vaccine manufacturer in the world – highlighted that the value-making practices of India’s multinational pharmaceutical companies contrast sharply with their counterparts from the ‘Western world’. He explained that while firms from the Global North generate income through intellectual property and monopolies, Indian firms focus on cost-effective production and wide accessibility, challenging traditional notions of value in the pharmaceutical sector.

In this chapter, I explore how value is created through the development, manufacturing, and distribution of off-patent medicines. Between 2015 and 2023, I visited many factories, offices, and warehouses across India to document the expansion of the local pharmaceutical industry. Drawing on interviews with several company directors and executives, I delve into the business models and revenue-generating strategies India’s firms employ. The sample includes a wide range of enterprises: small and medium-scale businesses; biological and chemical firms; bulk drugs producers and generic formulators, manufacturing, and marketing companies; as well as international firms and India-focused businesses. However, these firms share one common characteristic: they generate revenue from drugs originally developed in the West, which have since lost their patent.

They form an industry that contrasts sharply with the ‘intellectual property-driven knowledge capitalism’ that has captured researchers’ attention to the detriment of the ‘IP-renting countries’, typically in the Global South (Kang 2021). Most studies assume that when patented drugs get stripped of their intellectual property (IP) rights, they become ‘de-assetised’ (Bourgeron and Geiger 2022), that is, no longer ‘owned or controlled, traded, and capitalised as a revenue stream’ (Birch and Muniesa 2020: 2). Hence, we rarely consider the generic industry as a critical value-making site, but rather we see it as the key to democratising access to medicines and an ally in the struggle against patents alongside activist and humanitarian actors (Biehl 2007; Lakoff 2004). From this perspective, India is the ‘pharmacy of the developing world’, supporting pharmaceutical affordability in the Global South against the backdrop of intellectual property laws (Guennif 2013).

Exploring alternative models of pharmaceutical value creation is thus critical in global health research (Cassier 2023). The IP-rich industry has been extensively critiqued for its inherent practice of turning lifesaving products into objects of speculation and capital accumulation (Dumit 2012; Helmreich 2008; Rajan 2006). The strategies of multinational companies from the North typically involve IP rights (Zeller 2007), which help establish ‘monopoly rents’ by granting rights of exclusion to the IP owner (Geiger and Gross 2021; Vezyridis and Timmons 2021). Hence, alongside research and development efforts, drugs are made profitable through the intensive management of legal and regulatory domains to create and extract value (Geiger and Finch 2016; Roy 2020). Such IP strategies are considered responsible for excessive prices and deteriorated pharmaceutical access. They are said to be at the root of the ‘scarcity regime’ of the Global North (Roy and King 2016). Moreover, although the expiration of patents generates new prospects for patients worldwide, it also brings about new capitalistic forms of appropriation (Hayden 2007, 2008, 2010, 2013). In fact, ‘generics are compatible with both the privatisation and the pharmaceuticalisation of public health’ (Hayden 2007: 488). Moreover, many interactions between IP-protected and generic companies (e.g., licensing patented drugs) blur the boundaries within the global pharmaceutical industry (Nouguez 2017; Rault-Chodankar 2022).

To contribute to these debates and illustrate how the value-making strategies of India’s firms shape an alternative form of globalisation, this chapter starts by unveiling the existence of original value-making practices beyond the IP-rich industry of the Global North. I then dive into my fieldwork data to show how India’s companies resort to inventive copying to generate some form of intellectual property that does not rely on patents. Next, I discuss how they diversify and adapt their manufacturing capacities to cater to small market niches, which is not profitable for other multinational firms. Then, I show how they develop distribution networks in the Global South through non-contractual relationships with suppliers, wholesalers, retailers, and doctors, contrasting with the asymmetrical relationships that IP-based firms maintain with their buyers and suppliers. Finally, I suggest that these value-making practices reflect the rise of another form of globalisation that is not based on global monopolies and large-scale concentration of power but is instead driven by local market dynamics and deeply rooted in social and economic contexts.

Pharmaceutical value-making beyond the Global North

Large multinational pharmaceutical companies’ capitalisation on IP rights, such as patents, is well documented (Kang 2021). The process starts with significant investment in research and development (R&D) to discover and formulate new drugs and treatments. Once a new product has been created, the company applies for a patent to secure exclusive rights to the product for a defined period, usually 20 years from the filing date. It can also prolong the legal protection of its drugs by making minor changes to the initial invention, a practice known as ‘evergreening’. These exclusive rights let the company market and sell its products at premium prices and enjoy a global monopoly on its sales, earning substantial profits (Kang 2020). Companies may also license the patented drugs to other companies for additional revenue without investing in production or marketing. At the same time, they heavily invest in legal counsel and regulatory affairs to enforce their IP monopolies. By having a well-established and exclusive distribution network, they can retain control over pricing and keep out potential competitors (they may also acquire the latter). Establishing exclusive relationships with suppliers and buyers also happens on a political level, with large companies lobbying for the establishment of international and national standards that help disqualify several competitors’ pharmaceuticals as ‘fake drugs’, labelling them as ‘counterfeit’, ‘substandard’, or ‘spurious’ (Hodges and Garnett 2020).

The pharmaceutical companies’ strategies do not all involve new scientific discoveries protected by the law or exclusive market presence. Outside the IP-based industry, notably in the Global South, the firms build monopolies that are more short-term, fluid, and local than those based on patents and brands, manufacturing technology, and global distribution networks. To enforce these monopolies, they do not rely on official standards but rather reappropriate them, thus giving shape to an alternative capitalist regime in which legal resources do not constitute a critical form of capital (Quet 2018). In the Global South context, contractual relationships are rarer, and business networks are embedded in various webs of social relationships. As such, they contrast with the large-scale strategies of logistics- and capital-rich multinational corporations that build on corporate, institutionalised, and contractual networks (Durand and Milberg 2020). Hence, the monopolies they create are often temporary and unstable and generate limited income for a short period. In contrast with the IP-capital-rich industry, these strategies yield a lower sale value and revenue. They are many steps removed from the emerging ‘intellectual-property monopoly capitalism’, led by large and sprawling technology-intensive companies (Rikap 2022a, 2022b) that dominate the hyper-specialised companies lower in the value chain (Schwartz 2022).

Companies which do not work with patents can have a more short-term focus, diversified strategies, and a tolerance for lower profits. In a way, such strategies seem to cater to the needs of patients otherwise left out by the IP-based industry. For example, Logan Williams explored an ophthalmology technology invented in the Global North that companies did not develop due to a lack of economic potential. She showed that Nepalese cataract surgeons were now using this technology as an inexpensive and convenient medical device with economic potential in South Asia (Williams 2017). While the pharmaceutical sector is not short of recent examples of value being ‘shifted’ rather than ‘created’ through patents (Reinhardt 2016), the Southern generic companies have ways of generating income by catering to the needs of a limited number of patients, something that large IP-based companies are unable or unwilling to do. Table 1 illustrates how pharmaceutical companies can operate differently across several segments of the pharmaceutical value chain.

‌

IP-based practices	Off-patent practices
Research & Development
Discovering, developing, and testing new molecules, expecting technological innovation	Developing and modifying existing formulations, expecting increased drug consumption
High investment in patent and copyright enforcement	Saving costs on legal fees but spending more on marketing efforts
Building brand loyalty with first-mover advantage and based on the company’s geographic origin (high symbolic capital)	Developing drug presentation with unique dosage, packaging, design, and information for niche markets
Manufacturing
Obtaining global manufacturing authorisations: US FDA, PIC/S	Obtaining various authorisations: CDSCO, then WHO, then US FDA and PIC/S
Focus on the single-technology effectiveness of specialised production systems	Focus on the general cost and quality effectiveness of diverse and adaptable production systems
Creating value through the capacity to produce high-value pharmaceuticals	Creating value through the price of land; capacity to produce large quantities
Distribution
Exclusive agreements with a small number of major suppliers, wholesalers, retailers, and doctors	Exclusive and non-exclusive agreements with multiple and small-sized suppliers, wholesalers, retailers, and doctors
Contractual relationships and professional network of the company	Informal relationships and critical reliance on social ties
Enjoying exclusivity by default thanks to patented products and brands	Adapting products to niche customer needs to create product singularity

Table 1 Comparison of value-making practices in the pharmaceutical industry

Having demonstrated the existence of original pharmaceutical value-making practices outside the IP-based industry, it would, however, be a mistake to encapsulate the Global South into a uniform model of ‘copycat capitalism,’ as opposed to the ‘global rentier capitalism’ of the Global North (Cassier 2019). The Global South countries showcase a wide diversity of situations correlated to the role of the state and the characteristics of local economic actors. In Mexico, early compliance with international intellectual property law has led expensive, foreign-made, patented drugs of the IP-based industry to dominate the market, leaving little room for the local private sector (Hayden 2008). In Nigeria, the historical merging of small-scale companies into more prominent groups to achieve economies of scale has limited the presence of low-margin drugs and the development of the local pharmaceutical industry (Peterson 2014). In Brazil, multiple drug companies, often publicly owned, have emerged by producing copies of drugs patented by multinationals from the Global North, thanks to the country’s unique patent regime and the support of the state (Cassier and Correa 2009; Lakoff 2004). In contrast, India’s pharmaceutical industry has developed rapidly thanks to its private sector, which has benefitted from the protectionist measures of the state and lack of adherence to the agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) before 2005. This unique political-economic assemblage now shapes the idiosyncratic value-making practices around off-patent drugs.

‘Alphonso mango instead of a mango’: Developing alternative intellectual properties

India’s pharmaceutical industry has over 10,000 companies of various sizes, including approximately 485 companies with export licenses1, with only a few listed on the stock exchange. They generally cannot afford to invest in drug discovery and development activities as large multinational firms. While R&D-related expenses amount to 8–15% of costs for European and North American pharmaceutical companies, they represent a tiny share of the annual turnover of India’s companies (Joseph 2016). These limited R&D investments are made by the most prominent companies, such as Dr Reddy’s and Biocon, and generally go towards developing generic versions of off-patent pharmaceuticals. One former executive of the large Indian companies Dubar, Intas, and Alchem, who now manages a small pharmaceutical distribution company based in Mumbai, explained that:

In India, there is significantly less spending on R&D. The big companies only invest 2–3% of their turnover. Among the 20,000 companies in India, only ten companies are spending on R&D: Dr Reddy, Dabur, Glenmark, Sun Pharma, CIPLA […] Why would they spend so much money when there are so many molecules available in the market?

In this context, ‘molecules’ refers to pharmaceutical compounds, particularly active pharmaceutical ingredients (APIs), that are already available for production. Rather than investing heavily in discovering new drugs, many Indian pharmaceutical companies focus on developing cost-effective generic alternatives. Even though some of India’s leading companies present themselves as innovation-driven and make more significant investments in R&D activities, their model primarily relies on developing and producing cost-effective generic alternatives. They rely, in a way, on alternative forms of intellectual property. Biocon is one of these companies, which heavily invested in the development of original biologic drugs (especially between 2002 and 2011) such as Nimotizumab and Itolizumab, two novel monoclonal antibodies, before going back to developing equivalents of existing cancer drugs in partnership with a US multinational firm. A former R&D executive at Biocon, who partnered with a Cuban research company to develop these products, explained that investing in R&D for novel drugs was ultimately part of the company’s strategy to build expertise in the development and manufacturing of biosimilar drugs:

The business model of Biocon was overall generics, so if you look at it, we developed small molecules. From there we moved to biosimilar insulins, and then we needed to get learnings on monoclonal antibody therapeutics. So, we got into this fantastic collaboration with CIM [Cuban company], and we learned that, and we used all the learning to run the biosimilar business. I strongly believed that the focus on novel drugs was there, but the return on investment was not enough.

In the past decade, most of Biocon’s profit has come from the sale of widely consumed biosimilars such as insulin glargine, pegfilgrastim, and Trastuzumab, which the company was able to develop as pharmaceutical equivalents and produce at a much lower cost. With these strategies, the largest Indian generic companies can hope to achieve a ‘first-to-file’ monopoly, that is, the right – granted to the first mover in certain countries like the United States – to sell exclusively at any price and for a limited period of time a product that is bioequivalent to the princeps drug. For the rest of the Indian companies, R&D activities rarely involve modifying an existing molecule; instead, they focus on changing how it is presented to the buyers and prescribers, such as pharmacists, doctors, and patients. These products constitute the firms’ ‘portfolio’, proudly displayed in their offices (see Figure 9.1).

Consequently, many of India’s drug development activities in the private sector are geared towards turning generic drugs into unique products by changing the dosage, mode of administration, and branding of the products, often known as ‘me-too drugs’. One company’s strategy was to improve the dissolution profile of a formulation. Its CEO explained that rather than merely propose a cheaper product, she was developing a more affordable and better product, or in her words, an ‘Alphonso mango instead of a mango’ (a tastier variety of mango). Thus, one active area of India’s incremental innovation has been novel drug delivery systems (NDDS). Successful examples include an Indian-improved version of the antibiotic product Ciprofloxacin, which challenged the dominant position of the multinational firm Bayer in early 2000. One R&D executive, who recalled his participation in the development of a treatment only available as an injection into a topical gel, nevertheless confirmed the scarcity of radical pharmaceutical innovation in India.

There is some innovation in NDDS, but it is not a big thing. Apart from Zydus, no Indian pharmaceutical company has developed a molecule in ten years. The market is filled with generic drugs because the patent law in India was only applied after 2005. The companies can only come with new brands from existing generic drugs.

NDDS are generally tricky to protect through the courts, unlike product patents that retain their value because large firms can build robust legal defences (Geiger and Finch 2016). As a result, NDDS can only secure monopolies for a short period until other companies copy the product. Drug copying usually happens once the drugs are adopted and known by enough patients for their copy to be profitable. Another way to create differentiation through copying is to change the dosage of generic medicines. The director of a medium-sized company was planning to commercialise a drug for pre-menopausal women (Vagifam) at a lower dosage to create a short-term monopoly:

Somebody gave us this product for development. […] This product, Vagifam, is used for pre-menopausal women. It’s a single-use formulation which women need to use in their vaginas to reduce the symptoms of menopause. Now, the usual dose was 25 mg, but for no reason, no one decided to introduce this only in 10 mg. […] They each will cost 4–5 euros. So, the cost of the drug, in this case, is very minuscule.

These ‘supergenerics’, named as such because of their use of ‘sameness and similarity as generative forms of distinction and value’ (Hayden 2013: 601), are often prescribed, sold, and purchased under brand names. The presentation and branding of drugs is thus a significant area in which India’s generic companies have innovated in recent years, capitalising on colours, shapes, designs, and packaging materials, as well as including detailed information about the product on the label, to foster a sense of reliability. In parallel, other companies have started reemphasising the generic aspect of their products, for instance, by developing minimalist packaging or emphasising the lower prices of ‘pure generics’ to appeal to specific population categories, even if their prices are not necessarily lower than the competition.

This drive to create unique generic products has led to the proliferation of multiple pharmaceutical products across India’s markets. In June 2023, the Indian pharmaceutical marketplace 1mg.com offered over 12,300 paracetamol-based products in various forms involving various dosages and combinations, commercialised under more than 1,100 different brands. However, these brands survive not by relying on copyright enforcement, exclusive agreements, and monopoly-building but by catering to diverse market needs and patient niches. Most small-scale Indian companies choose not to register their brand names to save on some administrative and legal consulting fees. However, while intellectual property is virtually absent from their strategies as suppliers of generic drugs, the Indian companies have to contend with other regulations to expand their production capacity, especially manufacturing standards. The following section documents how Indian companies create value through manufacturing strategies that differ significantly from those of large foreign multinationals.

Amla candy, cough syrups, and niche markets: The value of flexible manufacturing

India now hosts over 2,000 pharmaceutical factories certified by the World Health Organisation2. It has the highest number of US FDA-approved drug-manufacturing plants outside the USA3. Since the 1970s, investors from various sectors have seen India’s pharmaceutical manufacturing industry as a safe and dynamic economic space and an opportunity to diversify their portfolio. So much so that the overall manufacturing capacity of India’s pharmaceutical companies has not been fully utilised, and several plants have been shut down in the last 20 years as they failed to adopt national and international manufacturing practices while remaining profitable (e.g., India’s Schedule M; see Iyer 2008).

The surviving manufacturing plants could upgrade their production processes to comply with international manufacturing rules. One factory from Himmatnagar (Gujarat), set up in 2014, which produced specialised injections, was, however, running at only 10% of its capacity due to a lack of buyer orders. The facility would have been worth little if the value was based on its current usage. However, the CEO explained that the company’s sales value had continuously increased since it obtained its first manufacturing license and anticipated that its upcoming PIC/S certification (standards of the European Free Trade Association) would increase its sales value even more. He therefore had to keep a costly workforce on the payroll, including compliance and quality officers, even though production was insufficient to make the company’s operations profitable. Thus, to hold onto certifications and maintain the company’s value, the managers paradoxically had to create an unprofitable manufacturing system. When I met him in 2017, the CEO explained that the plant should now be worth 45 crore rupees (5.7 million USD) when they had invested 30 crore rupees (3.8 million USD), even though the factory was not economically viable. The CEO explained that this was a long-term strategy supported by local investors looking to diversify their assets:

For this kind of company, you should not be looking for short-term profits. At first, we had difficulty finding investors, but we found one big investor with the Vohra Samaj. The Harsolia family is one of the big families that invested, and one son is now in charge of the financial department. They are wealthy because they have shares in the automobile sector, but they wanted to develop a vertical in pharmaceuticals.

This drive to diversify investments is a visible trend within pharmaceutical organisations. For many companies, a key strategy is to comply with specific manufacturing standards (chiefly, Good Manufacturing Practices – GMPs) rather than focus on only the most demanding ones, like the IP-rich pharmaceutical industry. Indian companies often follow an inverse process, first obtaining less stringent certifications from local agencies, then meeting World Health Organisation (WHO) standards to access donor-based markets in the Global South, and eventually complying with the most stringent standards set by the USA or the EU. The GMPs are constantly changing, and as they do, the current GMPs (cGMPs) also affect the value of companies, for compliance with these practices determines which markets a company can access and the price at which it can sell pharmaceuticals. The inflation of norms has led to a race to obtain and hold onto certifications, reflected in the growing number of regulatory consultants specialised in compliance with the production standards of the various health authorities.

Manufacturing is not fundamentally driving valuation in India, especially compared to the United States (Rajan 2006: 127). The Indian firms’ strategy instead consists of validating their manufacturing capability, that is, their ability to produce and sell multiple products in competition with multinational firms (Hughes 2013). The strategies of Indian companies generally focus on improving manufacturing capacities rather than developing ways to produce innovative pharmaceuticals. For instance, a manufacturing company from Ambernath (Maharashtra) could access the European market as a supplier of API through a so-called written confidential with an Austrian company. The European company vouched that the plant complied with the PIC/S certification requirements for importing Indian products. However, the head of business development explained that they were still applying for the PIC/S certification to diversify their customer base but also to find another source of valuation for his company:

We cannot produce for the domestic market because there is too much cost compression, and eventually, our products will get a bad purity profile. This is why we mostly work in exports with partners from Europe or the US. […] For now, we don’t have the big certifications, but I can tell you the factory is already compliant. But we are looking to get the PIC/S certification even if we don’t really need it because it will give us more credit [credibility].

Another manufacturing plant in Sanand (Gujarat) produced amoxicillin and potassium clavulanate tablets for two companies, one Indian and the other British. The CEO assessed the value of the company’s plant against the income he could generate by producing the same product for different companies since it did not require further investment. In contrast with the hyperspecialised production lines for patent technologies, the Indian plants can integrate the production of diverse pharmaceuticals to maximise their capacity and revenue. Some Indian companies notably developed small-scale systems to produce monoclonal antibodies to cater to the limited domestic demand for these biological drugs. The most iconic example is probably the case of a small-scale plant from Ahmedabad, which was simultaneously manufacturing amla (Indian gooseberry) candy and cough syrups to make full use of its production capacity. The following section goes one step further in the pharmaceutical value chain to understand how Indian companies create value by distributing drugs to the Global South.

The ‘minuscule networks’: Distributing to the rest of the world

A significant portion of India’s pharmaceutical revenue is derived from the Global South, or to use the industry’s terminology, the ‘Rest of the World’. In the year 2020, sales on the domestic market accounted for 50% of the industry’s revenue, while sales in other low- and middle-income countries (LMICs) contributed 25% of its overall earnings. Large foreign companies often handle the distribution of Indian-made products to high-income markets. Complying with existing regulations, convincing medical practitioners, and negotiating with insurance companies are complex and costly activities that Indian firms often cannot manage alone. Instead, they focus on distributing their products to ‘semi-regulated’ markets in the Global South. The Indian brands must develop unique strategies, as the geographical origin and associated perceptions of quality have a considerable impact on the consumption of generics, and brands from India usually have a negative reputation (Baxerres, Kpatchavi, et al. 2021).

Access to the markets of the Rest of the World is facilitated by many intermediaries, which Indian companies leverage to distribute their products. India’s business networks are significantly based on family, community, regional, and socio-professional ties, a dynamic that profoundly permeates how South–South networks are shaped (Rault-Chodankar 2020). The companies rely extensively on their social ties to secure, protect, and control networks in a Global South context, where value chains are governed by multiple ‘middlemen’ or ‘traders’, in contrast with North–South networks characterised by power asymmetries (Horner and Murphy 2017). Networking is paramount in India’s pharmaceutical industry, with companies relying extensively on social ties to secure and control market access. For instance, the CEO of an Ahmedabad-based company used a family connection in Ghana to find a distributor for his antidiabetic products, which were manufactured in his uncle’s factory in Baddi (Himachal Pradesh). Additionally, to forge new connections, visiting cards (see Figure 9.3) are frequently exchanged during industry events, demonstrating another way Indian firms make contact and build crucial networks.

Contacts in international markets are particularly crucial to learning about local manufacturing and commercial standards. One manager found a Danish consultant from India, certified in clinical studies, to help his company register a generic version of a drug treating menopausal symptoms on the EU market. Yet other companies generated revenue through their networks by obtaining exclusive information about missing products in various markets. One company identified a treatment for polycystic ovary syndrome and irregular menstrual cycles in women that was still sold only in Europe and the USA. These examples illustrate the strength of small ties in India’s pharmaceutical industry, as confirmed by this company director based in Ahmedabad, who recalled how helpful his network has been in the early days:

I had a friend, a chartered accountant, who gave me advice in accountancy. He gave me very simple books on finance. They were caricature books, comic books on finance. I enjoyed, and I understood how balance is made. And it is my friend from college days who taught me how to make project reports and how to borrow money. If you look at my networks, these are my minuscule networks which have built me.

Certain companies with more limited ‘social capital’ struggled to access supply chains and distribution networks. For instance, a newly built factory in Gujarat could not find buyers for its specialised injections. The CEO, a Muslim community member whose local board owned the company, argued that they were excluded from Hindu networks because they were Muslim. Consequently, they could only manufacture for large Muslim-owned companies like Cipla. He explained that most of the social networks of his Muslim caste (Bohra) were still in the automotive parts manufacturing industry. Another manufacturer of low-cost pharmaceuticals, such as cough syrups, based in Surendranagar (Gujarat), stated that being in a city that was not a business hub was a significant disadvantage. The manager had to travel weekly to Ahmedabad, two hours away by car, to meet potential buyers. With a limited command of English and knowledge of information technology, he explained that he struggled to find customers.

I travel weekly to Ahmedabad to meet customers because they do not come to Surendranagar. Other firms from Ahmedabad, they just talk to their neighbours and find connections, so it’s hard for us. They find marketing firms and sell their products. For us, we tried to improve our marketing, but the internet is not so good in Surendranagar. We have paid GoDaddy to create a website, but it does not work.

The Indian companies also leverage their social networks to build exclusive relationships with distributors. In India, whether they work in private clinics or public hospitals, doctors generally prescribe not the generic but the branded version of a drug, despite the medical associations’ recommendations and unsuccessful legislative attempts to encourage the prescription of generic medicines. Promoting brands is not so much a matter of convincing customers of the quality of a given product but instead of ensuring that the hospitals, pharmacists, and doctors will not even consider another brand. Consequently, many companies’ activities involve promoting products to those influencing their sale or prescription. Due to physicians’ prescription practices, pharmacies and hospitals must store specific brands. At the same time, pharmacists can also bypass prescriptions and sell prescription drugs without an official document from a doctor (Dahdah et al. 2018). If a doctor prescribes a generic brand name, the pharmacists will choose the product from a series of generic brands with the same chemical formula. Building solid and exclusive ties with medical practitioners is thus a significant way of securing industry and regional monopolies. Pharmacists are also the leading partners in selling over-the-counter drugs when a doctor’s prescription is not required. Furthermore, having a local distribution network provides companies with valuable data on local customer preferences, buying patterns, and market trends, which they can use to make informed business decisions and develop new strategies. The companies can also use this information to tailor their marketing efforts to local customer needs and increase customer loyalty.

Although some medical-scientific arguments are commonly used to highlight the unique benefits of specific dosages, India’s companies mainly draw on preexisting scientific data to promote cheaper branded variations of a molecule. These practices differ from the ‘scientific marketing’ activities described in markets of the Global North, designed to generate new needs and to convince the medical community, including health agencies and officials at different levels (Gaudillière 2015). For example, Greffion and Breda (2015) argue that French medical representatives (MRs) primarily promote the prescription of the costliest and most recent drugs. In India, the far wider variety of low-cost brands, the limited number of people covered by health insurance, and the absence of social security suggest a different role for MRs, geared towards convincing not medical authorities and private and public insurance to accept new molecules, but rather the patients, doctors, and retailers to adopt different versions of existing products.

A country like Ghana is also host to these lively promotional practices, where 2,175 private pharmacies are supplied by 576 private wholesalers, a situation which contrasts drastically with that witnessed in Benin, where a few wholesaler distributors have a strong monopoly (Baxerres, Codjo, et al. 2021). In India, pharmaceutical companies extensively use their connections with medical professionals to make them prescribe their products. For example, the CEO of a company from Ahmedabad, a former medical representative, was promoting formulations for men with erectile dysfunction (generic Sildenafil). To do so, he developed exclusive agreements with doctors and local wholesalers to prevent them from proposing other generic alternatives. In India, former medical representatives extensively use their professional networks to create pharmaceutical enterprises. The ongoing war between marketing firms to poach one another’s most experienced MRs by offering them better income and higher positions is evidence of the importance of local connections in the sector.

In this context, business consultants play a crucial role. Former executives of large pharmaceutical companies often rent out their networks as a fee-based service. The director of a pharmaceutical consultancy based in Mumbai was posted in Africa as a regional manager for an extended period and built a 20-year career in the sector. He explained how his extensive transnational network could help him find buyers and a range of helpful information that can generate economic revenue:

Over the years, whatever network I have developed can be divided basically into three: one is my core network of core people that I know are looking for a product. They are all connected, and these people are also people who would respond to me in case. So, these are the people you have to talk to. So, believe me, if you have a contact list of 500, this core list is just 10–20 maximum, no more than that. And then there is the other category they will tell you maybe they are interested, maybe they will come back to you, maybe they will not, but they are the potential clients. And number 3 is you know some people you just have to pass on the information, and maybe if they are interested, they will come back to you.

Indian business networks are, however, not as exclusive as in the IP-based industry. For example, one company that had set up a European branch also marketed the products of other companies based in India. Local networks thus also work as connectors by facilitating interaction through shared culture, language, or community ties. By the same token, they can serve as exclusion tools to keep out competitors. Unlike in the patent-protected pharmaceutical industry, access and exclusion coexist as strategies in India’s pharmaceutical networks. Extensive fluidity, the blurred boundary between the interpersonal and the corporate, and the non-contractual nature of inter-company relationships are distinct specificities of the pharmaceutical industries of the Global South. India’s firms bring business practices that shape unique technoscientific assemblages, which deeply contrast with the intellectual-property monopoly capitalism led by IP-based companies.

Conclusion: An ordinary globalisation

This chapter examines the value-making practices of the pharmaceutical industry beyond the large and innovative multinational companies of the Global North. India’s pharmaceutical business strategies illustrate how firms can access niche markets with off-patent formulations, develop cost-efficient and adaptable production systems, and form diversified distribution networks through exclusive and non-exclusive agreements with local suppliers, wholesalers, retailers, and doctors.

So far, pharmaceutical capitalism has primarily been studied from/in the Global North, looking at large multinational companies and ‘high-end’ processes of transnational interconnection. By examining the smaller, more localised, less radically innovative pharmaceutical companies in the Global South, this chapter answers the call to integrate actors and objects that are ‘non-hegemonic’ and almost ‘ordinary’ but still play an instrumental role in global economic change, as there are many of them and they are highly active (Mathews et al. 2012).

The dynamism of India’s pharmaceutical companies illustrates the liveliness of ‘low-end’ globalisation processes, that is, the ‘transnational flow of people and goods involving relatively small amounts of capital and informal, sometimes semi-legal or illegal transactions, commonly associated with the “developing world”‘ (Mathews 2011: 19–20). This concept has been instrumental in highlighting how certain social groups, typically considered marginal, actively participate in globalisation processes, even though they do not belong to ‘worlding cities’ or large multinational companies (Choplin and Pliez 2015).

Regarding relations of domination, it is crucial to recognise that several forms of capitalism can grow in parallel and interact without strong relations of domination. Indian firms are dominant in many ways. For instance, they play a crucial role in the global supply chain for generic medicines, often providing the bulk of affordable medications for low- and middle-income countries. Their dominance is characterised not by monopolistic control but rather by their extensive reach, adaptability, and ability to innovate within the constraints of existing technologies and markets. Indian pharmaceutical companies have mastered the art of reverse engineering and the development of cost-effective manufacturing processes, which has allowed them to thrive in both local and international markets, especially within the Global South.

These original value-making practices shape an alternative form of globalisation. Indian firms appropriate and adapt existing drugs, finding new ways to create value in local and international markets, particularly in the Global South. By leveraging off-patent pharmaceuticals, they carve out niches that larger multinational corporations often overlook. This approach not only democratises access to essential medicines but also underscores the importance of alternative, non-monopolistic forms of globalisation that significantly contribute to economic and social development.

More scholarly attention must thus be paid to non-monopolistic strategies to understand the global diversity of technoscientific capitalism. Objects without intellectual property value, such as generic pharmaceuticals, also have an intense economic afterlife, thus suggesting that globalisation studies should consider old technologies (e.g., off-patent pharmaceuticals) as driving modern capitalist history just as much as shiny, IP-protected innovations (see Edgerton 2011).

In essence, the chapter underscores the need to expand our understanding of global economic dynamics to include these ‘ordinary’ actors and objects who, despite their lack of hegemonic power, play a vital role in shaping the contours of global capitalism. Ordinary strategies and practices also offer valuable insights into how economic value can be generated and sustained outside the paradigms of high-end innovation and monopolistic practices. They enrich our understanding of the complex and multifaceted nature of technoscientific globalisation.

Endnotes‌

References

ARTE Reportage, Inde: la guerre des vaccins (ARTE, 2019) https://www.arte.tv/fr/videos/071609-000-A/inde-la-guerre-des-vaccins/.

Baxerres, C., A. Codjo, and D. K. A. Kpatchavi, ‘Distribution and Access to Medicines’, in C. Baxerres, and M. Cassier, eds., Understanding Drugs Markets (Routledge, 2021), pp. 72.

Baxerres, C., A. C. Kpatchavi, and D. K. Arhinful, ‘When Subjective Quality Shapes the Whole Economy of Pharmaceutical Distribution and Production’, in C. Baxerres, and M. Cassier, eds., Understanding Drugs Markets (Routledge, 2021), pp. 249–73.

Biehl, J., ‘Pharmaceuticalization: AIDS Treatment and Global Health Politics’, Anthropological Quarterly, 80 (2007): 1083–1126.

Birch, K., and F. Muniesa, eds., Assetization: Turning Things into Assets in Technoscientific Capitalism (MIT Press, 2020), pp. 1–41 https://direct.mit.edu/books/book/4848/AssetizationTurning-Things-into-Assets-in.

Bourgeron, T., and S. Geiger, ‘(De-)Assetizing Pharmaceutical Patents: Patent Contestations Behind a Blockbuster Drug’, Economy and Society, 51 (2022): 23–45.

Cassier, M., ‘La Fin du Partage? Les Capitalismes de la Copie Face au Capitalisme de la Rente Globale: Une Nouvelle Géographie des Industries de Santé’, Mouvements (2019): 107–19.

Cassier, M., Il Y a Des Alternatives: Une Autre Histoire Des Médicaments (XIXe-XXIe Siècle) (Seuil, 2023).

Cassier, M., and M. Correa, ‘Éloge de la Copie: Le Reverse Engineering des Antirétroviraux Contre le VIH/Sida Dans les Laboratoires Pharmaceutiques Brésiliens’, Sciences Sociales et Santé, 27 (2009): 77–103.

Choplin, A., and O. Pliez, ‘The Inconspicuous Spaces of Globalization’, Articulo – Journal of Urban Research, 12 (2015): Article 12 https://doi.org/10.4000/articulo.2905.

Dahdah, M.A., A. Kumar, and M. Quet, ‘Empty Stocks and Loose Paper: Governing Access to Medicines Through Informality in Northern India’, International Sociology, 33 (2018): 778–95.

Dumit, J., ‘Prescription Maximization and the Accumulation of Surplus Health in the Pharmaceutical Industry’, in K. S. Rajan, ed., Lively Capital (Duke University Press, 2012), pp. 45–92.

Durand, C., and W. Milberg, ‘Intellectual Monopoly in Global Value Chains’, Review of International Political Economy, 27 (2020): 404–29.

Edgerton, D., The Shock of the Old: Technology and Global History since 1900 (1st edn; Oxford University Press, 2011).

Gaudillière, J.-P., The Development of Scientific Marketing in the Twentieth Century: Research for Sales in the Pharmaceutical Industry (Routledge, 2015).

Geiger, S., and J. Finch, ‘Promissories and Pharmaceutical Patents: Agencing Markets Through Public Narratives’, Consumption Markets & Culture, 19 (2016): 71–91.

Geiger, S., and N. Gross, ‘A Tidal Wave of Inevitable Data? Assetization in the Consumer Genomics Testing Industry’, Business & Society, 60 (2021): 614–49.

Greffion, J., and T. Breda, ‘Façonner la Prescription, Influencer les Médecins’, Revue de la Régulation. Capitalisme, Institutions, Pouvoirs, 17 (2015) https://doi.org/10.4000/regulation.11272.

Guennif, S., ‘L’Économie Politique du Brevet au Sud: Dimensions Industrielle et Sanitaire’, Mondes en Développement, 160 (2013): 85–98.

Hayden, C., ‘A Generic Solution? Pharmaceuticals and the Politics of the Similar in Mexico’, Current Anthropology, 48 (2007): 475–95.

Hayden, C., ‘No Patent, No Generic: Pharmaceutical Access and the Politics of the Copy’, in M. Biagioli, P. Jaszi, and M. Woodmansee, eds., Contexts of Invention (University of Chicago Press, 2008), pp. 62–90.

Hayden, C., ‘The Proper Copy’, Journal of Cultural Economy, 3 (2010): 85–102.

Hayden, C., ‘Distinctively Similar: A Generic Problem’, UCDL Review, 47 (2013): 601.

Helmreich, S., ‘Species of Biocapital’, Science as Culture, 17 (2008): 463–78.

Hodges, S., and E. Garnett, ‘The Ghost in the Data: Evidence Gaps and the Problem of Fake Drugs in Global Health Research’, Global Public Health (2020): 1–16.

Horner, R., and J. T. Murphy, ‘South–North and South–South Production Networks: Diverging Socio-Spatial Practices of Indian Pharmaceutical Firms’, Global Networks (2017): 1–26.

Hughes, S. S., Genentech: The Beginnings of Biotech (University of Chicago Press, 2013).

Iyer, P. K., Structure and Performance of Small and Medium Scale Pharmaceutical Firms, SSRN Scholarly Paper, 15 March 2008 https://papers.ssrn.com/abstract=1752125.

Joseph, R. K., Pharmaceutical Industry and Public Policy in Post-Reform India (1st South Asia edn; Routledge, 2016).

Kang, H. Y., ‘Patents as Assets: Intellectual Property Rights as Market Subjects and Objects’, in K. Birch and F. Muniesa, eds., Assetization: Turning Things into Assets in Technoscientific Capitalism (MIT Press, 2020), p. 28.

Kang, H. Y., ‘Patent Capital in the Covid-19 Pandemic: Critical Intellectual Property Law’, Critical Legal Thinking, 9 February 2021 https://criticallegalthinking.com/2021/02/09/patent-capital-in-the-covid-19-pandemic-critical-intellectual-property-law/.

Lakoff, A., ‘The Anxieties of Globalization: Antidepressant Sales and Economic Crisis in Argentina’, Social Studies of Science, 34 (2004): 247–69.

Mathews, G., Ghetto at the Center of the World: Chungking Mansions, Hong Kong (University of Chicago Press, 2011).

Mathews, G., G. L. Ribeiro, and C. A. Vega, Globalization from Below: The World’s Other Economy (Routledge, 2012).

Nouguez, É., Des Médicaments à Tout Prix: Sociologie Des Génériques En France (Presses de Sciences Po, 2017).

Peterson, K., Speculative Markets: Drug Circuits and Derivative Life in Nigeria (Duke University Press, 2014).

Quet, M., ‘Diversions de Flux et Contestations du Régime’, in M. Quet, ed., Impostures Pharmaceutiques: Médicaments Illicites et Luttes Pour l’accès à La Santé (La Découverte, 2018), pp. 187–212.

Rajan, K. S., ed., Biocapital: The Constitution of Postgenomic Life (Duke University Press Books, 2006).

Rault-Chodankar, Y.-M., ‘Chapitre 6. Des Communautés de Ressources Économiques’, in Les Petites Entreprises Pharmaceutiques Indiennes, Agents d’une Globalization Alternative (Université de Paris, 2020), pp. 189–232 https://hal.archives-ouvertes.fr/tel-02484731/.

Rault-Chodankar, Y.-M., ‘Domestiquer la Norme Mondiale: Brevet Pharmaceutique, Bonnes Pratiques de Fabrication et Contrôle du Prix des Médicaments en Inde’, L’Espace Politique, 45 (2022) https://doi.org/10.4000/espacepolitique.10628.

Reinhardt, U. E., ‘Value Creation and Value Shifting in Health Care’, Health Affairs Forefront, 1 June 2016 https://www.healthaffairs.org/do/10.1377/forefront.20160601.055099/full/.

Rikap, C., ‘Amazon: A Story of Accumulation Through Intellectual Rentiership and Predation’, Competition & Change, 26 (2022a): 436–66.

Rikap, C., ‘From Global Value Chains to Corporate Production and Innovation Systems: Exploring the Rise of Intellectual Monopoly Capitalism’, Area Development and Policy, 7 (2022b): 147–61.

Roy, V., ‘A Crisis for Cures? Tracing Assetization and Value in Biomedical Innovation’, in K. Birch and F. Muniesa, eds., Assetization: Turning Things into Assets in Technoscientific Capitalism (MIT Press, 2020), pp. 97–124 https://direct.mit.edu/books/book/4848/AssetizationTurning-Things-into-Assets-in.

Roy, V., and L. King, ‘Betting on Hepatitis C: How Financial Speculation in Drug Development Influences Access to Medicines’, BMJ, i3718 (2016).

Schwartz, H. M., ‘Intellectual Property, Technorents and the Labour Share of Production’, Competition & Change, 26 (2022): 415–35.

Vezyridis, P., and S. Timmons, ‘E-Infrastructures and the Divergent Assetization of Public Health Data: Expectations, Uncertainties, and Asymmetries’, Social Studies of Science, 51 (2021): 606–27.

Williams, L. D., ‘Getting Undone Technology Done: Global Techno-Assemblage and the Value Chain of Invention’, Science, Technology and Society, 22 (2017): 38–58.

Zeller, C., ‘From the Gene to the Globe: Extracting Rents Based on Intellectual Property Monopolies’, Review of International Political Economy, 15 (2007): 86–115.