China is one of the fastest-growing developing countries and with its 1.3 billion people, it is the most populous. Despite poverty in rural areas, a growing urban middle class is being increasingly affected by diseases such as type 2 diabetes, driven by factors such as a sedentary lifestyle and diets high in saturated fat and refined carbohydrates.

Increased life expectancy also has an impact, as type 2 diabetes most often occurs in older people. In fact, China, along with India and many developing countries, are the areas in which type 2 diabetes is increasing the most rapidly. Some 30 to 40 million people in China are estimated to have type 2 diabetes.

With limited infrastructure for the care of chronic illnesses such as diabetes, the country is ill-equipped to deal with this epidemic, particularly in the face of continued rapid urbanisation. Lifestyle- driven diseases such as diabetes can take a greater toll in a country like China, where economic development, accompanied by unhealthy lifestyle changes, is occurring at a much faster rate than in other countries where the rate of diabetes has increased more gradually.

As part of our commitment to stem the tide of diabetes in the developing world, we have taken a Triple Bottom Line approach to tackling diabetes in China. The foundation for this work is the Novo Nordisk Way of Management, which includes the company’s Vision, Values and commitment to the Triple Bottom Line, particularly social responsibility.

“We want to improve the conditions for people with diabetes in China and you can’t do that by just peddling your product,” says Thorkil Kastberg Christensen, president of Novo Nordisk China.

“We think what we have accomplished in China so far can serve as a model for other developing countries. You must have a vision. You need to know what the barriers are and you must have a relentless urge to keep working at it, year after year, to get the results. It is important to show a willingness to make an investment in China – and I’m not talking about bricks and mortar and other fixed assets, but an investment in people, so that you have a capable organisation to carry out this huge task. That kind of investment is more sustainable in the long run.”

 Novo Nordisk has had an affiliate in China since 1994. The headquarters and R&D Centre are located in Beijing while the production plant for packaging and quality control of insulin is located in Tianjin. Liaison offices are located in Shanghai, Guangzhou, Wuhan, Shenyang and Hong Kong.

Novo Nordisk's presence in China 
(click to see map)

Novo Nordisk employs over 300 people working in Sales, Marketing, Production, R&D, Regulatory, HR, IT, Finance and other administrative functions. The R&D Centre in China, first established in October 1997, has evolved into a centre of excellence for Novo Nordisk in molecular biology and protein expression using microorganisms.

Novo Nordisk is building a new, bigger packaging and quality control plant, slated to become operational in the first half of 2003. It will have the capacity to produce 20 million units per year. The plant supplies all insulin products and devices for China.

 We have found in our work in China that healthcare delivery varies considerably from place to place, depending on the available resources, training and interest in diabetes amongst doctors, and the patients’ willingness to accept as well as their ability to pay for treatment.

Yet there is emerging evidence that diabetes education, awareness and improving motivation for self-care enhance treatment, reduce complications and thus reduce the overall costs of diabetes to society.

To this end, Novo Nordisk has designed an approach to diabetes care in China that takes into account the three keystones of sustainable development: it aims to be socially just, environmentally sound and economically viable. In meeting these goals, we engage with a wide variety of stakeholders and build our progress on meaningful partnerships with key people and institutions involved in the delivery of diabetes care in China.

Novo Nordisk's social investment in China
(click to see illustration)

A lack of education about diabetes results in low diagnosis rates. In China, the diagnosis rate for type 2 diabetes is about 10–15%, compared to, for example, 50% in Europe.

In order to address this gap, Novo Nordisk China has introduced many programmes for educating medical professionals, among them the courses offered by the Steno Diabetes Center. In addition, the company organises annual medical congresses attended by some 500 top Chinese doctors each year in the diabetes field.

In the past five years, we estimate that 35,000 doctors in China have been educated through various diabetes programmes sponsored by Novo Nordisk. Nurse education programmes are also increasing. There is a growing recognition for the need for doctors and nurses to work together in teams.

Lack of awareness about diabetes among the general public is compounded by misunderstandings around, for instance, the use of insulin. Lack of education and awareness about diabetes is faced elsewhere in the world, but nowhere on the scale and significance of China, with its huge population.

In order to help eliminate those misunderstandings, educating the general public about diabetes is an important element of the Novo Nordisk approach in China. For instance, we have established 70 patient education centres in hospitals in 47 cities. These centres, each staffed by nurses, and doctors, serve approximately 50,000 patients each year through educational seminars.

Novo Nordisk provides all patient education materials and supports annual nurse training. The goal is to encourage a greater degree of self-care for people with diabetes. This is a revolutionary concept in a country where just a decade ago it was unthinkable that such a centre would exist, or that a patient could inject himself or herself with insulin.

Other efforts by Novo Nordisk and partners to enhance public awareness about diabetes include:

• Funding the development of China’s first Chineselanguage diabetes information website aimed at both patients and healthcare providers. It has received over 50,000 hits since it was established in October 2000. About 46 million people in China have access to the internet.
• Initiating the NovoCare Club for people with diabetes in July 2001 in order to meet their individual needs and serve them better. It had nearly 30,000 members at the end of 2002.
• Working with the media to spread the word about diabetes, resulting, in 2002 alone, in 22 television programmes and about 40 national radio programmes (reaching 600 million people) and about 160 print media mentions.
• Sponsoring over 100 free diagnosis clinics over the past five years, particularly in parks frequented by many people.
• Sponsoring 10 mobile clinics to reach communities without diabetes clinics.

What has the impact of these programmes been? A nurse at Beijing Insulin Diabetes Hospital says it has lessened the burden of her work, improved her professional skills and knowledge of diabetes and helped lift some of the pressure on the hospitals to perform multiple tasks.

A doctor at the hospital says, “It is a win-win cooperation. The hospital and Novo Nordisk join together to promote the need for greater awareness and better treatment of diabetes among healthcare professionals in China. At the same time, the scientific updates sponsored by the company are a good way to keep abreast of latest developments.”

The doctor also points to the importance of the cascading effect of such educational programmes: that health professionals in urban areas try to ensure that colleagues in more remote districts also benefit.

As one way to address the problem, Novo Nordisk will launch in 2003 a physician residency programme in which 50 physicians from small hospitals in remote areas will spend three to six months in a diabetology residency programme in one of ten partner teaching hospitals.

A 60-year-old Chinese woman with type 2 diabetes, who is a member of the NovoCare Club, says that it has “helped me master more knowledge of diabetes than before. I can take the initiative to cooperate with my doctor for the treatment. I am now in good spirits and have better control of my blood sugar. After retirement, I am now staying at home to take care of my grandchild, so it’s important that I feel well.”

In order to increase the activity level of all education programmes on diabetes in China to a much higher level, the Chinese Ministry of Health launched, in collaboration with Novo Nordisk, the National Diabetes Management Project (NDMP).

The NDMP aims to provide diabetes education and training to physicians and nurses and to establish models of diabetes care in hospitals and community health centres. This model will then be cascaded to all 311 county levels, cities and townships throughout China during the five-year project period. The project is cofunded by the World Diabetes Foundation.

Novo Nordisk’s overall goal in China is to educate an ever increasing number of doctors, nurses, patients and members of the public. The ambition is to educate at least 20,000 doctors per year in 2003 and 2004. The collaboration with the Ministry of Health will greatly increase this number, as the ministry can utilise its infrastructure and administrative means.

One of the keys in making Novo Nordisk’s business in China an expression of the company’s commitment to sustainable development is how well its people support that ideal. Certainly, the company’s policies support such a vision, but to what extent that vision is experienced by employees depends on leadership, training, self-motivation and finding the balance between compassion and competitiveness.

These qualities do not seem to be lacking at Novo Nordisk in China. In fact, attracting and retaining employees does not appear to be a problem. The company receives about 3,000 job applications a year and has an employee turnover rate of less than 10%. This is considerably lower than the turnover rate in the pharmaceutical industry in China, which is between 30% and 40%.

“When you face the patients and they tell you that with your products they are having a healthy and happy life, you can feel the social responsibility in your daily work,” says Shen Bo, senior product manager in the Marketing department at Novo Nordisk in China. “When doctors tell me that we are doing a good job educating patients and doctors, I feel motivated in my work.” Liu Qi, a public relations specialist with the company, says that living the Triple Bottom Line in her daily work is natural because

“Novo Nordisk is a healthcare company. We don’t provide cigarettes or chewing gum; we’re providing products and services that help people suffer less from a disease, both physically and mentally. When I introduce my work to friends or relatives, and tell them I work for the best company in diabetes care in the world, they are always very interested. They tell me about people they know who have diabetes and whether I can tell them more about the disease. You become an ambassador for your company, even off the job.”

 Most significantly, Novo Nordisk finds that one of the best ways to attract and retain the right people is to invest in their training. Each employee receives approximately 60 hours per year of training, which includes 16 hours of teambuilding, 36 hours of in-house training, and eight hours of training through external programmes. Every new employee attends a four-day induction course, and it is extended to 10 days for sales staff.

Some of the training programmes are specially designed for China while others are part of the company-wide offering. A series of courses is designed for specific jobs. The need for additional training is consistently analysed and follow-up sessions are held as necessary. An internal team for training people is also being developed in China.

The development of Novo Nordisk’s employees in China is a social investment that has an impact on the local community. The training, upgrading of skills and education are a particularly meaningful contribution to the competence levels of a developing country.

In the longer term, the education and training undertaken by Novo Nordisk employees in China increases their overall employability. Their know-how adds value to society when these employees assume positions in local companies.

For now, there is more than enough challenge for the employees of Novo Nordisk in China. “In China it is not yet possible to have a sustainable business model in which the health authorities alone support the infrastructure,” says Thorkil Kastberg Christensen. “In time, the Ministry of Health may be able to take over the programmes we are sponsoring, but until then we believe that we are in a position to help, and improve diabetes care in China.”

STAR brings diabetes knowledge to China In the past two years, some 800 doctors in China have learned more about diabetes through state-of-the-art courses organised by the Steno Diabetes Center (SDC) in Denmark in cooperation with Novo Nordisk in China.

The aim is to update the knowledge of Chinese diabetologists with the latest information about the disease. The courses are part of the STAR project (Steno Training and Application of Resources), headed by Ebbe Eldrup, chief physician at the SDC. The SDC, owned by Novo Nordisk but part of the Danish public health system, is a specialised hospital that links the treatment of diabetes with teaching, research and development.

The STAR project was initiated in 2000 and receives continuous annual funding from the Novo Nordisk Foundation, with the overall goal of contributing to increased knowledge about diabetes in developing countries.

India is also a focus of STAR. In India, the courses in practical diabetology and clinical research methodology are offered, while in China, it was determined that health professionals would most benefit from courses that updated on the state-of-the-art in diabetes care.

In 2001, courses were held in Beijing, Guangzhou and Shanghai, and in 2002, doctors in Dalian, Zengzhou, Nanjing and Chengdu attended the update courses. About 100–130 doctors attend each course. The lectures are complemented by workshops and question- and-answer sessions. These courses are extremely valuable in helping to improve diabetes care in China because the SDC has a very good reputation among diabetes experts in China, who play an important role in helping disseminate knowledge about diabetes.

Compared to the total number of doctors in China, these courses address relatively few. It is, however, a joint target for the SDC and Novo Nordisk to work with the specialists to encourage cascading the knowledge to as many doctors as possible.

2000–2001	China	OECD 1)
Poverty (%)	19 2)	4-17 3)
Life expectancy at birth	71	78
Child mortality (1,000 live births)	32	6
Urban population (%)	38	79
Hospital beds per 1,000 capita	3 4)	4-21
GDP growth (%)	7	3
Health expenditure (% of GDP)	5 4)	7-14

1)	US/Western Europe: Data from year 2000
2)	Population living at less than USD 1 a day. China's national powerty line is 5%
3)	Population below 50% of median income; range from Luxembourg to the US
4)	Data from year 2000
	Sources: Diabetes Atlas 2000 World Bank data  UN Human Development Report 2002