Until a year ago, CROs operating in India centered either in the big cities or around the peri-urban areas. But today, more than one-third of these CROs have moved their activities to interior tier 2 cities or even smaller towns of India.

Multinational corporations like Quintiles, Icon and PPD figure among the growing legion of CROs that are in pursuit of class B and C cities, since the last year or so, said sources. And at least 50% of the CROs are expected to migrate to these less-popular towns in a couple years’ time.

Why are these urban-oriented CROs taking to India’s hinterlands, all of a sudden? It is a capacity issue, we might say, thanks to the increasing flux of new clinical studies coming to India.

Capacity is definitely a problem. Because the majority of hospitals and other bigger institutions crowded in the metros do not involve in clinical research due to various reasons, and the small catchment area left is bombarded with an increasing number of studies.

Saturation alone, however, does not explain the full story.

For instance, clinical studies in India, in terms of numbers, have not grown exponentially last year. There was actually a dip. According to figures attributed to the Indian Society for Clinical Research (ISCR), Mumbai, the number of trials registered in India went down to 158 in 2009 compared to 229 in 2008 – over a 30% drop in the year 2009 as compared to a 29% growth in 2008. Meanwhile, the global decline in clinical studies due to economic downturn averaged around 11% during this period.

More Stable, More Credible

Evidently, there are other triggers as well. India’s villages are a lure because this is where the biggest chunk of patients from its one billion-plus populace live. Metabolic diseases are as high among the villagers as those in metros.

“Since the major portion of clinical studies carried out in India belongs to metabolic, cardiovascular and cancer segments, enrollment of patients becomes much easier for CROs from these non-urban cities,” pointed out Dr. Kiran Marthak, director, Veeda Clinical Research, a leading CRO from western Indian city of Ahmedabad, which offers Phase I and IIa trial services with facilities in UK and Belgium.

Veeda, which has already moved a considerable part of its studies to tier 2 and tier 3 towns, finds that the process of getting patients and obtaining their informed consents are rather hassle-free, as the education levels in smaller cities are rising.

Smaller cities also offer considerable cost benefits while setting up facilities like trial sites compared to urban centers, Dr. Marthak added.

Physicians from non-urban centers may not be highly specialized but they do usually have large practices. Access to a large patient base and credibility among their patients make these physicians any time a preferred choice for a CRO. To top it all, they are not as busy as their urban counterparts and can dedicate more time for clinical research.

“The outcome of a trial can go good or bad depending upon the time devoted by the investigator,” noted Dr. Tufail Syed, director, Medpace Ltd., the Indian arm of a Cincinnati, OH-based global CRO specializing in metabolism, cardiovascular and oncology areas.

Small-town trial sites have less competition. They don’t have to handle multiple studies. Again, since class B cities require more time to grow into a much bigger metro, the trials sites in such places could be more secure.

Stability and credibility are the two important, pressing needs that compel CROs look at the non-urban centers, according to Dr. Syed.

Infrastructure: A Problem?

In a short while, Dr. Syed’s Medpace has relocated around 30% of its Phase II and III clinical studies in secondary cities. Medpace, which is keen to offer services with local pharma firms as well, would like to move class C towns also if the study demands so.

The opportunity looks quite big, as India has countless developing cities and aspiring towns. Despite the potential, these often remote locations are lacking in civic infrastructure and other amenities. Faster modes of transportation, communication or logistic chains – the vital aspects for the smooth maintenance of sensitive clinical studies – still remain a far cry for most these places.

However, CROs are hopeful that it is only a matter of time that these facilities improve. They believe the pace of growth in tier 2 and 3 cities is so rapid that the necessary logistics will be in place even as more and more players traverse them.

“Infrastructure will come up as more business move in to these towns as is the case with every city,” commented Munish Mehra, managing director, Global Drugs Development Experts, a Washington-based SMO offering patients recruitment and other clinical trial services across India, Central and South America, Eastern Europe and Russia.

The non-urban proposition is somewhat symbiotic, he asserted. While CROs ensure enhanced quality of trials besides time and cost advantages, the smaller cities in turn benefit from newer treatments and latest medical technologies at no cost.

S. Harachand is a pharmaceutical journalist based in Mumbai.