FORTUNE -- Sanofi-aventis can't hire fast enough in China. The French drug giant has been paring its staff in the U.S. and Europe, but it is expanding its Chinese workforce by one-fifth every year and vying with other multinationals to recruit thousands of new sales representatives. These pitchmen, armed with information on Sanofi's latest cardiovascular and diabetes drugs, will fan across the mainland in pursuit of untapped markets.
"Everyone is expanding -- the industry has a roughly 28% turnover rate," says Tom Kelly, head of Sanofi's China business, in an interview. Sanofi did $686 million in revenue last year; Kelly aims to increase that number to more than $2 billion by 2015.
The drug industry, like just about every other industry these days, is looking to China for growth. But Big Pharma needs it especially bad. Over the next five years, drug companies will lose patent protection of products worth $140 billion in annual sales, according to IMS Health. Multinational corporations like Sanofi (SNY), Pfizer (PFE, Fortune 500), and GlaxoSmithKline (GSK) have been working furiously to bridge that cliff -- diversifying, laying off thousands of employees, executing mega-mergers -- but still face looming holes in their balance sheets.
There's reason to believe that China could provide a solution. The pharmaceutical market there -- currently the fifth biggest in the world -- will rise to the third spot by 2013, according to IMS Health. Drug sales are expected to increase by $40 billion over the next five years, accounting for about a third of the world's total growth. That expansion is driven by demographic changes such as the rising middle class and the increased prevalence of chronic illnesses like diabetes and heart failure.
The most dramatic shift, though, is coming from the Chinese government, which recently announced a massive program to boost healthcare spending, which is currently just 4.5% of the GDP (by comparison, the U.S. spends 16%). There's an economic incentive: In order to grow domestic consumption, China must create a social safety net so that consumers will stop savings so much. It has earmarked $125 billion for healthcare with a goal of attaining universal coverage by 2020.
For Big Pharma, that edict is a mixed blessing. Hundreds of millions of Chinese citizens will have the ability to purchase prescription drugs -- but the government will play a larger role in determining how much they pay. "There's a bit of growing uncertainty and unease, because there are changes going on and people aren't quite sure where they're heading," says Chris Arzt, managing principal of the Shanghai office of consulting firm ZS Associates.
"If you'd have asked me a year ago, I'd say people are bullish," says Arzt. "They still are -- but there's a bit of an element of worry."
Lower prices, but higher volume
The pharmaceutical market in China is incredibly fragmented. There are thousands of distributors and manufacturers, none of whom have sizable market share, and hundreds of thousands of retailers. Most customers pay for drugs out of pocket, and the bulk of spending is on over-the-counter generic drugs and traditional Chinese medicine.
Prescription drug makers primarily sell their wares to wealthier citizens. Many of the treatments they sell in China are no longer protected by patents -- and have thus lost much of their sales to generic substitutes in the Western world -- but still command a premium because Chinese customers are wary of tainted products. "There is still a very strong value perception and premium that comes with the brand equity these companies bring," says Sati Sian, General Manager of China for IMS Health. "There's a real trust of foreign produced goods, just like you see with cars."
Big pharmaceutical companies aren't yet sure whether those pricing premiums will suffer because of government intervention. China has created an "essential" list of drugs that will be priced and distributed by the government, but the impact of having a drug on the list is still unclear, says Arzt. "Is that a good thing or a bad thing? Can I make up in volume the revenue that I've lost in pricing?" he says. "A lot of the companies were skeptical, and are getting more skeptical about the tradeoff."
Sanofi's Kelly says the increased sales from government coverage and better diagnosis will outweigh any pricing pressure. "There's going to be implications on pricing and reinforcement, but, net-net, its going to be very favorable," he says, pointing out that insuring nearly one billion people is "unprecedented in human history."
A better regulated healthcare system would help even the playing field for multinational corporations, says Arzt. Because purchasing and pricing decisions are often made on an ad-hoc basis by regional distributors, preference often goes to local companies. "If youre based in a province and employing 500 people, the government is likely to make sure you're the supplier of choice," he says. "I think another long-term good thing, partly driven by reform, is regularizing the markets."
Multinationals move in
Although half of the top ten pharmaceutical companies in China are multinationals, none command more than 2.5% of the total market share, according to Sanofi. Last year, the 15 biggest drug makers in the world derived just 0.9% of their combined sales from China. Many of the most popular products in China are traditional Chinese medicines, says Arzt, and they are growing faster than prescribed drugs. "Multinationals are losing share -- they're growing nicely, but they're consistently losing share," he says.
Western companies have recently made massive long-term investments in manufacturing facilities and partnerships with local players. Pfizer plans to attain a 6% market share in China in three years. Novartis (NVS) announced last November that it will spend $1.25 billion on R&D centers. Eli Lilly (LLY, Fortune 500) created a $100 million venture capital fund to invest in Chinese life sciences companies. Nearly all have boosted their sales forces.
But it will take more than raw investment to make inroads in China, says Sati. Because the market is so fragmented, he says, drug makers must learn to embrace complexity. "The basis of success is: Who has the smartest execution?"
Many companies are still calibrating their drug portfolios. Because the range of incomes in China is so varied, businesses must look for growth and both the high and low ends of the market. As a result, they must sell everything from high-end oncology treatments to rabies medicine, says Kelly. The epidemiological profile in China is also unique -- and changing.
"Liver cancer, gastric cancer, esophageal cancer -- in the western world they're not every significant, but in China they're very major," he says. One predominant disease, he says, is Hepatitis B, which affects some 10% of the Chinese population but only a tiny number of people in the US.
Drug makers are looking to expand in sectors other than pharmaceuticals, such as generics, vaccines, consumer products, and traditional Chinese medicine. For example, Novartis recently purchased a local vaccine maker, and Sanofi is awaiting approval of a deal with a local vitamins and supplements producer. After experiencing the pain of depending too much of blockbuster drugs, Big Pharma has learned the lesson of diversification.
Sati says multinational companies are learning to cater to regional tastes. "They are adopting commercial execution depending on the local environment," he says. In southern China, for example, commercial activity still takes place in large hospitals; in the West, companies must form partnerships with tiny local distributors.
Sanofi is divided into ten regional divisions, says Kelly, each with its own local human resources and government affairs teams. The company is working as fast as it can to staff up those units, but must compete with other companies for limited talent. It can be difficult, he says, to convince experienced employees who live in cities to move to rural areas. "Once you bring them to headquarters, people don't want to go back to a tier two market."