Vasant Narasimhan has spent his tenure making Novartis easier to understand. The company shed consumer health, Alcon and Sandoz, concentrating capital and management attention on innovative medicines. That focus is now being tested by the ordinary but unforgiving rhythm of pharmaceuticals: successful products eventually face competition, while their replacements remain scientifically uncertain. In the first quarter of 2026, net sales declined 5% at constant currencies and core operating income fell 14%. The margin remained a strong 37.3%, but US generic erosion weighed heavily. Narasimhan’s strategic simplification has reached the stage where it must produce pipeline productivity, not only a cleaner corporate structure.
The underlying portfolio contains important momentum. Kisqali, Pluvicto, Kesimpta, Scemblix, Leqvio and other priority brands grew rapidly, demonstrating strength across oncology, neuroscience and cardiovascular disease. Yet aggregate performance can be overwhelmed when a very large medicine loses exclusivity. Novartis expects low-single-digit sales growth for 2026 and a low-single-digit decline in core operating income. That outlook is manageable, but it creates little space for clinical, regulatory or manufacturing mistakes. Narasimhan must sequence launches and evidence so that multiple products contribute rather than relying on one successor.
His medical training and development background suit the scientific task. The harder leadership question is organisational: how to make a company of Novartis’s scale allocate resources with the conviction of a focused biotechnology group while maintaining global manufacturing and compliance. The answer cannot be more projects. It must be better decisions about which mechanisms, diseases and platforms deserve investment, accompanied by a willingness to stop programmes early when evidence weakens.
Radioligand therapy must become an industrial capability
Pluvicto has established radioligand therapy as one of Novartis’s distinctive platforms. It combines a targeting molecule with a radioactive isotope to deliver treatment to cancer cells. Clinical promise alone is insufficient because the product has a short shelf life and requires coordinated production, transport and treatment sites. Scaling demand therefore resembles building a time-sensitive industrial network. Narasimhan must ensure that isotope supply, specialised plants, quality systems and hospital capacity advance together.
Manufacturing disruptions in this field carry unusual consequences. A conventional tablet can often be stocked; a radioligand dose is made for a specific treatment window. Novartis should invest in geographic redundancy and transparent communication with centres. Capacity decisions need conservative assumptions about maintenance and regulatory inspection. The company can create a moat through reliable delivery, but only if commercial enthusiasm does not run ahead of the physical system.
The platform also raises questions of access. Specialised infrastructure may concentrate treatment in wealthy urban centres. Novartis should work with health systems to train staff, establish referral pathways and evaluate cost in relation to outcomes. Expansion into Asia requires country-specific handling of isotopes and hospital readiness. A therapy cannot be globally successful if its operating model excludes most eligible patients.
Acquisitions must add science, not disguise gaps
The completed acquisition of Avidity Biosciences extends Novartis into RNA-based medicines for muscle disease. The strategic logic is attractive: targeted delivery of oligonucleotides may address conditions beyond the reach of traditional drugs. The transaction also commits substantial capital to programmes whose value depends on clinical execution. Narasimhan should preserve scientific teams and establish clear development milestones rather than absorbing the company into layers of central process.
Pharmaceutical acquisitions often look most compelling before pivotal data arrive. Competitive auctions can transfer much of the expected value to sellers. Novartis needs a consistent framework that compares buying an asset with licensing, partnering or funding internal research. Success should be measured against the cost of capital and the alternatives considered at the time, not only whether an acquired drug eventually gains approval. Transparent post-deal accountability will improve future decisions.
The company’s narrower scope makes disciplined business development more visible. There is no diversified conglomerate to absorb a weak return. That is healthy. Narasimhan can use the balance sheet to accelerate platforms where Novartis has development or manufacturing advantage, but should avoid assembling unrelated late-stage products simply to fill a revenue chart. Portfolio coherence matters because talent and regulatory expertise compound within chosen fields.
Commercial growth depends on evidence and access
Medical affairs should remain independent enough to protect the quality of evidence after launch. Physicians need balanced information about limitations, not simply commercial messages. Novartis can use registries and real-world studies to identify safety signals and treatment gaps, then feed those findings back into development. This learning loop is one advantage of focus: commercial scale can make the next scientific decision better.
Kisqali’s expansion in breast cancer shows the importance of generating evidence across disease stages. Earlier treatment can increase the eligible population, but health systems require proof of long-term benefit and manageable toxicity. Kesimpta and Leqvio similarly compete in categories where convenience and adherence matter alongside efficacy. Novartis must make the economic case through real-world outcomes rather than relying on list prices and promotional reach.
Pricing pressure is intensifying, particularly in the United States. Government negotiation, insurer controls and public scrutiny are changing launch economics. In China and other Asian markets, national reimbursement can unlock large volumes at lower prices. Narasimhan needs commercial models that recognise these realities early in development. Trials should collect outcomes relevant to payers, and manufacturing should be designed for wider access. A medicine that succeeds only at the highest price will have a narrower strategic life.
Trust is essential. The industry’s use of patient data and artificial intelligence can improve trial recruitment and discovery, but requires clear governance. Models trained on unrepresentative populations may miss safety or efficacy differences. Novartis should validate tools across geographies and keep accountable experts in the decision loop. AI may reduce the time required to identify a target; it cannot eliminate biological uncertainty or ethical responsibility.
Asia is part of the research system, not only a sales market
Regulatory execution is a further source of advantage. Agencies are increasingly willing to use accelerated pathways and real-world evidence, but they expect robust post-approval commitments. Novartis should design development plans that answer regulators in the United States, Europe, Japan and China without duplicating every study. Early dialogue can shorten timelines, yet speed must not weaken the evidence needed by physicians and payers. Safety systems should be prepared for broader populations before launch.
Supply resilience extends beyond radioligands. Complex biologics, devices and specialised raw materials create dependencies that became visible during the pandemic. Narasimhan should map critical suppliers, qualify alternatives and maintain capacity where interruption would harm patients. Inventory raises cost, but essential medicines require a different optimisation from consumer goods. Procurement performance should include continuity and quality, not simply price.
Novartis also needs disciplined communication around pipeline setbacks. Drug development produces failures, and a focused portfolio can make each one appear more consequential. Leaders should explain what the data changed and how resources will move, without defending an obsolete hypothesis. Investors can tolerate scientific risk more readily than shifting definitions of success. Internally, teams need recognition for stopping a weak programme before it consumes a pivotal trial.
The company’s environmental footprint is material in manufacturing and supply chains. Water, solvents and energy should be managed as operating inputs, especially in regions exposed to climate stress. Cleaner processes can reduce cost and regulatory risk. Access commitments should also include reliable local supply, not only differential pricing. A medicine unavailable during disruption has no social value.
Novartis has a large presence in India and a broad Asian commercial footprint. The region offers skilled researchers, diverse patient populations and growing health systems. Narasimhan, who was born in the United States to Indian parents, has a personal connection that should not substitute for institutional strategy. The company can locate global development and data work in India while strengthening local clinical and regulatory capability. It should also ensure that intellectual work is matched with senior decision authority.
Asian markets vary widely in reimbursement, diagnosis and infrastructure. Cardiovascular medicines may address enormous need but require screening and sustained adherence. Advanced oncology can be limited by testing and treatment capacity. Novartis should partner with public systems, hospitals and local companies where collaboration expands the patient pathway. Product launches that ignore diagnosis or distribution will underperform regardless of demand.
Narasimhan must also manage culture after years of restructuring. Focus can energise scientists, but repeated portfolio changes create fatigue and fear that the next strategic priority will move again. Leaders should make decision criteria explicit and provide credible career paths across research, development and commercial functions. A productive pipeline depends on people sharing negative results early. Psychological safety is therefore a financial asset.
The next twelve to twenty-four months will test the logic of the focused Novartis. Priority brands must offset erosion, Pluvicto capacity must support its clinical opportunity and the Avidity portfolio must progress without losing speed. Narasimhan has already completed much of the corporate surgery. He now needs to demonstrate that the resulting organisation learns faster and executes more reliably. Patent losses are inevitable; a growth gap is not. His legacy will rest on whether Novartis can convert scientific focus into a repeatable cycle of medicines whose value survives tougher payers, complex manufacturing and global expectations of access.
