A century after insulin’s discovery transformed Type 1 diabetes from fatal to manageable, access remains deeply unequal. Writing exclusively for PharmaBoardroom, Access to Medicine Foundation CEO Jayasree Iyer explores why half of those who need insulin worldwide still go without it and how only systemic, long-term collaboration between industry, governments, and investors can ensure that the next century of diabetes innovation serves all patients.
The discovery of insulin in 1921 transformed Type 1 Diabetes (T1D) from a death sentence into a chronic, manageable condition. A century later, however, the story of insulin is one of deep inequity, with millions of people still going without this life-saving medicine. Estimates show that one in two people needing insulin worldwide cannot access it. It is a disparity rooted in limited availability and unaffordable prices in a market dominated by only a few companies. The race to develop weight-loss drugs for rich markets has further aggravated the gulf in care.
This is especially devastating for children and their caregivers. In low- and middle-income countries (LMICs), paediatric T1D remains disproportionately fatal. In some sub-Saharan African (SSA) countries, a 10-year-old with T1D may only live until age 19, while in high-income countries, life expectancy often exceeds 75 years. Optimal glycaemic control is achieved in just 12.7 percent of children in low-income countries, compared to 32.4 percent in high-income settings. For a century-old medicine, these numbers are a stark reminder that progress is unevenly shared.
For almost 20 years, the Access to Medicine Foundation has been evaluating the pharmaceutical industry’ performance on access and determining priorities for the future. The paradox is that demand for treatment for type 1 and type 2 diabetes has never been higher. Ageing populations, lifestyle shifts and rising obesity rates are driving unprecedented global need. Yet the growth of the market has not translated into broader access. Treatments continue to expand only where patients can pay, leaving those in poorer countries behind. This is a huge problem, since LMICs account for 80 percent of global diabetes cases.
The structure of the market helps to explain these challenges. The main global production and supply of insulin is concentrated among just three major multinational companies – Novo Nordisk, Eli Lilly and Sanofi – which limits availability in many countries. And while efforts have been made for more convenient and effective analogue insulins to be added onto the World Health Organization (WHO) Essential Medicines List (EML) and the EML for Children in 2021, they remain largely unaffordable and unavailable in LMICs.
The result is a large gap in access. The 2024 Access to Medicine Index found, for example, that Novo Nordisk registers its analogue insulins in an average of only five low-income countries (LICs), compared to 20 for its human insulins. Sanofi and Lilly’s analogue insulins are also only registered in a handful of LICs, with Lilly’s insulin glargine in just one.
So, what can be done? First and foremost, pharmaceutical companies must acknowledge the scale of the problem and commit to do far more. While corporate donation programmes do save lives and must be sustained, they are no substitute for long-term, scalable solutions. A sustainable approach to access requires investments, agreements and commitments from all players involved in delivery right across the healthcare ecosystem. This includes governments. It is therefore disappointing that the UN’s carefully drafted political declaration on tackling non-communicable diseases – including diabetes – failed to win approval recently at a special High Level Session of the General Assembly due to U.S. objections.
The fact is promising approaches to improving access do exist. Sanofi’s Global Health Unit, for example, delivers analogue insulins in 69 LMICs, reaching 51,000 patients with pre-filled pens, and Novo Nordisk’s iCARE model covers 46 SSA countries, plus Indonesia, with a combination of human and analogue insulins. Eli Lilly has also pledged to reach at least one million people annually by 2030 via a technology transfer agreement with Egypt’s EVA Pharma. Yet according to the 2024 Access to Medicine Index, such initiatives address just 1 percent of the combined type 1 and type 2 diabetes burden across the 113 LMICs covered in scope. When it comes to children, the latest ATMF report on diabetes found that fewer than 10 percent of an estimated 825,000 children and young people living with T1D were reached by access programmes across 71 LMICs in 2023.
The rise of GLP-1 receptor agonists – the new and highly profitable class of drugs marketed for both obesity and diabetes – has intensified the challenge. GLP-1 demand, fuelled by celebrity endorsements, has prompted companies to reallocate resources, production capacity and investment toward newer treatments, sometimes at the expense of insulin supply. Novo Nordisk’s plan to phase out human insulin pen production in favour of GLP-1 products has already disrupted supply in countries including India, Indonesia and South Africa.
Patients and practitioners need choices – and this should not be seen as a privilege. In high-income countries, people living with diabetes can select the formulation and delivery method that works best for them, be it human or analogue insulin, pen or vial, daily or weekly injections. For many of those in low-resource regions, these options are simply unavailable.
Innovation must also be inclusive. New treatments that reduce injection burden and improve adherence are potentially revolutionary – especially so in low-resource settings where frequent clinic visits and limited healthcare infrastructure add to the challenge of daily disease management. Yet most access plans for such emerging therapies are focused narrowly on upper-middle income countries. The recent identification of a new, non-autoimmune subtype of diabetes among children and young people in Africa highlights the urgent need to invest in regionally relevant research and to ensure that clinical trials and development plans include diverse populations from the very beginning.
This is where investors and the private sector have a pivotal role to play. By aligning commercial incentives with equitable access, investors can help ensure that companies prioritise sustainable delivery models and inclusive innovation. The good news is that despite the recent pushback against ESG standards overall, several pharmaceutical investors are still urging stronger human rights due diligence on access and affordability of essential medicines like insulin.
Today, the global diabetes market is at a turning-point. The GLP-1 revolution has unleashed bumper sales and unprecedented investment for companies that have the power to make a difference. The industry has the tools, the expertise and the scale to unlock access for millions of underserved patients. Current geopolitical challenges should not be allowed to thwart well-made plans to expand access for people who are dying needlessly. The choices made now will decide whether insulin and future diabetes innovations continue as privileges for the few or finally deliver on the promise unlocked a century ago to help the whole world.
