Counting the cost of diabetes in global south

‘Iration my insulin every month,” said Khushi Ahuja, a law student from Delhi who has type 1 diabetes and relies on human insulin manufactured by the US company Eli Lilly. While insulin is available at no cost in some public hospitals in India, it is mostly up to individuals to buy the drug.

“Every month I hear about insulin prices rising and I feel guilty about burdening my parents,” Ahuja said. “I skip meals to make my insulin last longer.”

Eli Lilly and two European companies, Novo Nordisk and Sanofi, control 99% of the market by value and 96% of the market by volume. The three manufacturers produce 83% of the insulin sold in low and middle-income countries, where it is now estimated that one in two people who rely on insulin do not have sufficient access to the drug. Earlier this month, all three companies made a commitment to cutting the costs of insulin in the US, where the drug was sold at the highest price in the world.

Ahuja will not benefit from the price cuts, but she hopes the announcement will mark a change in how global insulin suppliers view the drug.

Elizabeth Pfiester, director of T1International, a non-profit organisation advocating for people with type 1 diabetes, said: “Even though people in the United States are paying the highest dollar-for-dollar amount, many people around the world, particularly in the global south, have to pay up to 100% of their income to access insulin.”

According to T1’s data, the average out-of-pocket costs of insulin and diabetes supplies in the US cost 10% of GDP per capita, but in Kenya this rises to 125% of GDP per capita.

Claudia Martínez, research programme manager for diabetes at the Netherlands-based Access to Medicine Foundation, said: “In recent years, companies have been doing more to increase insulin accessibility in lowerincome countries.”

Novo Nordisk has been praised for initiatives such as “Defeat Diabetes”, which includes reducing the price of human insulin. And Eli Lilly’s 30x30 programme aims to increase healthcare access for 30 million people in “resource-limited settings” annually by 2030. Diabetes is a large focus of the project, said Michael Mason, executive vice-president of Eli Lilly.

The company also works with Unicef and Life for a Child, donating vials of insulin and resources to projects in low and middle-income countries including Kenya and Malawi.

Most of the projects focus on children, but there are plans to extend the scheme to under-30s.

The company will also offer pro bono technology transfer and active pharmaceutical ingredients at a reduced cost to an Egypt-based insulin manufacturer. Mason said the Africanproduced insulin will be distributed in 18 months’ time and is projected to benefit 1 million people a year.

Accessibility of insulin around the globe is a “real big focus” for Eli Lilly, said Mason. “We want to make sure we’re good corporate citizens – make sure we improve the lives of people who live with diabetes,” he said.

However, the voluntary schemes and donations that manufacturers support cannot be enforced or demanded by governments.

Mohammed Seyam, a young doctor living with diabetes in Gaza, who is T1’s representative for the Middle East and north Africa, said: “The ministry of health here in Palestine mainly relies on donations but not directly from manufacturers.”

The doctor said he spent 40% of his salary since November 2022 buying analogue insulin produced by Novo Nordisk privately for his own use because there is a shortage of the medicine in Gaza. Unlike human insulin, analogue insulin – added to the WHO essential medicines list in 2021 – works as soon as it is injected and has no peak activity times. Analogue insulin has also been associated with a lower risk of hypoglycaemia.

Although insulin is necessary for people with type 1 diabetes to survive, the global insulin market is not covered by any international regulation.

David Beran, a researcher at Geneva University, said that while wealthy countries can cap prices on the medication, governments in low and middle-income countries have “very little power to negotiate”.

When the Argentinian government introduced price caps on insulin in 1985, Eli Lilly withdrew from the country entirely, leaving Argentinians stranded without access to insulin.

“The question is: do we see companies that sell medicine as different to companies that sell computers or soft drinks?” Beran said. “Insulin is a life-or-death matter but these are private companies beholden, in a sense, only to their shareholders.”