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Newsletter Edition #374 [The Curated Primer]
Readers,
In today's edition, activists are calling for including insulin analogue pens as a first-line treatment option in the World Health Organization’s forthcoming guidelines for type 1 diabetes.
Despite insulin being indispensable, the quality of treatment people receive still depends largely on where they live and what they can afford. They are calling for easy-to-use pens to become a part of recommended guidelines so that these treatments become the global standard of care.
In this guest essay, Canadian activists from Voices in Action (VIA) Diabetes, take a critical look at the "two-tier system of diabetes care that leaves millions without the treatment options routinely available elsewhere".
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Priti Patnaik, Founder & Publisher, Geneva Health Files
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I. GUEST ESSAY
End The Global Double Standards in Diabetes Care
Including insulin analogue pens as a first-line treatment option in the World Health Organization’s forthcoming guidelines for type 1 diabetes should be fundamental.
By Olivia Rafferty1, James Elliott1, Lucía Feito Allonca1
- Voices in Action (VIA) Diabetes, Toronto, Canada. olivia@viadiabetes.com
All authors live with type 1 diabetes.
For people living with type 1 diabetes – when your body can no longer produce insulin – access to daily insulin treatment is essential to stay healthy, and alive. Yet despite insulin being indispensable, the quality of treatment people receive still depends largely on where they live and what they can afford. There are many insulin delivery methods available, from more difficult-to-use vials and syringes, to insulin pens, which are becoming the standard of care in most high-income countries – and are often preferred by people with diabetes – to insulin pumps, which are still a luxury for many.
When insulin was first discovered 105 years ago, its patents were symbolically sold for $1 CAD by its discoverers, Frederick Banting, James Collip, and Charles Best, to ensure universal access to all. However, since then, a market oligopoly has emerged, comprising of three dominant pharmaceutical corporations, namely Eli Lilly, Novo Nordisk, and Sanofi, which has created availability barriers globally.
The World Health Organization has relationships with all three of these giants. Notably, the Novo Nordisk Foundation pledged up to DKK 380 million ($57.76 million) to the WHO last year to expand their ongoing relationship – and in March this year, it announced it has committed a further $7.9 million to “strengthen health systems against the rising burden of cardio-renal-metabolic diseases, including obesity and diabetes”.
The access to diabetes treatment options has been profoundly unequal. Millions in need of insulin still do not have reliable and affordable access, the only treatment option for the over 9.5 million people with type 1 diabetes. In addition, modern, more efficacious, and person-preferred insulins and insulin delivery devices – analogue insulin, insulin pens, and pumps – are often unaffordable and unavailable in low-resource settings.
This perpetuates a global double standard of care whereby people with diabetes living in high-income countries, or with higher-paying jobs, can choose newer analogue insulins in preferred pen devices or pumps that can help them to achieve better control of their condition, while people living in low-resource settings are relegated to using human insulin in vials (if they are lucky enough to even get that access).
Vials are a lot more complex to use, with more room for error, and are particularly difficult to use for those with limited sight, for example. Meanwhile, insulin pens support simpler administration, are a lot more portable, and offer a higher dosing accuracy.
This is not simply a gap in access—it is a two-tier system of diabetes care that leaves millions without the treatment options routinely available elsewhere.
The benefits of insulin analogues and insulin pens
The question, therefore, is no longer whether better treatment options exist, but whether they should be considered the global standard of care.
The benefits of insulin analogues to manage type 1 diabetes are clear.
Systematic reviews and meta-analyses comparing insulin analogues to human insulin have shown a reduction in the total number of hypoglycaemic episodes, as well as nocturnal hypoglycaemia, severe hypoglycaemia and HbA1c levels (measures average blood sugar levels over the past two to three months), which are used to show how well blood sugar levels are being managed.
Hypoglycaemia is when a person’s blood sugar drops too low – and in severe cases can cause seizures, loss of consciousness, or death.These benefits are not marginal. They translate into fewer medical emergencies, better long-term glucose control and, ultimately, improved quality of life for people living with diabetes.
Recent research on treating type 1 diabetes in low-resource settings also supports the benefits of insulin analogue pens: a study evaluating the impact of switching children in the low-income country, Mali, from insulin in vials and syringes to a basal-bolus regime delivered by insulin analogue pens has shown marked improvement in HbA1c and a reduction of diabetic ketoacidosis (widely known as DKA) – a potentially life-threatening acute complication of diabetes. DKA is when insulin is not being absorbed into the bloodstream, forcing the body to break down fat and muscle for energy instead of glucose, and producing high levels of blood acids called ketones. Severe cases of this also lead to comas or death.
Why the opportunity is now
Scientific evidence alone, however, does not change clinical practice. Global standards do.
Currently, the World Health Organization (WHO) is developing treatment guidelines on the use of insulin for people living with type 1 diabetes mellitus to improve the quality of care worldwide.
The WHO has an opportunity to include analogue insulin pens and take a decisive step towards ending the double standard in diabetes care. This is because when a treatment is included in WHO guidelines, it signals that it is vital for public health and should be made affordable and accessible; that countries should include it in their national policies; and that corporations should register it in all countries. Overall, inclusion in WHO guidelines decisively determines that a treatment should be made available for all.
In other words, the upcoming guidelines are not simply a technical document – it is a policy signal that can shape procurement decisions, national treatment protocols, and future market competition for years to come.
Importantly, this recommendation would not come ahead of the market. It would reflect the direction in which the insulin market is already moving. And, with over three quarters of the insulin market by value targeted to produce insulin analogues, now is the time for countries to prioritize procuring person-preferred insulin analogue pens.
The market has already moved on from older insulins and insulin injection devices. Historically, it was not possible for low- and middle-income countries to roll out insulin analogue pens because of their high price tags, but things are changing.
Due to increasing production of biosimilar insulin analogues and improved procurement practices, the prices of these products are coming down in some markets. For example, Brazil, South Africa, and China are procuring insulin analogue pens at below USD$3 per pen as of 2025. And this price tag can go much lower.
A 2024 study by Barber et al. demonstrated that delivering analogue insulin in a reusable pen device – easily accessible in high-income countries – could cost USD $111 per patient per year, which (at the time of the study’s publication) was 30% less than human insulin in a vial. So low-income countries are actually currently spending more on diabetes care.
Continuing today’s double standard of care is therefore not only unacceptable from a health equity perspective, but also unnecessary when considering costs. And that means ending the double standard of care is both paramount and possible.
A moment for the WHO to lead
To date, the WHO has shown leadership in improving access to analogue insulin pens through the inclusion of long- and rapid-acting insulin analogues in the WHO Essential Medicine List (EML) in 2021 and 2025 respectively. This was accompanied by the addition of a long-acting insulin analogue to the WHO insulin prequalification programme in 2023, and the invitation for manufacturers’ expression of interest for rapid-acting insulin prequalification in 2026.
What people living with diabetes need to see now, is continued leadership from the WHO. There are no public statements so far on what WHO intends to do. This could indicate a hesitation on doing what is required.
Guiding countries to aim for higher standards of care by introducing analogue insulin pens in the upcoming guidelines for the use of insulin in the treatment of adults with type 1 diabetes while simultaneously advocating for urgent price reductions, would be a significant move towards establishing equality in care for people with diabetes.
It’s a step that the WHO must take. It’s time to take a definitive step towards ending the global double standards of diabetes care and making insulin analogue pens the first line for type 1 diabetes treatment.
Also see:
Private Foundations and Global Health Governance A Case Study of the Novo Nordisk Foundation: United Nations University International Institute for Global Health
From us:
Priti Patnaik
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