Health Diplomacy for Collective Leadership in Access to Insulin for Diabetes and Well-Being
Introduction
Over a century after its discovery, insulin remains a lifeline for millions with type 1 diabetes and is essential for over 60 million people with type 2 diabetes. Yet its access and diabetes burden continue to be a global concern. The number of people living with diabetes increased from 200 million in 1990 to 830 million in 2022, with prevalence rising much faster in low- and middle-income countries (LMICs) than in high-income ones. In 2021 alone, diabetes and related kidney disease caused over 2 million deaths, while high blood glucose contributed to around 11 percent of all cardiovascular deaths. Figure 1 depicts the share of people with diabetes as of 2024. Despite its critical role, access to insulin remains severely unequal across countries, with one in two people needing insulin for type 2 diabetes unable to obtain it.
Figure 1: Share of People with Diabetes (2024)
Source: Our World Data
With the theme of “Diabetes and Well-being,” World Diabetes Day 2025 resonates the importance of healthcare providers, policymakers, and communities looking beyond blood sugar control and focusing on the complete well-being of individuals, including mental, social, and economic dimensions of living with diabetes. Ensuring that people have access to affordable insulin, essential related technologies, and continuous support is central to achieving that vision. Insulin access can be effectively analyzed through the World Health Organization “4As” framework—Availability, Accessibility, Affordability, and Acceptability. These interconnected dimensions correspond to the three critical stages of insulin provision: manufacturing, distribution, and patient use. Barriers at any point along this chain can severely compromise effective diabetes care.
As the global supply chain and health systems function in the geopolitical and geo-economic ecosystem, health diplomacy becomes essential to address the crisis of insulin. As an art and science of multi-sectoral actors navigating political processes to influence global health policy and health outcomes, health diplomacy offers a framework for addressing insulin access inequities by negotiating fairer access to life-saving medicines. By linking national priorities with global cooperation, diplomacy can help realign markets, increase partnerships, and build collective leadership toward a shared goal of ensuring insulin is available, accessible, affordable, and acceptable for all.
Availability: Manufacturing Concentration and Dependence
Manufacturing concentration and limited geographic diversification represent the first critical barrier. Only around 20 countries manufacture insulin, leaving over 170 nations dependent on imports. The global market is dominated by a handful of multinational producers, restricting competition and contributing to persistent supply gaps and high costs.
The shift toward newer analog insulins and advanced delivery devices, such as injection pens, has further increased manufacturing complexity and cost, affecting the LMICs disproportionately. One global modeling study projects insulin use for type 2 diabetes to increase from 526 million vials in 2018 to 634 million by 2030, a 20 percent surge. Without substantial improvements in production capacity and equitable distribution, half of the 79 million adults projected to need insulin by 2030 will remain untreated.
In parallel, the global innovation ecosystem for insulin is expanding rapidly, offering promising alternatives to traditional injection-based delivery. Cutting-edge developments such as insulin patches, insulin eye drops, and sublingual insulin tablets are in various stages of research and regulatory evaluation. These innovations aim to improve patient comfort, adherence, and glycemic control by reducing dependence on needles and enhancing convenience. However, while such technological advancements signal progress, equitable access to both conventional and emerging insulin products remains uneven across regions.
In India, around 101 million people (about 11.4 percent of the population) are living with diabetes, yet insulin access remains well below the WHO target of 80 percent treatment coverage.These figures underscore the urgent need to expand regional manufacturing capabilities and reduce reliance on a few dominant producers to improve global insulin availability.
Accessibility and Affordability: Distribution and Supply-Chain Challenges
Even when insulin is technically available within national systems, accessibility and affordability often remain constrained by weakened procurement processes, high mark-ups, tariffs, and fragile cold-chain logistics. In many LMICs, public-sector facilities face frequent stock-outs, forcing patients to resort to private pharmacies at significantly higher costs.
In India, for example, the mean availability in the public sector was only 66.7 percent, and patients paid up to 128 percent above import prices due to cumulative mark-ups and tax burdens. These system inefficiencies underscore the critical importance of transparent procurement systems, price regulation, and robust public-sector distribution networks to ensure insulin is both accessible and affordable across all population groups.
Acceptability: Patient-Level Barriers and Effective Use
Ensuring insulin availability and affordability is necessary but not sufficient. Patients must also be willing and able to use insulin effectively. Acceptability depends on proper prescription, education, self-monitoring, and consistent follow-up. Yet, in many settings, knowledge gaps, fear of injections, and lack of supportive devices or counseling hinder adherence.
Common challenges include low health literacy, poor transportation access, financial constraints, and missed outpatient appointments. Additionally, the absence of structured diabetes education programs means patients often lack training on correct injection techniques and hypoglycemia management. Addressing these issues requires investments in patient education, healthcare workforce training, and digital support systems to improve treatment adherence and outcomes.
Insulin as a Health Diplomatic Imperative
Health diplomacy becomes a vital tool for ensuring equitable access to insulin across countries, as it requires coordinated policies that address every stage of the supply chain, i.e., from production to patient use. To break the concentration of insulin manufacturing only among a few players, the WHO Insulin Prequalification Program has opened doors for new manufacturers, particularly from the Global South, to enter international markets. By aligning regulatory standards and fostering trust in product quality, prequalification reduces dependence on a few producers and enables countries to negotiate better terms. For instance, in 2023, India launched its first biosimilar insulin Aspart (INSUQUICK), a rapid-acting insulin analog aimed at lowering costs and improving supply security. Similarly, India’s largest insulin manufacturers continue to produce a full range of recombinant human and analog insulins and have expanded global exports through WHO prequalification initiatives, positioning India as a potential anchor for regional insulin security.
Pooled procurement mechanisms exemplify collective action to improve accessibility. The European Union, through its regional cooperation and a joint procurement mechanism for essential medicines, mitigates supply vulnerabilities and strengthens regional resilience. It has pioneered price regulation and transparency measures with European Federation of Pharmaceutical Industries and Associations (EFPIA) members committing to filing for pricing and reimbursement in all EU countries within two years of authorization and supporting equity-based tiered pricing frameworks. The Program has successfully procured human and analog insulins at competitive prices for six member-states since 1976, demonstrating the power of regional cooperation.
Health diplomacy also facilitates the development of technological solutions and infrastructure investments. The COVID-19 pandemic accelerated cold chain development for vaccine distribution, creating opportunities to leverage this infrastructure for insulin. International collaboration on solar-powered refrigeration units and passive cooling technologies represents the kind of innovation-sharing that diplomatic frameworks can enable.
At the national level, China’s National Volume-Based Procurement (NVBP) program, launched in 2022, pooled national demand and negotiated directly with manufacturers, reducing insulin prices by about 42 percent and expanding coverage to millions. Bhutan has integrated insulin access into its National Diabetes and NCD Program, ensuring consistent availability across all district hospitals through international partnerships. In sub-Saharan Africa, Tanzania has transitioned from donor-supported to nationally funded NCD programs, which include insulin procurement, distribution, and patient education, thereby improving the sustainability and continuity of care. Collectively, these approaches demonstrate that improving insulin access is not merely a health issue, but a priority for health diplomacy and global governance, requiring strategic procurement, regulatory alignment, and system-wide integration to ensure affordability and universal reach.
Collective Leadership: A Diplomatic Framework for Universal Access
Achieving universal insulin access requires collective leadership across governments, multilateral organizations, civil society, academia, and industry, coordinated through health diplomacy. The WHO Global Diabetes Compact, launched during insulin’s centenary, represents institutional diplomacy at scale, uniting diverse actors to work towards the five global coverage targets for 2030, including 100 percent access to affordable insulin for people with type 1 diabetes and 80 percent treatment coverage for those with type 2.
Regional platforms amplify this collective action, such as African Union initiatives, ASEAN cooperation, and the G20 health track, which provide contextually appropriate forums for South-South partnerships that challenge historical medicine access inequities. The International Diabetes Federation and national diabetes associations amplify patient voices in diplomatic spaces, ensuring that access improvements reflect the real needs of the community rather than a top-down approach.
Conclusion
As the world marks World Diabetes Day 2025 on November 14, anchored in collective leadership, transparent governance, and an unwavering commitment to the well-being of every person living with diabetes, it is imperative that insulin access becomes a diplomatic priority. Health diplomacy, through strengthened manufacturing diversity, efficient pooled procurement, and collective leadership across borders, offers a proven pathway to bridge persistent access gaps. By combining national stewardship with regional cooperation and global solidarity, countries can move from competition to collaboration.