Five Years of the Global Diabetes Compact: Progress, Persistent Gaps, and the Fight for Universal Insulin Access
Key Insights
The WHO Global Diabetes (search) Compact marks five years of advancing diagnosis, care, and insulin access targets, yet 40 million people still lack access to life-saving insulin globally.
An estimated 43% of people with diabetes (search) remain undiagnosed, and only one in two with type 2 diabetes worldwide can obtain needed insulin, with Africa facing the worst access at one in seven.
Three manufacturers — Sanofi, Eli Lilly, and Novo Nordisk — control 90% of the $29.4 billion insulin market, limiting competition and keeping prices out of reach in low- and middle-income countries.
Five years after the World Health Assembly endorsed the Global Diabetes (search) Compact (GDC), the landmark WHO initiative has galvanized stakeholders around common diabetes coverage targets — yet the gap between ambition and reality remains stark. More than a century after insulin's discovery transformed type 1 diabetes from a death sentence into a manageable condition, an estimated 40 million people still cannot obtain this essential medicine, mostly in low- and middle-income countries.
"Science gave us insulin, and more than a century later, we still owe its promise to millions of people," said Dr Catharina Boehme, officer-in-charge of the WHO South-East Asian region, speaking at an anniversary event on the margins of the World Health Assembly in Geneva. "Five years ago, the Global Diabetes (search) Compact was created to fulfill this promise and give what we owe people with diabetes."
Ambitious Targets for 2030
The GDC sets several key diabetes (search) targets for 2030: 80% coverage of diagnosis for people with diabetes, 80% of those diagnosed achieving good glycemic and blood pressure control, 60% of people with diabetes aged 40 or older receiving statins, and 100% of people with type 1 diabetes having access to affordable insulin and blood glucose self-monitoring.
"Even if they sparked debate, they are brilliant goals," said Professor Peter Schwarz, president of the International Diabetes (search) Federation (IDF). He described the present reality — in which an estimated 43% of people with diabetes remain undiagnosed and without insulin — as a "severe ethical issue."
The Compact represents the first time global diabetes (search) coverage targets have been established alongside a clear operational agenda for access to essential diabetes medicines and technologies. This has included the progressive inclusion of insulin analogues into the WHO Essential Medicines List (EML), and last year, the GLP-1 (search) drug class for type 2 diabetes management was also added. In May, WHO invited manufacturers to submit generic versions of semaglutide and rapid-acting insulin products for prequalification review.
A Market Dominated by Three Players
Insulin production today is dominated by three manufacturers — Sanofi, Eli Lilly, and Novo Nordisk — which control 90% of a market estimated at $29.4 billion in 2024. This concentration limits competition and neutralizes the price-reducing effect that could result from biosimilar insulin introduction.
The situation has grown more concerning as leading manufacturers discontinue key products. Sanofi discontinued its human insulin Insuman in 2023, and Novo Nordisk is withdrawing its Levemir insulin. The Institute for Health Metrics and Evaluation (IHME) found only a single-digit percentage point increase in the number of people receiving diabetes (search) care globally, even as cases accelerate.
The access crisis has also reached high-income countries: in the United States, approximately 16.5% of people who need insulin — roughly 1.3 million adults — ration its use by delaying or reducing doses due to cost.
Regional Disparities and the South-East Asia Burden
South-East Asia faces what Boehme described as a "shocking trajectory." One in five adults in the region lives with diabetes (search), representing roughly one-third of the global total. WHO projections indicate the number will reach 320 million by 2030. Currently, only one in three adults with diabetes in the region receives treatment, and less than 15% have adequately controlled blood glucose levels.
Africa confronts an even more severe access crisis. A mere 1% of diabetes (search) care investment is directed to the region, and IDF predicts a more than 140% increase in people living with diabetes by 2050, reaching 60 million. The proportion of undiagnosed diabetes is highest in Africa at an estimated 72.6%.
"Political ambition and commitment and targets are hugely important to drive the agenda forward," said Sanne Frost Helt, a senior director at the World Diabetes (search) Foundation. "But they become meaningless if we don't have action on the ground."
Bright Spots in Implementation
Despite the challenges, concrete progress is emerging. The SEAHEARTS initiative, which integrates cardiovascular disease and diabetes (search) care into primary health systems, has enrolled 43.5 million patients across 180,000 healthcare facilities. The goal is to place 100 million patients on protocol-based diabetes management by 2030, with 50 million achieving glycemic control.
The 2024 endorsement of the Colombo Call for Action provides a roadmap for WHO South-East Asian member states to reduce type 2 diabetes (search) risks and expand access to diagnosis and care. In Bangladesh, the World Diabetes Foundation is partnering with religious leaders — imams — to raise community awareness about diabetes prevention.
"We've succeeded in gathering stakeholders around a common agenda," said Dr Bianca Hemmingsen, WHO's technical lead on the project, citing the diverse coalition of civil society groups, people living with diabetes (search), and governments now aligned behind the Compact's goals.
The Path Forward
Dr Bente Mikkelsen, board member of the World Diabetes (search) Foundation and former WHO director for noncommunicable diseases, expressed excitement that the initiative has moved beyond resolution approval into implementation. Yet fundamental barriers persist: data gaps obscure the true prevalence of type 1 diabetes in the Global South, where children may be dying undiagnosed; social stigma complicates care-seeking in parts of Africa; and health systems remain ill-equipped for the projected surge.
"Health systems are just not geared to tackling such a surge in diabetes (search)," warned Helt. "Not from a prevention point of view, not from an early detection point of view, and not from a care perspective."
The most recent WHO estimates indicate more than 830 million adults were living with diabetes (search) in 2022. IDF's more conservative estimate of 589 million reflects definitional differences between researchers, though Schwarz believes both figures underestimate the true burden. By 2050, the number of people living with diabetes is projected to increase nearly 50% globally.
"Insulin does not belong to me, it belongs to the world," Frederick Banting, one of insulin's discoverers, is said to have declared. More than a century later, the Global Diabetes (search) Compact represents the most coordinated effort yet to fulfill that promise — but as Boehme noted, the anniversary is "an opportunity not only to celebrate five years of partnership, but to renew our shared commitment to delivering diabetes care at scale, for everyone who still lacks access today."