Vital medicine for diabetes has poor availability and affordability in middle- and low-income countries, according to the Prospective Urban Rural Epidemiology study’s findings published in The Lancet, Diabetes and Endocrinology.

Researchers collected data from 604 communities in 22 high-income countries, 8 upper-middle-income countries, 5 lower-middle-income countries, and 5 low-income countries. The diabetes medications that were investigated were metformin (100mg), gliclazide (80 mg), glibenclamide (5 mg), and insulin (50 IU/ml). The investigators measured medication availability based on results from a pharmacy audit, and they calculated affordability information based on medicine costs and household income surveys. Participant data included baseline demographics and sociodemographics, clinical measurements and diagnoses, and current medical treatments and adherence.

Metformin was available in 88.7% of the communities overall and in 100% of the high-income countries, 88.2% of the upper-middle-income countries, 86.1% of the lower-middle-income countries, and 64.7% of the low-income countries. Glibenclamide was available in 69.3% of the communities overall and in 84.1% of the high-income countries, 70.9% of the upper-middle-income countries, 62.5% of the lower-middle-income countries, and 57.4% of the low-income countries. Gliclazide was available in 57.9% of the communities overall and in 75.2% of the high-income countries, 71.7% of the upper-middle-income countries, 31.7% of the lower-middle-income countries, and 52.9% of the low-income countries. Insulin was available in 48.3% of the communities overall and in 93.8% of the high-income countries, 40.2% of the upper-middle-income countries, 29.3% of the lower-middle-income countries, and 10.3% of the low-income countries. 

In general, metformin was the most affordable medicine at 2.3% of the monthly capacity–to-pay, and insulin was the least affordable at 10% of the monthly capacity-to-pay. Medicine was least affordable in rural low-income countries and rural India, with 36.4% and 52.6% unable to pay for metformin, respectively. Medication use was associated with affordability and availability. Among participants diagnosed with diabetes, 74% in high-income countries used diabetes medicine, compared with 50.1% in upper-middle-income countries, 56% in lower-middle-income countries, and 29.6% in lower-income countries.

Related Articles

This study only analyzed specific medications and not all available diabetes medications, used self-reported diagnoses, and only collected information from pharmacies and not hospitals.

In conclusion, affordability and availability were determining factors for use of diabetes medication, low- and middle-income countries have poor availability and affordability, and the cost of insulin was proportionally more expensive in low-income countries.

This study was supported by the Population Health Research Institute, the Canadian Institutes of Health Research, and Heart and Stroke Foundation of Ontario. Please refer to reference for a complete list of authors’ disclosures.


Chow CK, Ramasundarahettige C, Hu W, et al. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study [published online August 28, 2018]. Lancet Diabetes Endocrinol. doi:10.1016/S2213-8587(18)30233-X.