South Africa’s public healthcare system has exhausted its supply of human insulin pens due to the pharmaceutical industry’s shift in production priorities to weight-loss drugs that use similar delivery devices.
Novo Nordisk, the supplier of human insulin pens to South Africa for the past decade, did not renew its contract, which expired last month. No other company has bid on the new contract to supply 14 million pens over the next three years at approximately $2 per pen.
“Current manufacturing capacity limitations mean that patients in some countries, including South Africa, may have limited access to our human insulins in pens,” said Ambre James-Brown, a spokeswoman for Novo Nordisk. The company did not specify which other countries are affected.
Novo Nordisk’s weight-loss drugs Ozempic and Wegovy, widely prescribed in the U.S., are sold in single-use pens produced by the same contracted manufacturers who make the insulin pens. A month’s supply of Ozempic in the U.S. costs about $1,000, far more than insulin.
Impact on South Africa
Novo Nordisk dominates the global market for insulin pens and has supplied South Africa since 2014. Eli Lilly, another major producer, has also indicated difficulty keeping up with the demand for its weight-loss drug Zepbound.
“This is because of the global demand for Ozempic and similar drugs,” said Khadija Jamaloodien, director of sector-wide procurement for South Africa’s health service. “They’re focusing on the more profitable line.”
Novo Nordisk continues to supply human insulin in vials to South Africa, where over four million people live with diabetes. However, insulin pens are easier to use and more precise. Pens can dispense a given amount of insulin with a simple dial and quick injection, whereas vials require drawing insulin into a syringe, confirming the dose, and injecting it.
The vial system was mostly phased out for South Africans in 2014, but recently, the National Department of Health instructed clinicians to teach patients how to use vials and syringes again.
“Insulin vials and syringes are outdated and difficult to use,” stated a national association of diabetes specialists in a public letter to the government. “They contribute negatively to quality of life for people with diabetes and lead to poor medication adherence, resulting in costly long-term complications.”
The Human Cost
Muhammed Adnan Malek, a 19-year-old student in Zeeland, South Africa, has used insulin pens from the public health system for nine years. “I’ve never used syringes, so I asked an 80-year-old I know with diabetes about it. He said it’s very difficult to give the exact dose,” Malek said. “With insulin, being a unit higher or lower has a big effect. An overdose can cause hypoglycemia, leading to coma or death.”
Jamaloodien’s office has instructed clinicians to reserve the remaining pens for those who will struggle most with using vials and syringes—small children, the elderly, and visually impaired individuals.
Boitumelo Molema, a 22-year-old student, recently found her usual clinic out of stock of insulin pens. After visiting two more clinics without success, she bought them at a private clinic for $10 each, a significant financial burden.
James-Brown, the Novo Nordisk spokeswoman, said the company alerted South Africa last year about not bidding on the next contract for insulin pens. However, Jamaloodien stated the company only mentioned a “supply constraint” without indicating a complete exit until the contracting process ended in January. This delay, due to staffing constraints, has led to a scramble to find a new supplier.
Broader Implications
Novo Nordisk started making pens in 1985, and these, along with pumps, are standard care for Type 1 diabetics in industrialized countries. Wealthy individuals in low-income countries also use them.
South Africa is unique among low-resource countries for supplying insulin pens through its public health service. Eighty percent of people with diabetes live in low- and middle-income countries. GLP-1 drugs like Ozempic, used for diabetes treatment in high-income countries, are not on the WHO’s essential medicines list or the diabetes treatment guidelines of low- and middle-income countries.
Novo Nordisk’s insulin access policy provides insulin at $3 per vial to low- and middle-income countries and $2 per vial to humanitarian groups like Médécins Sans Frontières (MSF). Novo Nordisk signed an agreement last year with South African drugmaker Aspen Pharmacare to produce 60 million vials by 2026.
MSF reports that patients in crisis zones, such as Gaza and Ukraine, struggle to revert to vials and syringes. “In the dark without electricity, it’s easy to measure insulin in a pen, which clicks to indicate increments,” said Leena Menghaney of MSF’s Access campaign. “But it’s much harder to confirm a syringe dosage.”