Published in PLOS One on 2026-01-02, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Margaret L. Prust, Christina M. Lalama, Sylvia Kehlenbrink, Olatubosun Akinnola Akinola, Renatus Nyarubamba, Ajmina Hasan Flabe, Abigail Foulds, Graham D. Ogle, Edna Majaliwa, Bedowra Zabeen, Kaushik Ramaiya, Alana Garvin, Jing Luo
Source: PLOS One • DOI 10.1371/journal.pone.0333652
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Long-acting insulin analogues are the standard of care for Type 1 diabetes (T1D) in high-income countries but remain inaccessible in many low-resource settings. Cost-effectiveness is a key consideration for their adoption. This analysis evaluated the cost-effectiveness of biosimilar insulin glargine (IGlar) versus neutral protamine Hagedorn (NPH) insulin in youth with T1D in Tanzania and Bangladesh.
Data from the HumAn-1 trial informed a short-term economic model comparing NPH and IGlar over 12 months. The analysis, conducted from a health systems perspective, incorporated micro-costing data for insulin, injection supplies, blood glucose monitoring, and estimated hospitalization costs for complications. Effectiveness was based on a reduction in nocturnal hypoglycemia. In both countries, we calculated incremental cost-effectiveness ratios per quality-adjusted life year (QALY) gained in scenarios that compared IGlar against NPH across delivery devices (i.e., vials, cartridges, single-use pens).
IGlar was cost-effective compared to NPH when provided in cartridges in Bangladesh at a threshold of three times gross domestic product per capita. Other delivery devices in Bangladesh and all options in Tanzania were not cost-effective at current prices. If offered, IGlar vials would be cost-effective in Tanzania and Bangladesh if the price introduced was no more than 32% or 134% higher, respectively, than the current prices of NPH vials. Annual per patient costs and other cost-effectiveness thresholds were explored.
In low-resource settings, IGlar can be a cost-effective alternative to NPH, largely due to reduced nocturnal hypoglycemia, but the delivery device for the insulin has a major impact on the costs and cost-effectiveness comparisons.
Background
The number of people worldwide living with type 1 diabetes mellitus (T1DM) is projected to increase from 8.4 million in 2021 to over 13 million in 2040 [1]. Approximately one-fifth of people living with T1DM are in low-and lower-middle-income countries (LMICs) based on modeling from 201 countries using 2021 data [1], and individuals in these countries have substantially worse outcomes due to limited access to insulin, supplies, and skilled care. The same model projects that a 10-year-old diagnosed with T1DM in a high-income country could expect to live an additional 65 years, whereas a child diagnosed at the same age in a low-income country would only be expected to live 13 additional years.
Long-acting insulin analogues, which have become the de facto standard of care in high-income countries [2], offer several advantages over basal human insulins, such as fewer nighttime hypoglycemic events and once-daily dosing [3]. Treatment of micro- and macrovascular complications of diabetes, which are consequences of prolonged or recurrent hyperglycemia, accounts for the largest share of diabetes expenditure [4]. Maintaining blood glucose levels within recommended targets in order to limit the development of diabetes-related complications is a key treatment goal of diabetes therapy [5].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider financing & policy desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Margaret L. Prust, Christina M. Lalama, Sylvia Kehlenbrink, Olatubosun Akinnola Akinola, Renatus Nyarubamba, Ajmina Hasan Flabe, Abigail Foulds, Graham D. Ogle, Edna Majaliwa, Bedowra Zabeen, Kaushik Ramaiya, Alana Garvin, Jing Luo. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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