One Billion Patients, One Medicine That Works — and a Price That Excludes
Science has solved obesity as a chronic disease. The data attest to it: GLP-1 agonists reduce body weight by 15 to 20% on average, improve blood sugar levels, decrease cardiovascular risk, and even seem to modulate addictive behaviors. Within a few weeks at the beginning of 2026, the oral version of Wegovy captured a significant share of new American prescriptions. Medicine has rarely produced a class of molecules so effective against a disease so widespread.
Yet by 2030, fewer than 10% of people who would benefit from these treatments will have access to them, according to WHO estimates. At the same time, the number of obese adults worldwide is expected to double, surpassing one billion. The obstacle is not technical. It is not clinical. It is entirely economic and political.
The Essential Points
- GLP-1 medications reduce weight by 15 to 20% on average and captured a significant share of new American prescriptions in early 2026
- The WHO has recommended these treatments since December 2025 for obese adults, but estimates that fewer than 10% of potential beneficiaries will have access by 2030
- 3.7 million deaths were associated with obesity in 2024; the number of obese adults could exceed one billion by 2030
- GLP-1 patents have expired or do not exist in China, India, and Brazil, countries that account for 40% of the world’s population and one-third of obese adults
- No voluntary licensing mechanism is in place to organize large-scale access in middle-income countries
GLP-1 was not born fully formed. Glucagon-like peptide-1 is a natural hormone secreted by the intestine after a meal. It signals satiety to the brain, slows gastric emptying, and stimulates insulin secretion. Researchers spent thirty years understanding its mechanisms, synthesizing stable analogous molecules, and demonstrating their clinical efficacy at large scale. Semaglutide first authorized for type 2 diabetes, tirzepatide next, then higher-dose formulations for obesity: each step represented considerable investment in R&D and clinical trials.
This context matters, because it partly explains why prices are what they are. But it does not justify their extent.
Novo Nordisk and Eli Lilly Have Built a Global Duopoly
Two companies control the bulk of the global GLP-1 market for obesity: Danish Novo Nordisk with semaglutide (Ozempic for diabetes, Wegovy for obesity) and American Eli Lilly with tirzepatide (Mounjaro, Zepbound). Their combined valuation exceeded 1 trillion dollars in 2024, propelled by demand that still exceeds production capacity.
The monthly cost of treatment ranges between 900 and 1,300 dollars in the United States before reimbursement. Even in Europe, where national regulators negotiate tariffs, the annual cost per patient exceeds 3,000 euros in most countries. In middle-income countries, these prices are simply prohibitive for public health systems.
This is not a problem of exceptional margins: the pricing structure of innovative medications incorporates the cost of R&D, failed clinical trials, patent protection duration, and expected shareholder returns. But it also incorporates, in the American case, the complete absence of price negotiation by Medicare until a recent reform, and the practice of “evergreening,” which consists of artificially prolonging intellectual property protection through patent filings on derivative formulations. Novo Nordisk thus holds a very large number of patents related to semaglutide.
The WHO Recommends, But Lacks Tools to Accelerate Access
In December 2025, the WHO published its first global guidelines on the use of GLP-1 in obesity treatment. The recommendation is clear: these treatments are effective, safe, and should be integrated into first-line care for adults with a body mass index above 30, or above 27 with comorbidities. This is the first time the organization has formally recommended a class of anti-obesity medications.
The symbolic scope is real. The WHO officially recognizes that obesity is a chronic disease requiring long-term medical treatment, not just lifestyle advice. It represents a break with decades of discourse centered on individual willpower.
But the WHO has no direct leverage over prices. The organization can recommend treatments, can urge member states to negotiate licensing agreements, can provide technical support to generic producers. It cannot impose a price or force a compulsory license. As shown by the structural fragilities of global health documented by the JdP, the international institutional architecture of health rests on mechanisms of recommendation, not constraint.
The WHO recommendation therefore does not automatically translate into access. It creates scientific and political legitimacy that can accelerate negotiations, but negotiations must still be conducted, country by country, molecule by molecule.
Patents Expire Where Needs Are Greatest
This is where the situation becomes more complex than it appears. In China, India, and Brazil, patents on semaglutide either have not been filed, are vulnerable to legal challenges, or are nearing expiration. These three countries represent 40% of the world’s population and roughly one-third of obese adults. They are also leading pharmaceutical manufacturing powers: India produces 20% of global generics, China has multiplied its capacity in biologics and synthetic peptides.
Indian manufacturers have already announced generic versions of semaglutide. Cipla, Sun Pharma, and several mid-sized players have filed approval applications with the Central Drugs Standard Control Organisation. In China, competitor molecules developed locally, such as mazdutide from Innovent Biologics, are already in advanced trial phases. In Brazil, discussions are underway within ANVISA on the authorization of biosimilar versions.
The potential is there. But it does not automatically convert into access.
First reason: GLP-1s are complex biological peptides, not simple small chemical molecules. Their large-scale synthesis requires specialized equipment and rigorous quality control processes. The production of peptide biosimilars is intrinsically more difficult and more costly than that of standard generics. Manufacturers like Biocon in India are developing these capacities, but scaling up takes time.
Second reason: even a price divided by ten would represent a monthly cost of 90 to 130 dollars, or still between 1,000 and 1,500 dollars per year. In countries where median monthly income does not exceed 300 to 500 dollars, treatment remains out of reach without substantial public subsidy.
Third reason: no multilateral mechanism coordinates access to these molecules. The Medicines Patent Pool, which played a central role in access to antiretrovirals and antivirals against COVID-19, has not yet concluded voluntary licensing agreements with Novo Nordisk or Eli Lilly for GLP-1s. Exploratory discussions have taken place, but no announcement has been made as of publication.
Three Access Models Compete
Facing this impasse, three solution logics are in competition.
The first is that of accelerated bilateral negotiation. The European Union negotiates prices collectively, but with unequal results across member states. Countries like Norway and the Netherlands have obtained substantially lower prices than American tariffs. This negotiating capacity depends on market size and buyer unity. Applied to middle-income countries, it yields marginal results: the volumes are larger, but health systems lack the resources to finance even reduced prices at large scale.
The second logic is that of technological workaround. Several startups and research academies are working on oral formulations at lower production cost, long-acting conjugates requiring fewer injections, or new-generation molecules with different mechanisms of action. American biopharmaceutical company Structure Therapeutics is developing an oral version of GLP-1 designed from the outset for minimal production cost. The horizon remains three to five years for these alternatives.
The third logic is that of regulatory and political pressure. In 2024, Medicare negotiated direct prices on ten drugs for the first time in the United States, under the Inflation Reduction Act. GLP-1s did not appear on this first list, but the mechanism is in place. In parallel, several Global South governments, including Bangladesh and Nigeria, have signaled interest in invoking compulsory licenses under the WTO TRIPS agreement, which allows patents to be bypassed in case of public health emergency. This path remains politically risky, as it exposes the countries concerned to diplomatic pressure from states where the laboratories in question are headquartered.
These three logics are not mutually exclusive. They are progressing in parallel, at different speeds.
The Cost of Non-Access Is Itself an Economic Argument
The issue must be named in its economic dimension, because it is often the only language that shifts positions.
Obesity is not merely a risk factor: it is a multiplier of medical costs. An obese adult generates substantial additional health expenditures per year in high-income countries. Type 2 diabetes, cardiovascular disease, sleep apnea, certain cancers: each of these comorbidities represents treatment costs that exceed that of GLP-1 prevention. The argument of “too expensive” reverses when one calculates the cost of non-treatment over ten years.
This is precisely the argument advanced by health economists who advocate for including GLP-1s in reimbursable care baskets of public systems. The United Kingdom began reimbursing semaglutide within the NHS in 2023, with a three-year scaling plan targeting patients at high cardiovascular risk. Data presented at the ESC 2024 Congress concerned the international randomized clinical trial SELECT, which showed a 20% reduction in combined major cardiovascular events (cardiovascular deaths, non-fatal infarctions, and non-fatal strokes) in patients treated with semaglutide. This type of data is precisely what can convince finance ministries, not just health ministries, to invest in access.
The same logic applies to middle-income countries. The economic cost of obesity represents a significant share of annual GDP in countries like Brazil, according to various estimates. A mass treatment program at negotiated prices, even if costly, could have a positive return on investment over a decade. Several Brazilian health economists have published modelings to this effect, although these projections remain contingent on assumptions about treatment adherence rates and effects on comorbidities.
This question points to a broader issue of global health financing, documented in our analysis on the health achievements of the twenty-first century: middle-income systems lack not only money. They lack multiyear financing mechanisms that allow them to subscribe to costly treatments upfront, before comorbidities make the bill even heavier.
The Medicines Patent Pool Must Enter the Game
Recent history of global health provides a useful precedent. The Medicines Patent Pool concluded its first voluntary licensing agreement with a private pharmaceutical company — Gilead Sciences — in July 2011, opening the way to the production of affordable versions of antiretrovirals against HIV. These agreements enabled Indian and African generic manufacturers to produce versions of the same molecules, sometimes at a price one hundred times lower. The result: coverage of antiretroviral treatments in low and middle-income countries progressed from less than 5% to more than 75% in twenty years, according to UNAIDS.
The model is not perfect. It works better for diseases that concentrate international political attention like HIV or tuberculosis than for less “visible” diseases like obesity, long perceived as a problem of rich countries or a matter of individual behaviors. This bias is itself an obstacle: obesity today massively affects middle and working classes in emerging countries, fueled by dietary transition and urban sedentarization, but the mental framework that defines it as a pathology subject to international solidarity remains to be built.
This is precisely what the WHO recommendation of December 2025 begins to change. By classifying obesity as a chronic disease requiring medical treatment in the same way as diabetes or hypertension, the WHO creates the political framework that could enable the Medicines Patent Pool to negotiate the first voluntary licenses on GLP-1s. Exploratory discussions are underway, without an announced timeline at this stage.
The ball is in the court of Novo Nordisk and Eli Lilly. Both companies face growing pressure from their institutional shareholders, increasingly sensitive to ESG criticism on medication access. Novo Nordisk has announced a reduced-price access program targeting a number of low-income countries, but this program does not cover middle-income countries, which nonetheless represent the majority of untreated patients. Eli Lilly has launched a similar initiative, limited to a few countries. These announcements are real and must be recognized as such. They remain far too insufficient given the scale of the problem.
The architecture for broader access exists. The precedents are there. The actors are identified. The question that remains open is that of timing: how many years, how many deaths associated with obesity, how many billions of dollars in avoidable medical costs will need to be documented before a global agreement is reached? WHO data provide a provisional answer: if nothing changes by 2030, nearly nine out of every ten people who could benefit from these treatments will not receive them.
Sources
- WHO — Global Guideline on the Use of GLP-1 Medicines in the Treatment of Obesity, December 2025
- IQVIA Institute — GLP-1 Prescription Data in the United States, Q1 2026 (quarterly report)
- Medicines Patent Pool — Analysis of Semaglutide Patents, 2024
- UNAIDS — Global Report on HIV/AIDS, ARV Coverage Data 2023
- European Observatory on Health Systems and Policies — Comparative Prices of GLP-1s in Europe, 2024
- OECD — Obesity Update, Medical Costs Associated with Obesity Data, 2023
- ESC Congress 2024 — Preliminary Results of NHS Semaglutide Reimbursement Program
- CMS / Medicare – IRA Drug Price Negotiation (primary source)
- Medicines Patent Pool – GLP-1 Request for Proposals (primary source)
- MPP – First Agreement with Gilead (July 2011)
- Sun Pharma – DCGI Semaglutide Approval (primary source)
- World Obesity Atlas 2025 – World Obesity Federation
- KFF – Medicare Drug Price Negotiation
- Reddie & Grose – Semaglutide Patent China/India/Brazil
- Pharmaceutical Journal (RCP) – NHS Wegovy Launch 2023
- UNAIDS – Fact Sheet 2025