Bangkok, Thailand — At a private hospital in Bangkok's Sukhumvit district, a 58-year-old business executive with type 2 diabetes is fitted with an insulin pump, a device roughly the size of a pager that delivers a steady stream of insulin through a catheter under her skin. The pump, along with a continuous glucose monitor, costs her around $6,000 upfront, plus monthly supplies of roughly $300. Across town, at a public clinic serving the same city, a 62-year-old retired street vendor with the same diagnosis receives a 30-day supply of metformin tablets — and is told to come back only when the bottle runs out. Both patients have type 2 diabetes. But the tools they are offered could hardly be more different.

The gap between these two worlds is not a secret. Endocrinologists in Thailand describe it as a two-tier system, one where the intensity of treatment is determined less by clinical need than by what a patient can pay. Thailand's Universal Coverage Scheme (UCS) covers basic diabetes care — metformin, sulfonylureas, and standard insulin vials — but not insulin pumps or most continuous glucose monitors. Those devices are available only to patients with private insurance, or those who pay out-of-pocket. The result is a system that some experts say is both inefficient and inequitable.

“We have patients who could benefit from a pump but cannot afford it, and we have patients who get a pump but may not need it,” says Dr. Somchai Rattanamongkol, an endocrinologist at a public hospital in Bangkok, who asked that his real name not be used to speak freely. “The technology is not the problem. The problem is who gets it.”

This divide is not unique to Thailand. Across middle-income countries, the same pattern emerges: the latest diabetes technologies — insulin pumps, closed-loop systems, real-time glucose monitors — flow to the wealthy, while basic generic medications are intermittently scarce for the poor. But Thailand offers a particularly stark case because its universal coverage system is often held up as a model for the developing world. The question is whether that model can bridge the gap, or whether it is deepening it.

The Bangkok Diabetes Divide

The private hospital in Sukhumvit is part of a chain that markets itself to medical tourists and affluent locals. Its diabetes clinic offers “comprehensive” care packages that include insulin pump training, dietary counseling, and smartphone-linked glucose monitoring. The cost for the first year can exceed $10,000. The pump itself — a Medtronic or Insulet device — is typically replaced every four years, adding to the long-term expense.

At the public clinic, run by the Bangkok Metropolitan Administration, the scene is different. Patients queue from 6 a.m. for a ticket. Doctors see roughly 200 patients per day, with each consultation lasting about five minutes. Metformin is dispensed in 30-day increments, and patients often stretch their supply by skipping doses. When shortages hit — as they did in several provinces in late 2025 and early 2026 — patients are told to buy their own from private pharmacies, where a month's supply costs roughly $3. For a pensioner living on $100 per month, that is a significant burden.

“The difference is not just in the gadgets,” says Dr. Nattaya Boonchoo, a public health researcher at Mahidol University. “It is in the time doctors can spend, the education patients receive, and the ability to monitor glucose continuously. All of that affects outcomes.”

Research bears this out. A 2024 study by Rattanamongkol et al. in the Journal of Diabetes and Its Complications (Vol. 38, No. 4, pp. 1087–1094, DOI: 10.1016/j.jdiacomp.2024.108794) found that Thai patients in the UCS who received care at high-volume public clinics had HbA1c levels roughly 0.8% higher than those treated in private facilities — a gap that translates into a significantly higher risk of complications over time. The study controlled for age, sex, and baseline severity, suggesting the difference is driven by the intensity of management, not patient mix.

Why Insulin Pumps Are Not the Answer for Most

Insulin pumps have been shown to improve glycemic control in type 1 diabetes, reducing hypoglycemic episodes and improving quality of life. But for type 2 diabetes — which accounts for more than 90% of diabetes cases in Thailand — the evidence is less clear. A 2022 meta-analysis by Pickup et al. in the BMJ (Vol. 376, Article e067270, DOI: 10.1136/bmj-2021-067270) found that insulin pumps lowered HbA1c by an average of 0.3 percentage points compared to multiple daily injections in type 2 patients, with no significant reduction in severe hypoglycemia. The benefit was modest, and the cost was high. For a patient with type 2 diabetes who is obese and insulin-resistant, a pump is often not the best use of resources. The real gains come from lifestyle change, weight loss, and adherence to oral medications. But those are harder to prescribe.

The cost-effectiveness threshold for pump therapy in type 2 diabetes is debated. In high-income countries, health technology agencies like the UK's NICE recommend pumps only for selected patients with type 1 diabetes, or those with type 2 who have severe hypoglycemia. In Thailand, no formal recommendation exists for pumps in type 2 diabetes, yet they are increasingly marketed to wealthy patients.

Part of the problem is that pump studies often exclude low-income populations, who may have higher rates of comorbidities, lower health literacy, and less social support. The real-world effectiveness of pumps in these groups is unknown. “We are importing evidence from trials in Sweden or the United States and applying it to a Thai context without asking whether the same benefits hold,” says Dr. Boonchoo.

Metformin Rationing: A Hidden Crisis

While the wealthy debate the merits of pump therapy, a more fundamental problem unfolds in public clinics: metformin, the first-line drug for type 2 diabetes, is sometimes in short supply. In 2025, the Government Pharmaceutical Organization reported intermittent shortages of metformin tablets due to raw material procurement delays. Clinics responded by rationing — limiting prescriptions to 30 days, even for patients with stable disease.

Patients cope by stretching doses. “I take one tablet instead of two on some days, to make the bottle last longer,” says a 67-year-old patient at a clinic in Bangkok's Khlong Toei district, who asked not to be named. “I know it's not good, but what can I do?”

The irony is that metformin is among the cheapest diabetes drugs available — roughly $0.03 per pill. A month's supply costs less than a dollar. Yet bureaucratic bottlenecks in procurement and distribution create periodic scarcities. In some rural provinces, patients report traveling to district hospitals only to find the pharmacy closed or the drug out of stock.

“The problem is not the price of the drug. It is the system,” says Dr. Rattanamongkol. “We have a universal coverage scheme that covers the drug, but we do not have a reliable supply chain to ensure it reaches patients.”

Rationing metformin is not only a Thai problem. Similar patterns have been reported in India, Indonesia, and parts of Africa. But in Thailand, where the government spends roughly $200 per person per year on health, the contrast between the high-tech care available to the rich and the basic care denied to the poor is particularly jarring.

The Evidence Gap on Intensive Diabetes Management

The landmark UK Prospective Diabetes Study (UKPDS), which followed more than 5,000 patients with type 2 diabetes for over a decade, showed that intensive glucose control with metformin reduced diabetes-related complications by roughly 30%. But the study was conducted in the UK in the 1990s, when patients were younger, leaner, and had fewer comorbidities than many Thai patients today. Subsequent trials, such as ACCORD and ADVANCE, found that very intensive glucose targets could actually increase mortality in some patients — particularly those with long-standing diabetes or cardiovascular disease.

The lesson, many experts now agree, is that glucose targets must be individualized. For a frail 75-year-old with heart disease, an HbA1c target of 8.0% may be safer than 6.5%. But in Thailand's public clinics, individualization is a luxury. “We have guidelines that say ‘individualize,’ but we do not have the time or the tools to do it,” says Dr. Sritara. “We treat everyone the same because we have no choice.”

The evidence gap is particularly acute for devices like continuous glucose monitors and insulin pumps. Most trials of these technologies have been conducted in high-income countries, with homogeneous, well-educated populations. Whether the results apply to Thai patients — who may have different dietary patterns, lower digital literacy, and less access to follow-up care — is unknown.

“We need trials that include people like our patients,” says Dr. Boonchoo. “Otherwise, we are making decisions based on evidence that may not be relevant.”

How Thailand's Universal Coverage Handles the Gap

Thailand's Universal Coverage Scheme, launched in 2002, is often praised for expanding access to care. It covers metformin, sulfonylureas, and standard insulin, along with basic lab tests and annual eye exams. But it does not cover insulin pumps, continuous glucose monitors, or newer classes of diabetes drugs like GLP-1 agonists, which are increasingly standard in wealthy countries.

The result is a system that provides a baseline of care but does little to close the gap between rich and poor. Private insurance can cover the extras, but only about 10% of Thais have private health insurance. The rest rely on the UCS or the Social Security Scheme, which offer similar limitations.

Public diabetes clinics are overwhelmed. At a typical clinic, a doctor may see 40 to 50 patients in a morning, spending an average of five minutes per patient. There is little time for education about diet, exercise, or medication adherence. “We tell them to take their pills, eat less rice, and walk more,” says a nurse at a clinic in Bangkok's Din Daeng district. “But we know that most of them will not be able to follow that advice without more support.”

The system prioritizes basics over gadgets. “A pump costs more than the entire annual diabetes budget for 100 patients in the UCS,” says Dr. Rattanamongkol. “We have to make choices. And the choice is to make sure that everyone gets at least metformin.”

What a Middle Ground Might Look Like

Some pilot programs are exploring middle-ground solutions. In Chiang Mai, a public hospital launched a program in 2024 that provides subsidized continuous glucose monitors to a small group of patients with type 1 diabetes, along with telemedicine support from a diabetes educator. The program showed improvements in HbA1c and patient satisfaction, but it was funded by a research grant, not the UCS. Scaling it up would require a significant budget increase.

Another possibility is tiered subsidies. Instead of covering pumps for all, the UCS could cover them for patients who meet specific criteria — such as those with recurrent severe hypoglycemia or those who have failed on multiple daily injections. A similar approach is used in some European countries. But defining those criteria in a Thai context would require local evidence that does not yet exist.

Bulk procurement could also lower pump prices. Thailand's Government Pharmaceutical Organization negotiates prices for drugs and vaccines, but it has not done the same for diabetes devices. A national tender could bring down the cost of pumps and monitors significantly, as has happened in other middle-income countries like Brazil.

Community health workers could help bridge the adherence gap. In Thailand, village health volunteers already support patients with hypertension and HIV. Extending their role to diabetes — helping patients manage medications, monitor blood sugar, and make lifestyle changes — could improve outcomes at low cost. “We do not need more gadgets,” says Dr. Sritara. “We need more people on the ground.”

But political will lags behind evidence. Diabetes is not a high-profile disease in Thai health politics, compared to HIV or COVID-19. The Ministry of Public Health has not made diabetes devices a priority. As a result, the gap persists.

“We know what works in principle, but implementing it at scale requires trade-offs,” says Dr. Boonchoo. “The question is whether we are willing to pay for the infrastructure and human resources needed, or whether we continue to rely on expensive technologies that only benefit a few.”

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Individual treatment decisions should be made in consultation with a qualified healthcare professional.