India has the second highest rate of diabetes in the world, and with the monthly fee reduced to $14, why are GLP-1 weight loss drugs still not selling well?

The Indian weight-loss drug market is serving as a cautionary tale for the global pharmaceutical industry regarding market expectations. Despite the large-scale generic production of GLP-1 drugs in India and prices dropping to $14 per month, sales have fallen far short of expectations, revealing deeper cultural, social, and regulatory barriers beyond price.

As of July this year, approximately thirty generic GLP-1 drugs have been launched in Indian pharmacies. Nomura Holdings predicted last year that sales of related drugs would reach $261 million by 2026, but according to data from research firm Pharmarack Technologies, as of July this year, actual sales were only about 20% of that forecast.

The sluggish market has directly impacted the pharmaceutical industry's growth bets on India. An executive at Novo Nordisk (the maker of Wegovy and Ozempic) stated that manufacturers are increasingly concerned about the slow market progress.

Pharmarack Vice President Sheetal Sapale stated bluntly, "Exponential growth is not going to happen; there is already a realistic understanding of the market size among all parties."

Price advantage cannot automatically translate into demand.

The Indian market was initially seen as a crucial testing ground for GLP-1 drugs expanding beyond the US and Europe. India has a population of 1.4 billion, the third-highest obesity rate after the US and China, and is the world's second-largest country in terms of diabetes patients. Metabolic diseases such as thyroid disease and fatty liver are also rapidly increasing.

In March of this year, the Indian patents for the active ingredients Ozempic and Wegovy expired, and with the influx of generic drugs into the market, prices as low as $14 per month, hundreds of millions of potential patients are theoretically able to afford them.

However, the price reduction did not lead to a surge in sales. Chittaranjan Yajnik, a researcher in Puna studying diabetes and obesity, points out, "Drug acceptance depends on generational history, local culture, geographical conditions, and the socioeconomic group to which the patient belongs; it's not just a matter of price."

Cultural beliefs constitute a hidden obstacle

In India, cultural attitudes toward obesity are quite complex, posing a hidden barrier to drug promotion.

In Hindu tradition, Kubera, the god of wealth, is depicted as a pot-bellied figure, symbolizing abundance and good fortune.

Vandita Morarka, founder of the nonprofit One Future Collective, stated that weight in India "is a sign of wealth, meaning you are well-fed in a country that has experienced severe poverty, drought, and malnutrition; it's a status symbol."

At the same time, obesity is also seen as a lack of willpower, and this contradictory mindset has led to patients concealing their treatment.

Saloni Paliwal, co-founder of the weight loss website Voy India, said the stigma surrounding injectable diet pills is: "You're taking shortcuts. You should work hard like everyone else, go to the gym, eat less." Patients even discuss in WhatsApp group chats and Reddit posts how to secretly inject themselves and how to refrigerate the drugs without their families' knowledge.

Female patients face additional obstacles

In major markets, women make up the vast majority of weight-loss drug users, but Indian women, especially those in traditional families, often lack autonomy in their medical expenditures, and medication decisions often require the consent of their husbands, parents, or in-laws.

"My patients often come to me saying they've only saved enough for about three months' worth of treatment and ask me to expedite their procedures," said Dr. Swati Pradhan, a doctor in Mumbai.

Furthermore, the widespread dissemination of misinformation has exacerbated patients' anxieties.

Jennifer Joseph, a 33-year-old IT professional in Pune, said that while she was taking the medication, her parents were worried because they didn't understand the treatment, and her friends kept forwarding her news about fake drugs, reports of serious side effects, and cases of complications. "I won't lie, it really scared me. When you keep seeing negative headlines, it's easy to start questioning your decision."

Regulatory restrictions make marketing extremely difficult.

Pharmaceutical companies also face strict restrictions on drug advertising under Indian law.

In an effort to circumvent the ban on direct drug advertising, Eli Lilly launched a public health awareness campaign during a high-profile cricket match in February, promoting obesity as a disease and encouraging people to seek medical attention. While the advertisement did not mention Lilly's GLP-1 drug, it prominently featured the company name.

However, India's drug regulatory agency subsequently halted weight-loss-related promotional activities in March, deeming such practices equivalent to direct advertising. Currently, Eli Lilly's related advertisements are still accessible online, but the outdoor billboards directing users have disappeared.

Long-term game replaces short-term burst expectations

These challenges have prompted the industry to reassess its strategies for promoting GLP-1 drugs in India and other emerging markets.

Mumbai-based diabetes physician Rajiv Kovil believes pharmaceutical companies need to help patients better understand these drugs and may need to offer complementary services such as supplements to improve patient acceptance of GLP-1 therapy. "Generic drugs were once thought to be disruptive to the market, but that hasn't happened," he said. "This will be a much longer game."

The experience in the Indian market shows that while lowering prices is a necessary condition for pharmaceutical companies that intend to replicate the success story of GLP-1 drugs globally, truly opening up the market also requires addressing multiple complex factors rooted in culture, society, and regulation.

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