OBJECTIVES: To assess the cost-effectiveness (CE) of starting insulin detemir (IDet) ± oral glucose-lowering drugs (OADs) in people with type 2 diabetes (T2D) in countries in different economic circumstances based on observational data gathered in routine clinical practice. METHODS: The A1chieve® study assessed safety and outcomes over 24 weeks in 66,726 people with T2D starting insulin analog therapy. The CE analyses included people starting IDet in Algeria (n=473), India (n=1,491), Mexico (n=101), Indonesia (n=109), South Korea (n=487) and in Malaysia based on people in 4 ASEAN countries (n=456). Data were collected on clinical effectiveness, adverse events, and patient reported outcomes using the EQ-5D questionnaire. CE analyses used the IMS CORE diabetes model with 1 and 30 year time horizons, with country-specific costs for complications and therapies and background mortality rates. Incremental cost-effectiveness ratios (ICER) are expressed as cost/QALY in local currencies, USD and fractions of local GDP per capita based on starting IDet. CE was pre-defined as <3*GDP. RESULTS: One-year ICERs were Algeria (DZD 617,658; USD 7,758; GDP 1.48), India (INR 58,454; USD 1,054; GDP 0.71), Mexico (MXN 62,952; USD 4,835; GDP 0.48), Indonesia (IDR 22,920,222; USD 2,381; GDP 0.68), South Korea (KRW 4,273,409; USD 3,935; GDP 0.18), Malaysia (MYR 17,613; USD 5,758; GDP 1.34). 30-year ICERs were: Algeria (DZD 368,200; USD 4,625; GDP 0.88), India (INR 39,214; USD 707, GDP 0.48), Mexico (MXN -2,887; USD -222; GDP -0.02); Indonesia (IDR 3,995,329; USD 415; GDP 0.12), South Korea (KRW 15,139; USD 14, GDP 0.00) and Malaysia (MYR 10,499; USD 3,432; GDP 0.80). Sensitivity analyses on the 30 year time horizon showed the findings to be robust. CONCLUSIONS: Starting IDet in T2D as performed in the A1chieve® study was found to be cost-effective across all country settings based on a 1 and 30 year time horizon.