In terms of human development, poverty means far more than being economically poor. It includes and overlaps with all types of social vulnerability. In addition to those living in absolute economic poverty, there are disadvantaged populations who have relatively little access to health services because of factors including ethnic group, geographical location, gender, education, living conditions, social exclusion and migration.

Poverty and health

Across the countries of the world, poor people and those from disadvantaged social groups face greater exposure to many health threats, and when they fall sick they are much less likely to receive adequate care than those who are not poor and disadvantaged. When they suffer from a long-term chronic disease such as asthma, lack of access to health care is likely to be an ongoing problem.

The goal of health equity is to accelerate health progress among poor and socially excluded groups. Pro-poor approaches can help to achieve this, by ensuring health services give special attention to the needs of the most disadvantaged groups. Asthma guidelines and services can include such approaches.

Finding and addressing disparity

Special efforts need to be made to address barriers to care and increase early and effective treatment for the poorest and most vulnerable communities. It may be useful to consider the following steps, inspired by efforts to address poverty in tuberculosis control.

Step 1: Promote standardised management of asthma

The first step towards ensuring poor and vulnerable groups receive care is having national asthma guidelines with a standardised approach for diagnosis and treatment of all patients.

Step 2: Identify the poor and vulnerable groups in the country

Countries should be monitoring the prevalence of and deaths from asthma over time (for example, in demographic health surveys). If this surveillance includes geographical and socio-economic data, researchers can assess who is suffering from asthma. If access to services and outcomes of asthma care could also be monitored, countries could work out which groups are not getting adequate access and care.

Step 3: Determine which barriers prevent access of the poor and vulnerable groups to services that provide asthma diagnosis and treatment

These are likely to include:

  • Economic barriers
  • Geographical barriers
  • Social and cultural barriers
  • Health system barriers

Many poor and vulnerable groups encounter more than one of these overlapping sets of barriers and have greater difficulty in overcoming them than the non-poor. To identify the barriers, it is helpful to consider all of the steps a person has to take from the onset of symptoms to receiving a diagnosis and treatment. Since asthma is a chronic disease, it is necessary to then consider the person’s ongoing access to medicines and care.

Step 4: Assess potential actions to overcome the barriers to access

As asthma is a global challenge, asthma services need to be an integral part of all primary care services. Implementing the Practical Approach to Lung Health (PAL) strategy is one key activity, since it includes asthma diagnosis and care at the primary health care level. By decentralising care according to an integrated and properly resourced strategy, countries should find that patients are less likely to go directly to secondary or tertiary hospitals, or seek out expensive private practitioners.

Step 5: Identity situations and groups that require special consideration

There are some workplaces that can cause or greatly exacerbate asthma, for example, mines, factories and workplaces that involve organic dusts, cleaning products and pollutants. The poor and socially excluded may be more likely to work in these settings where environmental controls are inadequate and where external support is required to highlight and improve conditions. Another issue is indoor air pollution caused by smoke from domestic use of solid fuels, particularly biomass fuels, for cooking and heating. Those most at risk are the most vulnerable, such as the poor, women and young children.

Step 6: Include asthma and other respiratory NCDs in discussions about health financing

Health financing in low-income settings is often focused on communicable diseases. Chronic, noncommunicable diseases such as asthma should be included in discussions about financing. When budgeting for asthma, countries should consider evidence-based solutions for overcoming barriers faced by the poor regarding asthma diagnosis, medicines and care.

Step 7: Evaluate the impact of pro-poor measures

Socio-economic questions can be included in asthma prevalence surveys, and periodic studies of care-seeking, use of medicines and services can be conducted.

-Karen Bissell, Innes Asher, Gillian Mann, Donald A Enarson

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