Cost-effectiveness of Asthma Management using Inhaled Corticosteroids
Many governments have overlooked asthma in their plans to address non-communicable diseases (NCDs) and have made little progress in improving access to asthma management and medicines, especially the inhaled corticosteroids (ICS) crucial for the long-term control of asthma. Most governments invest very little in improving asthma patients’ quality of life and reducing the huge financial costs borne by national and state economies, health services, patients and families. Systematic monitoring and evaluation, at the country and global level, of the costs and outcomes of asthma management activities will be essential for improving economic and patient outcomes.
Asthma competes with other NCDs
In 2011, a World Health Organization (WHO) report estimated that, out of the four major groups of NCDs, respiratory diseases had the second highest predicted economic burden for 2011-2025: a cost of US$1.59 trillion. For the 2011 United Nations High-Level Meeting on NCDs, WHO listed ‘highly cost-effective interventions’ that governments should consider prioritising in order to reduce the economic impact of NCDs, so-called ‘best buys’: interventions that would be the most cost-effective, and also affordable and feasible for countries to implement. Cost effectiveness analysis compares the value of the resources spent on an intervention with the quantity of health gained as a result.
Unfortunately, the ‘treatment of asthma based on WHO guidelines’ did not meet the criteria for ‘best buys’ in WHO’s Global Action Plan for the Prevention and Control of NCDs 2013–2020. Another of WHO’s reports, ‘Scaling up action against NCDs’, which was designed to help governments budget for and plan implementation and expansion of their NCD activities, limited its scope to WHO’s ‘best buy’ interventions, so did not include asthma management in its costing scenarios.
Asthma treatments are effective and cost-effective
In 2017, WHO published an updated analysis of the cost-effectiveness of a range of interventions that are relevant to its Global Action Plan. Using a method known as ‘WHO-CHOICE’, they assessed evidence of each intervention’s effectiveness and estimated the cost of the intervention, including medicines, administration, training and other programme elements. Statistical models were then used to estimate the effect of the intervention, in terms of health-adjusted life expectancy over the next 100 years, and its likely cost.
Among the 89 interventions for NCD risk factors and diseases assessed, two are relevant to asthma:
- Symptom relief for patients with asthma with inhaled salbutamol
- Treatment of asthma using low dose inhaled beclometasone and a shortacting β2-agonist
Economists assumed that the interventions would be implemented according to WHO’s recommended step-wise approach to the intensification of asthma management. Both interventions were found to be effective for improving the control of asthma, with a cost-effectiveness ratio of more than 100 international dollars per Disability Adjusted Life Year (DALY) averted in low- and middle-income countries (LMICs).
More country-level research needed for better targeting and delivery of asthma care
What is needed is better evidence of how to deliver effective asthma management in diverse health systems and contexts, and how to ensure that the right patients receive the right medicines. It will be crucial to gather evidence of the outcomes achievable with new ways of targeting and delivering standardised, affordable asthma care, especially in LMICs. By analysing costs as well as programme and patient outcomes, health services will be able to develop models for highly cost-effective, affordable and feasible interventions. A clear view of the burden, costs and outcomes should help LMIC governments see why and how they should be prioritising asthma care.
Conclusion
Countries need to evaluate the costs and outcomes of their asthma management activities. Research regarding the implementation of asthma interventions in diverse settings would help governments and health providers see how the provision of affordable quality-assured essential asthma medicines and more efficient, targeted and equitable delivery of standardised asthma management can reduce the economic and patient burden of asthma. The basic asthma intervention (Standard Case Management, see Chapter 11) and the essential asthma medicines are already known to be effective. Now we need to see how to improve the delivery of asthma care, so that more people will receive the appropriate essential medicines for their condition.
