With good long-term management, the burden of asthma can be reduced.

The Global Asthma Report 2014

Asthma can be effectively and affordably managed in low-resource countries. In 2012 WHO published guidelines for asthma management in low-income settings.

ASTHMA MANAGEMENT IN LOW-INCOME COUNTRIES

Low-income countries face extra challenges to achieve good asthma management compared with other countries. They have more difficulty achieving an uninterrupted supply of quality-assured, affordable essential asthma medicines, well-trained health professionals, well-organised health services to provide long-term care, standardised management of asthma with appropriate use of inhaled corticosteroids, and information systems for monitoring and improving quality of care. To achieve all these vital components of asthma care, commitments are needed from governments, and such commitments may be harder to achieve where resources are scarce, making the contributions of national non-governmental organisations (NGOs) and global governmental agencies such as the World Health Organization (WHO) vital.

Goals for successfully managed asthma

The goals for successfully managed asthma (National Asthma Management Strategies) are the same in low- as in middle- and high-income countries – people with asthma will have minimal symptoms and minimal side effects of any medicines, and have no limitations on their lifestyle due to asthma.

Inhaled corticosteroids are essential to success

Inhaled corticosteroids (asthma preventer medicines) are essential for achieving these goals and managing patients with persistent asthma over the long term. However, studies in low-income countries have found that health care workers often don’t prescribe inhaled corticosteroids for asthma. When they do prescribe them, patients often abandon them and rely on bronchodilators (reliever medicines) instead.

Patients may be inclined to believe that bronchodilators are effective because these medicines provide quick relief from symptoms and that inhaled corticosteroids are not effective because they observe no immediate, obvious effect from them. These beliefs are understandable, and common in people throughout the world, resulting in the need for active asthma education as part of good asthma care. In low-income countries where these medicines are less well known, the education task is harder. Further, in low-income countries the cost of inhaled corticosteroids is usually much higher than bronchodilators and may not be affordable. Consequently patients are likely to over-use bronchodilators and under-use inhaled corticosteroids.

Projects undertaken with the International Union Against Tuberculosis and Lung Disease (The Union) in Benin and Sudan evaluated asthma treatment outcomes after one year of follow-up. They found that asthma severity and symptom frequency reduced significantly when patients took preventer treatment regularly. However there were challenges: practitioners demonstrated only moderate adherence to guidelines when grading the severity of their patients’ asthma and prescribing inhaled corticosteroids. A substantial proportion of patients also stopped taking their inhaled corticosteroids.

What is needed to manage asthma effectively in low- and middle-income countries?

The under-use of inhaled corticosteroids is resulting in inadequate asthma control, frequent unplanned visits to the emergency room or hospitalisations, and an unnecessary reduction in quality of life for those who live with asthma which, in low-income countries, places a disproportionate burden on the people with asthma and society at large. There are several reasons for the failure of health systems to provide appropriate asthma care. To turn this situation around requires action on several fronts:

Countries need to apply guidelines for standard case management of asthma

The term ‘standard case management’ encompasses diagnosis of asthma, standardisation of treatment according to severity based on asthma guidelines, and patient education, coupled with a simple system for monitoring patient outcomes. Appropriate training of health care workers and availability of essential asthma medicines are key to the effectiveness of standard case management. The Union’s asthma guidelines were pilot-tested in health centres in Algeria, Guinea, Ivory Coast, Kenya, Mali, Morocco, Syria, Turkey, and Vietnam. Investigators concluded that the measures were feasible, effective, and cost-effective. In four recent asthma projects that involved The Union, in Benin, China, El Salvador and Sudan, the training of clinicians in guideline implementation and outcome evaluation was combined with the procurement of affordable essential medicines for asthma. All countries observed a substantial reduction in the severity of asthma for the majority of enrolled patients and the almost complete disappearance of visits to emergency services and hospitalisations in patients that were adhering well to treatment.

Clinicians and health care workers need to be trained to identify asthma patients

In Huaiyuan County, Anhui Province, China, a project with The Union revealed that asthma was not being diagnosed in the participating facilities before the project was introduced. Patients presenting with cough and difficult breathing were usually diagnosed with chronic bronchitis and treated with a combination of antibiotics, systemic steroids, xanthine derivatives and/or oral β-2 agonists.

Inhaled corticosteroids had never been available prior to the project. After training, health workers identified a substantial number of asthma patients who were treated with inhaled corticosteroids and inhaled salbutamol. What this project suggested was both that asthma may be a hidden disease in rural China and that it is feasible to train health workers to provide standardised case management of asthma.

Quality-assured essential asthma medicines need to be accessible and affordable to all who need them

In low-income countries, essential asthma medicines are more likely to be unavailable than in more affluent countries (see Essential Medicines). They are more likely to be of inadequate quality (see Quality of Inhalers) due to inadequate government regulation. They are also more likely to be unaffordable, in that an inhaled corticosteroid inhaler may cost as much as the equivalent of two weeks wages. Such high costs are a major obstacle to the person with asthma receiving the medicine they need.

A situation analysis in Benin prior to the project there revealed that only 11% of asthma patients were prescribed inhaled corticosteroids. In both El Salvador and Sudan, inhaled corticosteroids were not available in the pilot sites before the project. The Union, through its Asthma Drug Facility (ADF) 2008-2013, worked with several countries running pilot projects which demonstrated that the price of essential asthma medicines could be markedly reduced through negotiation with suppliers of quality-assured medicines so that they could be procured at affordable prices. In Benin, the price of the inhaled corticosteroid beclometasone was €4.27 per inhaler before this process and was reduced to €1.98 when procured through the ADF. Similar price reductions were achieved for El Salvador and Sudan. Benin also established a financial mechanism to ensure an uninterrupted supply of essential medicines for asthma. Known as a Revolving Drug Fund, this mechanism works because, after an initial capital investment, medicine supplies are replenished with monies collected from the sales of medicines. Such funds become self-financing and build demand for quality-assured, affordable essential asthma medicines.

Health services need to serve chronic patients effectively

In many low-income countries the huge majority of asthma patients are only being treated on an emergency basis – when they arrive in the emergency department with an acute attack of asthma. Health services need to be organised for the long-term management of asthma, with trained health care workers and regular follow-up of patients. This will reduce emergency visits and hospitalisations, and empower patients and their families to manage their asthma.

Collecting and monitoring data helps to assure quality of care

Information systems are less likely to be well developed in low-income countries than in more affluent countries. To evaluate the effectiveness and quality of asthma care, an information system allowing outcome assessment of registered asthma patients and overall evaluation of asthma management should be established for facilities providing care.

Patient education is needed to overcome fears and encourage self-management

Patient education is essential to prevent unnecessary concerns about asthma and asthma medicines, especially in low-income countries where there has been little experience with asthma. Patients need to learn that inhaled corticosteroid inhalers are not addictive or dangerous. They need to understand that their condition is ongoing, possibly lifelong, and that it is variable (i.e. the timing and extent of symptoms varies). They also need to learn how to manage their asthma: how and when to take their medicines and when to seek help from health care facilities.

Governments need to help set up long-term management of asthma

An uninterrupted supply of quality-assured, affordable essential asthma medicines, organised services and trained human resources are the minimum requirements for the health services to manage asthma. These are harder to achieve in low-income countries. Political commitment is critical for establishing and maintaining the long-term management of asthma, especially in resource-limited settings.

Conclusion

In low-income countries, where asthma is not as well recognised and effective asthma management has not been commonplace, carefully planned programmes can be introduced to improve management. The components include access to quality-assured essential asthma medicines, asthma management guidelines, health service organisation, patient education and political commitment.

Recommendation

Governments in low-income countries should make commitments to ensure that the supply of quality-assured, affordable essential asthma medicines is uninterrupted, health professionals are appropriately trained, and health services are organised to manage asthma.

Karen Bissell, Chiang Chen-Yuan, Nadia Aït-Khaled, Christophe Perrin

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