Asthma Management in Low- and Middle-Income Countries
Although asthma is a common problem in both high-income and low- and middle-income countries (LMICs), the management of asthma is often inadequate, especially in resource-limited settings. This chapter provides a summary of the current challenges facing asthma diagnosis and management in LMICs, and recommends forging strategic collaborations and a generic framework and guidelines for asthma in LMICs.
The recent Global Asthma Network (GAN) Phase I study revealed that among those who had asthma confirmed by doctors, the proportion of individuals with uncontrolled asthma was substantial (see Global Asthma Management and Control). Among those with severe asthma symptoms, a very high proportion of children, adolescents and adults used short-acting β2-agonist (SABA) for symptom relief. Unfortunately, the proportion of children, adolescents and adults with severe asthma symptoms who used either inhaled corticosteroid (ICS), or ICS and long-acting β2-agonist in a combined inhaler was much lower than the proportion of individuals using SABA, and many of them did not use ICS for asthma management (see Global Asthma Management and Control).
This is likely to be related to a number of factors including neglect of asthma, underutilisation of guidelines which include systematic strategies and effective treatments, and international leadership. To fundamentally transform the fight against asthma and to meet the United Nations’ Sustainable Development Goal (SDG) Goal 3 “ensure healthy lives and promote well-being for all at all ages”, there is a long way to go.
This chapter provides a summary of the current challenges facing asthma diagnosis and management in LMICs, and recommends forging strategic collaborations and a generic framework and guidelines for asthma in LMICs.
Gaps in management of asthma and chronic respiratory diseases (CRDs) in LMICs are the same as for tuberculosis (TB) initiated some decades ago. These are: lack of political commitment; delay in implementing all the currently available interventions; scarcity of funding; leadership and governance; weaknesses in health systems which are incapable of providing effective and efficient services across the care continuum; lack of guidelines and information systems; poor or no availability and affordability of essential diagnostic tools and; most importantly, lack of availability of affordable, quality-assured, essential asthma medicines.
For asthma the TB programmatic management model could be implemented. This model was developed by The International Union Against Tuberculosis and Lung Disease to improve case finding and treatment for TB known as the Directly Observed Therapy Strategy (DOTS) “a cohort monitoring approach”. Both the World Health Organization (WHO) with its Practical Approach to Lung Disease (PAL) and the Global Initiative for Asthma (GINA) suggest a syndromic approach for asthma diagnosis in LMICs. The Global Alliance Against Respiratory Diseases (GARD), which is supported by WHO, advocates that the goals and action plans of CRD control need to be tailored according to the income level of the country and approaches will be developed from available management plans and international guidelines, according to specific country needs. All stress the importance of measuring variability in airflow for confirmation, using peak flow monitoring or spirometry with reversibility testing. However, access to these tools remains limited in LMICs, such that diagnostic capacity is severely constrained. The GINA strategy is widely used in LMICs, and in 2019, GINA recommended a fundamental change in asthma management which simplifies the use of essential asthma medicines.
To fundamentally transform the fight against asthma and CRDs management in LMICs, it will strategically be essential to:
- achieve a high-level of political commitment and a greater investment in asthma services in LMICs
- achieve rapid progress towards universal health coverage through health systems strengthening, while also ensuring universal access to quality people-centred asthma prevention and care, and other respiratory tract diseases including COVID-19
- advance research and development, to address underlying drivers of morbidity and mortality as well as rapid uptake of uninterrupted supply of new and more effective tools for diagnosis, and affordable, quality-assured, essential asthma medicines
- promote an up to date curriculum, programmatic management with skilled health workers, proactive utilisation of guidelines and systematic strategies with sound information system of recording and reporting for cohort evaluation
- promote partnership and commit stakeholders by actively engaging people and communities of those affected by asthma, and their families
In conclusion an effective asthma response requires a global, regional, and country specific approach with multi-sectorial and multi-stakeholder actions, with recognition of differences among and within countries, needs of the affected individuals, and communities. The achievement of the SDGs calls for action to address this through improved prevention and control, until a cure for asthma is found. There is an immediate need to strengthen partnership with and within international organisations working on asthma including WHO (PAL, GARD), The Union, GINA, GAN, Forum of International Respiratory Societies (FIRS) and patient organisations. These organisations need to forge strategic collaborations and recommend a generic framework and guidelines for asthma in LMICs, to ensure that quality-assured combination inhalers (see New Approaches with Asthma Medicines) are also accessible and affordable in resource limited settings, safeguarding that no one is left behind.