Asthma is a serious burden in low- and middle-income countries

The Global Asthma Report 2014

The reduction in emergency room visits from one year of enrolment in the asthma standard case management project in Sudan 2007-08.

Figure 1: The reduction in emergency room visits from one year of enrolment in the asthma standard case management project in Sudan 2007-08.

Number of emergency visits and hospitalisations in Benin: initial at enrolment versus one year 2007-08.

Figure 2: Number of emergency visits and hospitalisations in Benin: initial at enrolment versus one year 2007-08.

Asthma is a serious burden in low- and middle-income countries and we should accelerate efforts to make asthma a lung health priority. Asthma management and control is feasible and it should be on everyone’s agenda.

ASTHMA AS A LUNG HEALTH PRIORITY IN LOW- AND MIDDLE-INCOME COUNTRIES

It is essential that asthma becomes an explicit global health priority, alongside and complementary to other non-communicable diseases (NCDs) including chronic obstructive pulmonary disease (COPD), and lung infections such as pneumonia and tuberculosis. Asthma, because it causes such a burden of disease, should be one of the top priorities of governments, development partners and partners in lung health, yet at the present time it has little profile with them. We must accelerate our efforts to overcome the operational bottlenecks that are preventing patients from receiving care in low-income settings. Implementing standard case management (see Management of Asthma/Asthma Management in Low-Income Countries), strengthening health systems at all levels, starting from the community level, and using appropriate technologies efficiently are the way to go.

Asthma is already an epidemic

It is concerning that the global burden of asthma, which is already substantial in terms of both morbidity and economic costs, seems to be increasing rapidly as the world becomes more westernised. Low- and middle-income countries shoulder most of the asthma-related deaths. The recent Global Burden of Disease (GBD) study estimated that asthma was the 14th most important disorder in terms of global years lived with disability. Therefore when assessing health priorities, allocating resources, and evaluating the potential costs and benefits of public health interventions, asthma should be among the top priorities of Ministries of Health in low- and middle-income countries.

Underprivileged settings and fragile health systems are characteristics of Low- and Middle-income countries

Within low- and middle-income countries poverty has a larger effect on the quality of life of communities, and on health system preparedness for disease, compared with high-income countries. Poverty is a vicious cycle that may deprive people of their basic human rights. Poverty affects both systems and people: it constrains education and health systems as well as people’s ability to seek education and health care. Poverty also exacerbates risk factors, such as indoor air pollution and tobacco consumption, and increases the burden of communicable and non-communicable diseases.

How far are we from welfare and equity?

Access to and affordability of asthma management and control:

Disparities in health coverage within low- and middle-income countries are huge and expenditure on health and development is generally very low. Barriers to accessing health services are many, so when combined with the low coverage of health insurance, families may face catastrophic out-of-pocket expenditure when a family member has asthma. Absence of guidelines (see Management of Asthma/Asthma Management Guidelines) and non-standardisation of asthma management increases the cost and has the potential to force families into poverty due to direct and indirect costs to themselves. This can lead to disastrous events for individuals and society - children may be stopped from attending school so that their treatment can be purchased and breadwinners may be unable to work on their farms and feed their families because of severe asthma symptoms.

In low- and middle-income countries, there are various operational bottlenecks facing asthma management and control. The reasons for these include: a lack of consensus around asthma as a priority; lack of training of health care workers; lack of patient education in chronic disease management; lack of diagnostic equipment such as peak flow meters and mouthpieces; lack of access to essential asthma medicines; the high cost of these inhalers and delivery devices (holding chambers or spacers); and the effect of international agreements such as Trade-Related aspects of Intellectual Property Rights (TRIPS) on the costs of, and access to, essential asthma inhalers.

These problems can be addressed successfully. For example, studies in 2007-8 in Sudan (Figure 1) and Benin (Figure 2) trained health workers and delivered standard case management of asthma. Among patients present at the one year follow-up visit, 50% improved in Benin and 82.6% improved in Sudan, with a huge reduction in emergency room visits and economic costs.

Asthma and Stigma:

Asthma symptoms, especially breathlessness, can cause fear and other psychological and emotional suffering. Stigma within communities is noticeable; it can delay health seeking and case detection, and it hinders adherence to long-term management.

The stigma hinders everyday life including the ability to socialise. In some places there is a reluctance to marry a person with asthma to avoid passing the disease on to future offspring. Some refuse to use preventive inhalers as they see it as a declaration of having asthma for the rest of their life.

Slow progress getting asthma high on the political agenda:

The High Level Meeting of the 66th Session of the United Nations General Assembly held in September 2011 issued a Political Declaration that focused the attention of world leaders and the global health community on the prevention and control of NCDs. Asthma is included in the global NCD agenda under “chronic respiratory diseases”, yet the proposed interventions will do little to prevent or control it - unless the declaration is backed-up with national and international political commitment, support and resources.

Following the Declaration, low- and middle-income countries committed themselves to developing national action plans to control these chronic conditions. However, strategic and collaborative action has been slow. Technical and financial assistance should be given to low- and middle-income countries so that they can build a responsive health infrastructure, capable of tackling the physical, social and economic conditions that affect the burden of asthma on their populations.

Efforts should be speeded up collectively by:

  • Investing in research to measure asthma trends in relation to geographic location, socio-economic status and marginalised populations.
  • Developing pro-poor strategies in which asthma is a “lung health priority” and developing guidelines that integrate asthma care at community and primary health care levels.
  • Developing the capacity of human resources to diagnose and manage asthma, through standardised case management, and to respond to patients’ needs.
  • Procuring a regular supply of quality-assured, affordable asthma medicines and equipment through a regular supplier that is linked to an asthma management programme (see Management of Asthma/Essential Medicines and Asthma Management in Low-Income Countries)
  • Strengthening referral procedures for asthma patients within the health system.
  • Adopting The Union’s innovative application of the Directly Observed Treatment Short-course (DOTS) strategy for treatment of tuberculosis in the community in low- and middle-income countries to asthma and lung health. Integrating asthma management with DOTS has already shown success in improving treatment outcomes and reducing the burden of asthma in resource-poor settings.
  • Strengthening community systems, such as informal health providers, in order to increase access to care and case detection, and to reduce stigma.
  • Establishing “patients networks” to empower patients as central partners in the efforts to manage asthma and to advocate for greater political commitment.
  • Utilising innovations and appropriate technologies in a sustainable manner to support standard case management; by improving awareness, case detection, adherence and long-term follow-up. For example, a Sudan pilot project using rapid mobile asthma Short Message Service (SMS) texts showed that such SMS use was feasible, reduced rates of loss to follow up, and supported standard case management by improving awareness, case detection, adherence, and long-term follow-up.

Conclusion

Asthma has a low profile in the health priorities of low- and middle-income countries. The identification of asthma as a lung health priority would give it attention along with COPD, pneumonia, and tuberculosis.

Recommendation

Governments in low- and middle-income countries should make asthma a health priority, in order to more quickly invest in asthma research relevant to their populations, integrate care at community and primary health care levels with appropriate referral procedures, and develop capacity in standard case management of asthma.

Asma El Sony, Nadia Aït-Khaled, Javier Mallol

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