India
Government initiatives have been helpful
Amongst India’s 1.36 billion people, about 35 million suffer from asthma. In the GAN Phase I study asthma prevalence was lower than Phase III of ISAAC. Exposure to some causal environmental factors have also reduced over this time. Underdiagnosis and inadequate treatment are important challenges in India. Most people do not have health insurance and there is a wide gap in healthcare facilities across different economic strata. Although most types of inhaled corticosteroids (ICS), β2-agonist and combination inhalers are available at pharmacies these are expensive in comparison to oral formulations. Asthma treatment guidelines of national societies are available but need updating.
Clean environment
There has been a decline in exposure to factors such as biomass fuel, truck traffic and maternal tobacco smoking. The Government has distributed almost 80 million liquid petroleum gas connections at concessional rates to poor families to reduce exposure to biomass fuel cooking. Strict emission norms for vehicle engines have helped in cleaning the city environment. These are pleasing steps towards a cleaner environment both at home and on roads.
Barriers in treatment
GAN Phase I found that in fewer than 30% of people with current wheeze, the diagnosis of asthma was confirmed by a doctor. Even in these diagnosed patients, the daily use of ICS was less than 10%. More than 25% of patients are hospitalised at least once a year probably due to inadequate treatment. A large number of patients in India still consider asthma as a stigma and therefore conceal the disease. Asthma also has different deceptive symptomatic names, such as cough, saans and dama. Many patients take treatment only when they are unable to tolerate the agony of symptoms. A large number of people with asthma still use oral treatment instead of inhalers. Despite these barriers, with frequent and regular patient education programmes, the acceptability of inhaler treatment for asthma is gradually increasing.
Availability of medicines
A low-income person sick with asthma may spend 80% of personal savings buying medicine. However essential asthma medicines are available now for poor patients because the Government of India launched Ayushman Bharat Yojana in 2018. This provides free treatment to hospitalised patients at government and selected private hospitals.
Rajasthan initiatives
In India the maximum deaths and Disability Adjusted Life Years (DALYs) due to asthma occur in the state of Rajasthan (Western India) according to the Global Burden of Disease study in 2016. Since 2011 the most important medicines are provided free to all outdoor and indoor patients at government hospitals. The state has undertaken pooled procurement of medicines for Rajasthan’s 75 million people, leading to a large reduction in procurement cost. The state provides asthma patients with free metered-dose inhalers, dry powder inhaler capsules and nebuliser solutions. Thus, asthmatic patients are accessing treatment more easily, but adherence issues still persist.
