Childhood asthma in low and middle-income countries: Where are we now?

Pediatric asthma has been increasing in LMICs (Low Middle-Income Countries), leading to an important burden for both children and national health systems. Implementing measures to achieve control are influenced by the degree of organization health systems have, the availability and affordability of essential asthma medications, and the effective implementation of asthma programs and asthma guidelines. In this review authors give an updated view of the current situation of these components of asthma management in LMICs.

Access to affordable medicines and diagnostic tests for asthma and COPD in sub Saharan Africa: the Ugandan perspective.

BACKGROUND: Equitable access to affordable medicines and diagnostic tests is an integral component of optimal clinical care of patients with asthma and chronic obstructive pulmonary disease (COPD). In Uganda, we lack contemporary data about the availability, cost and affordability of medicines and diagnostic tests essential in asthma and COPD management. METHODS: Data on the availability, cost and affordability of 17 medicines and 2 diagnostic tests essential in asthma and COPD management were collected from 22 public hospitals, 23 private and 85 private pharmacies. The percentage of the available medicines and diagnostic tests, the median retail price of the lowest priced generic brand and affordability in terms of the number of days' wages it would cost the least paid public servant were analysed. RESULTS: The availability of inhaled short acting beta agonists (SABA), oral leukotriene receptor antagonists (LTRA), inhaled LABA-ICS combinations and inhaled corticosteroids (ICS) in all the study sites was 75%, 60.8%, 46.9% and 45.4% respectively. None of the study sites had inhaled long acting anti muscarinic agents (LAMA) and inhaled long acting beta agonist (LABA)-LAMA combinations. Spirometry and peak flow-metry as diagnostic tests were available in 24.4% and 6.7% of the study sites respectively. Affordability ranged from 2.2 days' wages for inhaled salbutamol to 17.1 days' wages for formoterol/budesonide inhalers and 27.8 days' wages for spirometry. CONCLUSION: Medicines and diagnostic tests essential in asthma and COPD care are not widely available in Uganda and remain largely unaffordable. Strategies to improve access to affordable asthma and COPD medicines and diagnostic tests should be implemented in Uganda.

Asthma medications should be available for over-the-counter use: pro.

Medications that provide quick relief of symptoms and that control airway inflammation are the mainstays of asthma treatment. However, adherence to these medications is suboptimal. The inconvenience and costs associated with obtaining these prescription-only medications are factors that contribute to poor adherence. The Food and Drug Administration recently requested public comment on a new paradigm whereby specific prescription-only medications could be made available over the counter, provided that conditions for their safe use could be established. Many organizations expressed opposition, including the American Thoracic Society and other societies representing patients with respiratory diseases. These organizations cited unsubstantiated benefits and unnecessary risks as reasons to oppose greater over-the-counter availability of current prescription-only medications. This article examines the rationale for, and potential ramifications of, making asthma medications available for nonprescription use.

Asthma medications should be available for over-the-counter use: con.

The United States Food and Drug Administration recently considered a policy to transfer inhaled short-acting bronchodilators to over-the-counter status if conditions of safe use can be established. The American Thoracic Society filed a comment in opposition to the proposal. This article examines the negative consequences that might result from allowing nonprescription access to bronchodilators and other inhaled asthma medications. Such a proposed policy change conflicts directly with current guidelines for asthma management and would undermine efforts to achieve adequate asthma control in patients. In addition, a policy change to convert asthma medications to over-the-counter status could result in increased costs to patients as well as increased health care costs to society overall due to a worsening of asthma control in the population.

Essential medicines for COPD and asthma in low and middle-income countries.

Access to medications for chronic disease management is limited in many low and middle-income countries (LMICs), resulting in suboptimal care and avoidable morbidity and mortality. We performed a survey of COPD and asthma medicines that appeared on the national essential medicines lists (NEMLs) of 32 LMICs. Nearly all countries (>90%) had assigned essential medicines for treatment of exacerbations and early stable disease stages, but not for steps 4 (22%) and 5 (6%) controlled asthma management. The number of treatment options was limited, with long-acting ß2-agonists (LABA) and combination dosage forms being notably absent. Suboptimal availability of chronic respiratory disease medicines suggests that implementation of NEMLs is the main problem in clinical practice.

The availability, pricing and affordability of three essential asthma medicines in 52 low- and middle-income countries.

BACKGROUND: Almost 300 million people suffer from asthma, yet many in low- and middle-income countries have difficulty accessing essential asthma medicines. Availability, price and affordability of medicines are likely to affect access. Very few studies have included asthma medicines, particularly inhaled corticosteroids, in these countries. Reflections about international reference prices (IRPs) are generally absent from pricing studies, yet some IRPs may be masking the extent of access problems. OBJECTIVES: Our objective was to determine the availability, pricing and affordability of beclometasone, budesonide and salbutamol, the three asthma medicines on the World Health Organization's Model List of Essential Medicines (EML) in selected low- and middle-income countries and to reflect on the appropriateness of using IRPs. METHODS: A cross-sectional pricing survey was conducted in 52 countries. Data were collected on country demographics including national currency, $US exchange rate and daily wage of the lowest-paid unskilled government worker. Pricing and availability data were collected for salbutamol, beclometasone and budesonide in two private retail pharmacies, the national procurement centre and a main public hospital. RESULTS: Availability was particularly poor for corticosteroids, and worse in national procurement centres and main hospitals. The surveyed strength of beclometasone was only on the EML of ten countries. Considerable variability was found in pricing and affordability across countries. Procurement systems appeared largely inefficient when Asthma Drug Facility prices were applied as references. Some countries appear to be subsidising asthma medicines, making them free or less expensive for patients, while other countries are applying very high margins, which can significantly increase the price for patients unless a reimbursement system exists. CONCLUSIONS: Findings raise important policy concerns. Availability of inhaled corticosteroids is poor; many EMLs are not updated; IRPs can be misleading; health systems and patients are paying more than necessary for asthma medicines, which are unaffordable for many patients in many countries.

A policy of free access to asthma medicines in Brazil: an opportunity for pharmacists to optimize asthma treatment.

Asthma is a chronic inflammatory disorder of the airways that is characterized by recurrent symptoms associated with airflow limitation and by bronchial hyper-responsiveness. Free asthma treatment has been guaranteed in Brazil since 2003, notably after the Brazilian government decided to support drugs for the most serious forms of the disease. The asthma treatment access policy in Brazil offers a new opportunity for pharmacists to work closely with patients, and for caregivers and health care teams to promote educational activities and patient counselling about asthma. Pharmacists have an important role in the management of drug therapy within the health care team. Pharmacists should be prepared to engage with the latest concept of health care delivery proposed for Brazilian Unified Health System. These are centred on forming health care networks and strengthening multidisciplinary teams to integrate all professionals who are in charge of patient care.

A national survey of availability of key essential medicines for children in Sri Lanka.

OBJECTIVES: To investigate the availability of key essential medicines for children in Sri Lanka. METHODS: This national survey assessed the availability of 25 key essential medicines for children using the WHO/Health Action International medicine price methodology. Data were collected from a representative sample of 40 public hospitals (Outpatients Department pharmacies), 40 private and 8 'Rajya Osusala' (ROS) pharmacies. The hospitals and pharmacies were selected from 8 provinces using a multistage clustered approach to represent different levels of public hospitals. Descriptive statistics were used for analysis. RESULTS: The mean per cent availability of the basket of survey medicines was 52% in pubic hospitals when compared to 80% in private, and 88% in ROS pharmacies. teaching/general hospitals had better availability (mean per cent availability 62%) than district hospitals (54%), peripheral units (49%) and central dispensaries (45%). Availability of anti-infectives, anti-asthma medicines and oral liquid preparations of carbamazepine, iron, paracetamol, domperidone and ibuprofen was found to be less in public hospitals than private and ROS pharmacies. Availability in public hospitals similar to that of private and ROS pharmacies was only for paracetamol tablet, oral rehydration salt, vitamin C and chlorphenamine syrup. CONCLUSIONS: Key essential medicines for children were less available in public hospitals than in private and ROS pharmacies. This deprives children from access to effective and safe medicines more in the public hospitals than in the private sector or ROS.

World Allergy Organization survey on global availability of essentials for the assessment and management of anaphylaxis by allergy-immunology specialists in health care settings.

BACKGROUND: The availability of anaphylaxis guidelines and of medications, supplies, and equipment for the assessment and management of anaphylaxis by allergy-immunology specialists in health care settings worldwide is unknown. OBJECTIVE: To ascertain the global availability of these essentials. METHODS: A survey instrument was developed and sent by e-mail in 2008 to a nonrandomized convenience sample of representative leading allergy-immunology specialists in 52 countries identified through the World Allergy Organization. Responses were analyzed by country. RESULTS: Surveys were returned from 44 of 52 countries on 6 continents, for an 85% response rate. Anaphylaxis guidelines were reported to be in use in 70% of the 44 responding countries. The diagnosis of acute anaphylaxis was reported to be based on clinical history and physical examination alone in 63% of responding countries. Medications for anaphylaxis treatment were reported to be available in the 44 responding countries as follows: epinephrine (adrenaline) for injection, 100%; any intravenous glucocorticoid, 89%; any intravenous H1-antihistamine, 77%; any intravenous H2-antihistamine, 70%; glucagon, 73%; atropine, 73%; dopamine, 86%; noradrenaline, 70%; vasopressin, 64%; and a beta 2-agonist for nebulization, 86%. Supplies and equipment for anaphylaxis treatment were reported to be available in responding countries as follows: for giving supplemental oxygen, 95%; for intubation, 89%; for giving intravenous fluid resuscitation, 91%; for monitoring oxygenation using pulse oximetry, 91%; and for continuous noninvasive blood pressure and cardiac monitoring, 81%. CONCLUSIONS: Allergy-immunology specialists reported that except for epinephrine ampules life-saving essentials for the assessment and management of anaphylaxis in health care settings were not universally available worldwide in 2008.

Availability, price and affordability of asthma medicines in five Indian states.

SETTING: States of Haryana, Karnataka, Maharashtra and Rajasthan, and Chennai (capital of Tamil Nadu State), India. OBJECTIVE: To assess the availability, price and affordability of beclomethasone and salbutamol inhalers in five Indian states using a standardised methodology. DESIGN: Data on the availability and price of two essential medicines for asthma, beclomethasone (50 microg/dose) and salbutamol (0.1 mg/dose) inhalers, were collated from five medicine price studies on essential medicines. RESULTS: Beclomethasone and salbutamol inhalers were available in 25% and 30% of public facilities in Rajasthan State only. The procurement price for beclomethasone and salbutamol was respectively 0.74 and 0.56 times the international reference price (IRP). The availability of beclomethasone inhalers was poor in the private sector (10-65%) in four states. The availability of salbutamol inhalers ranged from 20% to 95% as an innovator brand and 83% to 100% as the generic. The price of beclomethasone was 0.87-1.49 times the IRP, while salbutamol cost 0.82-1.12 times the IRP. Purchasing one inhaler each of salbutamol and beclomethasone cost between 1.6 and 2.3 days' wages for the lowest paid government worker. Eighty per cent of the population earn less than this wage. CONCLUSIONS: Essential inhalation medicines for asthma were not available in the public sector where low-income populations receive treatment. Steroid inhalers were not readily available in the private sector. Essential inhalation medicines for asthma are not affordable for the majority of the population.