Essential Asthma, COPD Therapy Mostly Unavailable in Low/Middle Income Countries

The availability of asthma and COPD treatments in low- and middle-income countries falls far short of the WHO goal for access to essential medicines.

Essential medicines for treating asthma and chronic obstructive pulmonary disease (COPD) — particularly corticosteroid inhalers — are largely unavailable and unaffordable in low- and middle-income countries (LMICs), according to a systematic review published in The Lancet Global Health.

The World Health Organization (WHO) Global Action Plan seeks 80% availability of the essential medicines for treating noncommunicable diseases. For asthma and COPD, essential medication involves inhaled therapies including short-acting beta-agonists, muscarinic antagonists, and corticosteroids. Investigators therefore conducted a systematic review to determine the affordability, cost, and availability of essential asthma and COPD medications in LMICs.

The investigators searched 7 databases for research articles published between January 1, 2010, and June 30, 2022. The primary outcome measures sought were availability (relative to WHO target of 80%), cost (compared with median price ratio), and affordability (measured by number of days of income of the lowest paid government worker needed to purchase the medication).

A total of 29 studies providing data from 60 LMICs that met inclusion criteria. There was a low risk of bias for all studies and all showed heterogeneity. The 80% availability target was met by 6 of 58 countries for short-acting beta-agonists (SABAs), by 3 of 48 countries for inhaled corticosteroids (ICSs) and by 0 countries for inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) combination inhalers.

Cost was reported in 12 studies; median price ratios were 1.1-351 for SABAs, 2.6-340 for ICSs, and 24 for ICS-LABAs. “The cost of medicines varied substantially between countries; for example, the [median price ratio] for ICSs was 0.12 in Guinea but 340 in Uganda, noted study authors.

Effective inhaled medicines, which have been widely available in high-income countries for decades, offer substantial opportunities to improve the long-term management of asthma and COPD in LMICs.

Affordability data was available in 10 studies. Reviewers found that systemic corticosteroids for managing asthma and COPD exacerbations were more widely available and affordable than ICS. For SABA inhalers, which investigators said were the “most affordable” medication, the cost was typically 1 to 4 days’ wages. In contrast, ICS cost 2 to 7 days’ wages and ICS-LABAs cost at least 6 days’ wages. Review findings also indicated that generic medicines and drugs purchased in public facilities were generally more affordable.

This review is limited, said the study authors, because (1) it provides a narrative review rather than a meta-analysis; (2) it lacks generalizability because of the included studies’ differing methodologies and geographical areas, differing disease prevalence rates, and differing healthcare settings; 3) it lacked data from most LMICs; and (4) all studies were completed before the COVID-19 pandemic.               

In summary, said study authors, “Most medicines failed to reach the [WHO] target of 80% availability, and a month’s supply cost of more than a day’s wage of the lowest paid government worker. Availability and affordability of inhaled corticosteroids was particularly poor, both as separate and combination inhalers, compared with inhaled SABAs and systemic steroids.” The researchers further noted that “Effective inhaled medicines, which have been widely available in high-income countries for decades, offer substantial opportunities to improve the long-term management of asthma and COPD in LMICs.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures


Stolbrink M, Thomson H, Hadfield RM, et al. The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review. Lancet Glob Health. 2022;10(10):e1423-e1442. doi:10.1016/S2214-109X(22)00330-8.