Better access to standard treatment for adult asthma in resource-limited countries

Dear Editor,

Thank you for publishing Diallo et al.’s article, which highlights an avoidable care gap in the management of adult asthma that urgently needs to be closed.^[1] Asthma is one of the most common non-infectious respiratory disorders, affecting over 262 million individuals and causing over 455,000 deaths yearly worldwide.^[2] In Guinea, where an estimated 2,000 people die from asthma each year, the impact of the disease is particularly acute and demands focused attention from national policymakers.^[2] Despite many years of research into its pathophysiology and interventions with proven efficacy in modifying the disease, uncontrolled asthma continues to be an important issue in many low- and middle-income countries (LMICs). This unmet need for asthma control does not reflect failure of treatment but rather gaps in access and availability. The retrospective study recently published in this journal by Diallo et al. from the Pneumophthisiology Department of Ignace Deen National Hospital in Conakry, Guinea, represents a timely and important contribution to our understanding of asthma management in adult patients from LMICs.^[1] Providing granular detail on barriers to receipt of standard asthma treatment and clinical outcomes among a representative sample of patients with asthma seen in ambulatory care, this report illustrates how system-level deficiencies interact with household economic realities and patient-related factors to lead to poor asthma control in sub-Saharan Africa and elsewhere.

Standard of care asthma management guidelines, as published by the Global Initiative for Asthma (GINA), clearly indicate that asthma should be treated with inhaled corticosteroids (ICS), with or without a long-acting b₂-agonist (LABA), for all adolescents and adults.^[3] Notably, the GINA 2021 update marked an important shift away from short-acting b₂-agonists (SABA) only treatment, emphasizing that ICS should be part of asthma management at every step, including mild disease. ICS therapy decreases airway inflammation, prevents exacerbations, and improves quality of life and lung function over time when used regularly. Using only SABA is associated with worse outcomes.^[3] While GINA’s stepwise approach is widely endorsed, it often requires tools such as spirometry or peak-flow meters that may be unavailable in many primary-care settings in LMICs. These constraints highlight the need to adapt guideline recommendations to the realities of providers in these environments, ensuring that core principles, such as regular ICS use, can still be prioritized even in the absence of advanced diagnostics. The Guinea study found that only a small proportion of patients received ICS-containing background therapy; instead, most were prescribed SABA or systemic corticosteroids such as prednisolone. This treatment imbalance resulted in a majority of patients experiencing uncontrolled or partially controlled asthma, in contrast to higher-income settings where better access to standard asthma treatment results in higher control rates (above 70%).^[4] Uncontrolled asthma leads to more frequent exacerbations, hospital visits, worse quality of life, and early deaths. To clarify the barriers and match solutions more directly, these challenges can be separated as follows:

System-level barriers: Limited availability of ICS and ICS-LABA inhalers, inadequate health infrastructure, and lack of diagnostic tools make standard asthma treatment difficult to access. To address this, policymakers should prioritize inclusion of these medications on national essential medicines lists, improve supply chains, and facilitate access to affordable inhaled therapies.

Provider-level barriers: Many physicians in resource-limited settings lack training in current asthma guidelines, may misdiagnose asthma, or may default to prescribing SABA or systemic steroids rather than controller therapy. Solutions include providing targeted guideline training, refresher courses, and access to simplified decision aids to ensure that regular ICS use becomes standard practice among providers.

Patient-level barriers: Concerns about medication side effects, low awareness of the benefits of controller therapy, poor inhaler technique, and economic constraints all limit effective asthma management. Solutions here include offering more patient education, implementing community-based peer support, and practical training in inhaler use during clinic visits.

Separating barriers in this way can help decision-makers design interventions that are more precise, targeted, and effective.

A key strength of this article is its clear identification of barriers to standard asthma treatment. The main reason patients do not receive controller medication is a lack of prescription. Other reasons include high medication costs, poor availability, negligence, and personal beliefs.^[2] By listing these reasons, the article shows how barriers within the health system, providers, and patients contribute to poor asthma control. Controller medications were not widely prescribed, pointing to specific, fixable problems: physicians often lack awareness of guidelines, misdiagnose asthma, or do not prioritize controller therapy. Research in West Africa shows low provider awareness and poor adherence to asthma management, especially in clinics with few resources. The Guinea study identified high costs as a barrier. SABA inhalers may be affordable, but ICS and ICS-LABA usually cost more than a week’s minimum wage.^[5] Inhaled medications are less readily available than systemic corticosteroids, leading to frequent overuse of the latter.^[2] The study also found that patients with poor inhaler technique and poor adherence were much more likely to have uncontrolled asthma. Poor technique and inconsistent use were each linked to poor control, matching findings from Ethiopia and highlighting changeable risk factors. The study also showed that doubts about medication, fears of corticosteroid side effects, and social pressure contributed to poor adherence. People living outside Conakry were more likely to have uncontrolled asthma, likely due to less access to specialists and pharmacies. These findings highlight targets for education, decentralized care, and better primary-care provider training in Guinea and similar LMICs.

Policy-wise, this study further highlights the need for asthma to be incorporated into non communicable diseases (NCD) care programs. Merely listing recommended ICS and ICSLABA inhalers as essential medicines is not enough if the prices remain out of reach for patients. Implementing price control measures, pooled procurement programs, or providing subsidies for asthma medications are all feasible policy levers that have been successfully employed to improve access to antituberculosis and antiretroviral medications in resource-limited settings. Training and retaining clinicians in proper asthma management is also critical. Regular training updates to refresh knowledge of guideline-directed asthma management, provide instructions on inhaler technique, and promote rational prescribing may help clinicians provide better care to patients. Pharmacy and nursing staff may also be leveraged to educate patients on adherence and correct inhaler technique, as they are often the most accessible health workers for patients in LMICs.

This study is limited by its cross-sectional design, which cannot establish causality. It applies the GINA criteria to define asthma control and identifies country-specific barriers to care. The authors explain why patients miss controller therapy and propose studies to analyze the costs of asthma follow-up. Future research on the economic burden of asthma treatment in Guinea will guide insurance reforms and demonstrate the value of preventive controller therapy.

Adult asthma in LMICs reveals global health inequities. Financial strain, weak health systems, and patient beliefs block access to standard asthma treatment and worsen control, as the Guinea study shows. Policymakers, health workers, specialists, and global partners must take specific steps: Subsidize ICS inhalers to make them affordable, and ensure every rural nurse is trained in inhaler technique. These targeted actions can make effective asthma care a reality everywhere.