Asthma a global concern

Asthma Drug Facility a practical solution

12 November 2012 Karen Bissell, Christophe Perrin

Providing access to affordable quality assured essential asthma medicines

What is Asthma?

Asthma - Global Context

Asthma is the most common chronic disease among children 235 million people worldwide suffer from asthma Asthma is a non-communicable disease (NCD) Asthma often goes undiagnosed, untreated or poorly treated Effective medicines are available Unfortunately, for many people with asthma particularly the poor these medicines are too costly or not available at all

Recommended medicines for asthma

On the WHO Essential Medicines List (EML)
Inhaled corticosteroids (Preventers, Controllers. Antiinflammatories that treat the underlying disease) beclometasone

Inhaled bronchodilators (Relievers. Make the airways expand so that airflow to lungs can increase) salbutamol Persistent asthma needs long-term management with both
www.GlobalADF.org

Trends in asthma prevalence and severity ISAAC study data Phase 1 and 3
International study of asthma & allergies in childhood

The burden of asthma has been growing over the past 30 years, particularly in the low- and middleincome countries least able to absorb its impact.

In phase 3, highest prevalence of symptoms of severe asthma was found in LMICs, not HICs.

Changes in prevalence over time

Increasing in prevalence in many lower income countries

Factors Affecting Asthma

It is important to distinguish between the triggers of asthma attacks and the causes of the underlying asthmatic trait.

Asthma and Air Pollution

The prevalence of asthma is higher in children living near sources of traffic pollution.

Asthma and COPD

Smoking is the leading risk factor for COPD and worsens asthma.

Essentials of Asthma Management

Inhaled corticosteroids are essential

The under-use of inhaled corticosteroids results in poor asthma control, frequent unplanned visits to the emergency room, more hospitalisations, and an unnecessary reduction in quality of life for those who live with asthma.

The Role of Guidelines in Managing Asthma

Despite the success of asthma management guidelines so far, increased efforts are required to improve adherence to guidelines and promote the delivery of quality asthma care.

Affordability of medicines Since 1998, Union studies have shown the high cost of essential asthma medicines, particularly inhaled corticosteroids:
Majority of patients cannot afford these medicines, listed as essential by WHO

Non-essential medicines are often available at very high cost

Only a minority of very rich patients would be able to purchase these

Essential Medicines: Availability

Source: The Union and The University of Auckland, NZ in Global Asthma Report The Union, ISAAC, 2011

Availability of Beclometasone 100g HFA

Medicine recommended in the WHO Essential Medicines List

Survey of 50 countries It was on the national Essential Medicines List in only 10 countries (i.e. 20%) It was available in: 41% of private pharmacies surveyed 17% of public hospitals surveyed
Source: The Union and The University of Auckland, NZ in Global Asthma Report The Union, ISAAC, 2011

Essential Medicines: Affordability

Source: The Union and The University of Auckland, NZ in Global Asthma Report The Union, ISAAC, 2011

Affordability of Beclometasone 100g HFA

To buy one inhaler, a patient spends over 5 days wages in Ethiopia over 8 days wages in Malawi almost 14 days wages in Madagascar Note: a person with severe asthma needs approx 16 inhalers per year.
Source: The Union and The University of Auckland, NZ in Global Asthma Report The Union, ISAAC, 2011

Not treating asthma costs more than treating it properly

For countries and for patients, costs increase when asthma is not treated or incorrectly treated.

There are unnecessary expenses of emergency visits, hospitalisations, and ineffective and inappropriate medicines

Economic Burden and Poverty

Most persistent asthma can be well controlled with corticosteroids, good education and follow-up by health care workers.

However, the majority of patients in low- and middleincome countries dont get these medicines or caretheir asthma is not properly controlled.

Sabir Nazar for The Union

Many end up repeatedly going to the emergency room or even getting hospitalised.

Sabir Nazar for The Union

This costs the patient a huge amount of money, and billions for countries in direct and indirect costs. It is also very disruptive to the lives of patients, their families, and their workplaces.

Finlands asthma success story

For example, in Finland, the mortality, number of hospital days and disability due to asthma fell 7090% between 1994 and 2010 and a conservative estimate of the savings was $300 million in 2007 alone.

Source: Reissel E et al, Finnish Medical Journal 2010

Equity issues for poor and marginalised

Less able to seek diagnosis and the necessary long-term care With lower levels of education and health literacy, they are less empowered to understand how to use the medicines correctly and how to self-manage their asthma Disproportionately disadvantaged when they cannot attend school or work due to asthma Less able to control their environment to reduce factors that trigger their asthma
Home - heating, mould, animals, smoking Workplace pollutants, employment conditions

The Unions response

Improve affordability of essential asthma medicines in developing countries Improve skills of health personnel by the development of a training package

Assess quality of care by regular monitoring and evaluation

Ait-Khaled N et al. Allergy 2007;62:230-36.

A Practical Solution: Asthma Drug Facility (ADF)

Provides affordable access to quality-assured, essential asthma medicines for lowand middle-income countries

Promotes a quality improvement package for the diagnosis, treatment and management of asthma

How does the ADF work?

Unlike TB and HIV essential medicines, asthma inhalers are not part of the WHO Prequalification Programme So, ADF organises qualification of manufacturers and products, using a Quality Assurance system based on WHO norms and standards. ADF establishes contracts with these selected manufacturers for qualified products and proposes these products to countries, organisations, programmes Countries purchase at affordable prices ADF provides training materials and an information system for following patient progress

Reduction in annual costs for a patient with severe asthma when medicines purchased through ADF
(in Euros, based on 2009/2012 ADF prices)
90 80 70 62 60 50 40 30 20 10 0 BENIN SALVADOR SUDAN In 2012, ADF procurement 48 36 40 35 33 In 2010, ADF procurement In 2009, national procurement 79 83

ADF Product Prices for 2012

Additional costs: transport, insurance, preshipment inspection and 10% fees for ADF services
Product Primary Supplier (Country) Price per unit FCA (USD)

Beclometasone 100g/puff 200 doses, HFA inhaler*

Salbutamol 100g/puff 200 doses, HFA inhaler* Budesonide 200g/puff 200 doses, HFA inhaler*

Beximco (Bangladesh)
GSK Export (UK) Cipla/Medispray (India)

1.28

1.08

2.60

Fluticasone 125g/puff 120 doses, HFA inhaler

Cipla/Goa (India)

2.50

*On the 17th WHO Essential Medicines List, March 2011

Financing solutions
Current options available for countries: - The Global Fund: through the Practical Approach to Lung Health (PAL) component of TB grants eg: Burundi, Indonesia - Governmental budget line eg: El Salvador, Vanuatu - Other donors: budget line to purchase asthma medicines (eg: Kenya, Vietnam) and sometimes to initiate a revolving fund (eg: Benin, Sudan)

Benin & its revolving fund mechanism

After an initial donation from The Union in 2009, Benin has been able to place 5 consecutive orders of inhalers through ADF, plus 3 orders of related devices (peak-flow meters, spacers,). Benins 5th order of inhalers has been made without being dependent on a donor or governmental funds.

Sudan & stigma faced by asthmatics

In some countries, Sudan for example, asthma patients: - may be considered, as a wife or husband, likely to transmit asthma to their children - may be seen as being sick more often than the rest of the population, reducing their chances of getting married.
Education and adequate asthma treatment will help to make stigma a story from the past for these patients

Challenges and barriers (1)

for management of asthma in LMIC countries
Prevalence of asthma increasing in urban areas Asthma is a major cause of unplanned hospital visits Countries prioritise communicable diseases, not NCDs Lack of political will for asthma and commitment from respiratory specialists, public health specialists, health workers Patients have poor access to health services. Chronic diseases need long-term management. This is often not available or well organised. Lack of health personnel trained in asthma care

Challenges and barriers (2)

for management of asthma in LMIC countries
Asthma medicines are mostly not affordable for patients or health services Funds often not allocated for purchasing essential medicines Evidence-based guidelines not available or not implemented Corticosteroids often not on the national Essential Medicines List (EML) Non-essential medicines pushed by pharmaceutical companies and specialist physicians

Getting asthma on the global health agenda

Advocating for asthma as one of the NCDs: UN High-Level Meeting in September 2011 Global Monitoring Framework 2012 availability of essential NCD medicines mentioned New WHO guidelines on management of asthma and COPD in primary health care in low-resource settings - appearing soon PAL strategy implemented in around 50 countries (as part of Stop TB strategy). Funds made available by The Global Fund through TB applications, until December 2011 ADF model being considered for increasing access to other NCD medicines

Global Asthma Report 2011 www.globalasthmareport.org

(including preliminary results of a survey done on pricing, availability and affordability of essential asthma inhalers in 50 countries)

WHO Essential Medicines Monitor August 2011

NCD Alliance Briefing paper on Access to Essential Medicines for NCDs

Making Asthma a Global Priority

What needs to be done
Invest in asthma research. Ensure that good-quality asthma drugs are affordable and accessible. Reorganise health services for long-term treatment. Support priority interventions for NCDs.

Contact

Asthma Drug Facility International Union Against Tuberculosis and Lung Disease
adf@theunion.org www.GlobalADF.org (English, French and Spanish)