COPD burden and healthcare management across four middle-income countries within the Breathe Well research programme: a descriptive study
Authors: d’Elia Alexander , Jordan Rachel E , Cheng KK , Chi Chunhua , Correia-de-Sousa Jaime , Dickens Andy P , Enocson Alexandra , Farley Amanda , Gale Nicola , Jolly Kate , Jowett Sue , Maglakelidze Mariam , Maglakelidze Tamaz , Martins Sonia Maria , Pan Zihan , Sitch Alice , Stavrikj Katarina , Turner Alice , Williams Siân , Adab Peymane 
Published: December 2024

Background
Chronic obstructive pulmonary disease is one of the world’s leading causes of morbidity and mortality, with many low- and middle-income countries still experiencing an increase. Effective management requires a strong primary healthcare system, to prevent, diagnose in a timely way, and manage prevalent disease for a long period of time through to end of life, but this is inadequate in many middle-income countries.
The Breathe Well programme was a multinational collaboration between the University of Birmingham, United Kingdom, and partner institutions in four middle-income countries: Brazil, China, Georgia and North Macedonia. This review, conducted at the start of the programme, aimed to set the context for our research programme and future research, health care and policy needs by describing these four national health systems, risk factors, current burden and management of chronic obstructive pulmonary disease patients.

Design and methods
A descriptive review based on publicly available data identified from MEDLINE, national and international websites, supplemented by local expert opinion. For each of the included middle-income countries, we present and discuss the ability of the healthcare systems to effectively diagnose and manage chronic obstructive pulmonary disease, the barriers and limitations, including history of the healthcare system, organisation and governance, financing and medicines. The health and health care of chronic obstructive pulmonary disease patients are further illustrated by a hypothetical patient case developed with local clinical experts.

Results
While the sizes and features of the populations differ, the number of doctors tends to be low across most countries, the number of smokers high, the out-of-pocket expenses also high and the provision of diagnosis and management for chronic obstructive pulmonary disease in primary care suboptimal. Primary prevention including smoking cessation is insufficient across the participating countries. Cost and availability of care and medications are common barriers to effective chronic obstructive pulmonary disease management.

Limitations
This study is not a comprehensive systematic review. It provides a useful broad description of the subject, but we did not seek to produce detailed accounts.

Discussion
While there is vast diversity in settings and context, some challenges appeared to be shared: a lack of human and material resources in the primary care systems with an apparent power imbalance between primary and secondary care, pushing care burden to secondary care and potentially worsening geographic and economic health inequities. High cost (relative to average earnings) and low accessibility of long-term medications lead to high out-of-pocket expenditure, affecting quality and equity. There is generally suboptimal primary prevention with high smoking rates and high levels of air pollution. Improvement of prevention, diagnosis and management of chronic obstructive pulmonary disease via stronger primary care could help reduce health inequalities.

Future work
This study provided useful context for prioritising research questions within the Breathe Well programme and beyond. Research recommendations included assessment of resource-effective methods for primary prevention, screening and community-led management of chronic obstructive pulmonary disease cases, as well as mapping the educational needs of primary care staff which were then prioritised by local stakeholders including patients, clinicians, healthcare managers and policy-makers. It will be essential to update information on local context at regular intervals to ensure currency of research plans.

Funding
This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme as award number 16/137/95.