Professor Refiloe Masekela, a Paediatric Pulmonologist, Dean and Head of UKZN’s School of Medicine and President of the South African Thoracic Society and Scientific member of GINA says South Africa faces a severe asthma crisis, with one in five adolescents showing symptoms and the country ranking among the highest globally for asthma-related deaths.
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Most of us take breathing for granted, doing so more than 28 000 times a day without a second thought. For someone living with poorly controlled asthma, every breath is a struggle. Waking up at night with a tight chest, struggling for air can be a frightening experience. This a daily burden that no child or adult should have to endure in a country with the knowledge and tools to control asthma better.
Asthma is the most common non‑communicable disease affecting children worldwide. In South Africa, the burden is alarmingly high, ranking second-highest in the world. According to the recent Global Asthma Network Phase One study, 1 in 5 adolescents in South Africa reports symptoms compatible with asthma. Yet despite being a common condition — and despite the availability of effective asthma controller medicines for more than six decades — people in this country continue to die from asthma, and if they survive the disease, half of asthmatic have very severe asthma that is poorly controlled.
Asthma deaths are often sudden and silent and frequently go uncaptured in official statistics, occurring at home or being misclassified in health records. What we do know, however, is deeply concerning: South Africa ranks among the top 20 countries globally for asthma‑related deaths. This should trouble us all, because asthma is largely preventable and controllable.
Why must we act now?
The Global Initiative for Asthma (GINA), the leading global authority on asthma management, has set a clear theme for World Asthma Day 2026: “Access to anti‑inflammatory inhalers for everyone with asthma – still an urgent need.” This message reflects a persistent and dangerous reality. Too many people living with asthma rely almost exclusively on reliever inhalers (the blue asthma pumps) that provide rapid symptom relief but do nothing to treat the underlying airway inflammation that causes asthma attacks.
This approach is not only inadequate — it is dangerous. The vast majority of asthma deaths occur in people who are not using anti‑inflammatory treatment (controller medication), particularly during flare‑ups. These anti-inflammatory asthma pumps should be used chronically and need to be used in a sustained way for people to derive benefit. No patient with hypertension or diabetes would take their pills once off when they are feeling unwell. It is accepted that the medicine should be taken chronically to prevent complications. But, in asthma this is a scenario that plays itself out on a daily basis.
So, what needs to change?
In late 2024, the South African Thoracic Society convened a national Asthma Summit, bringing together clinicians, health economists, the Department of Health, pharmacy groups, private health funders, and patient organisations. The goal was simple but urgent: to chart a practical path towards better asthma care in South Africa.
One of the most important recommendations to emerge from this process was the need to expand access to combination inhalers containing both a reliever and an anti‑inflammatory medicine — specifically budesonide‑formoterol — for all people with asthma. GINA now recommends this treatment approach across the full spectrum of disease, from the mildest to the most severe forms. The body of evidence supporting this approach is both from the highest level of evidence in clinical trials and real-life studies. This approach is how some high-income countries have succeeded in reducing deaths from asthma to near zero, a classical example being Finland. The Finnish National Asthma Program is a shining example of how a national 10 year strategy was able to have impressive gains reduced deaths, hospitalisations and disability from asthma by providing appropriate diagnostic tools and treatment at the primary care level.
The argument to improve access to inhaled steroid and formoterol combination inhalers for all is compelling. These inhalers have a dual function: they provide immediate symptom relief while simultaneously treating the underlying airway inflammation. They can be used when patients feel unwell and as part of long‑term disease control. A patient only needs to carry one inhaler. This simple pragmatic approach also allows for ease of asthma education at the primary care level where over 80% of asthmatics are seen. This simplified strategy has been shown to reduce severe asthma attacks, prevent deaths and significantly improve quality of life.
Critics of using this effective approach often point to cost. While combination inhalers may incur higher upfront costs than using separate inhalers for reliever and anti-inflammation, international experience tells a different long‑term story. Brazil, for example, has led the way by making these medicines widely available through its public health system called the Popular Pharmacy Program, rolled out to ensure access to asthma treatments. Robust health‑economic data from Brazil shows that this approach is ultimately more cost‑effective, reduces hospital admissions, emergency visits and prevents loss of productivity.
The choice before us, therefore, is not merely financial. It is ethical. Do we continue to rely on cheaper, less effective treatments that place lives at risk, or do we invest in proven therapies that prevent deaths and allow people to live full, productive lives?
Encouragingly, momentum is building globally. On 27 May 2025, the World Health Assembly adopted a resolution calling for improved access, affordability and availability of safe, effective, quality medicines — including those for asthma. This global commitment places responsibility squarely on national health systems to respond meaningfully to the needs of people living with chronic lung diseases.
It is time for both government and the private sector in South Africa to act decisively. Ensuring access to effective, life‑saving asthma treatment for all South Africans is not only possible — it is long overdue.
*** Professor Refiloe Masekela is a Paediatric Pulmonologist, Dean and Head of UKZN’s School of Medicine and President of the South African Thoracic Society and Scientific member of GINA.
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