The global respiratory care readiness gap: national capacity for asthma and COPD management and respiratory mortality across WHO member states

Abstract Background Asthma and chronic obstructive pulmonary disease (COPD) cause avoidable mortality, yet the basic health-system capacity needed for diagnosis, monitoring, and treatment is unevenly distributed. We assessed global variation in technical respiratory care readiness and its relationship with asthma and COPD mortality. Methods We conducted an ecological, cross-sectional analysis of 200 countries using WHO-linked public datasets and World Bank income classifications. Technical respiratory care readiness was defined using five country-level indicators: bronchodilator inhalers, steroid inhalers, budesonide-formoterol inhalers, peak-flow measurement, and spirometry. Primary outcomes were 2021 age-standardised asthma and COPD mortality rates. Log-linear models estimated associations between readiness and mortality, adjusted for tobacco use, clean-fuel access, and World Bank income group. A burden-readiness typology identified countries with high combined asthma/COPD mortality and low readiness. Results Technical readiness data were available for 192 countries; 155 countries had complete data for adjusted models. Median technical readiness was 4.0 of 5 components (IQR 2.0-5.0), equivalent to 80.0% readiness (IQR 40.0-100.0). Readiness was lowest in low-income countries and highest in high-income countries. Low-income countries had limited availability of budesonide-formoterol inhalers (5%), spirometry (7%), peak-flow measurement (21%), steroid inhalers (35%), and bronchodilator inhalers (46%). The estimated percentage changes in mortality per 10%-point increase in technical readiness were -2.1% for asthma mortality (95% CI -7.6 to 3.8), -0.7% for COPD mortality (-4.4 to 3.1), and -0.6% for combined mortality (-4.2 to 3.0); all confidence intervals included the null. The typology identified 21 high-burden/low-readiness countries. Conclusion The adjusted analyses did not show statistically significant independent associations between technical readiness and mortality. Descriptive burden-readiness mapping identified countries where high asthma/COPD mortality coincided with weak reported availability of essential inhaled medicines and basic diagnostic tools. These observations support readiness-burden mapping as a prioritisation approach for more detailed assessment of chronic respiratory care capacity.