**1. Introduction - Managing bronchial asthma in primary health care**

According to the International Study for Asthma and Allergies in Childhood (ISAAC), comparing phase one in 1994 to three in 2000–2003, asthma prevalence expressed by wheezing the last 12 months in 13–14 years old is increasing in developing countries. Asthma prevalence is higher in developed countries, but asthma is more severe in developing countries [1].

The definition of a primary care facility is the site where the first patient contact occurs [2]. If we take Syria as an example of developing county, primary healthcare (PHC) facilities are officially healthcare centers under the control of the Ministry of Health, which among other services provided, host World Health Organization (WHO) programs for tuberculosis and chronic respiratory diseases [3, 4]. In addition, there are many other providers of PHC services which include emergency departments(ED), general outpatient clinics in public hospitals, school health clinics, clinics in workplace settings, and internal and general clinics within the private sector.

Asthma patients may present for treatment in any of these primary care facilities in Syria. A multicenter survey of primary care clinics revealed that 13% of patients aged over 6 years attended with asthma [5]. Another study showed that 51% of asthma patients are treated in ED only, and only 9% are treated in primary care centers [6]. Many developing countries like Sudan, Algeria and some African countries had the same use of ED [6]. The same underutilization of community primary healthcare services has also been observed in China in 2014 [7].

There are questions about the quality of care provided in these clinics with regard to their adherence to Global Initiatives for Asthma (GINA) guidelines. Evidence suggests that there may be over prescribing of oral corticosteroids and antibiotics and under-prescription of inhaled corticosteroids [5, 6], so there is a need to improve practice bringing it more into alignment to international guidelines.

It may be considered by many that it is not possible to follow guidelines in developing countries and those that have economic and political pressures. However, a pilot program to test the feasibility of a providing systematic follow-up of uncontrolled asthma patients in a general free of charge hospital in Syria showed that it is possible to achieve asthma control following to GINA guidelines even in very poor community [8]. The same was mentioned by the Union in an international survey for other developing African and Mediterranean countries [9], the same in a recent study in Sudan [10].

A Ministry of Health—WHO program for non-communicable diseases in Syria including an intensive courses for asthma and COPD for GPs in health centers has been launched since the beginning of 2015 in a pilot site from Syria. However, unlike developed countries, in Syria, presentations are very personalized, there are no established accredited modules or curricu‐ lum for continuing medical education for primary care physicians and nurses. In order to make optimum improvements in care across the country, we need to ensure that high-quality training interventions are made available for healthcare providers who are working in a primary care setting, aiming to increase both their competence and confidence in the essentials of asthma management. This program needs to incorporate accredited educational materials, a process for monitoring and continuous evaluation, and collaborative efforts with an inter‐ national agency such as the Global Alliance against Chronic Respiratory Diseases (WHO– GARD www.who.int/gard ) [8]. A survey conducted by the International COPD Coalition gave the same conclusions about absence of curriculum for education for asthma and COPD [11].

Primary healthcare services are free of charge in Syria, and other developing countries hosting WHO programs, and are staffed by full-time qualified nurses who are supported by part-time physicians, who also provide services in the private sector. In addition, some patients who are able to pay for healthcare may refer themselves directly to private pulmonologists, without being referred from primary care. Since 2006, WHO launched programs for asthma and COPD at primary care level in Syria and other developing countries, and training was undertaken on site [3–5, 8].

In this paper, we share our experience in developing countries and will present first field surveys in developing countries. Second, we will comment on the international programs of WHO and International Primary Care Respiratory Group (IPCRG). And third, we will give our evidence-based recommendations.
