Patients with asthma need uninterrupted supplies of affordable, quality-assured essential medicines. However, access in many low- and middle-income countries (LMICs) is limited. The World Health Organization (WHO) Non-Communicable Disease (NCD) Global Action Plan 2013–2020 sets an 80% target for essential NCD medicines’ availability. Poor access is partly due to medicines not being included on the national Essential Medicines Lists (EML) and/or National Reimbursement Lists (NRL) which guide the provision of free/subsidised medicines. We aimed to determine how many countries have essential asthma medicines on their EML and NRL, which essential asthma medicines, and whether surveys might monitor progress. A cross-sectional survey in 2013–2015 of Global Asthma Network principal investigators generated 111/120 (93%) responses—41 high-income countries and territories (HICs); 70 LMICs. Patients in HICs with NRL are best served (91% HICs included ICS (inhaled corticosteroids) and salbutamol). Patients in the 24 (34%) LMICs with no NRL and the 14 (30%) LMICs with an NRL, however no ICS are likely to have very poor access to affordable, quality-assured ICS. Many LMICs do not have essential asthma medicines on their EML or NRL. Technical guidance and advocacy for policy change is required. Improving access to these medicines will improve the health system’s capacity to address NCDs.

PHA 2014; 4(3): 141–144 © 2014 The Union AFFILIATIONS 1 Médecins Sans Frontières (MSF), Operational Centre Brussels, Medical Department, Operations Research Unit (LUXOR), MSF-Luxembourg, Luxembourg 2 International Union Against Tuberculosis and Lung Disease (The Union), SouthEast Asia Office, New Delhi, India 3 MSF, Mumbai, India 4 MSF, Medical Department, Brussels Operational Center, Belgium 5 MSF, General Direction, Luxembourg, Luxembourg 6 Department of Community Medicine, Employees State Insurance Corporation Medical College and Post Graduate Institute of Medical Sciences and Research, Bangalore, India 7 United Nations Children’s Fund/United Nations Development Programme/ World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland 8 University of St Andrews Medical School, Scotland, UK 9 International HIV/AIDS Alliance, Kyiv, Ukraine 10 Centre for International Health, University of Bergen, Bergen, Norway 11 University of Nairobi, Obstetrics and Gynecology, Nairobi, Kenya 12 Institute of Tropical Medicine, Antwerp, Belgium 13 Science and Technology Option Assessment (STOA), Directorate-General for Parliamentary Research Services (EPRS), European Parliament, Brussels, Belgium 14 Wellcome Trust, London, UK 15 The Union, Centre for Operational Research, Paris, France 16 London School of Hygiene & Tropical Medicine, London, UK. UNRESOLVED ISSUES

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

agement of patients with chronic airfl ow limitation in resource-limited settings should also be clarifi ed.Unfortunately, quality-assured essential medicine, such as inhaled corticosteroids and bronchodilators, for patients with airfl ow limitation may not be accessible or affordable in low-and middle-income countries. 5Even simple diagnostic tools such as peak fl ow meters are usually not available, let alone spirometers, and large numbers of patients in resource-limited settings repeatedly make unplanned health visits due to asthma attacks or exacerbations of chronic obstructive pulmonary disease in the absence of long-term management and care.Intention to treat therefore demands a system-wide approach to address the needs of the vulnerable.

The prevalence of diabetes mellitus is increasing at a dramatic rate, and countries in Asia, particularly India and China, will bear the brunt of this epidemic. Persons with diabetes have a significantly increased risk of active tuberculosis (TB), which is two to three times higher than in persons without diabetes. In this article, we argue that the epidemiological interactions and the effects on clinical presentation and treatment resulting from the interaction between diabetes and TB are similar to those observed for human immunodeficiency virus (HIV) and TB. The lessons learned from approaches to reduce the dual burden of HIV and TB, and especially the modes of screening for the two diseases, can be adapted and applied to the screening, diagnosis, treatment and prevention of diabetes and TB. The new World Health Organization (WHO) and The Union Collaborative Framework for care and control of TB and diabetes has many similarities to the WHO Policy on Collaborative Activities to reduce the dual burden of TB and HIV, and aims to guide policy makers and implementers on how to move forward and combat this looming dual epidemic. The response to the growing HIV-associated TB epidemic in the 1980s and 1990s was slow and uncoordinated, despite clearly articulated warnings about the scale of the forthcoming problem. We must not make the same mistake with diabetes and TB. The Framework provides a template for action, and it is now up to donors, policy makers and implementers to apply the recommendations in the field and to 'learn by doing'.

PHA 2014; 4(3): 141–144 © 2014 The Union AFFILIATIONS 1 Médecins Sans Frontières (MSF), Operational Centre Brussels, Medical Department, Operations Research Unit (LUXOR), MSF-Luxembourg, Luxembourg 2 International Union Against Tuberculosis and Lung Disease (The Union), SouthEast Asia Office, New Delhi, India 3 MSF, Mumbai, India 4 MSF, Medical Department, Brussels Operational Center, Belgium 5 MSF, General Direction, Luxembourg, Luxembourg 6 Department of Community Medicine, Employees State Insurance Corporation Medical College and Post Graduate Institute of Medical Sciences and Research, Bangalore, India 7 United Nations Children’s Fund/United Nations Development Programme/ World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland 8 University of St Andrews Medical School, Scotland, UK 9 International HIV/AIDS Alliance, Kyiv, Ukraine 10 Centre for International Health, University of Bergen, Bergen, Norway 11 University of Nairobi, Obstetrics and Gynecology, Nairobi, Kenya 12 Institute of Tropical Medicine, Antwerp, Belgium 13 Science and Technology Option Assessment (STOA), Directorate-General for Parliamentary Research Services (EPRS), European Parliament, Brussels, Belgium 14 Wellcome Trust, London, UK 15 The Union, Centre for Operational Research, Paris, France 16 London School of Hygiene & Tropical Medicine, London, UK. UNRESOLVED ISSUES

SETTING:Health services in low- and middle-income countries.BACKGROUND:The Global Plan to Stop TB, 2006-2015.OBJECTIVE:Using a framework for evaluation of public health systems, to evaluate evidence that tuberculosis (TB) services contribute to strengthening the health systems.DESIGN:Critical evaluation of published material.RESULTS:The Global Plan to Stop TB 2006-2015 identifies strengthening the health systems as one of its components. Published material illustrates substantial improvement of quality of TB services over the past decade. However, even where these services have achieved a high level of quality, there is little evidence to indicate that other health services in the same locations show similar quality.CONCLUSION:Policies, strategies and actions to strengthen health systems through TB services will require specific plans and priorities to achieve their objectives; this will not occur as a natural effect of improving TB services.

Asthma is a worldwide public health problem affecting about 300 million people. The majority of persons living with asthma are in the developing world where there is limited access to essential drugs. The financial burden for persons living with asthma and their families, as well as for healthcare systems and governments, is very high. Inadequate treatment and the high cost of medications leads to disability, absenteeism and poverty. Despite the existence of effective asthma medications and international guidelines, and progress made in the implementation of such guidelines over the last decade, the high cost of essential asthma medications remains a major obstacle for patient access to treatment in developing countries. The International Union Against Tuberculosis and Lung Disease has evaluated this problem and created an Asthma Drug Facility (ADF) so that countries can purchase affordable, good quality essential drugs for asthma. The ADF uses pooled procurement along with other purchasing and supply strategies to obtain the lowest possible prices. Accompanied by the implementation of standardized asthma management, the increased affordability of drugs provided by the ADF should bring rapid and significant health and cost benefits for patients, their communities and governments.

BACKGROUND:Private and non-private specialist practitioners are often considered an obstacle to the performance of the National Tuberculosis Control Programme (NTP).OBJECTIVE:To evaluate the impact of an intensive refresher course directed at specialist physicians in El Salvador, a questionnaire was sent to all course participants on their basic knowledge of tuberculosis (TB) control.RESULTS:Of 64 participants, 55 were assessed (86%); 33 were chest physicians and 22 belonged to other related specialities. The evaluation showed a considerable improvement in both groups in their ability to suspect the disease, in their tendency to avoid hospitalising patients and instead refer them to out-patient clinics, and in their adherence to the recommendations of the NTP manual (diagnostic procedures, treatment guidelines, case notification and cohort studies). Improvements were more noticeable, in all the parameters evaluated, among the non-chest physicians.CONCLUSION:The intervention model succeeded in improving the collaboration of private and non-private specialist practitioners with the NTP.

BACKGROUND This study describes the epidemiological trends of tuberculosis in Cuba and the performance of the tuberculosis control programme. The circumstances that caused an increase in the incidence of new cases of tuberculosis between 1991 and 1994 had been analysed and were corrected in 1995–7. METHODS A descriptive study of the incidence rates of new cases of tuberculosis notified from 1962 to 1997 was made, with special emphasis on the total change between 1965 and 1991 and the increase thereafter. RESULTS The case notification rate of 14.7 per 100 000 in 1994 was almost three times the rate found in 1991 (4.8 per 100 000) and reversed the mean annual decrease of 5% observed since 1965. This increase was almost twofold in the rate of smear positive new cases (4.4 per 100 000 in 1991 and 8.3 in 1994). From 1971 onwards the programme had achieved a cure rate of 90% throughout the country with only 2% absconding by applying directly observed treatment. The main factors associated with the increasing trends were: (1) a probable underdetection of cases for the 1988–92 period that generated contagious sources in the community; (2) improved case finding from 1993 onwards and the introduction of an expanded case definition in 1994; (3) a considerable increase in the diagnostic delay from initial medical consultation to beginning of antituberculosis treatment (56.9 days in 1993); and (4) operational changes in the tuberculosis control programme due to the economic crisis in Cuba. In 1995, 1996 and 1997 it has been possible to reverse this trend, achieving rates of 14.1, 13.5, and 12.2 per 100 000, respectively (7.6, 7.6, and 6.9 for smear positive cases) as a result of effective intervention correcting the problems identified. Reducing the diagnostic delay attributable to shortcomings in the health care system and the study of contacts were of particular importance for re-establishing the tuberculosis programme as a priority. CONCLUSIONS Cuba represents a good example of how it is possible to fight against tuberculosis effectively, even in a low income country, by applying control strategies advocated by the World Health Organisation and the International Union Against Tuberculosis and Lung Disease and by giving adequate support to the programme through political commitment.

It was the purpose of this analysis to summarize the salient findings made with the initial medical examination of asylum seekers in Switzerland. The evaluation covered the period from 1984 to 1987. The epidemiologic impact of diseases discovered by this screening and the logistic problems encountered with the decentralization of the program have required a modification and a reassessment of the necessary measures. As a consequence, indiscriminate stool examinations for bacteria and parasites have been abandoned. These examinations had required a considerable investment which is not considered to be justified by the limited epidemiologic significance of these intestinal pathogens. More emphasis is being placed on improved tuberculosis control measures, by providing concise guidelines for screening, prevention, and treatment. A simplified procedure for hepatitis B screening is to be maintained for the time being, conditional upon special emphasis on children, adolescents and adults of reproductive age groups. Hepatitis B vaccination of seronegative persons is a part of the standard basic immunization program. The core of the screening program and the delivery of initial preventive measures is to be carried out in the federal registration and transit centers for asylum seekers.

Mortality for tuberculosis declined from an average of 7.5% per year in 1952 to 1.7 in 1988, tuberculosis incidence declined by 5 to 6% per year since 1945 to 17.4% in 1988, and the annual risk of infection declined by 11.4% per year since 1945 to 10.9 per 100,000 inhabitants respectively. The crude prevalence of tuberculous infection in the Swiss population is estimated to be 22.3% for the year 1990. The age-specific prevalence of infection is mirrored in age-specific morbidity. Among Swiss citizens, tuberculosis has become a disease of the elderly and is on the brink of elimination. In contrast, tuberculosis among foreigners (40% of cases in 1988) occurs mainly among the young who experience a more than 10-fold elevated risk compared to their Swiss age peers. These data suggest that case-finding and contact investigations are the major intervention tools against tuberculosis in the Swiss population. The increased tuberculosis risk among foreigners and the young age of these patients suggest that identification of those at high risk and their preventive treatment will have to be pursued actively.