The ties that bind: innovation configurations in low- and middle-income healthcare delivery settings.

PURPOSE: This study examines innovation configurations (i.e. sets of product/service, social and business model innovations) and configuration linkages (i.e. factors that help to combine innovations) across six organizations as contingent upon organizational structure. DESIGN/METHODOLOGY/APPROACH: Using semi-structured interviews and available public information, qualitative data were collected and examined using content analysis to characterize innovation configurations and linkages in three local/private organizations and three foreign-led/public-private partnerships in Repiblik Ayiti (Haiti). FINDINGS: Organizations tend to combine product/service, social, and business model innovations simultaneously in locally founded private organizations and sequentially in foreign-based public-private partnerships. Linkages for simultaneous combination include limited external support, determined autonomy and shifting from a "beneficiary mindset," and financial need identification. Sequential combination linkages include social need identification, community connections and flexibility. RESEARCH LIMITATIONS/IMPLICATIONS: The generalizability of our findings for this qualitative study is subject to additional quantitative studies to empirically test the suggested factors and to examine other health care organizations and countries. PRACTICAL IMPLICATIONS: Locally led private organizations in low- and middle-income settings may benefit from considering how their innovations are in service to one another as they may have limited resources. Foreign based public-private partnerships may benefit from pacing their efforts alongside a broader set of stakeholders and ecosystem partners. ORIGINALITY/VALUE: This study is the first, to our knowledge, to examine how organizations combine sets of innovations, i.e. innovation configurations, in a healthcare setting and the first of any setting to examine innovation configuration linkages.

The AANS Harvey Cushing Medal: a demographic and academic analysis of its recipients.

Background: The Harvey Cushing Medal, awarded by the American Association of Neurological Surgeons, is the premier accolade in neurosurgery. The study's purpose was to examine the qualities and accomplishments of previous winners, emphasizing potential selection biases, with the aim to promote social justice and guide young neurosurgeons in their career paths. Results: Predominantly, recipients graduated from top-ranked United States News and World Report institutions and specialized in cerebrovascular and neuro-oncologic/skull base neurosurgery. A significant proportion held roles as department or division chairs and led neurosurgical organizations. All awardees were male, and there was a notable trend of increasing publication counts among more recent recipients. Conclusions: Commonalities among Harvey Cushing Medal winners include graduating from top institutions, holding significant leadership roles, and having an extensive publication history. However, the absence of female and underrepresented minority awardees underscores an urgent need for greater diversity in the selection process.

Authorship Disparities in International Neurosurgical Research Collaborations: A Bibliometric Analysis.

BACKGROUND: Research is pivotal to neurosurgical training and practice. The objectives of this study were to quantify neurosurgical research output by authors from low-income countries (LICs), using author affiliation as a proxy, and to understand the patterns of collaboration between LIC authors and their international partners. METHODS: PubMed, CINAHL, and EMBASE were searched for neurosurgical literature published by authors from the 27 World Bank LICs from 2010 to 2020. These articles were screened for relevance. Information about publication type, study design, and author demographics was then extracted from included articles. Scopus was subsequently used to determine the H-indices of the authors. RESULTS: The rate at which LIC authors have been publishing neurosurgical research has increased significantly from 2010 to 2020. Overall, 19 of the 27 LICs were represented. The LICs with the most research output includes Uganda, Ethiopia, and Rwanda. When LIC authors collaborated with authors from middle-or-high-income countries, these LIC researchers were solely listed in a middle authorship position more than 70% of the time. On average, the H-index of LIC authors was 4.9, compared with average H-indices of 8.7 and 16.8 for their MIC and HIC collaborators, respectively. CONCLUSIONS: The positioning of LIC researchers as middle author contributors revealed significant authorship disparities in international neurosurgical research collaborations. The average H-indices of authors from middle-or-high-income countries were more than 3 times greater than those of LIC authors. Quantifying this issue allows neurosurgical organizations to understand the current landscape and to set concrete goals for research capacity building in LICs.

Historical determinants of neurosurgical inequities in Africa and the African diaspora: A review and analysis of coloniality.

The movement to decolonize global health challenges clinicians and researchers of sub-disciplines, like global neurosurgery, to redefine their field. As an era of racial reckoning recentres the colonial roots of modern health disparities, reviewing the historical determinants of these disparities can constructively inform decolonization. This article presents a review and analysis of the historical determinants of neurosurgical inequities as understood by a group of scholars who share Sub-Saharan African descent. Vignettes profiling the colonial histories of Cape Verde, Rwanda, Cameroon, Ghana, Brazil, and Haiti illustrate the role of the colonial legacy in the currently unmet need for neurosurgical care in each of these nations. Following this review, a bibliographic lexical analysis of relevant terms then introduces a discussion of converging historical themes, and practical suggestions for transforming global neurosurgery through the decolonial humanism promulgated by anti-racist practices and the dialogic frameworks of conscientization.

Racial and Socioeconomic Disparities in Neurotrauma: Research Priorities in the New York Metropolitan Area Through a Global Neurosurgery Paradigm.

The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persists in the NYMA as well as in low- and middle-income countries (LMICs). Examples include (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic postinjury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.

Do social determinants of health impact access to neurosurgical care in the United States? A workforce perspective.

OBJECTIVE: This study attempts to use neurosurgical workforce distribution to uncover the social determinants of health that are associated with disparate access to neurosurgical care. METHODS: Data were compiled from public sources and aggregated at the county level. Socioeconomic data were provided by the Brookings Institute. Racial and ethnicity data were gathered from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research. Physician density was retrieved from the Health Resources and Services Administration Area Health Resources Files. Catchment areas were constructed based on the 628 counties with neurosurgical coverage, with counties lacking neurosurgical coverage being integrated with the nearest covered county based on distances from the National Bureau of Economic Research's County Distance Database. Catchment areas form a mutually exclusive and collectively exhaustive breakdown of the entire US population and licensed neurosurgeons. Socioeconomic factors, race, and ethnicity were chosen as independent variables for analysis. Characteristics for each catchment area were calculated as the population-weighted average across all contained counties. Linear regression analysis modeled two outcomes of interest: neurosurgeon density per capita and average distance to neurosurgical care. Coefficient estimates (CEs) and 95% confidence intervals were calculated and scaled by 1 SD to allow for comparison between variables. RESULTS: Catchment areas with higher poverty (CE = 0.64, 95% CI 0.34-0.93) and higher prime age employment (CE = 0.58, 95% CI 0.40-0.76) were significantly associated with greater neurosurgeon density. Among categories of race and ethnicity, catchment areas with higher proportions of Black residents (CE = 0.21, 95% CI 0.06-0.35) were associated with greater neurosurgeon density. Meanwhile, catchment areas with higher proportions of Hispanic residents displayed lower neurosurgeon density (CE = -0.17, 95% CI -0.30 to -0.03). Residents of catchment areas with higher housing vacancy rates (CE = 2.37, 95% CI 1.31-3.43), higher proportions of Native American residents (CE = 4.97, 95% CI 3.99-5.95), and higher proportions of Hispanic residents (CE = 2.31, 95% CI 1.26-3.37) must travel farther, on average, to receive neurosurgical care, whereas people living in areas with a lower income (CE = -2.28, 95% CI -4.48 to -0.09) or higher proportion of Black residents (CE = -3.81, 95% CI -4.93 to -2.68) travel a shorter distance. CONCLUSIONS: Multiple factors demonstrate a significant correlation with neurosurgical workforce distribution in the US, most notably with Hispanic and Native American populations being associated with greater distances to care. Additionally, higher proportions of Hispanic residents correlated with fewer neurosurgeons per capita. These findings highlight the interwoven associations among socioeconomics, race, ethnicity, and access to neurosurgical care nationwide.

An Assessment of Global Neurotrauma Prevention and Care Delivery: The Provider Perspective.

BACKGROUND: Neurotrauma is a leading cause of morbidity and mortality around the world. Assessment of injury prevention and prehospital care for neurotrauma patients is necessary to improve care systems. METHODS: A 29-question electronic survey was developed based on the Enhancing the Quality and Transparency Of health Research (EQUATOR) checklist to assess neurotrauma policies and laws related to safety precautions. The survey was distributed to members of World Health Organization regions that were considered to be experienced medical authorities in neurosurgery and traumatic brain injury. RESULTS: There were 82 (39%) responses representing 46 countries. Almost all respondents (95.2%) were within the neurosurgical field. Of respondents, 40.2% were from high-income countries (HICs), and 59.8% were from low- and middle-income countries (LMICs). Motor vehicle accidents were reported as the leading cause of neurotrauma, followed by workplace injury and assault. Of respondents, 84.1% reported having a helmet law in their country. HICs (4.38 ± 0.78) were ranked more likely than LMICs (2.88 ± 1.34; P = 0.0001) to enforce helmet laws on a scale of 1-10. Effectiveness of helmet laws was rated as 3.94 ± 0.95 out of 10. Measures regarding prehospital care varied between HICs and LMICs. Patients in HICs were more likely to use public emergency ambulance transportation (81.8% vs. 42.9%; P = 0.0004). All prehospital personnel having emergency training was also reported to be more likely in HICs than LMICs (60.6% vs. 8.7%; P = 0.0001). CONCLUSIONS: When injuries occur, timely access to neurosurgical care is critical. A focus on prehospital components of the trauma system is paramount, and policymakers can use the information presented here to implement and refine health care systems to ensure safe, timely, affordable, and equitable access to neurotrauma care.

Differences in outcomes of mandatory motorcycle helmet legislation by country income level: A systematic review and meta-analysis.

BACKGROUND: The recent Lancet Commission on Legal Determinants of Global Health argues that governance can provide the framework for achieving sustainable development goals. Even though over 90% of fatal road traffic injuries occur in low- and middle-income countries (LMICs) primarily affecting motorcyclists, the utility of helmet laws outside of high-income settings has not been well characterized. We sought to evaluate the differences in outcomes of mandatory motorcycle helmet legislation and determine whether these varied across country income levels. METHODS AND FINDINGS: A systematic review and meta-analysis were completed using the PRISMA checklist. A search for relevant articles was conducted using the PubMed, Embase, and Web of Science databases from January 1, 1990 to August 8, 2021. Studies were included if they evaluated helmet usage, mortality from motorcycle crash, or traumatic brain injury (TBI) incidence, with and without enactment of a mandatory helmet law as the intervention. The Newcastle-Ottawa Scale (NOS) was used to rate study quality and funnel plots, and Begg's and Egger's tests were used to assess for small study bias. Pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were stratified by high-income countries (HICs) versus LMICs using the random-effects model. Twenty-five articles were included in the final analysis encompassing a total study population of 31,949,418 people. There were 17 retrospective cohort studies, 2 prospective cohort studies, 1 case-control study, and 5 pre-post design studies. There were 16 studies from HICs and 9 from LMICs. The median NOS score was 6 with a range of 4 to 9. All studies demonstrated higher odds of helmet usage after implementation of helmet law; however, the results were statistically significantly greater in HICs (OR: 53.5; 95% CI: 28.4; 100.7) than in LMICs (OR: 4.82; 95% CI: 3.58; 6.49), p-value comparing both strata < 0.0001. There were significantly lower odds of motorcycle fatalities after enactment of helmet legislation (OR: 0.71; 95% CI: 0.61; 0.83) with no significant difference by income classification, p-value: 0.27. Odds of TBI were statistically significantly lower in HICs (OR: 0.61, 95% CI 0.54 to 0.69) than in LMICs (0.79, 95% CI 0.72 to 0.86) after enactment of law (p-value: 0.0001). Limitations of this study include variability in the methodologies and data sources in the studies included in the meta-analysis as well as the lack of available literature from the lowest income countries or from the African WHO region, in which helmet laws are least commonly present. CONCLUSIONS: In this study, we observed that mandatory helmet laws had substantial public health benefits in all income contexts, but some outcomes were diminished in LMIC settings where additional measures such as public education and law enforcement might play critical roles.

The Current State of Neurosurgery in Somaliland.

BACKGROUND: Surgical conditions account for as much as one third of the global burden of disease, yet 5 billion people worldwide do not have access to timely, affordable surgical care. These disparities in access to timely surgical care are most pronounced in low- and middle-income countries, where the availability of specialty surgical services such as neurosurgery are severely limited or completely absent. The African autonomous region of Somaliland, in the Horn of Africa, is one such region. METHODS: Discussions were conducted with key individuals in Somaliland to ascertain the current state of neurosurgery in Somaliland. RESULTS: The current state of neurosurgery in Somaliland was characterized. First, a background on the recent history of the republic and the surrounding region was furnished, which provides context for the challenging socioeconomic conditions in Somaliland. Brief biographical sketches were presented of local leaders and general surgeons who are actively working to improve economic and health conditions and who welcome opportunities to improve all health services, including neurosurgery. In addition, an overview was presented of new initiatives in capacity building in neurosurgery and sources of directed training and care in neurosurgery. CONCLUSIONS: This article provides the first-ever assessment of current neurosurgery-related activity in Somaliland. The article provides recommendations to guide the international neurosurgery community in future contributions.

Neurosurgery in Ethiopia: A New Chapter and Future Prospects.

BACKGROUND: Inequitable access to surgical care is most conspicuous in low-income countries (LICs), such as Ethiopia, where infectious diseases, malnutrition, and other maladies consume the lion's share of the available health resources. The aim of this article was to provide an update on the current state of neurosurgery in Ethiopia and identify targets for future development of surgical capacity as a universal health coverage component in this East African nation. METHODS: Publicly available data included in this report were gathered from resources published by international organizations. A PubMed search was used for a preliminary bibliometric analysis of scholarly output of neurosurgeons in Ethiopia and other low-income countries. Statistical analysis was used to determine the correlation between the number of neurosurgeons and academic productivity. RESULTS: Neurosurgeon density has increased >20-fold from 0.0022 to 0.045 neurosurgeons per 100,000 population between 2006 and 2020. The increase in neurosurgeons was strongly correlated with an increase in total publications (P < 0.001) and the number of new publications per year (P = 0.003). Despite recent progress, the availability of neuroimaging equipment remains inadequate, with 38 computed tomography scanners and 11 magnetic resonance imaging machines for a population of 112.07 million. The geographic distribution of neurosurgical facilities is limited to 12 urban centers. CONCLUSIONS: Ethiopian neurosurgery exemplifies the profound effect of international partnerships for training local surgeons on progress in low-income countries toward improved neurosurgical capacity. Collaborations that focus on increasing the neurosurgical workforce should synchronize with efforts to enhance the availability of diagnostic and surgical equipment necessary for basic neurosurgical care.

The Current State of Neurosurgery in Haiti.

BACKGROUND: Even though surgical conditions account for as much as 32% of the global burden of disease, 5 billion people worldwide do not have access to timely, affordable surgical and anesthetic care. Access to surgical care is separated along socioeconomic divides, and these disparities are most pronounced in low-and middle-income countries, such as the Caribbean nation of Haiti, where the availability of specialty surgical services like neurosurgery are scant, or completely absent. METHODS: This paper provides a narrative account of current neurosurgery-related activity in Haiti, a nation whose social, political, and economic context is unique in the Americas. RESULTS: After some background information and a bibliometric analysis of recent research efforts, we provide brief biographical sketches of Haiti's local neurosurgical leaders and an overview of recent initiatives in Haitian neurosurgical capacity building. CONCLUSIONS: The paper concludes with recommendations to guide the international neurosurgery community in future contributions.

The Bill & Melinda Gates Foundation: An opportunity to lead innovation in global surgery.

BACKGROUND: The Bill and Melinda Gates Foundation has made unparalleled contributions to global health and human development by bringing together generous funding, strategic partnerships, and innovative leadership. For the last twenty years, the Gates Foundation has supported the expansion of programs that directly address the fundamental barriers to the advancement of marginalized communities around the globe, with a transformative focus on innovations to combat communicable diseases and to ensure maternal and child health. Despite the wide spectrum of programs, the Gates Foundation has not, as of yet, explicitly supported the development of surgical care. METHODS: This article explores the pivotal role that the Gates Foundation could play in advancing the emerging global surgery agenda. First, we demonstrate the importance of the Gates Foundation's contributions by reviewing its history, growth, and evolution as a pioneering supporter of global health and human development. Recognizing the Foundation's use of metrics and data in strategic planning and action, we align the priorities of the Foundation with the growing recognition of surgical care as a critical component of efforts to ensure universal health care. RESULTS: To promote healthy lives and well-being for all, development of quality and affordable capacity for surgery, obstetrics and anesthesia is more important than ever. We present the unique opportunity for the Gates Foundation to bring its transformative vision and programing to the effort to ensure equitable, timely, and quality surgical care around the world.

Essential Neurosurgical Workforce Needed to Address Neurotrauma in Low- and Middle-Income Countries.

BACKGROUND: Among all trauma-related injuries globally, traumatic brain injury (TBI) and traumatic spine injury (TSI) account for the largest proportion of cases. Where previously data was lacking, recent efforts have been initiated to better quantify the extent of neurotrauma in low- and middle-income countries (LMICs). This information is vital to understand the current neurosurgical deficit so that resources and efforts can be focused on where they are needed most. The purpose of this study is to determine the minimum number of neurosurgeons to address the neurotrauma demand in LMICs and evaluate current evidence to support facility needs so that policy-based recommendations can be made to prioritize development initiatives to scale up neurosurgical services. METHODS: Using existing data regarding the incidence of TBI and TSI in LMICs and current neurosurgical workforce and estimates of case load capacity, the minimum number of neurosurgeons needed to address neurotrauma per population was calculated. Evidence was gathered regarding necessary hospital facilities and disbursement patterns based on time needed to intervene effectively for neurotrauma. RESULTS: There are 4,897,139 total operative cases of TBI and TSI combined in LMICs annually. At minimum, there needs to be 1 neurosurgeon only performing neurotrauma cases per approximately 212,000 people. Evidence suggests that patients should be within 4 hours of a neurosurgical facility at the very least. CONCLUSIONS: The development of neurotrauma systems is essential to address the large burden of neurotrauma in LMICs. The minimum requirements for neurosurgical workforce is 1 neurotrauma surgeon per 212,000 people.

Neurosurgery and Sustainable Development Goals.

BACKGROUND: On September 25, 2015, the United Nations General Assembly adopted a 17-goal action plan to transform the world by the year 2030, ushering in the Era of Sustainable Development. These Sustainable Development Goals (SDGs) were designed to continue where the preceding Millennium Development Goals left off, expanding on the Millennium Development Goal successes, and facing the challenges encountered during the previous decade and a half. The current Era of Sustainable Development and its impact on a breadth of neurosurgical concerns provide several unprecedented opportunities to enhance political prioritization of neurosurgical care equity. Neurosurgeons could therefore be well positioned to participate in the leadership of these global health development and policy reform efforts. METHODS: Each of the 17 SDGs was reviewed and analyzed for its relevance to the public health aspects of neurosurgery. The analysis was guided by a review of the literature performed in PubMed, Google Scholar, and the databases of the World Health Organization. RESULTS: Among the 17 SDGs, 14 were found to be of direct or indirect relevance to neurosurgeons and neurosurgical care delivery. Results of this analysis are presented and discussed, and recommendations are provided for using this knowledge to inform the emerging discipline of global neurosurgery. CONCLUSIONS: This article contributes to the global neurosurgery movement by providing the socially and globally conscious neurosurgeon with a compass for directing the place of neurosurgery in the international agenda for sustainable development.

Exploration of Global Health Careers Across the Medical Fields.

BACKGROUND: Despite expansion of interest among American medical students in global health (GH), academic medical centers face multiple obstacles to the development of structured GH curricula and career guidance. To meet these demands we sought to provide a systematic analysis of the accounts of GH experts. METHODS: We developed a collaborative, interview-based, qualitative analysis of GH experiences across six career-related themes that are relevant to medical students interested in GH: justification, medical education, economics, research prospects, law and ethics, and work-life balance. Seven GH faculty members were interviewed for 30-90 minutes using sample questions as guidelines. We applied a grounded theory approach to analyze the interview transcripts to discover an emerging theory pertinent to GH trainees. FINDINGS: Regarding justification, 4 respondents defined GH as work with the underserved irrespective of geographic location; 5 respondents found sustainability imperative; and all respondents believe GH creates better physicians. Respondents identified many physician competencies developed through GH medical education, with 5 respondents agreeing that work with underserved populations has transformative potential. Concerning economics, 3 respondents acknowledged GH's popularity among trainees, resulting in increased training opportunities, and 2 respondents emphasized an associated deficiency in program quality. All respondents described career models across specialties. Four respondents noted funding challenges when discussing research prospects. Within the theme of laws and ethics, 4 respondents perceived inadequate accountability, and 6 respondents identified ways to create accountability. Finally, 6 respondents recognized family demands can compromise one's GH career and thus work-life balance. CONCLUSION: Despite diverse perspectives on the meaning and sustainability of GH work, this analysis provides a nascent framework that may inform curricular development for GH trainees. Suggestions are offered for elaborating this framework to fully exploit the transformative potential of GH training in medical education.