Global Neurosurgery: A Retrospective Cohort Study to Compare the Effectiveness of Two Training Methods in Resource-Poor Settings.

BACKGROUND AND OBJECTIVES: Many low- and middle-income countries are experiencing profound health care workforce shortages. Surgical subspecialists generally practice in large urban centers but are in high demand in rural areas. These subspecialists must be trained through sustainable programs to address this disparity. We quantitatively compared the relative effectiveness of 2 unique training models to advance neurosurgical skills in resource-poor settings where formally trained neurosurgeons are unavailable. METHODS: Neurosurgical procedure data were collected from 2 hospitals in Tanzania (Haydom Lutheran Hospital [HLH] and Bugando Medical Centre [BMC]), where 2 distinct training models ("Train Forward" and "Back-to-Back," respectively) were incorporated between 2005 and 2012. RESULTS: The most common procedures performed were ventriculoperitoneal shunt (BMC: 559, HLH: 72), spina bifida repair (BMC: 187, HLH: 54), craniotomy (BMC: 61, HLH: 19), bone elevation (BMC: 42, HLH: 32), and craniotomy and evacuation (BMC: 18, HLH: 34). The number of annual procedures at BMC increased from 148 in 2008 to 357 in 2012; at HLH, they increased from 18 in 2005 to 80 in 2010. Postoperative complications over time decreased or did not significantly change at both sites as the diversity of procedures increased. CONCLUSION: The Train Forward and Back-to-Back training models were associated with increased surgical volume and complexity without increased complications. However, only the Train Forward model resulted in local, autonomous training of surgical subspecialists after completion of the initial training period. Incorporating the Train Forward method into existing training programs in low- and middle-income countries may provide unique benefits over historic training practices.

Neurosurgical capacity building in the developing world through focused training.

OBJECT: In Tanzania, there are 4 neurosurgeons for a population of 46 million. To address this critical shortage of neurosurgical care, the authors worked with local Tanzanian health care workers, neurosurgeons, the Ministry of Health and Social Welfare, and the Office of the President of Tanzania to develop a train-forward method for sustainable, self-propagating basic and emergency neurosurgery in resource-poor settings. The goal of this study was to assess the safety and effectiveness of this method over a 6-year period. METHODS: The training method utilizes a hands-on bedside teaching technique and was introduced in 2006 at a remote rural hospital in northern Tanzania. Local health care workers were trained to perform basic and emergency neurosurgical procedures independently and then were taught to train others. Outcome information was retrospectively collected from hospital records for the period from 2005 (1 year before method implementation) through 2010. Analysis of de-identified data included descriptive statistics and multivariable assessment of independent predictors of complications following a patient's first neurosurgical procedure. RESULTS: By 2010, the initial Tanzanian trainee had trained a second Tanzanian health care worker, who in turn had trained a third. The number of neurosurgical procedures performed increased from 18 in 2005 to an average of 92 per year in the last 3 years of the study period. Additionally, the number of neurosurgical cases performed independently by Tanzanian health care providers increased significantly from 44% in 2005 to 86% in 2010 (p < 0.001), with the number of complex cases independently performed also increasing over the same time period from 34% to 83% (p < 0.001). Multivariable analysis of clinical patient outcome information to assess safety indicated that postoperative complications decreased significantly from 2005 through 2010, with patients who had been admitted as training progressed being 29% less likely to have postoperative complications (OR 0.71, 95% CI 0.52-0.96, p = 0.03). CONCLUSIONS: The Madaktari Africa train-forward method is a reasonable and sustainable approach to improving specialized care in a resource-poor setting.

Brain surgery in the bush: adapting techniques and technology to fit the developing world.

The critical shortage of surgical services in many areas of the world has profound effects on local communities. Approximately 11% of global disease burden can be attributed to causes that are surgically treatable. Efforts have been made to recruit professionals from developed nations to compensate for the lack of such expertise. However, this practice has created a cycle of dependency on foreign-trained physicians and the medical tools they bring. Recognition of this problem calls for adaptation of a novel problem-solving approach. This article describes techniques and technology available in east Africa that have been adapted to allow basic and emergency neurosurgery to be performed in the absence of complex medical infrastructure and equipment. Commonplace items found in the local environment can be used to emulate more sophisticated instruments, and community-specific engineering programs can be developed to provide locally produced appropriate technology that promotes independence from Western sources. The local economy benefits from much-needed stimulation when these tools are created locally, and this allows for readily available replacement and repair. More studies are under way to identify problems and implement interventions that are realistic and appropriate for these populations.

Initial audit of a basic and emergency neurosurgical training program in rural Tanzania.

OBJECTIVE: As of 2006, only three formally trained neurosurgeons are licensed in Tanzania. Recently, efforts have increased toward training local Tanzanian physicians and assistant medical officers (AMOs) to meet the basic neurosurgical needs of nonurban areas. Between January and July 2006, an initial attempt at such an apprenticeship was undertaken with a locally trained AMO already performing general surgery at Haydom Lutheran Hospital, Tanzania. METHODS: Fifty-one neurosurgical patients were identified and their patient charts were requested from the medical records office. Records were not available for 4 of the 51 patients for undeterminable reasons. RESULTS: The neurosurgical infrastructure at HLH is basic but adequate for a number of procedures. Cases performed included ventriculoperitoneal shunts, repair of myelomeningoceles, and burr holes and craniotomies for trauma and biopsies. Of 51 patients initially identified, 14 (27%) were confirmed deceased and 20 (39%) confirmed living. The remaining 17 (33%) were lost to follow-up. There were no significant differences in the mortality rates of patients receiving care from the American-trained neurosurgeon and those receiving care from the Tanzanian AMO trained and mentored by the American neurosurgeon. CONCLUSIONS: This initial audit provides support for the development of limited neurosurgery programs in underserved communities. Combined utilization of available neurosurgeons and continued training for available local clinicians may help to meet this need.