Neurosurgical capacity building in the developing world through focused training

Clinical article

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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.

Abbreviations used in this paper:AMO = assistant medical officer; HLH = Haydom Lutheran Hospital; MD = medical doctor.

Article Information

Address correspondence to: Joyce S. Nicholas, Ph.D., 1901 Tate Springs Rd., Lynchburg, VA 24501. email: joyce.nicholas@centrahealth.com.

Please include this information when citing this paper: published online September 12, 2014; DOI: 10.3171/2014.7.JNS122153.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Most common procedures by year, beginning the year before program implementation.

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    Increases in total number of all cases (left) and total number of complex cases (right) performed, as well as the number of cases performed independently by Tanzanian health care providers, beginning the year before program implementation.

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    Computed tomography scans of a brain tumor removed independently by Tanzanian trainee. Left: Preoperative CT revealing a large left frontal enhancing mass. Right: Axial 2-year postoperative CT with minimal residual tumor. The patient is neurologically intact.

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    Overlay of Tanzania on the eastern United States. Figure created with permission using IfItWereMyHome.com.

References

  • 1

    Attebery JEMayegga ELouis RGChard RKinasha AEllegala DB: Initial audit of a basic and emergency neurosurgical training program in rural Tanzania. World Neurosurg 73:2902952010

    • Search Google Scholar
    • Export Citation
  • 2

    Basso APrevigliano IDuarte JMFerrari N: Advances in management of neurosurgical trauma in different continents. World J Surg 25:117411782001

    • Search Google Scholar
    • Export Citation
  • 3

    Bergen DCSilberberg D: Nervous system disorders: a global epidemic. Arch Neurol 59:119411962002

  • 4

    Black PM: The future of neurosurgery: a call to leadership. Clin Neurosurg 54:1851912007

  • 5

    Cadotte DWViswanathan ACadotte ABernstein MMunie TFreidberg SR: The consequence of delayed neurosurgical care at Tikur Anbessa Hospital, Addis Ababa, Ethiopia. World Neurosurg 73:2702752010

    • Search Google Scholar
    • Export Citation
  • 6

    de Villiers JC: A place for neurosurgery in a developing country?. Surg Neurol 46:4034071996

  • 7

    Debas HTGosselin RMcCord CThind ASurgery. Jamison DTBreman JGMeasham AR: Disease Control Priorities in Developing Countries ed 2New YorkOxford University Press2006. 12451260

    • Search Google Scholar
    • Export Citation
  • 8

    Dupuis CC: Humanitarian missions in the third world: a polite dissent. Plast Reconstr Surg 113:4334352004

  • 9

    El Khamlichi A: African neurosurgery: current situation, priorities, and needs. Neurosurgery 48:134413472001

  • 10

    El Khamlichi A: Neurosurgery in Africa. Clin Neurosurg 52:2142172005

  • 11

    El Khamlichi ADerraz SEl Ouahabi AAghzadi AJamily AEl Azouzi M: Pattern of cerebral aneurysms in Morocco: review of the concept of their rarity in developing countries: report of 200 cases. Neurosurgery 49:122412302001

    • Search Google Scholar
    • Export Citation
  • 12

    Haglund MMKiryabwire JParker SZomorodi AMacLeod DSchroeder R: Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg 35:117511822011

    • Search Google Scholar
    • Export Citation
  • 13

    Hayden MGHughes SHahn EJAryan HELevy MLJandial R: Maria Auxiliadora Hospital in Lima, Peru as a model for neurosurgical outreach to international charity hospitals. Childs Nerv Syst 27:1451482011

    • Search Google Scholar
    • Export Citation
  • 14

    Lindsay KW: Neurosurgical training in the United Kingdom and Ireland: assessing progress and attainment. Neurosurgery 50:110311132002

    • Search Google Scholar
    • Export Citation
  • 15

    Mæstad OMwisongo A: Haydom Lutheran Hospital—Final Project Review Bergen, NorwayCMI2009. (http://www.cmi.no/publications/publication/?3488=haydom-lutheranhospital-final-project-review) [Accessed August 3 2014]

    • Search Google Scholar
    • Export Citation
  • 16

    Mainthia RTye GWShapiro JDoppenberg EMRWard JD: A model for neurosurgical humanitarian aid based on 12 years of medical trips to South and Central America. Clinical article. J Neurosurg Pediatr 4:492009

    • Search Google Scholar
    • Export Citation
  • 17

    Taira BRKelly McQueen KABurkle FM Jr: Burden of surgical disease: does the literature reflect the scope of the international crisis?. World J Surg 33:8938982009

    • Search Google Scholar
    • Export Citation
  • 18

    World Health Organization World Federation of Neurology: Atlas: Country Resources for Neurological Disorders 2004 GenevaWorld Health Organization2004. (http://www.who.int/mental_health/neurology/epidemiology/en/index.html) [Accessed August 3 2014]

    • Search Google Scholar
    • Export Citation
  • 19

    Wright IGWalker IAYacoub MH: Specialist surgery in the developing world: luxury or necessity?. Anaesthesia 62:Suppl 184892007

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