The global neurosurgical workforce: a mixed-methods assessment of density and growth

Swagoto Mukhopadhyay Program in Global Surgery and Social Change, Harvard Medical School;
University of Connecticut Health Center, Farmington, Connecticut;

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Maria Punchak Program in Global Surgery and Social Change, Harvard Medical School;
David Geffen School of Medicine at UCLA, Los Angeles, California;

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Abbas Rattani Program in Global Surgery and Social Change, Harvard Medical School;
Meharry Medical College, School of Medicine;

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Ya-Ching Hung Program in Global Surgery and Social Change, Harvard Medical School;
Massachusetts General Hospital;

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James Dahm Program in Global Surgery and Social Change, Harvard Medical School;
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and

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Serena Faruque Program in Global Surgery and Social Change, Harvard Medical School;
Brigham and Women’s Hospital; Boston, Massachusetts;

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Michael C. Dewan Program in Global Surgery and Social Change, Harvard Medical School;
Vanderbilt University Medical Center, Nashville, Tennessee;

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Sophie Peeters Program in Global Surgery and Social Change, Harvard Medical School;
David Geffen School of Medicine at UCLA, Los Angeles, California;

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Sonal Sachdev Program in Global Surgery and Social Change, Harvard Medical School;
University of New South Wales, Sydney, New South Wales, Australia

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Kee B. Park Program in Global Surgery and Social Change, Harvard Medical School;

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OBJECTIVE

In 2000, the global density of neurosurgeons was estimated at 1 per 230,000 population, which remains the most recent estimate of the global neurosurgeon workforce density. In 2004, the World Health Organization (WHO) estimated that there were 33,193 neurosurgeons worldwide, including trainees. There have been no updates to this estimate in the past decade. Moreover, only WHO region–level granularity regarding neurosurgeon distribution exists; country-level estimates are limited. The neurosurgery workforce is a crucial component to meeting the growing burden of neurosurgical diseases, which not only represent high absolute incidences and prevalences, but also represent correspondingly high disability-adjusted life years affecting hundreds of millions of people worldwide. Combining the lack of knowledge about the availability of the neurosurgical workforce and the increasing demand for neurosurgical services underscores the need for a system of neurosurgical workforce density surveillance.

METHODS

This study involved 3 key steps: 1) global survey/literature review to obtain the number of working neurosurgeons per WHO-recognized country, 2) regression to interpolate any missing data, and 3) calculation of workforce densities and comparison to available historical data by WHO region.

RESULTS

Data for 198 countries were collected (158) or interpolated (40). The global total number of neurosurgeons was estimated at 49,940. Overall, neurosurgeon density ranged from 0 to 58.95 (standardized to per 1,000,000 population) with a median of 3.56 (IQR 0.29–8.26). Thirty-three countries were found to have no neurosurgeons (zero). The highest density, 58.95, was in Japan, where 7495 neurosurgeons are taking care of a population of 127,131,800.

CONCLUSIONS

In 2015, the Lancet Commission on Global Surgery estimated that 143 million additional surgical procedures are needed in low- and middle-income countries each year, and a subsequent study revealed that approximately 15% of those surgical procedures are neurosurgical. Based on our results, we can conclude that there are approximately 49,940 neurosurgeons currently, worldwide. The availability of neurosurgeons appears to have increased in all geographic regions over the past decade, with Southeast Asia experiencing the greatest growth. Such remarkable expansion should be assessed to determine factors that could play a role in other regions where the acceleration of growth would be beneficial.

ABBREVIATIONS

GNI = gross national income; IQR = interquartile range; LMICs = low- and middle-income countries; PGSSC = Program for Global Surgery and Social Change; WFNS = World Federation of Neurosurgical Societies; WHO = World Health Organization.

OBJECTIVE

In 2000, the global density of neurosurgeons was estimated at 1 per 230,000 population, which remains the most recent estimate of the global neurosurgeon workforce density. In 2004, the World Health Organization (WHO) estimated that there were 33,193 neurosurgeons worldwide, including trainees. There have been no updates to this estimate in the past decade. Moreover, only WHO region–level granularity regarding neurosurgeon distribution exists; country-level estimates are limited. The neurosurgery workforce is a crucial component to meeting the growing burden of neurosurgical diseases, which not only represent high absolute incidences and prevalences, but also represent correspondingly high disability-adjusted life years affecting hundreds of millions of people worldwide. Combining the lack of knowledge about the availability of the neurosurgical workforce and the increasing demand for neurosurgical services underscores the need for a system of neurosurgical workforce density surveillance.

METHODS

This study involved 3 key steps: 1) global survey/literature review to obtain the number of working neurosurgeons per WHO-recognized country, 2) regression to interpolate any missing data, and 3) calculation of workforce densities and comparison to available historical data by WHO region.

RESULTS

Data for 198 countries were collected (158) or interpolated (40). The global total number of neurosurgeons was estimated at 49,940. Overall, neurosurgeon density ranged from 0 to 58.95 (standardized to per 1,000,000 population) with a median of 3.56 (IQR 0.29–8.26). Thirty-three countries were found to have no neurosurgeons (zero). The highest density, 58.95, was in Japan, where 7495 neurosurgeons are taking care of a population of 127,131,800.

CONCLUSIONS

In 2015, the Lancet Commission on Global Surgery estimated that 143 million additional surgical procedures are needed in low- and middle-income countries each year, and a subsequent study revealed that approximately 15% of those surgical procedures are neurosurgical. Based on our results, we can conclude that there are approximately 49,940 neurosurgeons currently, worldwide. The availability of neurosurgeons appears to have increased in all geographic regions over the past decade, with Southeast Asia experiencing the greatest growth. Such remarkable expansion should be assessed to determine factors that could play a role in other regions where the acceleration of growth would be beneficial.

In 2000, the global density of neurosurgeons was estimated at 1 per 230,000 population, which remains the most recent estimate of the global neurosurgeon workforce density.2 This falls significantly short of the target growth of 1% per 5 years in the ratio of neurosurgeons per 100,000 population set by experts in the United States in 1977,9 or 1 neurosurgeon per 100,000 as we have come to understand it herein. Whether following the estimated findings from 2000 or the aspirational recommendations from 1977, the estimated need of neurosurgeons ranges from 29,388 to 73,470 based upon a global population of 7.347 billion in 2015. The deficit is most pronounced in low- and middle-income countries (LMICs), where the neurosurgeon density can be as low as 1 neurosurgeon per 9,000,000 people. In 2004, the World Health Organization (WHO) estimated that there were 33,193 neurosurgeons worldwide.7 There have been no updates to this estimate in the past decade. Moreover, only WHO global region–level granularity regarding neurosurgeon distribution exists; country-level estimates are limited.

The neurosurgery workforce is a crucial component to meeting the growing burden of neurosurgical diseases such as traumatic brain injuries and cerebrovascular accidents, which are rapidly increasing with global development and lifestyle changes.1,4 Additionally, pathologies such as traumatic spinal injuries, brain and spinal tumors, and congenital abnormalities are also increasing or continue to be major causes of morbidity and mortality. These diseases represent not only high absolute incidences and prevalences but also correspondingly high disability-adjusted life years, affecting hundreds of millions of people worldwide.

Combining the lack of knowledge about the availability of the neurosurgical workforce and the increasing demand for neurosurgical services underscores the need for a system of neurosurgical workforce density surveillance. Furthermore, such a system of surveillance is most valuable at national and subnational levels. To address this need, we conducted a global assessment of the available neurosurgical workforce, primarily by surveying relevant professional societies and providers. This work was completed in collaboration with and with support from the WHO, the World Federation of Neurosurgical Societies (WFNS), and the Global Neurosurgery Initiative under the Program for Global Surgery and Social Change (PGSSC) at Harvard Medical School.

Methods

This study involved 3 key steps: 1) global survey/literature review to obtain the number of working neurosurgeons per WHO-recognized country, 2) regression to interpolate any missing data, and 3) a calculation of workforce densities and comparison to available historical data by WHO region.

Global Survey

From February 2016 to July 2017, primary data were collected and assessed via a global survey carried out through a collaboration between the WHO, WFNS, and PGSSC. This survey inquired about the number of fully trained neurosurgical providers in each country, with a specific focus on obtaining primary data from LMICs. The survey was administered via email to neurosurgeons, associated healthcare providers, ministries of health, WHO country offices, and national hospitals, in that order of prioritization. Country-specific neurosurgeons were identified through WFNS membership records, country/regional neurosurgical societies and associations (e.g., European Association of Neurosurgical Societies, Asian Australasian Society of Neurological Surgeons), WHO country offices, the WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) registry, and the American Association of Neurological Surgeons (AANS) member database as well as Google and PubMed literature searches. PubMed searches consisted of the following query string targeting author affiliations:

[country][ad] AND (neurosurg*[ad] OR neurological surgeon[ad] OR neurosurgeon*[ad]

Contacts were emailed up to 3 times until new country-specific contacts were identified and the process was exhausted. For countries in which the ministry of health or other healthcare body confirmed an absence of neurosurgeons, a value of zero was documented. For countries for which primary data could not be obtained, data from available publications which specified a specific country’s neurosurgical workforce were used.

Regression Methodology

For each country without respondent contacts or a publicly available neurosurgeon census (40 of 198 countries), a linear regression was created to predict the neurosurgeon workforce size in 2016. Independent variables were chosen from World Bank and WHO data from which an optimized model (adjusted R2 0.902) was obtained via a correlation matrix. Final independent variables included population, gross national income (GNI) per capita, health expenditure per capita, and medical workforce of each country. Regression model calibration and discrimination, as well as model validation, was performed in the statistical software package R (R Foundation for Statistical Computing). After obtaining the estimated numbers of neurosurgeons, the density of neurosurgeons was calculated by dividing numbers of neurosurgeons by the 2016 population for each country.

Forty-two varied covariates from the World Bank’s World Development Indicators were used as the data sources to build a regression model to estimate the workforce in the countries without direct data. We used a correlation matrix to find the variables most correlated with the known workforce data, as well as variables maximally uncorrelated to each other. Using this information, we constructed several good simple linear models of 4 variables because it was noted that employing more than 4 variables did not lead to substantial improvement in R2. We then optimized for R2, as well as the Akaike information criterion and Bayes information criterion, on several good models to verify our choice. Finally, experiential and epidemiological judgment was used to verify our choice of covariates. The regression equation is as follows:

The regression coefficients and intercept are shown in Table 1.

TABLE 1.

Model regression coefficients and intercept

DescriptionValue
Intercept−84.241748
Coefficients
 Population (millions)5.836826
 GDP (billion $) per capita0.021733
 Health expenditure ($) per capita−0.152381
 Physicians per 100015.342577

GDP = gross domestic product.

Data Comparison

Data compiled through survey and regression were compared to the regional assessments performed by the WHO in 2004. Regression data were used to fill in those countries that lacked primary data from the survey or secondary data from the literature review. Results were categorized based upon the 6 WHO regions (African Region [AFR], Region of the Americas [AMR], South-East Asia Region [SEAR], European Region [EUR], Eastern Mediterranean Region [EMR], and Western Pacific Region [WPR]) and World Bank income categories (low, middle, and high income). Endpoints of comparison were absolute numbers of neurosurgeons present, and these comparisons were used to calculate relative rates of growth within regions compared to population growth. The growth rate was calculated using Microsoft Excel.

Results

Global Survey

The survey sent through the WHO, WFNS, and PGSSC networks yielded data on 129 countries. Data for 29 countries were obtained through the literature.

Regression

Regression was used to interpolate data for an additional 40 countries. The independent variables were chosen from World Bank and WHO data. An optimized model yielded an adjusted R2 value of 0.902. Final independent variables included population, GNI per capita, health expenditure per capita, and medical workforce of each country.

There were 3 countries that we were not able to predict in the model due to incomplete information on the independent variables. These countries were Libya, Somalia, and Kosovo (disputed territory). Seven countries with no reportable data following the data collection period were predicted to have no neurosurgeons available: Bahamas, Barbados, Iceland, Luxembourg, Malta, Maldives, and Palau. Predicted numbers of neurosurgeons ranged from 0 to 5436 (with 5436 being the number predicted for China).

Consolidated Findings

Altogether neurosurgeon availability was collected or predicted for 198 countries: 158 from original sources and 40 modeled (Fig. 1, Supplemental Table). For countries with World Bank designations, data were compiled for 30 low-income countries, 102 middle-income countries, and 53 high-income countries.

FIG. 1.
FIG. 1.

Graphically shows the spectrum of neurosurgeon densities as well as the median and IQR of densities. Each column on the x-axis is a country for which data were collected or interpolated. The y-axis represents densities of neurosurgeons per million population (pop.). Figure is available in color online only.

Of the 198 total countries included, 33 countries reported or were predicted to have zero neurosurgeons available. Of these, 5 were low-income, 18 were middle-income, and 10 were high-income countries representing 16.1%, 16.9%, and 18.5% of countries included within each income category.

Of countries estimated to have at least 1 neurosurgeon available, 35 countries were found to have less than 1 neurosurgeon per 1,000,000. Sixty-percent of these countries were low-income settings, and the remaining 40% were all middle-income. The countries were primarily located in Sub-Saharan Africa and Southeast Asia.

Increasing the neurosurgeon density requirement to 1 per 250,000 population led to an additional 31 countries falling below the stipulation. Nearly all of these countries were low-income or middle-income except Saudi Arabia (75 reported), Singapore (15 reported), and the United Kingdom (220 reported).

When the standard increased to 1 neurosurgeon per 100,000 population, 161 countries were unable to meet the threshold, while 33 could. Of these 33, 75.7% were high-income countries and the remaining 24.3% were middle-income. No low-income countries could meet this standard.

Overall, neurosurgeon density ranged from 0 to 58.95 (standardized to per 1,000,000 population) with a median of 3.56 (interquartile range [IQR] 0.29–8.26). Of countries that had at least 1 working neurosurgeon, the lowest density was in the Democratic Republic of the Congo where reportedly 4 neurosurgeons are providing care for approximately 74,877,030 people. The highest density, 58.95, was in Japan where 7495 neurosurgeons are taking care of a population of 127,131,800 (Fig. 1).

WHO Regions and Growth Rate

Current neurosurgeon densities within the WHO classified regions AFR, AMR, EMR, EUR, SEAR, and WPR were 0.51, 9.73, 3.27, 11.76, 2.59, and 12.08 per 1,000,000 population, respectively. By comparison to 2004, neurosurgical workforce growth was greatest in the South-East Asia Region (388.27%) versus the Region of the Americas, where the workforce remained relatively stagnant with a 10.84% increase. The population growth rates of these 2 regions were 13.65% and 9.48%, respectively (Table 2, Fig. 2).

TABLE 2.

Number of neurosurgeons, population growth rate, and neurosurgeon growth rate stratified by WHO geographic region

No. of Countries RepresentedPopulation
WHO Geographic AreaWHO 2004 Neurosurgeons*Neurosurgeons (2016)Neurosurgeon Density per Million (2016)2004201620042016Population Growth Rate (%)Neurosurgeon Growth Rate (%)
AFR2574880.511647643,958,472963,117,93849.5689.88
AMR860795409.731437895,717,402980,627,0889.4810.84
EMR116320733.271821512,309,000634,615,22223.8778.25
EUR732110,73011.764051951,679,070912,065,031−4.1646.56
SEAR102349952.596121,698,133,2811,929,990,81113.65388.27
WPR14,72222,11412.089251,725,643,1861,830,170,6436.0650.21

AFR = African Region; AMR = Region of the Americas; EMR = Eastern Mediterranean Region; EUR = European Region; SEAR = South-East Asian Region; WHO = World Health Organization; WPR = Western Pacific Region.

Includes trainees.

Number of countries from which data were obtained for the year specified.

FIG. 2.
FIG. 2.

Global map with relative densities of neurosurgeons per million population, with red indicating low densities and green indicating high densities. © OpenStreetMap contributors (http://www.openstreetmap.org/copyright). Figure is available in color online only.

Discussion

In 2015, the Lancet Commission on Global Surgery estimated that 143 million additional surgical procedures are needed in LMICs each year,3 and a subsequent study revealed that approximately 15% of those surgical procedures are neurosurgical.5 A sufficient workforce is needed to meet this neurosurgical burden; however, there are limited available data on the current neurosurgical workforce worldwide. To this end, our paper represents a call to action as opposed to a definitive ascertainment of the worldwide neurosurgical workforce. Moreover, our larger project is dynamic, and this work represents information obtained in a particular temporal interval. Figures are expected to change as new country-level data become attainable or accessible.

Such estimates are vital to determine the countries with the largest need for neurosurgeons. This information will enable governments and professional and international societies to determine where resources should be allocated to reach the optimal neurosurgical workforce to meet the large unmet burden. The need is particularly striking in LMICs, which have the greatest trauma burden and yet have the least access to neurosurgical services.

Neurosurgeon density is a useful measure, as it accommodates for the population of a country. This is the first study to assess neurosurgeon density worldwide in nearly 2 decades and with respondent data from nearly 140 countries. In 2001, El Khamlichi reported that there was a worldwide neurosurgeon density of 1 neurosurgeon per 230,000.2 In developing countries, only 6% of neurosurgeons provide services to 34% of the world’s population.2 In 2 separate WHO neurological workforce assessments published 13 years apart, it was noted that of the 103 countries sampled in 2004, the median number of neurosurgeons was 0.56 per 100,000 population,7 with a notable drop in 2017 of 0.34 neurosurgeons per 100,000 population in 108 sampled countries.8

In a previously published study from 2004, Africa and Southeast Asia had the smallest neurosurgeon densities.7 Our study also found that the densities of those regions remain the smallest when compared to the remaining WHO regions. However, it is encouraging to note that both regions experienced significant increases in the number of neurosurgeons in the past 12 years, with the neurosurgeon growth rate in Africa being 89.9%. The situation has been even more remarkable in Southeast Asia, where the neurosurgeon growth rate is 388.3% (Table 2).

One possible contributing factor for the high neurosurgeon growth rates seen in this study is the greater number of countries for which data were reported compared to previous publications. We report data on 198 countries using the global survey and regression methodology compared to the 103 countries included in the WHO study from 2004 or 108 countries in its 2017 study,7,8 which naturally increases the number of countries included in most regions. Nowhere is this more striking than in Africa, where we reported findings from 47 countries compared to the 16 included in the 2004 report or 40 from a specific survey of the neurosurgical workforce in Africa.2,7

Moreover, the true neurosurgeon growth rate is potentially even higher due to the fact that other studies included neurosurgical trainees in their calculations. In contrast, our study did not include trainees, and given vast differences in training and practice, we allowed respondents to determine the extent of their visible neurosurgical workforce. Differentiation of the constitution of neurosurgical workforce was considered out of the scope of this study. Nonetheless, although it is difficult to compare our data to previous estimates of neurosurgical capacity, given differing methodologies, the inclusion of trainees in the past makes our growth estimates conservative.

An additional limitation of this study is its reliance on suggested densities from 2000 and 1977, which were primarily based upon expert opinion. However, since there have been no updates to these suggestions, this article relies on their relevance and highlights the need to assess in an evidence-based manner how many neurosurgeons are needed to provide care for the global population across its varying settings.

Furthermore, the scope of this study is limited only to the neurosurgical workforce. As mentioned, the additional supporting systems, such as staff, infrastructure, and supply chains, have not been assessed. Accordingly, it is difficult to extrapolate what specific neurosurgical services are available for patients and their quality in varying settings. However, coordinated provision of these services requires the availability and tracking of skilled workforce, which this study accomplishes in the most exhaustive manner to date. Additionally, it is difficult to determine the actual work performed and impact of the existing workforce. Even if a country employs an adequate number of neurosurgeons, many might be retired, working on a part-time basis, primarily research based, or administrative, as well as engaged in other non-neurosurgical activities that decrease the amount of time devoted to providing clinical neurosurgical care.

A final limitation of this study is its reliance on survey and regression. For many countries, especially smaller countries without a neurosurgical society, the survey relied upon surgeon self-reporting to determine the number of neurosurgeons present in each country. In contrast, by targeting relevant professional societies and individuals, we aimed to minimize the impact that secondary sources could play on the results.

Our model predicted 0 neurosurgeons in 7 countries at the time of data collection (i.e., Bahamas, Barbados, Iceland, Luxembourg, Malta, Maldives, and Palau) that may likely be home to at least 1 neurosurgeon. This finding best represents the dynamic/living nature of the larger endeavor to quantify the country-specific neurosurgical workforce as information becomes attainable and accessible. For example, since the end date of the data collection phase (July 2017), we can report a density of at least 3, 10, and 2 neurosurgeons in Iceland, Luxembourg, and the Maldives, respectively. Variations in accessibility of primary sources represent a limitation of the study that we attempted to resolve with predictive modeling. However, predictive modeling also possesses its own limitations as it is in part dependent on using similarities in variables across non-modeled countries to predict/model values for countries without available data.

Our study’s conservative estimation of neurosurgical workforce density should also be contextualized within the provided range of potential neurosurgeons to account for differences in variables across WHO regions. Thus, 0 (zero) does not represent an absolute value, but is rather relative to the variables employed. The regression methodology used to interpolate data for 40 countries included in our results relied upon the accuracy of the underlying data collected. The reported precision of the regression results is within acceptable limits. However, the accuracy can only be determined as governmental institutions and professional societies begin to track, monitor, and update the availability of the neurosurgical workforce—which is at the root of this dynamic/living project.

Despite these limitations, this represents the most comprehensive and inclusive global survey of the neurosurgical workforce to date and serves as a foundation on which to assess worldwide neurosurgical capacity moving forward. In fact, sporadic data availability should serve as a call to action for countries—especially LMICs—to regularly surveil and document their existing neurosurgical workforce and to make the resulting information accessible for priority setting and capacity building efforts.

Conclusions

Based on our results, we can conclude that there are currently approximately 49,940 neurosurgeons worldwide. All geographic regions seem to have increased availability of neurosurgeons over the past decade, with Southeast Asia experiencing the greatest growth. Such remarkable expansion should be assessed to determine factors that could play a role in other regions where the acceleration of growth would be beneficial. At first glance, this significant growth in much of the world seems to nearly meet the density standard we set of 1 neurosurgeon per 100,000; however, this ratio fails to account for the great variability in neurosurgical workforce across and within countries.

As noted elsewhere,1,4,6 it is the non-equitable distribution of skilled neurosurgical workforce in addition to other region-specific factors, such as political instability, modernization, and economic prosperity, particularly within the LMICs, that results in disparities in the availability of neurosurgical care. Unless policymakers take proactive measures to counter the tendency for neurosurgeons to coalesce in one or two major cities, the population outside the catchment area, typically forming the majority of the population, will not be able to access life-saving and disability-averting neurosurgical care when needed.

This study highlights the spread of neurosurgeons across countries and identifies the countries with the greatest needs that currently have no neurosurgeon available. Additionally, variations in regional trends in scaling up neurosurgical workforce underscore the need to identify and remove barriers. Further, the next steps must include assessing the distribution of neurosurgeons to guide policymakers since neurosurgical needs can likely vary significantly both globally and within countries, which underlie referral patterns to higher-level care facilities. In parallel, programs to increase the volume of skilled neurosurgical workforce must be coupled with a strategy to improve access through optimization of distribution. To accomplish this, a systematic and sustained data collection by health policy institutions, governments, and professional societies is needed.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Mukhopadhyay, Punchak, Dahm, Dewan, Peeters, Sachdev, Park. Acquisition of data: Punchak, Rattani, Hung, Dewan, Peeters, Sachdev. Analysis and interpretation of data: Mukhopadhyay, Punchak, Rattani, Hung, Dahm, Faruque, Dewan. Drafting the article: Mukhopadhyay, Punchak, Rattani. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Mukhopadhyay. Statistical analysis: Mukhopadhyay, Punchak, Hung, Dahm, Faruque. Administrative/technical/material support: Mukhopadhyay, Rattani, Dahm. Study supervision: Mukhopadhyay, Park.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

References

  • 1

    Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al.: Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. J Neurosurg [epub ahead of print April 27, 2018. DOI: 10.3171/2017.11.JNS171500]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    El Khamlichi A: African neurosurgery: current situation, priorities, and needs. Neurosurgery 48:13441347, 2001

  • 3

    Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al.: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569624, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Park KB, Johnson WD, Dempsey RJ: Global neurosurgery: the unmet need. World Neurosurg 88:3235, 2016

  • 5

    Sader E, Yee P, Hodaie M: Assessing barriers to neurosurgical care in Sub-Saharan Africa: the role of resources and infrastructure. World Neurosurg 98:682688, 688.e1–688.e3, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Warf BC: Educate one to save a few. Educate a few to save many. World Neurosurg 79 (2 Suppl):15.e1515.e18, 2013

  • 7

    World Health Organization and World Federation of Neurology: Atlas: Country Resources for Neurological Disorders. Geneva: World Health Organization, 2004

  • 8

    World Health Organization and World Federation of Neurology: Atlas: Country Resources for Neurological Disorders, ed 2. Geneva: World Health Organization, 2017

  • 9

    Zuidema GD: The SOSSUS report and its impact on neurosurgery. J Neurosurg 46:135144, 1977

Supplementary Materials

  • Collapse
  • Expand

Illustration from Ferrareze Nunes et al. (pp 1304–1314). Copyright Juan C. Fernandez-Miranda. Published with permission.

  • FIG. 1.

    Graphically shows the spectrum of neurosurgeon densities as well as the median and IQR of densities. Each column on the x-axis is a country for which data were collected or interpolated. The y-axis represents densities of neurosurgeons per million population (pop.). Figure is available in color online only.

  • FIG. 2.

    Global map with relative densities of neurosurgeons per million population, with red indicating low densities and green indicating high densities. © OpenStreetMap contributors (http://www.openstreetmap.org/copyright). Figure is available in color online only.

  • 1

    Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al.: Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. J Neurosurg [epub ahead of print April 27, 2018. DOI: 10.3171/2017.11.JNS171500]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    El Khamlichi A: African neurosurgery: current situation, priorities, and needs. Neurosurgery 48:13441347, 2001

  • 3

    Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al.: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569624, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Park KB, Johnson WD, Dempsey RJ: Global neurosurgery: the unmet need. World Neurosurg 88:3235, 2016

  • 5

    Sader E, Yee P, Hodaie M: Assessing barriers to neurosurgical care in Sub-Saharan Africa: the role of resources and infrastructure. World Neurosurg 98:682688, 688.e1–688.e3, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Warf BC: Educate one to save a few. Educate a few to save many. World Neurosurg 79 (2 Suppl):15.e1515.e18, 2013

  • 7

    World Health Organization and World Federation of Neurology: Atlas: Country Resources for Neurological Disorders. Geneva: World Health Organization, 2004

  • 8

    World Health Organization and World Federation of Neurology: Atlas: Country Resources for Neurological Disorders, ed 2. Geneva: World Health Organization, 2017

  • 9

    Zuidema GD: The SOSSUS report and its impact on neurosurgery. J Neurosurg 46:135144, 1977

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