Mapping the global neurosurgery workforce. Part 2: Trainee density

Saksham Gupta Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts;
Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts;

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Zsombor T. Gal Harvard Medical School, Boston, Massachusetts;

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Tejas S. Athni Harvard Medical School, Boston, Massachusetts;

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Chrystal Calderon Department of Neurosurgery, University of the West Indies, St. Augustine, Trinidad and Tobago;

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William É Callison Harvard Medical School, Boston, Massachusetts;

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Olaoluwa E. Dada College of Medicine, University of Ibadan, Oyo State, Nigeria;

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Winston Lie Harvard Medical School, Boston, Massachusetts;

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Carolyn Qian Harvard Medical School, Boston, Massachusetts;

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Ramya Reddy University of Florida College of Medicine, Gainesville, Florida;

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Myron Rolle Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;

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Ronnie E. Baticulon Department of Neurosciences, Division of Neurosurgery, Philippine General Hospital, University of the Philippines, Manila, National Capital Region, Philippines;

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Bipin Chaurasia Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Madesh Province, Nepal;

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Ellianne J. Dos Santos Rubio Department of Neurosurgery, Curaçao Medical Center, Willemstad, Curaçao;

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Yoshua Esquenazi Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas; and

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Alexandra J. Golby Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts;

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Ahmad F. Pirzad Department of Neurosurgery, Kabul University of Medical Sciences, Kabul, Afghanistan

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Kee B. Park Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts;

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 MD, MPH , on behalf of the WFNS Global Neurosurgery Committee, EANS Global and Humanitarian Neurosurgery Committee, and CAANS Executive Leadership Committee
Free access

OBJECTIVE

A sustainable neurosurgery workforce depends on robust training pipelines, but the size and distribution of the global neurosurgery trainee workforce has not been described. The objective of this study was to identify the types of training programs that exist in the global neurosurgery workforce, the support that trainees receive, the diversity of trainee experiences, and the accreditation processes that exist to regulate training programs.

METHODS

This study was a subanalysis of a cross-sectional survey administered online in all 193 countries and 26 territories, independent states, and disputed regions as defined by the World Bank and United Nations. Participants were identified through neurosurgery society leadership, the personal contacts of the coauthors, and bibliometric and search engine searches. Population-weighted statistics were constructed and segregated by country income level and WHO regions.

RESULTS

Data were obtained for 187 countries (96.9%) and 25 additional territories, states, and disputed regions (96.2%). There were an estimated 1261 training programs and 10,546 trainees within the regions sampled, representing a global pooled density of 0.14 neurosurgery trainees per 100,000 people and a median national density of 0.06 trainees per 100,000 people. There was a higher density in high-income countries (HICs; 0.48 trainees per 100,000 people) compared with upper-middle-income countries (0.09 per 100,000), lower-middle-income countries (0.06 per 100,000), and low-income countries (LICs; 0.07 per 100,000). The WHO European (0.36 per 100,000) and Americas (0.27 per 100,000) regions had the highest trainee densities, while the Southeast Asia (0.04 per 100,000) and African (0.05 per 100,000) regions had the lowest densities. Among countries with training programs, LICs had the poorest availability of subspecialty training and resources such as cadaver laboratories and conference stipends for trainees. Training program accreditation processes were more common in HICs (81.8%) than in low- and middle-income countries (LMICs; 69.2%) with training programs.

CONCLUSIONS

The authors estimate that there are at least 1261 neurosurgery training programs with 10,546 total trainees worldwide. The density of neurosurgery trainees was disproportionately higher in HICs than LMICs, and the WHO European and Americas regions had the highest trainee densities. The trainee workforce in LICs had the poorest access to subspecialty training and advanced resources.

ABBREVIATIONS

COSECSA = College of Surgeons of East, Central, and Southern Africa; HIC = high-income country; LIC = low-income country; LMIC = low- and middle-income country; LoMIC = lower-middle-income country; UpMIC = upper-middle-income country; WB = World Bank.

OBJECTIVE

A sustainable neurosurgery workforce depends on robust training pipelines, but the size and distribution of the global neurosurgery trainee workforce has not been described. The objective of this study was to identify the types of training programs that exist in the global neurosurgery workforce, the support that trainees receive, the diversity of trainee experiences, and the accreditation processes that exist to regulate training programs.

METHODS

This study was a subanalysis of a cross-sectional survey administered online in all 193 countries and 26 territories, independent states, and disputed regions as defined by the World Bank and United Nations. Participants were identified through neurosurgery society leadership, the personal contacts of the coauthors, and bibliometric and search engine searches. Population-weighted statistics were constructed and segregated by country income level and WHO regions.

RESULTS

Data were obtained for 187 countries (96.9%) and 25 additional territories, states, and disputed regions (96.2%). There were an estimated 1261 training programs and 10,546 trainees within the regions sampled, representing a global pooled density of 0.14 neurosurgery trainees per 100,000 people and a median national density of 0.06 trainees per 100,000 people. There was a higher density in high-income countries (HICs; 0.48 trainees per 100,000 people) compared with upper-middle-income countries (0.09 per 100,000), lower-middle-income countries (0.06 per 100,000), and low-income countries (LICs; 0.07 per 100,000). The WHO European (0.36 per 100,000) and Americas (0.27 per 100,000) regions had the highest trainee densities, while the Southeast Asia (0.04 per 100,000) and African (0.05 per 100,000) regions had the lowest densities. Among countries with training programs, LICs had the poorest availability of subspecialty training and resources such as cadaver laboratories and conference stipends for trainees. Training program accreditation processes were more common in HICs (81.8%) than in low- and middle-income countries (LMICs; 69.2%) with training programs.

CONCLUSIONS

The authors estimate that there are at least 1261 neurosurgery training programs with 10,546 total trainees worldwide. The density of neurosurgery trainees was disproportionately higher in HICs than LMICs, and the WHO European and Americas regions had the highest trainee densities. The trainee workforce in LICs had the poorest access to subspecialty training and advanced resources.

In Brief

Researchers assessed the number and quality of neurosurgery training programs worldwide. They found that while there are more than 10,000 trainees, training quality and availability varied widely. This study highlights several regions that need more support to develop neurosurgery training programs.

A sustainable neurosurgery workforce depends on the development and maintenance of robust training systems that prepare medical graduates to manage its population’s neurosurgery needs.1 There is a tremendous variation of neurosurgery training practices across the world. Some countries rely on apprenticeship models with individual neurosurgeons, while others have standardized and regulated training requirements. Some countries have no trainees in place to sustain their future workforce.2

The main purpose of trainees is education so that they can join the consultant workforce, but they also use their training to provide value to the hospitals in which they work, often providing around-the-clock coverage for emergency services and operating rooms. One United States institution estimated the collective work of their on-call neurosurgery residents could generate more than $1.6 million annually in potential reimbursements.3

In this study, we sought to provide the first systematic estimation of the density of neurosurgery trainees and opportunities. These data are designed to help neurosurgeons, neurosurgery departments, and neurosurgery societies guide their educational efforts to improve access to neurosurgery training worldwide.

Methods

Objectives

The primary objective of this study was to quantify the number and distribution of neurosurgery trainees around the world. Secondary objectives included identifying the types of training programs that exist, the support that trainees receive, the diversity of trainee experiences, and the accreditation processes that exist to regulate training programs. This study was exempted from review by the Harvard Medical School IRB.

Study Design and Data Sources

The study protocol is detailed in our companion paper.45 Briefly, this paper is a subanalysis of a global cross-sectional survey with a hierarchical sample collection that was administered between October 2022 and March 2023 (Supplementary Fig. 1). Survey results were elicited from representatives in the 193 countries and 26 territories, independent states, and disputed regions defined by the World Bank (WB) and United Nations. All participants were either attending neurosurgeons, residents or fellows in neurosurgery, or general surgeons (n = 1) with medical doctorate degrees or equivalents (i.e., MBBS, MBBCh, etc.). Data were not obtained for 6 countries (Cuba, Iraq, Nigeria, Qatar, Tajikistan, and Turkey) and 1 independent economy (Macau), and the data available represented 96.9% of all countries and 95.4% of the global population. Countries with a population of fewer than 80,000 people were assumed to have no neurosurgery trainees if online public information was available about their hospitals and indicated no existing neurosurgery services.

Countries were classified by 2021 WB designation into low-income countries (LICs), lower-middle-income countries (LoMICs), upper-middle-income countries (UpMICs), and high-income countries (HICs).4 All non-HICs are collectively referred to as low- and middle-income countries (LMICs).

Statistical Analysis

All statistical analysis was performed in R (version 4.2.1, The R Project). Descriptive population-weighted statistics were calculated. Given the near-complete data collection, trainee densities in this study were assumed to be representative of global trainee densities.

Results

Survey Respondents

There were 171 survey respondents who provided data for 187 (96.9%) of 193 countries and 25 (96.2%) of 26 additional territories, independent states, and disputed regions as defined. The median age of the participants was 43 (interquartile range 36–55) years and 12.3% were women. Respondents included leaders of neurosurgery societies (n = 4, 2.3%), department chairs (n = 30, 17.5%), consultant neurosurgeons (n = 102, 59.6%), and residents and fellows (n = 29, 17.0%), among others. Most respondents had affiliations with organized neurosurgery societies (81.9%) and were practicing in LMICs (63.7%).

Trainee Workforce and Training Programs

There were an estimated 1261 training programs with 10,546 neurosurgery trainees in the countries and other regions sampled worldwide (excluding Cuba, Iraq, Qatar, Macau, Nigeria, Tajikistan, and Turkey), representing a pooled global trainee density of 0.14 per 100,000 people and a median trainee density of 0.06 per 100,000 people (Fig. 1). The pooled trainee densities in HICs, UpMICs, LoMICs, and LICs were 0.48, 0.09, 0.06, and 0.07 trainees per 100,000 people, respectively (Fig. 2A). The WHO Southeast Asia and African regions had the lowest pooled trainee density (0.04 and 0.05 trainees per 100,000 people, respectively; Fig. 2B). The WHO European and Americas regions had the highest density (0.36 and 0.27 trainees per 100,000 people, respectively; Fig. 2B).

FIG. 1.
FIG. 1.

Map showing the neurosurgery trainee density per 100,000 people. Countries near the average national median density (0.1 trainees per 100,000 people) are demonstrated in white, those increasingly above the median are demonstrated in increasingly dark blue, and those increasingly below the median are demonstrated in increasingly dark red. This figure was created with Datawrapper (Datawrapper GmbH).

FIG. 2.
FIG. 2.

Bar graphs of neurosurgery trainee density according to country income levels (A) and WHO regions (B). EMR = Eastern Mediterranean region; SEAR = Southeast Asia region; WPR = Western Pacific region.

The majority of training programs were in HICs (n = 696) rather than LMICs (n = 531). There were no training programs in 22.4% of HICs and 35.2% of LMICs. Training programs varied by type: countries with training programs had postgraduate neurosurgery residencies (89.8%), neurosurgery fellowships after a general surgery residency (40.6%), and postgraduate neurosurgery apprenticeships with individual surgeons (39.1%). Among 109 countries that had training programs and available data on training accreditation, 81 programs (74.3%) had a formal accreditation process to certify their programs. There were accreditation processes in place in 36 (81.8%) of 44 HICs and 45 (69.2%) of 65 LMICs with available data on accreditation.

Subspecialization and Resources

Trainees in LICs tended to have less access to training in neurotrauma, neurocritical care, tumor, open vascular, endovascular, functional, pediatric, spine, and peripheral nerve surgery than trainees in UpMICs/LoMICs, who had less access than trainees in HICs (Fig. 3). The greatest differences between HICs and LICs were in the percentage of trainees with exposure to functional and movement disorder surgery (57.4% vs 4.0%) and endovascular neurosurgery (54.9% vs 6.4%). Furthermore, trainees in LICs had lower access to cadaver laboratories and stipends for conferences and clinical travel (Fig. 3).

FIG. 3.
FIG. 3.

Bar graph of the proportion of trainees in HICs, UpMICs, LoMICs, and LICs with access to various subspecialty training and training resources (cadaver laboratories and stipends). Only countries with trainees are included. The vertical dotted line separates training availability in specific neurosurgery subspecialties (left side of the line) and extra general materials available to trainees (right side of the line).

Discussion

We estimate that there are approximately 1261 neurosurgery training programs and 10,546 trainees worldwide, and that the density of trainees is many times higher in HICs than UpMICs, LoMICs, and LICs. We identified several regional disparities in trainee workforce density, including fewer trainees per population in the WHO Southeast Asia and African regions. Trainees in LICs also had the least exposure to subspecialty training. These data serve as a baseline estimate to measure and monitor the growth of the neurosurgery trainee workforce. Although there is no recommended per capita density of neurosurgery trainees, the wide discrepancy between HICs and LMICs suggests that there is a dire need for more trainees, formal training programs, and subspecialization training in LMICs. These data can also help organizations and societies plan their educational outreach and development efforts.

Data Evaluation

Improving surgical educational opportunities has been identified as a priority in LMICs.5 Similar to other surgical subspecialties, fewer neurosurgery training programs and a smaller trainee density was identified in LMICs compared with HICs. This disparity is likely linked to other drivers of worse medical outcomes overall in LMICs, including less robust health systems, less medical infrastructure, and less financing for healthcare and medical education. This study also expands upon prior work identifying the relative lack of subspecialty training opportunities, cadaveric dissection laboratories, and resources for research in certain LMIC contexts.68 We found that neurosurgery trainees in lower-income countries tended to have less exposure to subspecialty topics and access to resources for training and research. This difference was especially stark for functional and vascular surgery, which limits the ability of trainees in LICs to provide care for epilepsy and stroke (Fig. 3). Disparities in exposure to spine and peripheral nerve surgery were also identified, but these disparities do not account for the quantity of trainees in other specialties who overlap in managing these conditions (i.e., orthopedics or plastic surgery).

There is also room for improvement for trainee subspecialization training in HICs, especially given the known associations with a focused and subspecialized practice and clinical outcomes for complex neurosurgery.912 There is momentum and pressure in HICs to increase trainee exposure to topics in global neurosurgery. For example, surveys and working groups have demonstrated that trainees and consultants in HICs feel high levels of interest, but have limited opportunities for involvement during training and into their careers.1315

The WHO Southeast Asia and African regions had the lowest trainee densities. Southeast Asia contains a diverse range of nations, including the highly population-dense Bangladesh and India, and the island-based Indonesia, Sri Lanka, and the Maldives. Each of these geographies brings their own challenges and opportunities for neurosurgery, especially in effective patient triage.16,17 Several innovative attempts have been made by Southeast Asian neurosurgeons and collaborators to improve the quality of training, including a recent educational boot camp in Myanmar.18 There have been several centralized attempts to standardize and expand neurosurgery training in India, proposals to lengthen training times, and incorporate skills laboratories for all trainees.17 Trainees may also be deployed in locations that can serve their education and improve access to care, which is currently implemented in Indonesia.

Surveys of young neurosurgeons and trainees in Africa highlighted some of the educational limitations that most trainees face, including low exposure to educational conferences, inability to attend national/international research conferences, and low access to cadaver laboratories.19,20 Major regional training centers are organized by the West African College of Surgeons and the College of Surgeons of East, Central, and Southern Africa (COSECSA), so supporting and working with these organizations may help build more training opportunities.21 There is a growing movement promoting global neurosurgery among medical students in African countries, so capitalizing on this motivation by increasing training opportunities for these students is paramount to fulfilling and sustaining the global neurosurgery workforce needs.22,23 Regional multi-institutional efforts to understand the stopgaps in the training pipeline serve as an example to other LMIC contexts with low trainee densities.7,24,25

The WHO European and Americas regions have the highest trainee densities. There is a need in these regions to expand neurosurgery education to include topics in global neurosurgery, particularly for HIC trainees, to improve the confidence of trainees in global neurosurgery and in broader public health advocacy.13,24,26,27

Solutions to the Trainee Shortage

Several solutions to the global trainee shortage have been posited, ranging from regional training conferences, "twinning" programs between departments and societies,15,2730 virtual education,3133 novel technologies that facilitate real-time remote collaboration and teaching,31 and collaborative training opportunities, among others.3436 Neurosurgery trainees also report that insufficient funding or the need to pay for their own education are considerable barriers to training.37 Regional educational centers of excellence such as CURE Uganda may help reduce costs associated with subspecialty training, which is often located in HICs.38

Regional and national neurosurgery societies are encouraged to develop formal accreditation processes for training programs in all countries. These processes should have a minimum set of standards and contain additional training requirements depending on each country’s disease burden.

In particular, the quality of training is diverse and variable across the African region. This situation is complex due to the region’s historical colonial legacy, resulting in Anglophone/Francophone programs across the region. Suggestions to harmonize such programs are now regularly promoted; one such approach would be to promote the development of an Anglophone African Board of Neurological Surgery encompassing the Anglophone training programs in the East, Central, and Southern Africa Region (e.g., COSECSA), the West African College, the South African College of Neurosurgeons, and the Egyptian training programs; and a separate Francophone African Board of Neurological Surgery encompassing the diverse Francophone programs in North and West Africa. In due course, the two lingual groups would consider developing a unified African Board of Neurological Surgery.

Cadaveric dissection laboratories are a gold standard for trainees to practice complex approaches outside the operating room, and expanding access to these laboratories can improve trainee confidence.39 Several efforts to develop regional dissection laboratories have benefitted dozens to hundreds of trainees and consultants.40 A variety of novel digital/virtual/augmented reality tools and simulation models may be effective tools to supplement education when cadaver laboratories are unavailable, particularly as endovascular treatment modalities have reduced trainee exposure to skull base approaches in open vascular cases.13,24,33,41 Neurosurgery education is not limited to trainees; longitudinal outreach programs (including "twinning" programs) and courses educate consultant neurosurgeons and trainees in complex neurosurgery with the goal of creating self-sustaining training programs.28,4244

There are several challenges in building a system to provide neurosurgical care that are related to building the trainee workforce. Neurosurgery training should be based on the needs and resources of each population, including HIC-led education courses for LMIC trainees. Trainees also depend on sufficient resources and the presence of allied professionals (nurses, first responders, neuromonitoring technicians) to focus on learning neurosurgery.

Setting Targets for 2030

The authors posit the need for a central, organized effort to estimate the neurosurgery trainee workforce and resources available to trainees in 2030. Targets for 2030 should be set after multilateral discussions with representatives from national and regional neurosurgery societies present and should establish goals for the neurosurgery trainee density in countries in different WHO regions and WB income levels. They should set goals for how training should be different according to specific national needs, and how centers of excellence in each WHO region can be used to support trainees in nations with poor opportunities. The de-identified data from this study and future efforts should be centrally stored to allow for trend analysis.

Limitations of the Study

This study has several pertinent limitations. Selection bias is present in the participants selected, given that the majority were found either through already-existing personal connections in global neurosurgery or through bibliometric searches, which is more likely to identify academic neurosurgeons. This bias may result in an overestimation of the trainee workforce given a potential desire of participants to inflate their workforce numbers to improve their reputation. Participants may also be biased to underestimate trainee numbers to encourage external support for their trainees. This study does not include trainees that are not formally neurosurgeons, but do perform some neurosurgery procedures in locations where task-sharing and task-shifting are necessary, so the workforce may be underestimated in some lower-income or developing countries.

Conclusions

There are an estimated 10,546 neurosurgery trainees in 1261 training programs around the world, representing a pooled global density of 0.14 neurosurgery trainees per 100,000 people. The consultant neurosurgeon density was higher in HICs than UpMICs, LoMICs, and LICs, and the trainee density was highest in the WHO European region. Most training programs were in HICs, and programs in HICs were more likely to have accreditation processes. Trainees in LICs had the least access to subspecialty training and cadaver laboratories.

Appendix

WFNS Global Neurosurgery Committee

Jebet B. Cheserem, MD,1 Abdesaamad El Ouahabi, MD,2 Tariq Khan, MD,3 and Angelos Kolias, MD, MSc, PhD4

EANS Global and Humanitarian Neurosurgery Committee

Andreas K. Demetriades, MBBChir, MPhil,5 Lukas Rasulic, MD, PhD,6 Nicolas Foroglou, MD, PhD,7 Debora Garozzo, MD,8 Pablo Gonzalez-Lopez, MD, PhD,9 Marcel Ivanov, MD, PhD,10 Jesus Lafuente, MD, PhD,11 Nicoló Marchesini, MD,12 Fatos Olldashi, MD,13 Vincenzo Paterno, MD,14 Ondra Petr, MD, PhD,15 Kresimir Rotim, MD, PhD,16 Jamil Rzaev, MD, PhD,17 Jake Timothy, MD,18 Magnus Tisell, MD, PhD,19 and Massimiliano Visocchi, MD, PhD20

CAANS Executive Leadership Committee

Ignatius Esene, MD, MSc, PhD, MPH,21 and Mubashir M. Qureshi, MBChB, MMed1

1Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya; 2Department of Neurosurgery, Mohammed Vth University, School of Medicine, Hôpital des Spécialités ONO, Rabat, Morocco; 3Department of Neurosurgery, Northwest School of Medicine, Peshawar, Khyber Pakhtunkhwa, Pakistan; 4Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridgeshire, United Kingdom; 5Department of Neurosurgery, Royal Infirmary, Edinburgh, Lothian, United Kingdom; 6Department of Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia; 7Department of Neurosurgery, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Greece; 8Department of Neurosurgery, Mediclinic Parkview Hospital, Dubai, UAE; 9Department of Neurosurgery, General University Hospital Alicante, Spain; 10Department of Neurosurgery, Sheffield Teaching Hospital, NHS Foundation Trust, Sheffield, South Yorkshire, United Kingdom; 11Spine Center, Hospital Del Mar, Barcelona, Catalonia, Spain; 12Department of Neurosurgery, University Hospital Borgo Trento, Verona, Veneto, Italy; 13Department of Neurosurgery, University Hospital of Trauma, Tirana, Albania; 14Department of Neurosurgery, International Neuroscience Institute, Hannover, Lower Saxony, Germany; 15Department of Neurosurgery, Medical University Innsbruck, Tyrol, Austria; 16Department of Neurosurgery, University Hospital Sisters of Mercy, Zagreb, Croatia; 17Federal Neurosurgical Center, Novosibirsk, Novosibirsk Oblast, Russian Federation; 18Department of Neurosurgery, Leeds General Infirmary, Leeds, West Yorkshire, United Kingdom; 19Department of Neurosurgery, Sahlgrenska University Hospital, Göteborg, Västra Götaland, Sweden; 20Institute of Neurosurgery, Catholic University of Rome, Roma Provincia, Italy; and 21Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon.

Acknowledgments

Mr. Athni was supported by the National Institute of General Medical Sciences, NIH, under grant no. T32GM144273. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the NIH.

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: Gupta, Gal, Athni, Calderon, Callison, Dada, Lie, Qian, Reddy, Rolle, Chaurasia, Park. Acquisition of data: Gupta, Gal, Athni, Calderon, Callison, Dada, Lie, Qian, Reddy, Rolle, Baticulon, Chaurasia, Dos Santos Rubio, Esquenazi, Golby, Park. Analysis and interpretation of data: Gupta, Baticulon, Chaurasia, Dos Santos Rubio, Esquenazi, Golby, Park. Drafting the article: Gupta, Pirzad. Critically revising the article: Gupta, Gal, Athni, Calderon, Callison, Dada, Lie, Qian, Reddy, Rolle, Baticulon, Chaurasia, Golby, Park. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Gupta. Statistical analysis: Gupta, Gal, Park. Administrative/technical/material support: Pirzad, Park. Study supervision: Chaurasia, Golby, Park.

Supplemental Information

Online-Only Content

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

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    Kanmounye US, Robertson FC, Thango NS, et al. Needs of young African neurosurgeons and residents: a cross-sectional study. Front Surg. 2021;8:647279.

  • 20

    Sader E, Yee P, Hodaie M. Barriers to neurosurgical training in Sub-Saharan Africa: the need for a phased approach to global surgery efforts to improve neurosurgical care. World Neurosurg. 2017;98:397402.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ukachukwu AK, Still MEH, Seas A, et al. Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030. J Neurosurg. 2022;138(4):11021113.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Dada OE, Ooi SZY, Bukenya GW, et al. Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a continental, multi-centre, cross-sectional study. Front Surg. 2022;9:766325.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kanmounye US, Zolo Y, Tsopmene MRD, et al. Understanding the motivations, needs, and challenges faced by aspiring neurosurgeons in Africa: an E-survey. Br J Neurosurg. 2022;36(1):3843.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Ferraris KP, Matsumura H, Wardhana DPW, et al. The state of neurosurgical training and education in East Asia: analysis and strategy development for this frontier of the world. Neurosurg Focus. 2020;48(3):E7.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Jean WC, Huynh T, Pham TA, Ngo HM, Syed HR, Felbaum DR. A system divided: the state of neurosurgical training in modern-day Vietnam. Neurosurg Focus. 2020;48(3):E2.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Shlobin NA, Kanmounye US, Ozair A, et al. Educating the next generation of global neurosurgeons: competencies, skills, and resources for medical students interested in global neurosurgery. World Neurosurg. 2021;155:150159.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Gandy K, Castillo H, Rocque BG, Bradko V, Whitehead W, Castillo J. Neurosurgical training and global health education: systematic review of challenges and benefits of in-country programs in the care of neural tube defects. Neurosurg Focus. 2020;48(3):E14.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Almeida JP, Velásquez C, Karekezi C, et al. Global neurosurgery: models for international surgical education and collaboration at one university. Neurosurg Focus. 2018;45(4):E5.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Maleknia P, Shlobin NA, Johnston JM Jr, Rosseau G. Establishing collaborations in global neurosurgery: the role of InterSurgeon. J Clin Neurosci. 2022;100:164168.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Fuller AT, Barkley A, Du R, et al. Global neurosurgery: a scoping review detailing the current state of international neurosurgical outreach. J Neurosurg. 2021;134(3):13161324.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Sommer F, Waterkeyn F, Hussain I, et al. Feasibility of smart glasses in supporting spinal surgical procedures in low- and middle-income countries: experiences from East Africa. Neurosurg Focus. 2022;52(6):E4.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Pascual JSG, Khu KJO. Resources for operative neurosurgical education among trainees in the Philippines. World Neurosurg. 2022;165:e292e297.

  • 33

    Nicolosi F, Rossini Z, Zaed I, Kolias AG, Fornari M, Servadei F. Neurosurgical digital teaching in low-middle income countries: beyond the frontiers of traditional education. Neurosurg Focus. 2018;45(4):E17.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Rubiano AM, Griswold DP, Adelson PD, et al. International neurotrauma training based on north-south collaborations: results of an inter-institutional program in the era of global neurosurgery. Front Surg. 2021;8:633774.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Karekezi C, El Khamlichi A, El Ouahabi A, et al. The impact of African-trained neurosurgeons on sub-Saharan Africa. Neurosurg Focus. 2020;48(3):E4.

  • 36

    Ormond DR, Kahamba J, Lillehei KO, Rutabasibwa N. Overcoming barriers to neurosurgical training in Tanzania: international exchange, curriculum development, and novel methods of resource utilization and subspecialty development. Neurosurg Focus. 2018;45(4):E6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Garba DL, Fadalla T, Sarpong K, et al. Access to training in neurosurgery (Part 2): the costs of pursuing neurosurgical training. Brain Spine. 2022;2:100927.

  • 38

    Kato Y, Liew BS, Sufianov AA, et al. Review of global neurosurgery education: horizon of neurosurgery in the developing countries. Chin Neurosurg J. 2020;6:19.

  • 39

    Kshettry VR, Mullin JP, Schlenk R, Recinos PF, Benzel EC. The role of laboratory dissection training in neurosurgical residency: results of a national survey. World Neurosurg. 2014;82(5):554559.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Konan ML, Diaby R, Ghomsi NC, et al. Establishing the first neurosurgical skill laboratory in West Africa: an initiative for an affordable regional education center. World Neurosurg X. 2022;15:100122.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Gasco J, Holbrook TJ, Patel A, et al. Neurosurgery simulation in residency training: feasibility, cost, and educational benefit. Neurosurgery. 2013;73(suppl 1):39-45.

  • 42

    Davis MC, Rocque BG, Singhal A, Ridder T, Pattisapu JV, Johnston JM Jr. State of global pediatric neurosurgery outreach: survey by the International Education Subcommittee. J Neurosurg Pediatr. 2017;20(2):204210.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Lu Z, Tshimbombu TN, Abu-Bonsrah N, et al. Transnational capacity building efforts in global neurosurgery: a review and analysis of their impact and determinants of success. World Neurosurg. 2023;173:188198.e3.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Haji FA, Lepard JR, Davis MC, et al. A model for global surgical training and capacity development: the Children’s of Alabama-Viet Nam pediatric neurosurgery partnership. Childs Nerv Syst. 2021;37(2):627636.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Gupta S, Gal ZT, Athni TS, et al. Mapping the global neurosurgery workforce. Part 1: Consultant neurosurgeon density. J Neurosurg. Published online January 16, 2024. doi:10.3171/2023.9.JNS231615

    • PubMed
    • Search Google Scholar
    • Export Citation

Supplementary Materials

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  • Expand
  • FIG. 1.

    Map showing the neurosurgery trainee density per 100,000 people. Countries near the average national median density (0.1 trainees per 100,000 people) are demonstrated in white, those increasingly above the median are demonstrated in increasingly dark blue, and those increasingly below the median are demonstrated in increasingly dark red. This figure was created with Datawrapper (Datawrapper GmbH).

  • FIG. 2.

    Bar graphs of neurosurgery trainee density according to country income levels (A) and WHO regions (B). EMR = Eastern Mediterranean region; SEAR = Southeast Asia region; WPR = Western Pacific region.

  • FIG. 3.

    Bar graph of the proportion of trainees in HICs, UpMICs, LoMICs, and LICs with access to various subspecialty training and training resources (cadaver laboratories and stipends). Only countries with trainees are included. The vertical dotted line separates training availability in specific neurosurgery subspecialties (left side of the line) and extra general materials available to trainees (right side of the line).

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    Rock J, Glick R, Germano IM, et al. The first neurosurgery boot camp in Southeast Asia: evaluating impact on knowledge and regional collaboration in Yangon, Myanmar. World Neurosurg. 2018;113:e239e246.

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  • 19

    Kanmounye US, Robertson FC, Thango NS, et al. Needs of young African neurosurgeons and residents: a cross-sectional study. Front Surg. 2021;8:647279.

  • 20

    Sader E, Yee P, Hodaie M. Barriers to neurosurgical training in Sub-Saharan Africa: the need for a phased approach to global surgery efforts to improve neurosurgical care. World Neurosurg. 2017;98:397402.

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    • Search Google Scholar
    • Export Citation
  • 21

    Ukachukwu AK, Still MEH, Seas A, et al. Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030. J Neurosurg. 2022;138(4):11021113.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Dada OE, Ooi SZY, Bukenya GW, et al. Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a continental, multi-centre, cross-sectional study. Front Surg. 2022;9:766325.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kanmounye US, Zolo Y, Tsopmene MRD, et al. Understanding the motivations, needs, and challenges faced by aspiring neurosurgeons in Africa: an E-survey. Br J Neurosurg. 2022;36(1):3843.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Ferraris KP, Matsumura H, Wardhana DPW, et al. The state of neurosurgical training and education in East Asia: analysis and strategy development for this frontier of the world. Neurosurg Focus. 2020;48(3):E7.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Jean WC, Huynh T, Pham TA, Ngo HM, Syed HR, Felbaum DR. A system divided: the state of neurosurgical training in modern-day Vietnam. Neurosurg Focus. 2020;48(3):E2.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Shlobin NA, Kanmounye US, Ozair A, et al. Educating the next generation of global neurosurgeons: competencies, skills, and resources for medical students interested in global neurosurgery. World Neurosurg. 2021;155:150159.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Gandy K, Castillo H, Rocque BG, Bradko V, Whitehead W, Castillo J. Neurosurgical training and global health education: systematic review of challenges and benefits of in-country programs in the care of neural tube defects. Neurosurg Focus. 2020;48(3):E14.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Almeida JP, Velásquez C, Karekezi C, et al. Global neurosurgery: models for international surgical education and collaboration at one university. Neurosurg Focus. 2018;45(4):E5.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Maleknia P, Shlobin NA, Johnston JM Jr, Rosseau G. Establishing collaborations in global neurosurgery: the role of InterSurgeon. J Clin Neurosci. 2022;100:164168.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Fuller AT, Barkley A, Du R, et al. Global neurosurgery: a scoping review detailing the current state of international neurosurgical outreach. J Neurosurg. 2021;134(3):13161324.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Sommer F, Waterkeyn F, Hussain I, et al. Feasibility of smart glasses in supporting spinal surgical procedures in low- and middle-income countries: experiences from East Africa. Neurosurg Focus. 2022;52(6):E4.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Pascual JSG, Khu KJO. Resources for operative neurosurgical education among trainees in the Philippines. World Neurosurg. 2022;165:e292e297.

  • 33

    Nicolosi F, Rossini Z, Zaed I, Kolias AG, Fornari M, Servadei F. Neurosurgical digital teaching in low-middle income countries: beyond the frontiers of traditional education. Neurosurg Focus. 2018;45(4):E17.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Rubiano AM, Griswold DP, Adelson PD, et al. International neurotrauma training based on north-south collaborations: results of an inter-institutional program in the era of global neurosurgery. Front Surg. 2021;8:633774.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Karekezi C, El Khamlichi A, El Ouahabi A, et al. The impact of African-trained neurosurgeons on sub-Saharan Africa. Neurosurg Focus. 2020;48(3):E4.

  • 36

    Ormond DR, Kahamba J, Lillehei KO, Rutabasibwa N. Overcoming barriers to neurosurgical training in Tanzania: international exchange, curriculum development, and novel methods of resource utilization and subspecialty development. Neurosurg Focus. 2018;45(4):E6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Garba DL, Fadalla T, Sarpong K, et al. Access to training in neurosurgery (Part 2): the costs of pursuing neurosurgical training. Brain Spine. 2022;2:100927.

  • 38

    Kato Y, Liew BS, Sufianov AA, et al. Review of global neurosurgery education: horizon of neurosurgery in the developing countries. Chin Neurosurg J. 2020;6:19.

  • 39

    Kshettry VR, Mullin JP, Schlenk R, Recinos PF, Benzel EC. The role of laboratory dissection training in neurosurgical residency: results of a national survey. World Neurosurg. 2014;82(5):554559.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Konan ML, Diaby R, Ghomsi NC, et al. Establishing the first neurosurgical skill laboratory in West Africa: an initiative for an affordable regional education center. World Neurosurg X. 2022;15:100122.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Gasco J, Holbrook TJ, Patel A, et al. Neurosurgery simulation in residency training: feasibility, cost, and educational benefit. Neurosurgery. 2013;73(suppl 1):39-45.

  • 42

    Davis MC, Rocque BG, Singhal A, Ridder T, Pattisapu JV, Johnston JM Jr. State of global pediatric neurosurgery outreach: survey by the International Education Subcommittee. J Neurosurg Pediatr. 2017;20(2):204210.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Lu Z, Tshimbombu TN, Abu-Bonsrah N, et al. Transnational capacity building efforts in global neurosurgery: a review and analysis of their impact and determinants of success. World Neurosurg. 2023;173:188198.e3.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Haji FA, Lepard JR, Davis MC, et al. A model for global surgical training and capacity development: the Children’s of Alabama-Viet Nam pediatric neurosurgery partnership. Childs Nerv Syst. 2021;37(2):627636.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Gupta S, Gal ZT, Athni TS, et al. Mapping the global neurosurgery workforce. Part 1: Consultant neurosurgeon density. J Neurosurg. Published online January 16, 2024. doi:10.3171/2023.9.JNS231615

    • PubMed
    • Search Google Scholar
    • Export Citation

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