Elsevier

World Neurosurgery

Volume 112, April 2018, Pages e240-e254
World Neurosurgery

Original Article
Neurosurgical Care: Availability and Access in Low-Income and Middle-Income Countries

https://doi.org/10.1016/j.wneu.2018.01.029Get rights and content

Highlights

  • This is the first study to quantify geographic access to neurosurgical care.

  • Countries in Sub-Saharan Africa have the least access to neurosurgical care.

  • Our method offers a way to monitor progress in increasing access to neurosurgical care.

Background

An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low-income and middle-income countries (LMICs) currently struggle to provide adequate neurosurgical services. Significant barriers exist, including limited access to trained medical, nursing, and allied health staff; lack of equipment; and availability of services at reasonable distance and at reasonable cost to patients. An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit.

Objective

To quantify the neurosurgical operational capacity and assess access to neurosurgical services in LMICs, by taking into account the location of workforce and services.

Methods

A total of 141 LMICs were contacted and asked to report the number of currently practicing neurosurgeons, access to computed tomographic and magnetic resonance imaging, and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons classification was used to stratify cities based on the level of neurosurgical care that could be provided. The data were geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a 2-hour travel time of a city offering differing levels of neurosurgical care.

Results

68 countries provided complete data (response rate, 48.2%). Eleven countries reported having no practicing neurosurgeons. The average percentage of the population with access to neurosurgical services within a 2-hour window is 25.26% in sub-Saharan Africa, 62.3% in Latin America and the Caribbean, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia.

Conclusions

There are several challenges to the provision of adequate neurosurgical services in low-resource settings. This study used mapping techniques to determine the current global neurosurgical workforce capacity and distribution. We have used our findings to identify areas for improvement. These include increasing and improving neurosurgical training programs worldwide, recruiting students and young physicians into the field, and retaining existing neurosurgeons within their home countries.

Introduction

An estimated 5 billion people globally lack access to basic surgical care.1 The vast burden of this deficit is borne by low-income and middle-income countries (LMICs), where 9 of 10 people do not have adequate access to safe, timely, and affordable surgical care.1 This lack of access contributes to over 18.6 million deaths per year—more than 6 times the number of deaths due to malaria, tuberculosis, and HIV/AIDS combined.1 Furthermore, the Global Burden of Disease figures estimate traumatic brain injuries to be responsible for 11.2% of total global disability-adjusted life years (DALYs).2 In fact, whereas the combination of HIV, tuberculosis, and malaria account for almost 3500 DALYs lost per 100,000 population, brain tumors, neurologic disorders, and road traffic injuries (with potential resulting head trauma) contribute to almost 5500 DALYs lost per 100,000.3 With increasing industrialization of LMICs and subsequent increase in road-traffic collisions, access to appropriate and timely neurosurgical care appears particularly necessary.4

Despite this obvious need, surgery continues to be neglected as an arm within the public health arsenal, and the role for provision of surgical specialty care has been almost completely ignored. Moreover, there are limited available data on the current global neurosurgical workforce, equipment availability, and capacity to access neurosurgical services within a critical amount of time. There are currently no city-level data on the availability of neurosurgeons and neurosurgical equipment. In a resource-limited world, such estimates are necessary to determine where resources should be placed to optimize neurosurgical coverage. In 2001, El Khamlichi et al.5 calculated a total of 23,940 neurosurgeons worldwide, which constituted a prevalence of 1 neurosurgeon per 230,000 people. However, the prevalence of neurosurgeons in sub-Saharan Africa was markedly lower, at 1 neurosurgeon per 3.1 to 6.4 million people.4, 5 Additionally, the uneven distribution of the current limited neurosurgical workforce, where the vast majority of neurosurgeons practice only in urban areas, leaves rural populations greatly underserved.6

There are several challenges to the provision of adequate neurosurgical services in low-resource settings. They include training sufficient neurosurgeons, nursing, and allied health staff and providing appropriately equipped surgical facilities. Lack of personnel and facilities results in patient difficulties in accessing neurosurgical services at a reasonable distance and cost. The notable lack of information regarding our current baseline capacity to respond to the burden of neurosurgical disease makes responding to these challenges even more difficult. The existing estimates of the neurosurgical workforce, equipment, and neurosurgical training capacity in LMICs are over a decade old.5 An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit.

This is the first study designed to accomplish the following: 1) to understand the neurosurgical operational capacity of hospitals in LMICs at the city level and 2) to estimate the percentage of the population with access to neurosurgical services in these countries within a set time.

Section snippets

Data Collection

Data were collected and assessed by a collaboration between the World Health Organization (WHO), the World Federation of Neurosurgical Societies (WFNS), and the Program in Global Surgery and Social Change at Harvard Medical School. LMICs were classified using the World Bank definitions.7 For each country, an electronic data collection tool was designed containing a prepopulated list of variables of interest (Appendix A). Contacts were obtained through several avenues. All board members of each

Results

All 141 LMICs recognized by the World Bank were contacted, and complete data on the number of neurosurgeons, access to essential imaging, and neurosurgical equipment were obtained from 68 countries. Primary contacts for the responding countries consisted of 53 neurosurgeons and 15 physicians who were not neurosurgeons. In cases where more than 1 individual responded from the country, the most senior person was appointed to be the data collector. Because of our sampling approach, most of the

Discussion

Access to safe surgery is an integral part of a country's healthcare system. It has been estimated that almost 22 million additional neurosurgical procedures are needed in LMICs each year to meet current demand.1, 4 Despite this need, there is a dearth of available published data on the current global neurosurgical workforce, equipment availability, and capacity to access neurosurgical services within a critical amount of time. This is the first study to understand the capacity and location of

Conclusions

This study was the first of its kind to quantify geographical access to neurosurgical care. Although in the past a neurosurgeon density of 1 neurosurgeon per 100,000 population was considered sufficient,25 it is clear from our study that when a 2-hour access window is considered, a vast percentage of LMICs do not meet either target. The most striking lack of access to neurosurgical care is among countries in sub-Saharan Africa, followed closely by the East Asia and Pacific region. Increasing

References (26)

  • ArcGIS 9.2

  • OpenStreetMap

  • World Pop

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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