A New Source of Nonprofit Neurosurgical Funding

Literature Review

A New Source of Nonprofit Neurosurgical Funding Amali M. Fernando1,2, Joyce S. Nicholas3, Peter O’Brien4, Hamisi Shabani5, Mohamed Janabi6, Peter Kisenge6, Dilantha B. Ellegala1, R. Daniel Bass1

Key words Funding mechanisms - Global treatment comparison - Nonprofit neurosurgery - Sociopolitical trends -

Abbreviations and Acronyms FDI: Foreign direct investments GDP: Gross domestic product NCD: Noncommunicable disease NGO: Nongovernmental organization PAC: Public Accounts Committee From the 1Virginia Neurospine, Forest, Virginia, USA; 2Loyola University, Chicago, Illinois, USA; 3Department of PA Medicine, School of Graduate Health Sciences, Lynchburg College, Lynchburg, Virginia, USA; 4Madaktari Africa, Centra Health, Lynchburg, Virginia, USA; 5Muhimbili Orthopedic Institute, Muhimbili Complex, Dar es Salaam, Tanzania; and 6 Jakaya Kikwete Cardiology Institute, Upanga West, Dar es Salaam, Tanzania To whom correspondence should be addressed: Amali M. Fernando, B.S. student [E-mail: [email protected]] Citation: World Neurosurg. (2017) 98:603-613. http://dx.doi.org/10.1016/j.wneu.2016.10.084 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

INTRODUCTION Funding a Nonprofit Health care workers seeking to effect longterm change in the developing world often engage through the nonprofit sector, a vessel for international aid that has been growing in popularity and in scope.1 The sector showed a 17% increase in employment in the United States from 2000 to 2010, a change higher than in both business and government sectors combined.2 Nonprofit registry with the Internal Revenue Service increased 2.8% in the decade between 2003 and 2013, bringing the total number of nonprofits to approximately 1.41 million 501(c)(3) groups. Of these groups, 37,732 are classified in the health category.1 Nonprofits, whether health related or otherwise, are dependent on multiple funding mechanisms. One method of

The purpose of this paper is to propose and qualify a novel funding mechanism for international neurosurgical nonprofits. The article first identifies and explains neurosurgeons’ means for practicing in the developing world through a literature review. After this examination of the current funding methods for surgical care in low-income regions, the work transitions to an explanation of the applications and limitations of a new resource: the internal wealth of a developing country. This wealth may be leveraged by way of a for-profit hospital to create sustainable and domestic funding for nonprofit neurosurgical training. The applicability of the proposed mechanism extends beyond the field of neurosurgery to nonprofits in any health-related discipline. Factors influencing the viability of this mechanism (including local disease burden, economic trajectory, and political stability) are examined to create a baseline set of conditions for success.

generating money is appealing to private donors. In 2014, more than U.S. $358 billion was charitably given to nonprofits, accounting for 15.86% of total nonprofit revenue.1 Dependence on acquiring donations precludes sustainability because of the inherent volatility of private donors. Furthermore, soliciting charitable giving demands “considerable staff, board, and volunteer effort, divert [ing] attention from other vital functions.”3 Although the value of private contributions to nonprofits increased every year between 2009 and 2014,1 donations have “been declining as a percentage of total revenue.”3 Nonprofits also generate income through grants from foundations and governments. U.S. $55 billion in foundation grants was given to 501(c)(3) groups in 2013. The money comes from more than 87,000 private institutions, which range from universities to trust funds.2,4 Academic institutions receive their funding in a manner similar to nonprofits; they receive philanthropic donations and grants, but they have the additional resource of internal funding. A portion of internal funding labeled as discretionary funding can be put toward grants. Foundation grants are given in cycles “typically lasting 3e5 years,”5 creating “income volatility”3 by forcing reapplying nonprofits in to competition with newer

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organizations.3,6 Alternatively, government grants are more stable; however, the money is dependent on the successful completion of audits and periodic reports. These tasks are “complex, burdensome, and overwhelming to nonprofit organizations”6 and take an even larger toll on start-up nonprofits.5,6 As of 2013, government grants made up 8.0% of nonprofit revenue.1 Madaktari Africa, the nonprofit medical training and education organization formed by one of the authors, was awarded a grant by the Department of Defense; the management requirements of the grant consumed an inordinate amount of time and effort for the small volunteer staff. Because of the onerous work involved in administering the grant, the organization did not pursue an additional 3-year grant cycle. As the nonprofit sector continues to grow, each organization faces “more competition for fewer donations and grants,”7 placing their funding, and thus their existence, at risk. Nonprofits dedicated to health care in lower-income countries are especially reliant on external financial resources. Although health-related nonprofits comprise only 12.9% of total public charities, their expenses make up 60.1% of total registered 501(c)(3) expenditures. These nonprofits alone required nearly U.S. $30.5 billion in charitable donations1

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to provide medical interventions and equipment. This fiscal need is shown in part by the nonprofit Madaktari Africa. The sole focus of the organization is medical training and education, and thus its expenses reflect the cost of deploying and maintaining both health care volunteers and a small core of staff. Over 3 years, the organization used U.S. $1.2 million in U.S. government funding, with an additional U.S. $400,000 in academic funding. In addition, the organization solicits private donations to function. It has used several fundraising strategies, from a large event in New York City featuring the president of Tanzania (Figure 1) to smaller-scale campaigns such as T-shirt sales and GoFundMe crowd-funding. Unlike grant money, the income generated from these different mechanisms varies annually. Although unpredictable, the value of these donations alters the capacity of the organization, resulting in an inconsistent level of service provided by Madaktari Africa or any similar nonprofit. These funding mechanisms are unable to meet the financial burden that accompanies all nonprofit health care work. Nonprofit organizations are also reliant on volunteer “time, talent, and information.”8 In 2014, nonprofits solicited 8.7 billion volunteer hours, drawing in 25.3% of the U.S. adult population, with 16.0

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million people volunteering on an average day. This statistic corresponds to a total value of approximately U.S. $179 billion. Of those who volunteered, 23.4% performed administrative and support tasks and an additional 23.8% spent their time “providing direct care and services.”1 At the height of its operation, Madaktari Africa had 139 volunteers, whose labor was valued at U.S. $1,793,760. International health-related nonprofits are also financially reliant on volunteers. They often defer the entire cost of care onto the volunteers, a practice that substantially limits the number of medical professionals able to volunteer their time. For most nonprofits operating in lowerincome and middle-income countries, the practice of short-term visits from volunteers precludes local community members from obtaining employment. For nonprofits providing medical services, it prevents the society from acquiring mastery of these skills.9 Most nonprofits operate on a crisis management or temporary relief basis, neglecting the need for systematic change.8,9 Instead of approaching locals as potential partners, instead of investing in existing networks, instead of aiming for the end of aid, nonprofits operate almost ritualistically9 without “oversight or accountability.”10 The served community has little chance to advise or appeal

Figure 1. Fundraiser in New York. This fundraiser featured the former president of Tanzania, Jakaya Kikwete (back row, third from the left).

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nonprofit decisions,10 which typically benefit corporations in the nonprofit’s home country instead of local businesses.9 This traditional form of aid does save lives in the wake of disease outbreaks or disasters. After the Ebola outbreak in 2014, approximately 13,000 health care workers were transported to West Africa by government agencies and nongovernmental organizations (NGOs) to extinguish the disease. Their shortterm deployment did limit the number of deaths to an estimated 11,000,11 yet once the aid workers departed, the affected countries were all left with physician densities under 0.1 per 1000 citizens, insufficiently prepared to meet even primary health care needs.12,13 Because donors are currently redirecting their resources to the ongoing refugee crisis in Europe, the NGOs will follow. These cases show that the presence of many international nonprofits is temporary; on the emergence of a new threat, funding dries up, and the agencies are forced to withdraw.9 They leave behind a population no closer to a stable means of survival, served by the same inadequate system that existed on their arrival.

A CONTRAST OF NEUROSURGICAL PRACTICE IN EASTERN AFRICA AND THE UNITED STATES Madaktari Africa and Neurosurgery Madaktari Africa is a nongovernmental nonprofit organization that was founded by the one of the authors (D.B.E.) to provide medical training and education in neurosurgery. Although the NGO is dependent on volunteers working alongside a small cadre of part-time paid staff when necessary, it uses the Train-Forward method, in which the volunteers train local doctors who then “pass on the newly taught skills to others,”14 expanding the pool of local, highly qualified medical professionals. The knowledge transfer involved in this training model includes not only procedures, but also protocols, and clinical pathways. Madaktari Africa is based in Tanzania, conducting training in hospitals across the country. When Madaktari Africa was founded in 2008, there were only 4 neurosurgeons serving the entire nation.15 By 2015, the organization had trained enough

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surgeons to more than triple that figure.14 This training is being “conducted under a memorandum of understanding with the Tanzanian Ministry of Health and Social Welfare, acting on behalf of the government of the United Republic of Tanzania.”16 Competency assessments are the responsibility of the medical director of the hospital who works in conjunction with the aforementioned ministry.17 The neurosurgeons trained by Madaktari Africa are capable of independently completing complex surgical interventions, ranging from tumor removals to ventriculostomies. The most common procedures are “shunt related, bur hole drilling and evacuation, spina bifida repair, bone elevation, craniotomy and evacuation, laminectomy, craniotomy, bur hole biopsy, and tumor excision.”17 However, medical staff members were also trained in “blood transfusion, discectomy, encephalocele repair, and external ventricular drain placement.”17 Although Madaktari Africa is committed to significantly improving surgical capabilities in East Africa, it does not aim to be permanent. The organization acknowledges that there will be a time “long after Madaktari has left”14 and it seeks to prepare local medical personnel to provide specialized and advanced care to communities in Tanzania and beyond. This method of providing health care can be made sustainable through a reliable source of funding. Substantial progress has already been made in provision and development of neurosurgical care at public hospitals in the eastern region of sub-Saharan Africa. Yet, stark qualitative and quantitative differences are apparent when the condition of the neurosurgical specialty in this area of the developing world is compared with that of more developed nations such as the United States. This contrast can be shown through an analysis of some of the simple outward aspects of neurosurgery, as it exists in different parts of the world. Conditions Treated Neurosurgery is often equated with brain surgery in popular culture, but according to a survey conducted by the American Association of Neurological Surgeons,16 62% of the 2,171,195 neurosurgical procedures conducted in the United

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States in 2006 were spine-related operations, with lumbar disc laminectomy taking the title of most common spinal procedure. Just 27% of the total neurosurgical operations that year were cranial procedures, supratentorial craniotomy being the most common among them.16 A study conducted in the same year at Black Lion Hospital in Addis Ababa, the tertiary public hospital in Ethiopia, shows a great difference in the type and number of neurosurgical cases performed. Of the 194 neurosurgical operations completed during the 8-month study period, spinal operations accounted for just 21% of the total, 7% of which were undertaken for the treatment of degenerative spine disease. Although spinal trauma was identified as an “extremely common” presentation at the studied hospital, it was noted that a lack of necessary instruments for realignment operations meant that many who incurred spinal injuries were treated with nothing more than bed rest.18 Fifty percent of the neurosurgical cases performed were cranial operations performed to treat traumatic head injuries, 11% were for the treatment of brain masses, and 8% for hydrocephalus. Fifty-five percent of the brain masses treated were caused by infections rarely seen in more developed nations such as the United States, most commonly tuberculosis.18 The average wait time for adult neurosurgical patients was 242 days, and the pediatric average was reported at 447 days.18 Revenue and Finance Hospitals systems and independent neurosurgeons in the United States generate revenue from multiple sources, primarily through reimbursement collected from patients and insurance companies for office visits and surgical operations. At public hospitals in the eastern region of sub-Saharan Africa, neurosurgeons are paid a salary by the government, amounting to several hundred per month.19 The few hospitals in this region that provide neurosurgical care are usually large, government-funded tertiary-care centers. Primary care at these hospitals is free in some cases, but the cost of treatment depends on the level of care that each patient requires.20 In Tanzania, for example, health care prices are set by the Ministry of Health and Social Welfare, and patients with serious

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diseases or injuries inevitably face more expensive medical bills.21 Equipment and Technology The diagnostic imaging machines that are so abundant in the United States are few and far between in the developing nations of this region.22 In many cases, the high cost of imaging studies is expensive enough to be prohibitive in a region where many live on just dollars a day.16 Those who can afford a magnetic resonance imaging or computed tomography scan are often required to travel to a separate facility that has the appropriate technology and then return to the hospital for treatment. The lack of neuroimaging equipment is exacerbated by the fact that many public hospitals in East African nations are faced with a more pressing need for basic neurosurgical equipment such as headlights, microscopes, electrocautery devices, microinstruments, and sterilization machines.16,22 Even more troubling than the lack of basic equipment is the overall lack of neurosurgeons. In 2015, there were only 565 neurosurgeons on the entire African continent compared with 4600 neurosurgeons in the United States alone.23 These deficits in equipment, technology, and staffing limit both the scope and number of cases that neurosurgeons in East Africa are able to treat, as well as the quality of the care that they are able to provide.23 Madaktari Africa is combating the dearth of machinery and expertise through equipment donations and the TrainForward model. The organization is committed to creating neurosurgical excellence in the community through the availability of modern technology and talented professionals. The practice of expanding local capabilities can produce sustainable surgical care if the funding persists. This training model is also being applied successfully to several healthrelated disciplines beyond neurosurgery, most notably cardiology. In partnership with the Jakaya Kikwete Cardiac Institute in Dar es Salaam, the first functioning cardiac catheterization laboratory was inaugurated in 2014. Since then, more than 300 invasive cardiac procedures have been performed, nearly 75% of which were completed by local physicians without any

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Figure 2. Tanzanian gross domestic product (GDP) (1990e2015). This figure shows the consistent upward trend of the Tanzanian economy. The gross domestic product was expected to resume

outside support. This program has replicated success of the Train-Forward model that began with neurosurgery. In doing so, it has shown the potential for comprehensive and tenable care worldwide, provided the financial burden can be overcome. SUSTAINABLE FUNDING FROM INTERNAL WEALTH A New Source of Nonprofit Income Nonprofit organizations are electing to engage in commercial activity to generate additional funding. Without forfeiting their nonprofit status, not-for-profit groups are covering their costs through contracts and fees for services that were formerly free of charge.3,7 Madaktari Africa was specifically designed to provide medical training in impoverished regions, and thus, it is limited in terms of the money it can generate through commercial enterprises. However, this funding mechanism can be altered to maximize income for nonprofit health care work. A for-profit hospital can be tailored as specifically as Madaktari Africa was, but with the goal of serving the nation’s existing wealthy population. A portion of this entity’s profits would go toward the 501(c)(3), a funding mechanism that is sustainable if the for-profit company is successful. The proposed relationship between Madaktari Africa and the hospital has the potential to show an unprecedented level of internally generated nonprofit funding.

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growth in 2016 and 2017. Graph created using data from the World Bank Group (2015).28 USD, U.S. dollars.

The hospital, which will be built in the city of Bagamoyo, is to give 3.5% of its revenue directly to Madaktari Africa. The projected net income, including first-year losses, hypothesizes that Madaktari Africa will receive more than U.S. $3.5 million in the first 4 years of operation. This estimated income surpasses the entire value that the government of Tanzania allocated to the health sector in fiscal year 2015.22,23 Even a pessimistic projection shows upward of U.S. $156,000 going toward nonprofit operations in the tenth year of the partnership. If the hospital succeeds, Madaktari Africa will be freed from dependence on donors and grant-making institutions, because it will function primarily through the preexisting capital within the region. An international nonprofit that uses this mechanism increases its capacity to recruit skilled medical professionals. Because organizations currently defer travel costs on to the volunteer, a not-for-profit group capable of removing the financial burden expects to see an increase in volunteerism. Organizations such as Madaktari Africa, which is devoted to training, would therefore see an increase in their fundamental capacity as nonprofits. This funding mechanism, unlike competitive grants and charitable contributions, will decouple a nonprofit’s income from the quality of its services, although the link between a nonprofit’s income and its effectiveness was tenuous under the existing model. Quality assurance for Madaktari Africa will continue

through the process of collecting outcome measures (given appropriate regulatory approvals) to track program effectiveness and maintain ongoing quality improvement. Similar methods can be used by all nonprofits operating under this funding mechanism to monitor, evaluate, and show the quality of their performance. The Potential within Developing Markets There are regions of the developing world with economic trends such that a for-profit hospital would be a viable enterprise. Africa shows a continually improving business environment24; in 2015, the World Bank Group asserted that nations in subSaharan Africa accounted for one half of the most improved countries in terms of ease of business.25 In 2006, the average gross national income per capita across the African continent was U.S. $1066, higher than India’s U.S. $820.24 By 2014, 2 African countries had gross national incomes per capita greater than China’s U.S. $7400.26 The same year, the average gross domestic product (GDP) per capita across Africa was U.S. $4919, up U.S. $112.95 from 201327 (Figure 2). Tanzania’s GDP has been growing rapidly and consistently and is maintaining low inflation rates; GDP increased an average of 4.5% a year between 1995 and 2013 and had a projected growth value of 7% in 2015.25,29 The nation experienced the creation of 1,026,000 jobs in 2015 and expects 21,436,000 more by 2030.26 The economic opportunity in Africa

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surpasses these values because a considerable amount of trade occurs outside official and legal institutions and thus “escapes detection in the official estimates of GDP.”30 Journalist Jonathan M. Katz describes the informal economy in Haiti, writing that unofficial professions can vary from carpentry to sales of merchandise and food.9 The informal economy would contribute about 55% of sub-Saharan Africa’s GDP31 or from 56.9% to 60.2% of Tanzania’s GDP.30,32 Slightly more than 5% of Tanzania’s estimated labor force was formally employed in 2013, whereas unemployment fluctuated around 9%, indicating that the informal economy constitutes most of Tanzanian employment.33 The informal sector is “a functioning part of an economy’s steady state”28 and “naturally declines as the economy grows (even with no change in tax policies)”28 because of the increased number of recognized employment opportunities.28 The creation of 1,026,000 Tanzanian jobs marks a decreasing informal sector and a growth of the formal economy. The growth of the GDP and the formal employment sector show the potential viability of for-profit ventures in developing areas. Furthermore, this development is bolstered by the Foreign Direct Investments (FDI) entering Africa. FDI represents, as marketing and business expert Vijay Mahajan argues, a market’s “past successes and the positive assessment of future activities.”24 In 2014, U.S. $128 billion in FDI flowed into Africa, more than “North America, Latin America and the Caribbean” received, marking African markets as especially promising.34 Demonstratively, companies based in Africa are turning considerable profits. The Zimbabwe-based distributing and marketing company Innscor Africa Limited35 started experiencing net revenues within 6 months of opening and reported an operating profit of U.S. $60,629,242 in 2015.24,36 Similarly, the African entertainment streaming service Iroko,36 which was founded in Nigeria and now serves “Nollywood” consumers worldwide, has generated a total of U.S. $25 million in under 6 years.37 Both Innscor and Iroko show the potential revenue and growth for companies operating in developing countries.

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Conditions for Success A for-profit venture needs a consumer base with sufficient disposable wealth, a sound organizational structure, a stable economic and political environment, and insulation from corruption to be given the best chance of long-term success. These qualities are interconnected, coming together to affect the viability of a forprofit institution generating enough money to fund a nonprofit. The developing world certainly does not possess all these characteristics, but the region need not fully show each one to house a successful business. In this section, the minimum levels of each quality necessary to make this funding mechanism feasible are discussed. For a hospital to generate funding for a nonprofit, there must first be a consumer need for additional health care facilities. The developing world is faced with disproportionately large levels of healthrelated issues, ensuring such a demand. Despite being home to only 11% of the world’s population, sub-Saharan Africa bears 24% of the global disease burden.38 Recent growth and subsequent modernization within these communities has introduced chronic noncommunicable diseases (NCDs) to regions still struggling with communicable disease. NCDs are “on the rise in Tanzania,”33 especially in urban areas, causing 31% of all deaths.33 As the East African life span continues to extend, the prevalence of NCDs and chronic illnesses will maintain their growth trends.39 Another 65% of deaths stem from “communicable, maternal, perinatal and malnutrition conditions,”38 which have been affecting Tanzanians for generations.38 Afrobarometer, a “crossnational survey research project managed by a network of African social scientists”40 found that approximately 47.4% of African families had gone without medicine or medical treatment in 2014.41 More than a quarter of participants indicated it was “difficult” or “very difficult” to obtain the medical care they needed at a “public clinic or hospital.”41 Care was more difficult to access in Tanzania; 39.7% of respondents reported that it was “difficult” or “very difficult.”41 Of Tanzanian respondents, 37.9% asserted that a family member had to go without medicine or medical care

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“several times” or “many times.”41 Limited access to treatment creates potential consumers for a private health care facility. Yet, for-profit hospitals are currently few and far between in developing countries. Tanzania’s Ministry of Health and Social Welfare reports 27 registered and operating for-profit hospitals,42 which means that the sector accounts for 15% of Tanzanian hospitals.42 Only 7 of these hospitals are located outside Dar es Salaam.42 The forprofit sector presently accounts for only 4% of hospital beds43 and 11.2% of total health spending.44 The need for health care facilities is exacerbated by a scarcity of funding. The region accounts for less than 1% of global health expenditure, creating a severe shortage of trained medical personnel.35 The existing private sector hospitals are running at an 87.5% staff shortage.44 Doctors comprise less than 2% of practicing health professionals, a severe insufficiency compared with the continental average of 9.7%.45 Subspecialty care, including neurosurgery, requires significant growth to meet regional needs.45 It will take an estimated addition of 600,000 hospital beds, 90,000 physicians, 500,000 nurses, and 300,000 community health workers to provide the nation with adequate care.45 Moreover, the Tanzanian Private Health Sector Assessment of 2013 iterates that “41 percent of household out of pocket expenditures are spent at nonprofit and for-profit facilities” even although only 28 percent of facilities are private.44 This report supports the belief that “Tanzanians are actively seeking health care in the private sector.”44 Thus, a private hospital in the nation would experience an already active consumer base, amplified by the population’s disproportionate disease burden. There must also be a sufficient amount of disposable wealth in the region for a hospital to generate a profit. Of the more than 900 million consumers in Africa, an estimated 50e150 million have disposable income comparable with that of “elite segments in other global markets.”24 The most recent estimates of the World Wealth Report show that this group has accumulated a total of U.S. $1.44 trillion.45 Moreover, the wealthy population is increasing in size; the number of high net worth individuals has

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been increasing since 2009 and grew by 5.2% in 2014.45 Tanzania was reported in December 2014 to have 5600 millionaires. These citizens commanded nearly 17% of the country’s national income.35 Dar es Salaam alone housed 1900 millionaires in 2012. By 2020, it is predicted that the city will contain approximately 1100 more.35 This wealthy population creates the possibility of funding the nonprofit without reliance on external money. Tanzanian President Magufuli augmented the consumer base by banning public servants from foreign travel.46 Diplomats and expatriates spent an estimated U.S. $10,000 on treatment outside Tanzania in 2014.44 Effectively, Magufuli’s ban forces senior government officials to purchase medical care within Tanzania instead of engaging in medical tourism. This will grant the hospital an additional resource as its staff works to create a stable patient population. Furthermore, the intended consumer base extends beyond the borders of Tanzania; the facilities will be marketed as a “destination hospital” to affluent consumers across sub-Saharan Africa.43 Vijay Mahajan’s analysis of the African markets shows that although there are significant differences between and within African nations, some “share common languages, culture or trade,” and thus, companies can effectively market their services across certain national borders.24 Travel into Tanzania from the other African countries is on the verge of becoming easier because of the upcoming electronic passports that will allow visa-free access into the nation. Intending to promote the “free movement of persons” around the African continent, the African Union will distribute these passports to the citizens of all member states by 2018, encouraging an expansion of the hospital’s consumer base.47 Thus, the hospital will be able to generate revenue through upper-class and middleclass consumers from nations beyond Tanzania. The hospital in Bagamoyo would also endear itself to African consumers at every income level who wish to show status and wealth. This desire has driven the successful growth of companies from Coca Cola to Johnnie Walker, which began marketing their products as upscale goods.24 These ventures show that, for the funding mechanism to succeed, the hospital must be marketed as a

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Figure 3. Location of destination hospital. The hospital is to be built on the coast of Pwani. The bottom left of the artist’s rendition shows a bird’s eye view of the facility. The facility will comprise multiple buildings connected via covered walkways and bridges.

fashionable facility. A study conducted by McKinsey, a worldwide management and consulting firm, concurred; it concluded that traveling patients are attracted by facilities with high-quality care and “attractiveness as a tourist destination.”39 The hospital in Bagamoyo intends to target those with expendable resources through the location, the facilities, and the services. The hospital is built on “the natural, idyllic beauty of coastal Tanzania,”48 providing a resortlike experience (Figure 3). Pwani, the region that will house the hospital, has only 1 other for-profit hospital, mitigating the amount of local competition.38 To draw in the wealthy population, the facilities are “ultramodern,”48 not only in function but also in appearance. Facilities of this caliber are crucial to the enterprise; the McKinsey study showed that 40% of medical travelers are in search of the “most advanced medical technology.”39

An additional 32% seek “better quality care for medically necessary procedures.”39 The for-profit hospital will generate revenue by providing access to such care. The facility in Bagamoyo intends to do so by employing well-trained physicians found through a “targeted recruitment effort.”48 Its services include a health club and spa amenities, making the complex appeal to those in possession of disposable wealth.48 Health-related not-for-profit groups with long-term goals in other developing regions can use this funding mechanism. By leveraging internal wealth, they can generate consistent funding if the region meets the additional conditions for success. In conjunction with a consumer base and a growing economy, a for-profit hospital requires stability and accountability. One common strategy intended to bring stability to an overseas corporation is the

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creation of a joint venture between internal and external investors. The local partners possess connections in both the private and public sectors as well as experience working through the bureaucratic system. “More joint ventures are formed than wholly owned subsidiaries when the host government is more restrictive”49 because the local investors’ insight becomes critical to the success of the venture.49 Tanzania is home to a successful joint venture: the Mnazi Mmoja NED Institute, a center for neurosurgery and neurointensive care.50 The Ministry of Health in Zanzibar facilitated the signing of an agreement in 2011, which brought together the Tanzanian Mnazi Mmoja Hospital and the Spanish foundation Neurocirugía Educación y Desarrollo (NED).50 Both parties financed the 2 operating rooms and 3 intensive care units, with Neurocirugía Educación y Desarrollo contributing “more than half”.50 Since the inauguration in 2014, the institute has reported significant success, although formal results have yet to be published. The hospital in Bagamoyo will be a similar consortium between U.S. and Tanzanian partners, a structure intended to enhance the viability of the project. The in-country leaders will be able to capitalize on the consumer’s culture and navigate the governmental regulations,49 an especially vital skill in the country ranked 139th in ease of doing business.51 The Tanzanian partners enable the hospital to be considered a local business, allowing it to circumvent restrictions on foreign companies. However, overseas investors fortify chances of success because they bring years of industry experience.49 In the case of the hospital in Bagamoyo, the U.S. partner, Executive Hospital Group, was necessary because it was capable of devoting “thousands of hours”43 to researching and ensuring project feasibility.43 The for-profit hospital is benefited by both groups of owners, making the joint venture model popular in international business.48,52 However, joint ventures, especially those in developing countries, are still prone to instability.48,52 One potential cause of inconstancy is conflict between the owners,53 which according to a study by Argente-Linares et al.53 can be

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prevented by clear majority ownership and local management. This study analyzed the partners’ degree of satisfaction under different organizational structures and found positive correlations with local management combined with majority ownership of either partner.53 A clear majority owner wards off conflict in decision making and local management “with specific knowledge of the market, the institutional environment and the functioning of the workforce” enhanced both partner’s satisfaction with the enterprise.53 The company Nigerian Airways shows the potential risks associated with foreign management. It was a tripartite corporation, in which the Nigerian government owned 51% of the business and 2 British companies, Elder Dempster Lines and BOAC, owned 32.5% and 16.5%, respectively.54 The airline boasted an expanding consumer base55 as Africa had a 45% growth in passenger turnout and Nigeria was driving Africa’s rapidly increasing international air traffic.56 Although the Nigerian airline’s operations were concentrated in Lagos, the company was managed by foreigners, not only British corporations but Dutch and South African ones as well.55 The foreign management brought neither local market expertise nor stability to the company. Rather, those years of mismanagement caused the company to accumulate a debt of U.S. $76,921,129 in 2015 value.54 This example shows the drawbacks of management ill suited to local operations. Even if a corporation uses this optimal organizational model, its profitability can be negatively affected by corruption. The Anti-Corruption Resource Center states “The complex corporate nature of joint ventures presents additional corruption challenges.”57 A corrupt activity is defined as one that involves “the abuse of entrusted power for private gain.”58 Obtaining objective data about the level of corruption in a region is implausible, not only because of the scope of this broad definition but also because corrupt activities are intentionally undisclosed. Even Transparency International,57 the coalition that compiles the Corruption Perception Index, asserts “There is no meaningful way to assess absolute levels of corruption in countries or territories on the basis of hard empirical data.”57 The

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Corruption Perception Index “is an indicator of perceptions of public sector corruption”57 rather than being a definite indictment of the leadership in the society. Tanzania ranks 117,57 better than 50 of the other ranked countries and notably better than most others in East Africa. However, such a poor ranking indicates that the public believes that “corruption is pervasive throughout Tanzanian society”59 and is thus “embedded in the de facto business environment in a country.”59 This systemic illicit activity coupled with an inefficient bureaucracy could interfere with the success of a for-profit venture. The Business Anti-Corruption Portal59 warns that the most affected sectors in Tanzania are “government procurement, land administration, taxation and customs.”59 Complying with government policies, especially tax policy, may be costly and time consuming, incentivizing employees to use facilitation payments.59 In the context of joint ventures in Tanzania, Transparency International suggests clarity both about jurisdictional reporting standards and “amongst the agreeing parties on who is responsible for anti-corruption compliance.”57 The group also supports the United Nations Global Compact recommendation of an anticorruption clause that allows for the termination of a contractual relationship if one partner is found guilty of corruption.57 Stanford University’s Hoover Institution asserts “The presence of perceived corruption retards economic growth, lowers investment, decreases private savings, and hampers political stability.”60 Yet, Tanzania shows an increasing gross national income, GDP, and FDI, indicating that the perception of corruption is lessening or at least stagnating. The government is attempting to curb corruption through laws such as the Prevention and Combating of Corruption Act and the Public Leaders Code of Ethics Act. Tanzania has also ratified both the United Nations Convention against Corruption and the African Union Convention on Preventing and Combating Corruption. These laws and conventions give Tanzania a “comprehensive legal framework to counter corruption.”59 Although many companies, such as the Nigerian Iroko, have succeeded without such a framework

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in place, it is a promising first step toward protection of a company’s profit margin.61 The Public Accounts Committees (PACs) in countries across Eastern Africa are “instrumental to keeping governments accountable” and researchers from the University of Melbourne found that Tanzania’s PACs were outperforming the others in the region by a large margin.62 Increased activeness of PACs, such as those in Tanzania, is strongly and positively correlated with less corruption.62 Active PACs, along with a presidential leadership keen on curbing corruption, serve as an additional reassurance that the for-profit hospital will not lose revenue to corruption. Yet, PACs and other bodies responsible for accountability have yet to expunge corruption from the country. Vijay Mahajan does not attempt to mitigate the potential costs of corruption. Rather, he notes that the obstacles in a developing country like Tanzania are reminiscent of the obstacles in China and India decades ago. He also posits the theory that business development, a process that will be furthered by for-profit ventures, will lead to “improvements in the political system.”24 An unstable political environment threatens the position of a business venture. Substantial changes in a nation’s political structure can translate to changes in government policies regarding health care institutions, thus altering the profitability of the enterprise. Unrest negatively affects patient inflow, especially in the case of destination hospitals. The McKinsey study showed that these types of hospitals suffered during periods of political instability; patient inflow decreased more than 20% in a single month after the onset of political unrest.49 The proposed funding mechanism is most likely to work in an area that has shown sustained political stability. The World Bank acknowledges the constancy in the Tanzanian political system, crediting it for the nation’s economic growth and future prospects.25 The nation has been a multiparty democracy since 199225 and has experienced “peaceful independence” since 1963.63 It shows a higher satisfaction with democracy than the continental average. In August 2015, a group of researchers applied a measure labeled the Index of Fluidity to Tanzania’s governing bodies between

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independence and the latest elections to determine the changeability of the nature of those institutions.64 The study concluded that Tanzania had a relatively low fluidity, especially compared with other African nations. Tanzania also showed less fluidity in government than Malaysia, Cambodia, Indonesia, and Thailand.64 A solid government structure precludes an unstable bureaucratic environment. Within this static political system, turnover must be relatively stable. In a democratic nation, this condition means that election results ought to be regarded as unaltered and authoritative. Eighty-one percent of Tanzanians believe they are completely free from coercive pressure when they vote and 76% believed that the 2010 elections were “fair and free”40 with few or no problems. The contentious 2015 election was marred by the annulment of votes from Zanzibar; the irregularities and alleged tampering exposed the imperfections of the Tanzanian political environment. However, the election results do not invalidate the feasibility of a for-profit hospital, because they did not induce a deterioration of the citizen’s approval for democracy. Rather, president John Magufuli had a 90.4% approval rating 100 days after taking office.65 Magufuli’s success extends to the archipelago of Zanzibar, where 98.1% of constituents approve of his anti-corruption measures.65 This stable turnover decreases the likelihood of major changes in policies that affect businesses or health care facilities, increasing the likelihood of the success of the funding mechanism. Political violence, commonly believed to be particularly prevalent in sub-Saharan Africa, poses a threat to a destination hospital. Although warfare has been a substantial part of these nations’ postcolonial experiences, it is both on the decline and nonunique to the region.66 A recent comparative study of armed conflict showed that the Asian continent had more wars per nation than did Africa between 1960 and 2008. This comparison is significant because the developing markets in Asia make up the largest recipient region of FDI in the world.65,67 Therefore, investors consider the markets to be lucrative despite the regional conflict. Thus, the wars in Africa should not be a deterrent for

enterprises in the African continent. The study also shows that Asian wars routinely last nearly twice the duration of African wars. Furthermore, civil wars, which “are and have been the dominant form of warfare in Africa,”66 have undergone a significant decline since the 1990s.66 These trends show the decreasing probability that warfare will impede the hospital’s profits. Nonprofits wishing to create a sustainable source of funding through a for-profit corporation must ensure a sizeable and active consumer base with increasing quantities of disposable wealth. Chances of the success of the endeavor are bolstered if the business solicits local investors and managers, and if the region shows commitment to decreasing corruption and civil unrest. Breaking Ground Once a nonprofit deems itself eligible for this funding mechanism, there are several steps that must precede the construction of a hospital. The future executive board of this hospital chose to confirm the potential of the venture for success by employing a syndicated market research company to perform an analysis of the hospital and health care sector in Tanzania, including an analysis of the health care needs of the community. The 10-week comprehensive market and industry feasibility study was conducted on the ground in Tanzania. It confirmed the viability of the for-profit hospital; this confirmation is an advisable step for other nonprofits transitioning to this form of funding. The architectural design of the hospital should be created by an entity with experience in the region. The executive board contracted with MASS, a team of designers and engineering consultants, who had experience in other East African countries. The team performed preestartup work in 2 phases: feasibility report and schematic design engagement. Before construction, the team required more than 4 months and U.S. $123,800. For every phase, up to and including construction, the cost is estimated to be U.S. $2,095,400. Until the hospital is operational, nonprofit work must still be funded through dependent sources of funding. While the hospital is under construction, Madaktari Africa will begin a phased approach to the opening of the hospital to

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limit financial exposure and counter setbacks as they arise. Two phases will occur before the construction is completed, serving to strengthen the institution’s reputation. Phase one is the creation and implementation of a telehealth system in Tanzania, which will beget quality health care services throughout the region. The organization is partnering with Salus Telehealth to increase the efficiency of this project. The revenue from this venture will be channeled toward both the hospital and phase 2: the opening of clinics across East Africa. These clinics, which will feature the telehealth systems, are intended to generate funds for the construction and furnishing of the hospital. They also provide a unique means to monitor, evaluate, and amend the services before the commencement of treatments in Bagamoyo. Both these projects are long-term; they will continue to provide medical services once the hospital is operational and, if necessary, funnel patients to the facility. While construction is under way, a marketing company with significant experience on the continent will be consulted to ensure patient interest in the facility on opening. The hospital will commence services in a phased manner; a plan designed to continue limiting unnecessary financial exposure. This phased approach to the commencement of services is advisable for all nonprofits considering this funding mechanism, because it minimizes the risk associated with a start-up venture. Once the for-profit hospital begins generating revenue, a locally conducted business will be primarily responsible for funding nonprofit health care work. CONCLUSIONS Although medical missions and nonprofit organizations are saving lives in the developing world, few are addressing the systematic insufficiencies that create the need for continual intervention. Moreover, these forms of international aid are limited in their extent to produce any long-term change because their funding is difficult to predict and burdensome to manage. The proposed solution is to leverage the internal wealth in the developing region to create funding that is dependable and sustainable. Further research must be undertaken to evaluate the effectiveness of

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nonprofits that adopt this method of funding. The success of this mechanism could lead to the expansion of nonprofit capabilities in the developing world, positioning them to remedy the structures that create the need for external intervention. The success of medical nonprofits must be measured not only by how many lives were saved but how quickly the organization made itself redundant by addressing the underlying causes of the issues it was designed to alleviate. ACKNOWLEDGMENTS The writers would like to thank Chitra Ellegala, the driving force of the study; Maarten Hoek for his insightful revisions; and Nicholas King, Tom Scott, and Chad Hoyt for their testimonies. REFERENCES 1. McKeever BS. Public Charities, Giving, and Volunteering. The Nonprofit Sector in Brief 2015. 2015. Available at: http://www.urban.org/sites/default/files/alfresco/ publication-pdfs/2000497-the-nonprofit-sector-inbrief-2015-public-charities-giving-and-volunteering.pdf. Accessed June 6, 2016. 2. Blackwood AS, Roeger KL, Pettijohn SL. Public Charities, Giving, and Volunteering. The Nonprofit Sector in Brief 2012. 2012. Available at: http://www. urban.org/research/publication/nonprofit-sectorbrief-public-charities-giving-and-volunteering-2012. Accessed June 8, 2016. 3. Center for Global Health. Funding Agencies for Global Health Opportunities. Available at: https:// cgh.uchicago.edu/page/funding-agencies-globalhealth-opportunities. Accessed July 1, 2016. 4. Froelich KA. Diversification of revenue strategies: evolving resource dependence in nonprofit organizations. Nonprofit and Voluntary Sector Quarterly. 1999;28:246-268. 5. Reiser L, Berardini TZ, Li D, Muller R, Strait EM, Li Q, et al. Sustainable funding for biocuration: The Arabidopsis Information Resource (TAIR) as a case study of a subscription-based funding model. Database (Oxford). 2016. http://dx.doi.org/ 10.1093/database/baw018. 6. Pettijohn SL. Federal government contracts and grants for nonprofits. Government-Nonprofit Contracting Relationships. May 2013. Available at: http://www.urban.org/sites/default/files/alfresco/ publication-pdfs/412832-federal-governmentcontracts-and-grants-for-nonprofits.pdf. Accessed June 16, 2016. 7. Dees J. Enterprising nonprofits. Harv Bus Rev. 1998;76:54-67. 8. Hartenian L. Nonprofit agency dependence on direct service and indirect support volunteers: an empirical investigation. Nonprofit Management & Leadership. 2007;17:319-334.

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9. Katz J. The Big Truck That Went By: How the World Came to Save Haiti and Left Behind a Disaster. New York, NY: Palgrave Macmillan; 2013. 10. Short-Term Medical Mission Trips Survey Results. Catholic Health Association. 2015. Available at: https://www.chausa.org/docs/defaultsource/international-outreach/short_term_medical_ mission_survey_results.pdf?sfvrsn¼0. Accessed December 15, 2016. 11. Wojda TR, Valenza PL, Cornejo K, McGinley T, Galwankar SC, Kelkar D, et al. The Ebola outbreak of 2014-2015: from coordinated multilateral action to effective disease containment, vaccine development, and beyond. J Global Infect Dis. 2015;7:127. 12. Global Health Repository: Data by Country. World Health Organization. Available at: http://apps. who.int/gho/data/node.main.a1444. Accessed July 21, 2016. 13. References: Definitions and Notes. Central Intelligence Agency. Available at: https://www.cia.gov/ library/publications/resources/the-world-factbook/ docs/notesanddefs.html?fieldkey¼2226. Accessed July 21, 2016. 14. Our Story. Madaktari Africa. Available at: http:// www.madaktari.org/. Accessed July 21, 2016. 15. Bertelme T. Send Forth the Healing Sun. Toronto: HarperCollins Canada; 2016. 16. AANS National Neurosurgical Procedural Statistics Survey Offers Insight into Practice Management World of Neurosurgeons. Am Assoc Neurol Surgeons Web site. 2008. Available at: http://www.aans.org/ Media/Article.aspx?ArticleId¼51669. Accessed June 13, 2016. 17. Ellegala DB, Simpson L, Mayegga E, Nuwas E, Samo H, Naman N, et al. Neurosurgical capacity building in the developing world. J Neurosurg. 2014; 121:1526-1532. 18. Vishwanathan A, Linehan L, Woodrow S, Abebe M, Sahlu A, Damtie ZG, et al. Neurosurgery in Ethiopiaea review of current status residency training and future directions. AANS Neurosurg. 2008;17. Available at: http://www.aans.org/en/ AANS%20and%20JNSPG%20Publications/AANS %20Neurosurgeon/AANS%20Neurosurgeon%20 Issues/2008/2008%20-%20Issue%203/Neurosurgery %20in%20Ethiopia%20-%20A%20Review%20of %20Current%20Status%20Residency%20Training %20and%20Future%20Directions.aspx?sc_data base¼web. 19. Neurosurgery. CPAs for Healthcare Professionals Web site. Available at: http://www.mdcpas.com/ specialities/medical/neurosurgery. Accessed June 13, 2016. 20. Strengthening Sub-Saharan Africa’s Health Systems: A Practical Approach. McKinsey and Company Web site. 2010. Available at: http://www. mckinsey.com/industries/healthcare-systems-andservices/our-insights/strengthening-sub-saharanafricas-health-systems-a-practical-approach. Accessed June 15, 2016. 21. Tanzania: Hospital Charges Up By Five Times More. allAfrica Web site. 2015. Available at: http://

www.WORLDNEUROSURGERY.org

611

LITERATURE REVIEW AMALI M. FERNANDO ET AL.

allafrica.com/stories/201512071383.html. Accessed June 15, 2016. 22. Fuller A, Tran T, Muhumuza M, Haglung MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2016;3:1-6. 23. Government Budget for Fiscal Year 2015/16: Citizen’s Budget Edition. Ministry of Finance in collaboration with Policy Forum. Available at: http://www.mof. go.tz/mofdocs/budget/citizens budget/citizens budget 2015_2016 _english.pdf. Accessed July 21, 2016. 24. Mahajan V. Africa Rising: How 900 Million African Consumers Offer More than You Think. Upper Saddle River, NJ: Wharton School; 2009. 25. World Bank Group. World Bank Group. Available at: http://www.worldbank.org/. Accessed July 21, 2016. 26. Gross National Income per Capita 2015, Atlas Method and PPP. Word Bank Group. 2016. Available at: http://databank.worldbank.org/data/ download/gnipc.pdf. Accessed July 1, 2016. 27. World Economic Outlook: Legacies, Clouds, Uncertainties. World Economic and Financial Surveys. International Monetary Fund. 2014. Available at: http://www.imf.org/external/pubs/ft/ weo/2014/02/pdf/text.pdf. Accessed July 3, 2016. 28. Ihrig J, Moe KS. Lurking in the shadows: the informal sector and government policy. J Development Econ. 2004;73:541-557. 29. Africa’s macroeconomic prospects j African Economic Outlook. African Economic Outlook. African Development Bank Group. 2016. Available at: http://www.africaneconomicoutlook. org/en/outlook/africa-s-macoreconomic-prospect. Accessed July 21, 2016. 30. Schneider F, Buehn A, Montenegro CE. Shadow economies all over the world: new estimates for 162 countries from 1999 to 2007. The World Bank Development Research Group Poverty and Inequality Team & Europe and Central Asia Region Human Development Economics Unit. July 2010. Available at: https://openknowledge. worldbank.org/bitstream/handle/10986/3928/wps 5356.pdf?sequence¼1. Accessed June 20, 2016. 31. Recognizing Africa’s Informal Sector. African Development Bank. 2013. Available at: http://www. afdb.org/en/blogs/afdb-championing-inclusivegrowth-across-africa/post/recognizing-africasinformal-sector-11645/. Accessed July 21, 2016. 32. Schneider F. Shadow economies around the world: what do we really know? Eur J Polit Economy. 2005;21:598-642. 33. Matotay E. Inequalities and structural transformation in Tanzania*. Development. 2014;57: 591-600. 34. Emerging Markets Center. Making Choices: Africa 2015. EY’s attractiveness survey. 2015. Available at: http://www.ey.com/publication/vwluassets/ey-africaattractiveness-survey-2015-making-choices/$file/ ey-africa-attractiveness-survey-2015-making-choices. pdf. Accessed June 10, 2016.

612

www.SCIENCEDIRECT.com

NONPROFIT NEUROSURGICAL FUNDING

35. The World Wealth Report from Capgemini and RBC Wealth Management. Capgemini. 2016. Available at: https://www.worldwealthreport.com/. Accessed July 22, 2016. 36. Financial Reporting. Innscor Africa Limited. Available at: http://www.innscorafrica.com/ financial-reporting/. Accessed June 15, 2016. 37. Our StoryeIroko. Iroko. Available at: http://iroko. ng/about/#our-story. Accessed June 15, 2016. 38. Sud N. Health and Education in Africa. International Finance Corporation. World Bank Group. Available at: http://www.ifc.org/wps/wcm/ connect/region__ext_content/regions/sub-saharan africa/investments/healtheducation/. Accessed July 7, 2016. 39. Monks K. United States of Africa? African Union Launches All-Africa Passport. Central News Network. July 19, 2016. Available at: http://www.cnn.com/ 2016/07/05/africa/african-union-passport/. Accessed July 13, 2016. 40. Bratton M, Gyimah-Boadi E. Political Risks Facing African Democracies: Evidence from Afrobarometer. 2015. Available at: http://afrobarometer. org/sites/default/files/publications/working papers/ afropaperno157.pdf. Accessed June 20, 2016. 41. The online data analysis tool. Afrobarometer. 2105. Available at: http://afrobarometer.org/ online-data-analysis/analyse-online. Accessed July 10, 2016. 42. Health Facility Registry Web Portal Site. The United Republic of Tanzania, Ministry of Health and Social Welfare. Available at: http://hfrportal. ehealth.go.tz/index.php?r¼site/index. Accessed July 22, 2016. 43. Mackintosh M, Banda G, Tibandebage P, Wamae W, eds. Making Medicines in Africa: the Political Economy of Industrializing for Local Health. London: Palgrave Macmillan; 2016. 44. Callahan S. Tanzania: Private Health Sector Assessment. International Finance Corporation. World Bank Group. 2013. Available at: http:// abtassociates.com/abtassociates/files/29/29f92d9960c8-435f-bad2-eac15b434680.pdf. Accessed June 15, 2016. 45. Hoyt CM, Scott TB, Thomson C, Janabi MY, Ellegla DB, O’Brien P, et al. Prospectus August 2015. 2015. 46. Veselinovic M. Where do Africa’s Multimillionaires Live. Central News Network. 2015. Available at: http://www.cnn.com/2015/04/14/africa/where-doafricas-multimillionaires-live/. Accessed June 17, 2016. 47. Magufuli Bans Foreign Travel for Senior Government Officials. Daily Nation. November 9, 2015. Available at: http://allafrica.com/stories/ 201511091895.html. Accessed July 13, 2016. 48. Doing BusinesseMeasuring Business RegulationseWorld. Available at: http://www. doingbusiness.org/. Accessed July 22, 2016. 49. Ehrbeck T, Guevara C, Mango PD. Mapping the Market for Medical Travel. The McKinsey Quarterly. May 2008. http://www.medretreat.com/templates/

userfiles/documents/mckinsey report travel.pdf. Accessed June 20, 2016.

medical

50. AA Mnazi Mmoja NED Institute. NED Fundaciòn. Available at: http://www.portalned.es/en/index. php/projects/medical/neurosurgery/mnazi-mmojaned-institute. Accessed September 30, 2016. 51. Yiu D, Makino S. The Choice Between Joint Venture and Wholly Owned Subsidiary: An Institutional Perspective. Organ Sci. 2002;13:667-683. 52. Sim AB, Ali Y. Performance of international joint ventures from developing and developed countries: an empirical study in a developing country context. J World Business. 1998;33:357-377. 53. Argente-Linares E, López-Pérez MV, RodríguezAriza L. Organizational structure and success of international joint ventures in emerging economies: the case of Spanish-Moroccan SMEs. Rev Managerial Sci. 2013;7:499-512. 54. Echenim S. Why Nigeria Airways Went Down. Leadership. September 12, 2015. http://leadership. ng/news/460463/new-national-carrier-learningfrom-mistakes-of-nigeria-airways. 55. Akpo E. The Birth, The Rise and the Fall of Virgin Nigeria (A Defunct Subsidiary of Virgin Group). 2013. Available at: http://www.academia.edu/ 3882049/The_Rise_and_Fall_of_Virgin_Nigeria_ A_defunct_subsidiary_of_Virgin_Group_. Accessed July 7, 2016. 56. Africa has seen strong growth in air traffic in recent years, but patterns of growth-and of service-reveal regional disparities. African Development Bank Group. Available at: http://www. infrastructureafrica.org/key-msg/sector/africa-hasseen-strong-growth-air-traffic-recent-years-regionaldisparities-are-great. Accessed July 22, 2016. 57. Corruption Perception Index (CPI) 2015. Transparency InternationaleThe Global AntiCorruption Coalition. Available at: http://www. transparency.org/about/. Accessed July 22, 2016. 58. Batabyal S, Chowdhury A. Curbing corruption, financial development and income inequality. Progress in Development Studies. 2015;15:49-72. 59. Tanzania Country Profile. Business AntiCorruption Portal. Available at: http://www. business-anti-corruption.com/country-profiles/subsaharan-africa/tanzania/snapshot.aspx. Accessed July 22, 2016. 60. Buscaglia E. Judicial Corruption in Developing Countries: Its Causes and Economic Consequences. Hoover Institution, Stanford University. 1999. Available at: http://www.hoover.org/ research/judicial-corruption-developing-countriesits-causes-and-economic-consequences. Accessed July 22, 2016. 61. Belitski M, Chowdhury F, Desai S. Taxes, Corruption, and Entry. Small Business Econ. 2016;47: 201. 62. Pelizzo R, Kinyondo A, Nwokora Z. The costs of party system change: the case of Tanzania. African Politics & Policy. 2015;1:453-473. 63. Chew A. Formal Sector Employment and Earnings, 2014, Tanzania Mainland. Tanzania National

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.10.084

LITERATURE REVIEW AMALI M. FERNANDO ET AL.

Bureau of Statistics, Statistics for Development. 2015. Available at: http://www.nbs.go.tz/nbstz/ index.php/english/statistics-by-subject/labourstatistics/239-formal-sector-employment-andearnings-survey-2014-tanzania-mainland. 64. Cooksey B, Kelsall T. The political economy of the investment climate in Tanzania. In: Crook R, ed. Africa Power and Politics. June 2011. Available at: http://www.tzdpg.or.tz/fileadmin/_migrated/ content_uploads/20110606_odi_report_on_tz_ investment_climate.pdf. Accessed June 19, 2016.

NONPROFIT NEUROSURGICAL FUNDING

65. Straus S. Wars do end! Changing patterns of political violence in sub-Saharan Africa. African Affairs. 2012;111:179-201. 66. World Investment Report 2016, Investor Nationality: Policy Challenges. United Nations. 2016. Available at: http://unctad.org/en/publication slibrary/wir2016_overview_en.pdf. Accessed June 20, 2016. 67. Nyanje P. Magufuli impresses many after 100 days. The Citizen. February 12, 2016, Available at: http://allafrica.com/stories/201602120884.html. Accessed July 13, 2016.

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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. Received 1 August 2016; accepted 15 October 2016 Citation: World Neurosurg. (2017) 98:603-613. http://dx.doi.org/10.1016/j.wneu.2016.10.084 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

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