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Neurosurgical Development in the East, Central, and Southern African (ECSA) Regions: Past, Present, and Future
Accepted Manuscript Neurosurgical Development in the East, Central and Southern African (ECSA) Regions: Past, Present and Future Paul H. Young, MD PII:
S1878-8750(16)31140-8
DOI:
10.1016/j.wneu.2016.10.139
Reference:
WNEU 4807
To appear in:
World Neurosurgery
Received Date: 26 October 2016 Accepted Date: 28 October 2016
Please cite this article as: Young PH, Neurosurgical Development in the East, Central and Southern African (ECSA) Regions: Past, Present and Future, World Neurosurgery (2016), doi: 10.1016/ j.wneu.2016.10.139. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Neurosurgical Development in the East, Central and Southern African (ECSA) Regions: Past, Present and Future Paul H. Young MD
M AN U
SC
RI PT
The East, Central and South regions of Africa (ECSA) constitute a population of well over 350 million people for whom neurosurgical care, until recently, was largely unavailable. Neurosurgical development in this region had not kept pace with other countries on the continent, especially those in North and South Africa. This lack of development of neurosurgery in ECSA was a microcosm of the region’s problems, where basic infrastructure including roads, housing, sanitation and education had not developed to a satisfactory level. As a result, specialized care such as neurosurgery had traditionally been considered an unattainable goal. In addition, for decades well intended medical volunteers and donations from developed countries had flooded the region, mostly into large public, but also private institutions, with little coordination and limited long term commitment. This often added to the problem, creating a sense of helplessness in healthcare stakeholders- recipients, providers, institutions and governmental ministries alike.
EP
TE D
With the dawn of the millennium, those volunteering in ECSA to provide assistance in manpower, training, or the provision of equipment and supplies began to ask themselves: How do we ensure that our efforts to provide assistance are sustainable.? How can we be certain that our manpower and donations be directed to the most appropriate need and then be utilized and maintained into a long term investment.? Or do we simply train surgeons on the front line to use what they have.? How do we fully educate new surgeons to provide quality care and drive the discipline of neurosurgery in the region forward.? Or do we simply train local general surgeons to do the commonest and basic neurosurgical procedures.? How do we convince the government to invest into neurosurgical care to make the practice of neurosurgery appealing, such that local surgeons not abandon the public system for private practice.? And how do we convince equipment and supply companies to invest time and talent into the region.?
AC C
To ensure sustainability, it was clear there needed to be a coordinated effort between international philanthropy and local institutions in order to collaborate on the best allocation of resources. Over the last ten years, International organizations such the Foundation for International Education in Neurosurgery (FIENS), Madaktari, the Neurosurgery Education and Development (NED) Foundation and the Duke Global Health Institute have taken on this challenge to coordinate the spectrum of volunteer efforts with local surgeons, institutions and the health ministries, while both demanding and documenting sustainability for their efforts. Until recently, there were no formal neurosurgical training programs within the ECSA region. Neurosurgeons were being trained by completing general surgical training and then going abroad for a period of one to two years, usually as an
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
observer in Europe or India. The major obstacles to training in ECSA included faculty with inadequate training and inexperience or those incapable or unwilling to teach, professional isolation due to private practice competition, politics or lack of CME opportunities, inadequate healthcare facilities with limited equipment, resources and poorly trained staff due to a lack of institutional and governmental support, and an absence of quality control with no standardization or credentialing. The two major inadequacies that limited formal neurosurgical training- a lack of properly equipped facilities and well trained faculty were addressed through the efforts of FIENS, and through a collaborative effort, a regional curriculum was developed. Today there are established training programs at the Universities in Zimbabwe, Sudan, Ethiopia, Tanzania and Kenya. Under the auspices of the College of Surgeons of East, Central and South Africa (COSECSA), a unified training program was designed to enhance the educational experience through rotations at participating institutions to take advantage of individual strengths. This includes rotations at hospitals in the private sector where facilities and standards of care are generally higher. The higher volumes and mix of cases in the public facilities, along with the higher quality of facilities and care in the private hospitals have proven to provide an excellent mix for training. To attest to this, the program has recently been approved by the World Federation of Neurosurgical Societies (WFNS) as a reference site for training of candidates from all English speaking countries around the world.
TE D
Via an unprecedented and overwhelming demonstration of resource sharing, the Duke Global Health Institute has provided ongoing manpower, equipment and financial support to the main teaching hospital in Uganda, leading to an immediate and dramatic transformation of the quality of health care, not just in neurosurgery, but in many allied disciplines. This has been carefully documented in ongoing quality analysis studies.
AC C
EP
The NED Foundation developed a collaboration with the local governmental health ministry to design, finance, construct, equip and jointly administrate a fully dedicated neurosurgical hospital in Zanzibar City, the first such joint project anywhere in Sub-Saharan Africa. This unique collaborative effort has ensured that a steady stream of volunteer international faculty and financial resources will be available in perpetuity to support a state-of-the-art educational and treatment facility. Similarly Madaktari, in cooperation with the Tanzanian ministry of health, has been building an innovative neurosurgery care delivery system throughout the country from the ground-up, utilizing the training of existing general surgeons and other primary health care practitioners to dramatically improve the availability of basic neurosurgical care. This is envisioned to become a template for other developing regions across the globe. To ensure a sustainable source of funding for this endeavor, Madaktari is promoting the establishment of a collaborative arrangement such that a for-profit hospital in the region will gener-
ACCEPTED MANUSCRIPT
ate income from the care of patients able to pay. A percentage of this income will then provide funding to Madaktari in perpetuity to support its work.
AC C
EP
TE D
M AN U
SC
RI PT
As far future plans in the region, professional practice support for new trainees and existing practitioners in ECSA needs to be significantly improved with greater access to state-of-the-art equipment, subspecialty care, practice coverage, readily accessible educational materials and conferences for ongoing CME and a recertification process. Distant learning needs to be made available in the form of web sites offering high definition and perhaps 3-D videos and simulations. Similarly, world-wide consultations with experts via the web should to be accessible. As a final step, the educational and volunteer programs that have developed and are ongoing across ECSA should develop collaboration with other programs throughout North, South and West Africa and around the world, to exchange faculty and training methodologies, to organize joint meetings and courses, to improve the practice milieu of providers and to adopt uniform training, credentialing and ongoing education standards. An African Congress of Neurosurgery to discuss continent wide volunteer efforts, manpower needs, academic and research issues, corporative support and the need for governmental support would be valuable in charting the way forward. And the formation of an African Board of Neurosurgery (AfBNS) would truly bring together African Neurosurgery to a platform that would match the very best in the world.
S1878-8750(16)31140-8
DOI:
10.1016/j.wneu.2016.10.139
Reference:
WNEU 4807
To appear in:
World Neurosurgery
Received Date: 26 October 2016 Accepted Date: 28 October 2016
Please cite this article as: Young PH, Neurosurgical Development in the East, Central and Southern African (ECSA) Regions: Past, Present and Future, World Neurosurgery (2016), doi: 10.1016/ j.wneu.2016.10.139. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Neurosurgical Development in the East, Central and Southern African (ECSA) Regions: Past, Present and Future Paul H. Young MD
M AN U
SC
RI PT
The East, Central and South regions of Africa (ECSA) constitute a population of well over 350 million people for whom neurosurgical care, until recently, was largely unavailable. Neurosurgical development in this region had not kept pace with other countries on the continent, especially those in North and South Africa. This lack of development of neurosurgery in ECSA was a microcosm of the region’s problems, where basic infrastructure including roads, housing, sanitation and education had not developed to a satisfactory level. As a result, specialized care such as neurosurgery had traditionally been considered an unattainable goal. In addition, for decades well intended medical volunteers and donations from developed countries had flooded the region, mostly into large public, but also private institutions, with little coordination and limited long term commitment. This often added to the problem, creating a sense of helplessness in healthcare stakeholders- recipients, providers, institutions and governmental ministries alike.
EP
TE D
With the dawn of the millennium, those volunteering in ECSA to provide assistance in manpower, training, or the provision of equipment and supplies began to ask themselves: How do we ensure that our efforts to provide assistance are sustainable.? How can we be certain that our manpower and donations be directed to the most appropriate need and then be utilized and maintained into a long term investment.? Or do we simply train surgeons on the front line to use what they have.? How do we fully educate new surgeons to provide quality care and drive the discipline of neurosurgery in the region forward.? Or do we simply train local general surgeons to do the commonest and basic neurosurgical procedures.? How do we convince the government to invest into neurosurgical care to make the practice of neurosurgery appealing, such that local surgeons not abandon the public system for private practice.? And how do we convince equipment and supply companies to invest time and talent into the region.?
AC C
To ensure sustainability, it was clear there needed to be a coordinated effort between international philanthropy and local institutions in order to collaborate on the best allocation of resources. Over the last ten years, International organizations such the Foundation for International Education in Neurosurgery (FIENS), Madaktari, the Neurosurgery Education and Development (NED) Foundation and the Duke Global Health Institute have taken on this challenge to coordinate the spectrum of volunteer efforts with local surgeons, institutions and the health ministries, while both demanding and documenting sustainability for their efforts. Until recently, there were no formal neurosurgical training programs within the ECSA region. Neurosurgeons were being trained by completing general surgical training and then going abroad for a period of one to two years, usually as an
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
observer in Europe or India. The major obstacles to training in ECSA included faculty with inadequate training and inexperience or those incapable or unwilling to teach, professional isolation due to private practice competition, politics or lack of CME opportunities, inadequate healthcare facilities with limited equipment, resources and poorly trained staff due to a lack of institutional and governmental support, and an absence of quality control with no standardization or credentialing. The two major inadequacies that limited formal neurosurgical training- a lack of properly equipped facilities and well trained faculty were addressed through the efforts of FIENS, and through a collaborative effort, a regional curriculum was developed. Today there are established training programs at the Universities in Zimbabwe, Sudan, Ethiopia, Tanzania and Kenya. Under the auspices of the College of Surgeons of East, Central and South Africa (COSECSA), a unified training program was designed to enhance the educational experience through rotations at participating institutions to take advantage of individual strengths. This includes rotations at hospitals in the private sector where facilities and standards of care are generally higher. The higher volumes and mix of cases in the public facilities, along with the higher quality of facilities and care in the private hospitals have proven to provide an excellent mix for training. To attest to this, the program has recently been approved by the World Federation of Neurosurgical Societies (WFNS) as a reference site for training of candidates from all English speaking countries around the world.
TE D
Via an unprecedented and overwhelming demonstration of resource sharing, the Duke Global Health Institute has provided ongoing manpower, equipment and financial support to the main teaching hospital in Uganda, leading to an immediate and dramatic transformation of the quality of health care, not just in neurosurgery, but in many allied disciplines. This has been carefully documented in ongoing quality analysis studies.
AC C
EP
The NED Foundation developed a collaboration with the local governmental health ministry to design, finance, construct, equip and jointly administrate a fully dedicated neurosurgical hospital in Zanzibar City, the first such joint project anywhere in Sub-Saharan Africa. This unique collaborative effort has ensured that a steady stream of volunteer international faculty and financial resources will be available in perpetuity to support a state-of-the-art educational and treatment facility. Similarly Madaktari, in cooperation with the Tanzanian ministry of health, has been building an innovative neurosurgery care delivery system throughout the country from the ground-up, utilizing the training of existing general surgeons and other primary health care practitioners to dramatically improve the availability of basic neurosurgical care. This is envisioned to become a template for other developing regions across the globe. To ensure a sustainable source of funding for this endeavor, Madaktari is promoting the establishment of a collaborative arrangement such that a for-profit hospital in the region will gener-
ACCEPTED MANUSCRIPT
ate income from the care of patients able to pay. A percentage of this income will then provide funding to Madaktari in perpetuity to support its work.
AC C
EP
TE D
M AN U
SC
RI PT
As far future plans in the region, professional practice support for new trainees and existing practitioners in ECSA needs to be significantly improved with greater access to state-of-the-art equipment, subspecialty care, practice coverage, readily accessible educational materials and conferences for ongoing CME and a recertification process. Distant learning needs to be made available in the form of web sites offering high definition and perhaps 3-D videos and simulations. Similarly, world-wide consultations with experts via the web should to be accessible. As a final step, the educational and volunteer programs that have developed and are ongoing across ECSA should develop collaboration with other programs throughout North, South and West Africa and around the world, to exchange faculty and training methodologies, to organize joint meetings and courses, to improve the practice milieu of providers and to adopt uniform training, credentialing and ongoing education standards. An African Congress of Neurosurgery to discuss continent wide volunteer efforts, manpower needs, academic and research issues, corporative support and the need for governmental support would be valuable in charting the way forward. And the formation of an African Board of Neurosurgery (AfBNS) would truly bring together African Neurosurgery to a platform that would match the very best in the world.