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Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change

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OBJECTIVE Worldwide disparities in the provision of surgical care result in otherwise preventable disability and death. There is a growing need to quantify the global burden of neurosurgical disease specifically, and the workforce necessary to meet this demand.METHODS Results from a multinational collaborative effort to describe the global neurosurgical burden were aggregated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were combined to generate incidence and volume figures for 10 common neurosurgical conditions. Next, a global mapping survey was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases per annum. The neurosurgical case deficit was calculated as the difference between the volume of essential neurosurgical cases and the existing neurosurgical workforce capacity.RESULTSEvery year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions, tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately 23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases-all in low- and middle-income countries-that go unmet each year. There exists a gross disparity in the allocation of the surgical workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.CONCLUSIONS Each year, more than 5 million individuals suffering from treatable neurosurgical conditions will never undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosurgeons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is necessary to prevent severe disability and death for millions with neurological disease.
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CLINICAL ARTICLE
ABBREVIATIONS HICs = high-income countries; LMICs = low and middle-income countries; PGSSC = Program in Global Surgery and Social Change; TBI = traumatic
brain injury; TSI = traumatic spinal injury; WFNS = World Federation of Neurosurgical Societies.
SUBMITTED June 21, 2017. ACCEPTED November 10, 2017.
INCLUDE WHEN CITING Published online April 27, 2018; DOI: 10.3171/2017.11.JNS171500.
Global neurosurgery: the current capacity and decit in
the provision of essential neurosurgical care. Executive
Summary of the Global Neurosurgery Initiative at the
Program in Global Surgery and Social Change
Michael C. Dewan, MD, MSCI,1,2 Abbas Rattani, MBe,1,3 Graham Fieggen, MD, MSc,4
Miguel A. Arraez, MD, PhD,5 Franco Servadei, MD,6 Frederick A. Boop, MD,7
Walter D. Johnson, MD, MBA, MPH,8 Benjamin C. Warf, MD,9,10 and Kee B. Park, MD1
1Global Neurosurgery Initiative–Program in Global Surgery and Social Change, Department of Global Health and Social
Medicine, Harvard Medical School, Boston, Massachusetts; 2Department of Neurological Surgery, Vanderbilt University
Medical Center, Nashville, Tennessee; 3Meharry Medical College School of Medicine, Nashville, Tennessee; 4Department of
Surgery, University of Cape Town, South Africa; 5Department of Neurosurgery, Carlos Haya University Hospital, Malaga, Spain;
6Department of Neurosurgery, Humanitas University and Research Institute, Milan, Italy; 7Department of Neurological Surgery,
University of Tennessee Health Sciences Center, LeBonheur Children’s Hospital Neurosciences Institute, Semmes-Murphey
Clinic, Memphis, Tennessee; 8Emergency & Essential Surgical Care Programme Lead, World Health Organization, Geneva,
Switzerland; 9Department of Neurological Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts;
and 10CURE Children’s Hospital of Uganda, Mbale, Uganda
OBJECTIVE Worldwide disparities in the provision of surgical care result in otherwise preventable disability and death.
There is a growing need to quantify the global burden of neurosurgical disease specically, and the workforce necessary
to meet this demand.
METHODS Results from a multinational collaborative effort to describe the global neurosurgical burden were aggre-
gated and summarized. First, country registries, third-party modeled data, and meta-analyzed published data were com-
bined to generate incidence and volume gures for 10 common neurosurgical conditions. Next, a global mapping survey
was performed to identify the number and location of neurosurgeons in each country. Finally, a practitioner survey was
conducted to quantify the proportion of disease requiring surgery, as well as the median number of neurosurgical cases
per annum. The neurosurgical case decit was calculated as the difference between the volume of essential neurosurgi-
cal cases and the existing neurosurgical workforce capacity.
RESULTS Every year, an estimated 22.6 million patients suffer from neurological disorders or injuries that warrant the
expertise of a neurosurgeon, of whom 13.8 million require surgery. Traumatic brain injury, stroke-related conditions,
tumors, hydrocephalus, and epilepsy constitute the majority of essential neurosurgical care worldwide. Approximately
23,300 additional neurosurgeons are needed to address more than 5 million essential neurosurgical cases—all in low-
and middle-income countries—that go unmet each year. There exists a gross disparity in the allocation of the surgical
workforce, leaving large geographic treatment gaps, particularly in Africa and Southeast Asia.
CONCLUSIONS Each year, more than 5 million individuals suffering from treatable neurosurgical conditions will never
undergo therapeutic surgical intervention. Populations in Africa and Southeast Asia, where the proportion of neurosur-
geons to neurosurgical disease is critically low, are especially at risk. Increasing access to essential neurosurgical care
in low- and middle-income countries via neurosurgical workforce expansion as part of surgical system strengthening is
necessary to prevent severe disability and death for millions with neurological disease.
https://thejns.org/doi/abs/10.3171/2017.11.JNS171500
KEYWORDS capacity; epidemiology; global; incidence; volume; workforce; worldwide
J Neurosurg April 27, 2018 1©AANS 2018, except where prohibited by US copyright law
M. C. Dewan et al.
J Neurosurg April 27, 20182
In 2015, the Lancet Commission on Global Surgery of-
fered a summary of the surgical burden and described
existing gaps in the provision of safe and affordable
surgical care worldwide.11 More than two-thirds of the
worlds population lack access to appropriate surgical and
anesthetic care, equating to an estimated 143 million nec-
essary surgical procedures that are left undone. This un-
treated surgical disease results in extreme economic costs
and profound disability and death.17
Within this tremendous burden of surgical disease re-
sides the contribution of neurosurgical disease. Obtaining
a reliable estimate of the volume of neurosurgical disease
requires addressing numerous challenges including sparse
epidemiological data, heterogeneous literature reporting,
and even competing denitions of disease entities. Fur-
thermore, quantifying the existing workforce of surgeons
capable of safely addressing neurological disease is dif-
cult. There exists neither a single worldwide registry of
neurosurgeons, nor even a consensus as to the requisite
training and competencies of a neurosurgeon.
Despite debate about the nature of neurosurgical dis-
ease and those capable of addressing it,1 there is grow-
ing recognition of a worldwide shortage of neurosurgeons,
particularly in low-resourced settings.2,13,20 Before pursu-
ing a targeted campaign to stem the disparity in special-
ized surgical care, a more denitive understanding of the
problem is essential, including regions with the greatest
need. In this report we summarize a body of research by
the Program in Global Surgery and Social Change aimed
at establishing the current status of neurosurgery world-
wide. Thus, we provide estimates of the global volume of
neurosurgical disease, the existing neurosurgical capacity,
and the current unmet neurosurgical need worldwide.
Methods
Volume of Neurosurgical Disease
We began by estimating the incidence of 10 conditions
encountered by neurosurgeons that form the foundation
of essential neurosurgical care: brain and spinal tumors,
hydrocephalus, traumatic brain injury (TBI), traumatic
spinal injury (TSI), neural tube defects, stroke, CNS vas-
cular anomalies, CNS infections, and epilepsy. Conditions
were identied by ranking commonly treated neurosur-
gical conditions described by an international panel of
neurosurgical providers (see Proportion Requiring Neu-
rosurgery below). Then, those conditions in which treat-
ment neglect would directly result in severe disability or
death were designated by this report as essential neuro-
surgical conditions. Notably excluded from the nal list
are degenerative spine disease and osteoporotic vertebral
fractures.15 The proportion and volume of patients suc-
cumbing to severe disability or death if these conditions
are not treated surgically is difcult to determine, particu-
larly in resource-limited settings. Due to the recognition
of limited capacity, this classication scheme of essential
neurosurgical care also excluded important conditions
such as pain disorders, spasticity, movement disorders,
and other conditions for which neurosurgical treatment
might offset disability and lost productivity. Competency
with the treatment of the 10 conditions above, however,
would equip a neurosurgeon anywhere with the ability to
treat the vast majority of patients with neurosurgical dis-
ease, and thereby most efciently avert severe disability or
premature death.
Reliable epidemiological gures were available for
two diseases (neural tube defect and stroke; http://ghdx.
healthdata.org/gbd-results-tool),10 thus our attention was
focused on the remaining conditions. National surgical
registries were available for brain and spinal tumors al-
lowing region-specic estimation of disease incidence.3
The Institute for Health Metrics and Evaluation has pub-
lished epidemiological gures for road trafc injuries in
each country, which were used to extrapolate the inci-
dence of TBI. The proportion of trafc collisions result-
ing in TBI was calculated via a meta-analysis of published
trafc injury data. Similarly, the proportion of TBI from
which trafc collisions is the mechanism of action was
calculated via a meta-analysis. Applying these ratios to the
incidence of road trafc injuries delivered an estimation of
total TBI from all causes.6
For the remaining conditions (hydrocephalus, TSI,
CNS vascular anomalies, CNS infections, and epilepsy),
an exhaustive systematic review was conducted to identify
studies reporting epidemiological data from large, popu-
lation-based cohorts. After extracting case numbers and
sample size, a meta-analysis was performed to estimate
disease incidence gures for each disease by WHO re-
gion and by World Bank income group. Finally, incidence
gures were multiplied by population estimates from the
WHO to generate estimates for the annual volume of dis-
ease globally. Detailed methodology and results are de-
scribed in detail elsewhere.3,7–9,11,16,19
Proportion Requiring Neurosurgery
Identifying the incidence of neurosurgical disease re-
quires an estimate of the proportion of neurological injury
or illness warranting surgical intervention. Some neu-
rosurgical diseases are best managed operatively, while
others require nonoperative neurosurgical management.
Some neurological conditions do not require neurosurgi-
cal expertise for optimal treatment. While surgical logs
from ideal health care systems offer reliable estimates
for surgical proportion (i.e., the fraction of neurological
conditions requiring surgery), their relevance may not be
generalizable to health care systems in differing settings.
Furthermore, we learn very little about the proportion of
disease beneting from nonoperative neurosurgical ex-
pertise or consultation. Thus, following the precedent es-
tablished by the Lancet Commission on Global Surgery,
we sought expert opinion from a broad, diverse group of
surgical providers.
Via electronic survey, nearly 200 neurosurgeons from
more than 50 countries were asked to estimate the pro-
portion of specic neurological disorders that, in an ideal
world, would require either neurosurgical operation or
consultation. To gauge degree of certainty, surgeons in-
dicated how condent they were in their estimation for
each disease. Finally, we sought to identify the number of
cases that can be reasonably performed each year by the
average practicing neurosurgeon. Surgeons indicated their
annual case volume and types of cases most frequently
J Neurosurg April 27, 2018 3
M. C. Dewan et al.
performed, then indicated how they perceived their work-
load at that clinical volume. The full questionnaire and
analytical methodology are described in detail elsewhere.5
Neurosurgical Workforce
Determination of the current neurosurgical workforce
was quantied via a large, multinational global mapping
project facilitated by the World Federation of Neurosur-
gical Societies (WFNS), the WHO, and the Program in
Global Surgery and Social Change (PGSSC) at Harvard
Medical School. Briey, Ministries of Health, ofcers of
the 130 societies registered with the WF NS, and the mem-
bers of the WHO Global Initiative for Emergency and
Essential Care were contacted via email for information.
For some countries an internet search was conducted to
identify the contact information for active neurosurgeons
willing and able to complete an online questionnaire on
capacity. Surgeons registered with the open access Glob-
al Neurosurgery forum (https://globalneurosurgery.org/
members) were also included. The data collection instru-
ment captured surgeon numbers and geographic locations,
as well as the presence of basic equipment germane to
neurosurgical care: high-speed drills, bipolar electrocau-
tery, imaging infrastructure, etc. For the purposes of the
current summary, we aggregated the number of neurosur-
geons by country and by WHO region to facilitate quanti-
cation of the current surgical capacity. A comprehensive
description of the methodology and results of the PGSSC
workforce mapping initiative is described elsewhere (un-
published data).14
Estimating the Decit in Neurosurgical Care
The unmet need, or decit in neurosurgical care, repre-
sents the difference between the total estimated number of
essential neurosurgical conditions presenting for treatment
and the current number of neurosurgical cases that can be
performed given the existing workforce. The number of
essential neurosurgical conditions was calculated by tak-
ing the product of neurosurgical volume (from each meta-
analysis by disease entity3,7–9,11,16,19) and surgical proportion
(from the provider survey5). The number of neurosurgical
cases that can be currently performed, on the other hand,
was obtained by taking the product of the number of neu-
rosurgeons (from the Workforce estimate [unpublished
data]) and the median number of cases performed (from
the provider survey estimate5). The decit was then cal-
culated on a regional and income-group basis to provide
a more granular description of need and volume, and to
highlight disparity in neurosurgical care across regions.
Then, a country-specic ratio of neurosurgeons to essen-
tial neurosurgical cases (both surgical and consultative)
was estimated. The total number of cases within a region
was allocated to each country according to the population
proportion of a given country within its WHO region and
World Bank income group. For the worldwide estimate,
all countries with available workforce data were included,
irrespective of WHO or World Bank classication. Incor-
porating the country-specic neurosurgeon gure from
the workforce survey, maps were then created to depict
this ratio using Tableau software.
Results
Estimations of the volume of each disease, the propor-
tion requiring neurosurgical intervention, and the quanti-
cation of the existing neurosurgical workforce have been
described in detail elsewhere. Here, we have aggregated
this information and synthesized the ndings into a di-
gestible summary.
Neurosurgical Cases by Region and Income Group
An estimated 13.8 million essential neurosurgical cas-
es develop each year, of which more than 80% arise in
low- and middle-income countries (Table 1). A detailed
breakdown of neurosurgical volume by disease can be
found in the Appendix (Tables S1–S23). Corresponding
to the regional population proportions, an expected 3.5
million and 3.7 million new cases are expected in South-
east Asia and the Western Pacic, respectively. Africa is
expected to endure nearly 2 million neurosurgical cases,
in contrast to about 665,000 cases in the US and Canada.
Europe, the Eastern Mediterranean, and Latin America
each will encounter between 1.1 and 1.8 million new neu-
rosurgical cases annually (Table 1). Among the conditions
we have dened as requiring essential neurosurgical care,
surgery for TBI (burr holes, craniotomy/craniectomy, etc.)
accounts for 45%, cerebrovascular accident for 20%, hy-
drocephalus for 7%, and brain tumors for 5%. Vascular
anomalies (2.2%), neural tube defects (0.3%), and spinal
tumors (0.1%) occupy a relatively modest proportion of the
global neurosurgical need.
The number of cases requiring neurosurgical consul-
tation—but not necessarily surgical intervention—is far
greater, approaching 22.6 million annually (Table 2).
Again, Southeast Asia and the Western Pacic bear the
greatest consultative demand with 5.8 million and 6.2 mil-
lion cases each year, respectively. Low and middle-income
countries (LMIC) endure the greatest burden at 17.6 mil-
lion cases, compared with 4.3 million cases in high-in-
come countries (HIC).
Neurosurgeons by Region and Income Group
We identied 49,940 practicing neurosurgeons world-
wide (unpublished data). Ninety-eight percent (98.9%) of
neurosurgeons were identied via the WFNS-sponsored
electronic survey, while 560 neurosurgeons (1.1%) from
34 countries (14.9%) in which no data were available were
imputed via statistical modeling. The greatest population
of neurosurgeons resides in the Western Pacic region,
with China and Japan alone accounting for more than
18,000 neurosurgeons. Europe and the US/Canada have
the next largest populations of neurosurgeons, with 10,719
and 5296 neurosurgeons, respectively. In the African re-
gion, with a population of 990 million, 488 neurosurgeons
were identied (Table 3). Forty-four percent (44%) of neu-
rosurgeons worldwide reside in high-income countries.
Previously, we have identied the mean neurosurgical
volume reasonably managed by a neurosurgeon in a given
country as 223 cases per year.5 This assumes a surgeon’s
perceived workload is maintained at a level of 75 out of
100 (where 0 is “not at all busy” and 100 is “extremely
busy, overworked”). The greatest total neurosurgical ca-
M. C. Dewan et al.
J Neurosurg April 27, 20184
TABLE 1. Estimated number of cases requiring neurosurgical operation, by WHO region and income group
WHO Region Brain Tumor Spinal Tumor TBI TSI Stroke HC NTD Vascular Anomalies Infection Epilepsy Total (95% CI)
AFR 63,343 1032 708,181 70,032 239,675 420,674 22,942 23,564 241,910 195,039 1,986,392 (377,966–3,564,330)
AMR-L 77,293 1317 514,592 41,294 103,362 123,924 3993 18,088 103,267 159,042 1,146,170 (657,411–1, 578,720)
AMR-US/Can 56,742 1848 414,171 9474 71,290 33,564 1250 13,515 2955 59,888 664,698 (247,052–906,397)
EMR 53,927 1673 518,981 17,523 178,223 89,168 4708 2799 32,649 157,363 1,057,015 (688,679–1,377,989)
EUR 148,819 3819 828,173 16,169 493,511 94,910 1949 47,473 25,494 96,575 1,756,891 (1,175,365–2,292,342)
SEAR 147,501 1044 1,631,484 137,389 657,300 124,708 10,394 29,657 446,085 319,221 3,504,783 (1,059,489–5,775,574)
WPR 187,524 7109 1,545,233 119,280 1,031,871 84,369 6864 145,684 116,641 426,298 3,670,873 (1,339,219–5,850,732)
HIC 181,465 5479 1,597,979 52,768 352,852 29,858 31,928 62,946 26,114 141,086 2,482,475 (871,290–3,414,859)
LMIC 720,074 16,666 4,458,615 438,524 2,407,551 740,305 3695 95,863 701,188 1,166,036 10,748,517 (4,601,979–15,505,041)
Global 735,180 17,840 6,160,814 399,606 2,760,403 971,317 35,622 311,407 969,001 1,413,426 13,786,823 (6,245,611–20,645,656)
AFR = Afric an Region; AMR-L = Region of the Americas (Latina America); AMR-US/Can = Region of the Americas (US and Canada); CI = condence interval; EMR = Eastern Mediterranean Region; EUR = European
Region; HC = hydrocephalus; NTD = neural tube defect; SEAR = Southeast Asia Region; WPR = Western Pacic Region.
TABLE 2. Estimated number of cases requiring neurosurgical consultation, by WHO region and income group
WHO Region Brain Tumor Spinal Tumor TBI TSI Stroke HC NTD Vascular Anomalies Infection Epilepsy Total (95% CI)
AFR 77,961 1195 1,265,685 113,128 417,498 449,356 25,740 33,994 318,882 325,065 3,028,504 (963,498–5,039,023)
AMR-L 95,129 1526 919,696 66,706 180,051 132,373 4479 26,094 136,124 265,070 1,827,247 (1,119,077–2,434,959)
AMR-US/Can 69,836 2141 740,221 15,305 124,183 35,853 1402 19,496 3896 99,813 1,112,147 (410,79–1,499,044)
EMR 66,372 1938 927,540 28,307 310,453 95,248 5283 4038 43,038 262,272 1,744,489 (1,159,625 –2,244,705)
EUR 183,162 4424 1,480,138 26,119 859,664 101,381 2187 68,486 33,605 160,958 2,920,125 (1,990,180–3,767,722)
SEAR 181,540 1209 2,915,844 221,936 1,144,975 133,211 11,662 42,784 588,021 532,035 5,773,216 (2,489,612–8,744,941)
WPR 230,799 8236 2,761,693 192,683 1,797,452 90,121 7701 210,168 153,754 710,497 6,163,104 (3,004,300–9,050,615)
HIC 223,341 6348 2,855,963 85,241 614,645 81,445 35,821 90,807 34,423 235,144 4,263,178 (1,506,562–5,707,516)
LMIC 886,245 19,308 7,968,589 708,385 4,193,799 790,780 4146 138,294 924,293 1,943,394 17, 577,232 (8,617,55224,0 52, 631)
Global 904,836 20,668 11,010,817 645,517 4,808,444 1,037,543 39,967 449,244 1,277,320 2,355,710 22,568,833 (12,167,919–31,750,174)
J Neurosurg April 27, 2018 5
M. C. Dewan et al.
pacity exists in the Western Pacic region, where more
than 22,000 neurosurgeons are capable of performing
nearly 5 million essential neurosurgical cases annually. In
contrast, the nearly 500 neurosurgeons in Africa can be
expected to perform approximately 110,000 neurosurgical
operations. Worldwide, and ignoring geographic boundar-
ies and uneven case distribution, the overall surgical ca-
pacity is approximately 11 million essential neurosurgical
cases per year (Table 3).
The Decit in Neurosurgical Care
The current decit in neurosurgical care is approxi-
mately 5.2 million (Table 3). This decit derives from
the difference between the number of essential cases en-
countered annually and the essential surgical capacity,
where essential surgical capacity excludes nonessential
cases performed by neurosurgeons, particularly in HIC.
To meet this demand, an estimated additional 22,626
neurosurgeons would need to be trained. The greatest
decit resides in Southeast Asia where nearly 2.5 million
essential cases go unmet. The tremendous shortage of
neurosurgeons in India—where 3500 neurosurgeons are
responsible for a population of more than 1.2 billion—is
largely responsible for this health care discrepancy. For
the entire region, 2.5-times the existing number of sur-
geons are needed to provide appropriate coverage. In Af-
rica, where more than 1.8 million cases are not being ad-
dressed by capable neurosurgeons, the surgical workforce
must increase by more than 1700% to meet the regional
demand. The vast majority of the population in Africa has
no access to a neurosurgeon, independent of other geo-
graphic, social, or nancial barriers that may exist.14 In
terms of essential care, three WHO regions—the region
of the Americas restricted to the US and Canada only, the
European region, and the Western Pacic region—do not
demonstrate a workforce decit, although the need for ad-
ditional neurosurgeons in these regions to meet neurologi-
cal conditions not accounted for in our analysis remains a
salient consideration.
Discussion
In this summary, for neurosurgical diseases, we es-
timate approximately 13.8 million new operative cases
and 22.6 million new consultative cases exist worldwide
each year. TBI and stroke-related conditions and sequelae
constitute approximately 60% of essential neurosurgi-
cal volume, with tumors, hydrocephalus, epilepsy, and
infectious-related conditions accounting for the majority
of the remaining proportion of disease. A tremendous dis-
parity exists in the global workforce; 82% of neurosurgi-
cal volume exists in LMICs where approximately 56% of
neurosurgeons reside. While Africa accounts for 15% of
the global volume of neurosurgical disease, African hos-
pitals and health care networks have access to less than
1% of the neurosurgeon community. An estimated 23,300
additional surgeons—approximately 11,300 in Southeast
Asia, and 8400 in Africa—are needed in low- and middle-
income countries to adequately address essential neuro-
surgical disease worldwide. For the rst time, an estimate
of the decit of neurosurgical care is provided. The world
maps (Figs. 1 and 2) offer a pictorial representation of the
volume of essential neurosurgical disease observed by
the existing neurosurgical workforce in a given country;
disparity in care is illustrated. Training capable and com-
petent neurosurgeons is a fundamental step in establish-
ing equal access to safe and timely neurosurgical care. A
benchmark is thus established for which to aim.
Examining Tables 1 and 2 more closely, there are 3 im-
portant observations that merit specic discussion. First,
these disease gures are estimates. While they derive from
the best available evidence and are computed using modern
statistical modeling, they remain susceptible to the same
methodological assumptions made for any epidemiologi-
cal estimation of disease incidence. Second, we notice that
diseases requiring advanced diagnostic equipment for di-
agnosis (e.g., MRI) are more likely to be underrepresented
in regions made up of predominantly low income or lower
middle income countries. CNS tumors are taken as an ex-
ample. There exists a positive correlation between age and
incidence of brain tumors. Most populations in HICs ex-
hibit a greater median survival than those in LMICs. Thus,
ignoring competing variables (such as carcinogenic expo-
sures, or prevention of metastatic spread) nding a higher
proportion of brain tumors in the US/Canadian region
than in African region follows logic. However, the degree
to which this difference exists suggests additional factors
are involved. For these less clinically overt diseases, a di-
agnosis bias almost certainly affects these results. Brain
and spinal tumors in low-resource settings are not being
TABLE 3. Summary of case volume, surgical capacity, and neurosurgical decit
WHO Region Case Volume Current Surgeons Case Capacity Case Decit* Additional Surgeons Necessary*
AFR 1,986,392 488 108,824 1,877,568 8420
AMR-L 1,146,170 4216 940,168 206,002 924
AMR-US/Can 664,698 5296 1,181,008 — —
EMR 1,057,015 2073 462,279 594,736 2667
EUR 1,756,891 10,719 2,390,337 — —
SEAR 3,504,783 4409 983,207 2,521,576 11,308
WPR 3,670,873 22,114 4,931,422 — —
Worldwide 13,786,823 49,940 11,136,620 5,199,883 23,318
* “Case Decit” and “Additional Surgeons Necessar y” are left blank for regions that have a capacity surplus. Capacity surplus suggests cases are being per formed by
neurosurgeons that fall outside of the denition of “essential neurosurgical care,” such as degenerative spine disease and movement disorders.
M. C. Dewan et al.
J Neurosurg April 27, 20186
diagnosed due to lack of equipment and/or lack of access
to the level of care requisite for their diagnosis. Converse-
ly, readily diagnosed diseases such as neural tube defects
are more likely to be captured by population-based epide-
miological studies, regardless of diagnostic infrastructure.
Third, while the estimates are staggering—especially in
relation to the existing workforce—they are most certainly
an underestimate of the true surgical responsibilities faced
by the global neurosurgery community. Absent from these
estimates are entities such as diagnostic procedures (lum-
bar punctures, ventricular taps, etc.), repeat or redo surger-
ies, and, importantly, the great proportion of neurosurgical
interventions that are deemed “nonessential” by the out-
lined criteria.
This year, nearly 5.2 million essential neurosurgical cas-
es are estimated to go unmet by a qualied neurosurgeon,
resulting in otherwise avoidable disability and death. Such
essential neurosurgical cases include relatively straightfor-
ward procedures such as burr hole craniotomy for hema-
toma evacuation and shunt insertion for childhood hydro-
cephalus. Interestingly, these are the only two surgeries
mentioned in the 44 essential surgical procedures listed
within the Disease Control Priorities series published by
the World Bank Group.4 However, extraaxial hemorrhage
and hydrocephalus represent only a small fraction of neu-
rosurgical conditions that result in severe disability and
death if left untreated. Essential operations as outlined in
this report also include brain tumor resection, cerebral an-
eurysm exclusion, and open spinal fracture reduction and
xation, all considered to require more advanced surgi-
cal technique and resources. Designating treatment tiers to
balance access to care and quality of delivery is imperative
to optimize geographic coverage. While a discussion of
this concept reaches beyond the scope of this summary,
the centralization of highly complex neurosurgical care—
while also prioritizing basic, emergency neurosurgical
care peripherally—is an important model that must remain
a priority for the global neurosurgery community, espe-
cially in LMICs.
Ongoing Efforts to Increase Neurosurgical Capacity
A number of efforts to increase neurosurgical capac-
ity in LMICs have already begun to make a difference.
Enabling nonneurosurgeons to perform neurosurgical in-
terventions (task-shifting) that are technically straightfor-
ward and have a high benet to risk ratio (such as emer-
gency evacuation of an epidural hematoma) is rational.
Likewise, teaching nonneurosurgeons to place shunts for
hydrocephalus has been advocated by some, but infant hy-
drocephalus is not immediately life-threatening; although
placing the initial shunt is not difcult, the signicant
complication rate requires timely neurosurgical expertise
for subsequent management. The ultimate goal should be
FIG. 1. The global decit of neurosurgical care: operations. ©OpenStreetMap contributors (http://www.openstreetmap.org/
copyright). Figure is available in color online only.
J Neurosurg April 27, 2018 7
M. C. Dewan et al.
to increase neurosurgical capacity by increasing the num-
ber of competent and accessible neurosurgeons in under-
served regions. The most sustainable way to achieve this
will be for adequately trained national neurosurgeons to
begin training programs in their home countries. This may
initially require the importation of expertise, but the need
for this would diminish over time if an investment is made
in training individuals from these countries.
The global neurosurgery community should prioritize
the provision of training to individuals from countries that
do not have adequate neurosurgery residency programs.
Historically, people who leave home to train in a high-in-
come country often fail to return. But in the past decade,
sub-Saharan Africa has benetted from an inux of neu-
rosurgeons because the few established training programs
on the continent have embraced the opportunity to incor-
porate trainees from the less developed countries into their
residency programs. Programs in Morocco, Senegal, Zim-
babwe, and South Africa have trained approximately 60
new neurosurgeons from other African countries thus far.
Also, a new East African training program has recently
been established in cooperation with The College of Sur-
geons of East Central and Southern Africa, with training
sites in Tanzania, Uganda, and Kenya. All these programs
provide more appropriately contextualized training in re-
gard to pathology and resource availability, and are more
likely to see their trainees return home to build neurosurgi-
cal capacity in their own countries. In addition, longitudi-
nal partnerships between centers in LMICs and academic
neurosurgery departments in HICs (Duke University, Uni-
versity of Alabama, University of Miami, The University
of Toronto, The Weill Cornell Medical College, The Bar-
row Neurological Institute, and others) are fostering con-
tinued training, mentoring, and collaborative research in
sub-Saharan Africa, Southeast Asia, and Latin America.
Other programs, such as CURE Hydrocephalus and Spina
Bida, provide subspecialty training fellowships to neuro-
surgeons from across the developing world. Furthermore,
organized neurosurgery (such as the Foundation for Inter-
national Education in Neurosurgery, the WFNS, the Asian
Australasian Society of Neurological Surgeons, the Amer-
ican Association of Neurological Surgeons, the European
Society of Pediatric Neurosurgery, and the International
Society of Pediatric Neurosurgery) has long been engaged
in international neurosurgery education. The past 10 years
have seen a noticeable escalation in awareness of and com-
mitment to global neurosurgery that should, if we stay on
mission, gradually improve access to neurosurgical care
for people everywhere.
The Way Forward
The Role of Professional/National Societies
National neurosurgical societies exist to represent their
FIG. 2. The global decit of neurosurgical care: consultations. ©OpenStreetMap contributors (http://www.openstreetmap.org/
copyright). Figure is available in color online only.
M. C. Dewan et al.
J Neurosurg April 27, 20188
community of neurosurgeons via surgical education, the
promotion of scientic exchange, establishment of prac-
tice guidelines, and at times the promotion of a legislative
agenda. For an individual surgeon, particularly one who
operates in a solo practice, the national society serves as
the most direct conduit to peer evaluation and feedback,
continuing surgical education, and surgeon fellowship. A
robust and active professional society serves to enhance
the quality of neurosurgical care delivery by its member-
ship. Thus, as the global neurosurgery effort matures, pro-
fessional societies are a natural springboard from which
to launch targeted intervention strategies, and may have
broader impact than simply targeting a specic hospital,
university, or institution.
Naturally, a professional society’s role depends upon
the resources and capabilities that exist on the ground. For
example, in low-resource settings, high-priority initiatives
of a neurosurgical society may include surveying region-
al disease burden, organizing available manpower, and
lobbying for federal support. Meanwhile, societies in re-
source-rich countries can invite meaningful participation
from LMIC surgeons, organize a workforce of members
interested in cross-national education and training, and
allocate activities, meetings, and funding to international
education and research initiatives. Indeed, some societies
in HICs are already playing an active role by doing just
this. Throughout, developing and fostering a relationship
between societies built upon respect and mutual benet
is essential to ensuring productive and sustainable cross-
collaborations.
The Role of Global Governance
The WFNS is a professional, nongovernmental organi-
zation representing 118 individual societies of neurosur-
gery worldwide. With the overarching purpose to promote
global improvement in neurosurgical care, capacity build-
ing through education and surgeon training is among the
dening principles of the Federation. For example, as the
glaring shortage of neurosurgeons in Africa has grown,
the WFNS has taken specic actions such as facilitation
of the “Africa 100” initiative championed by Professor
Majid Samii and designed to increase the number of per-
manent practicing surgeons on the continent. Via such ini-
tiatives, the Federation can work to establish educational
paradigms that incorporate open-access, web-based edu-
cational platforms accessible to trainees and consultants
from all corners of the globe. Indeed, the WFNS already
has a track record as a central, nonpartisan organization
for open collaboration between member partners and the
transfer of ideas and technologies across the many na-
tional societies. Moving forward, the WFNS is optimally
suited for advocacy toward and coordination of the neu-
rosurgery capacity building effort. In so doing, the Fed-
eration is well positioned to: 1) raise awareness of the un-
met neurosurgical care as a global public health issue; 2)
develop educational and practice guidelines based upon
member input; 3) collect and monitor global neurosurgical
workforce and capacity data; and 4) facilitate coordination
and collaboration between the academic community and
state-sponsored agencies toward efciently addressing the
worldwide decit in neurosurgical care.
Integrating Neurosurgery Within the Overall Surgical Community
Neurosurgical efforts aimed at LMICs would ben-
et greatly from integration with ongoing global surgical
programs through partnerships with professional societ-
ies, academia, and nongovernmental organizations, to
avoid duplication and to complement the surgical sys-
tem–strengthening efforts of each stakeholder. In many
regions, there already exist efforts designed to develop or
improve surgical and anesthesia service delivery, enhanc-
ing the overall surgical ecosystem. Consider, for example,
the essential nature of a blood bank for safe surgical care:
it matters little if packed red blood cells are used for a
postpartum hemorrhage, a malaria crisis, or a severe TBI.
Surgeons of all types and anesthetists can work together
synergistically to develop and maintain components of the
entire surgical delivery system. Partnership with United
Nations bodies, such as the WHO, provide collaborative
arrangements with local governments that offer the ad-
vantage of enhancing service delivery mechanisms in-
country. The WHO, through the Emergency and Essential
Surgical Care Program, is poised to facilitate global coor-
dination of neurosurgical efforts along with other surgical
stakeholders as dened by the mandates of member states.
Currently, combined efforts targeting advocacy, ser-
vice delivery, data collection, essential medicines, and
health workforce are critical, thus fullling the mandates
of World Health Assembly Resolution 68.15 (2015) on
strengthening emergency and essential surgical care and
anesthesia as a component of universal health coverage,7
all with direct links to the sustainable development goals.18
Strengths and Limitations of the Study
The estimates and conclusions outlined in this sum-
mary must be considered in the context of several limi-
tations. First, most disease volume gures derive from
large systematic reviews and meta-analyses, as reliable,
population-based estimates for each country or region
are nonexistent. Similarly, the surgical workforce gures
relied upon accurate neurosurgical association reporting,
and at times questionnaire responses and statistical mod-
eling, all of which carry bias and intrinsic inconsistencies.
Throughout the tables and text, we assume that neurosur-
geons are optimally distributed geographically in relation
to the at-risk population. We also assume that each trained
neurosurgeon is capable of safely treating each condition
encompassed within the designation of essential neurosur-
gical care. While these assumptions are generally safe for
epidemiological modeling at the region- or country-level,
they would not permit accurate allocation of resources at
the city or hospital level. In relation to surgical capacity,
we have focused on the surgeon only—not the wealth of
infrastructure, equipment, and personnel required along-
side the surgeon to facilitate safe and timely provision of
neurosurgical care. We acknowledge the tremendous im-
portance of these resources, and we are actively conduct-
ing a worldwide survey to better understand their acces-
sibility to current and future surgeons.14
In an effort to prioritize the most life-threatening neu-
rosurgical conditions worldwide, we have deliberately ex-
cluded many important conditions commonly addressed
by neurosurgeons, most notably degenerative spine dis-
J Neurosurg April 27, 2018 9
M. C. Dewan et al.
ease. This relative limitation warrants specic elabora-
tion. In the US, with more than 5000 neurosurgeons, we
estimate the case capacity is nearly 1.2 million cases/year.
Meanwhile, the volume of essential neurosurgical cases is
estimated at only 576,000, suggesting a surplus of neuro-
surgeons exists in the US. We would caution the reader
against this conclusion. The majority of neurosurgical cas-
es performed in the US are for conditions falling outside
the designation used in this report of essential neurosurgi-
cal care. Indeed, entities like degenerative spine disease,
chronic pain, movement disorders, and many other con-
ditions are well known to cause disability and suffering
if left untreated. Thus, a shortage of neurosurgeons may
exist even in the most developed of countries, depending
upon the level and type of neurosurgical care demanded
by a given population. The scope and purpose of this pa-
per is to offer a description of the workforce capacity and
decit that exists for essential neurosurgical care, a des-
ignation that itself aims to prioritize those patients who
are most likely to benet from lifesaving and disability-
averting neurosurgical care.
Finally, this report ignores the concept of task sharing
and the number of procedures potentially performed by
nonneurosurgeon providers. Training general surgeons
in common neurosurgical procedures such as ventriculo-
peritoneal shunt insertion and burr hole craniotomy is a
practical strategy that might more quickly help curb the
overwhelming neurosurgical burden. Reasonable neuro-
surgical experts will disagree on the ethics and quality-
related implications of this frequently used strategy in the
realm of global health. The potential capacity-related con-
sequences of this strategy, however, are absent from the
gures provided above.
While inherent limitations exist for an epidemiological
survey and capacity estimation of this scope, careful and
deliberate measures were taken to ensure data validity and
provide methodological transparency throughout. Rather
than relying on surgical log data from hospitals and health
systems where the surgical care is known to be inadequate,
we approached surgical decit gures rst from the disease
component of the equation. Though data modeling was
necessary in some cases, the disease-specic estimates
represent the best available evidence to date, derived from
among the most comprehensive systematic reviews avail-
able in the neurosurgical literature. Additionally, surgical
provider data arose from the most far-reaching effort yet to
quantify the worldwide population of neurosurgeons, and
involved a partnering effort with many active international
neurosurgery initiatives such as the WFNS.
Conclusions
Each year, 13.8 million new essential neurosurgical
operative cases and 22.6 million new consultative cases
present worldwide. TBI, tumor, hydrocephalus, and stroke-
related conditions constitute the majority of essential neu-
rosurgical volume globally. Regional variation in disease
incidence is likely inuenced by a host of factors includi ng
baseline population demographics, risk factor exposure,
and genetic susceptibility. Wide workforce gaps exist,
and the uneven distribution of neurosurgeons to disease
volume creates large geographic pockets of surgical ac-
cess shortage. Nearly 23,000 additional neurosurgeons are
needed in low- and middle-income countries to adequately
address the unmet decit of more than 5 million neurosur-
gical operations worldwide.
Acknowledgments
We would like to thank Ron Baticulon, MD, for his graphical
expertise. The work in this report was enhanced by the logistical,
financial, or in-kind support that we received from the following
organizations: Boston Children’s Hospital Global Hydrocephalus
and Spina Bifida Fund, Harvard Medical School Department of
Global Health and Social Medicine, John D. and Catherine T.
MacArthur Foundation, Kellogg Institute for International Stud-
ies at the University of Notre Dame, Vanderbilt Medical Scholars
Program, Vanderbilt University Medical Center, and the WFNS.
Appendix
Collaborators
We would like to thank the following individuals for their
dedication and contribution to identifying the global neurosurgical
deficit. Collaborators are listed in alphabetical order:
Amos O. Adeleye, MBBS, Amit Agrawal, MCh, Blake C.
Alkire, MD, MPH, Julia R. Amundson, BS, Hildo Azevedo-Filho,
MD, PhD, Ronnie E. Baticulon, MD, Joseph S. Bell, PhD, Erica
Bisson, MD, MPH, Kamila M. Bond, BA, Vivek P. Buch, MD, Mat-
thew C. Davis, MD, Robert Dempsey, MD, Serena Faruque, MS,
PhD, Laurence Glancz, MBBS, BSc, William B. Gormley, MD,
MPH, MBA, Saksham Gupta, BA, Michael M. Haglund, MD, PhD,
MACM, Roger Härtl, MD, Joshua D. Hughes, MD, Ya Ching Hung,
MD, Yoko Kato, MD, PhD, Robert M. Koffie, MD, PhD, Ramesh
Kumar, MD, Jacob R. Lepard, MD, Jaims Lim, BS, Muhammad
Raji Mahmud, MD, John G. Meara, MD, DMD, MBA, Rania A.
Mekary, MSc, PhD, Basant K Misra, MD, Jacques J. Morcos, MD,
Swagoto Mukhopadhyay, MD, Brian V. Nahed, MD, MSc, Enrique
Osorio-Fonseca, MD, Sophie Peeters, BS, Maria Punchak, MSc,
Mahmood M. Qureshi, MD, Christian Lopez Ramos, BS, Vijay
Ravindra, MD, MSPH, Faith C. Robertson, BS, Jeffrey V. Rosen-
feld, MD, Gail Rosseau, MD, Andrés M. Rubiano, MD, Sonal
Sachdev, MD, Steven S. Senglaub, MS, Salman Y. Sharif, MD,
Mark G. Shrime, MD, MPH, PhD, Kerry A. Vaughan, MD, Eka J.
Wahjoepramono, MD, PhD, John C. Wellons III, MD, MSPH, and
Ismaeel Yunusa, PharmD.
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Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: Dewan. Acquisition of data: Dewan, Rat-
tani. Analysis and interpretation of data: Dewan, Rattani, Fieggen,
Arraez, Servadei, Johnson, Warf. Drafting the article: Dewan,
Fieggen, Arraez, Servadei, Boop, Johnson, Warf. Critically revis-
ing the article: all authors. Reviewed submitted version of manu-
script: all authors. Approved the final version of the manuscript
on behalf of all authors: Dewan. Statistical analysis: Rattani.
Administrative/technical/material support: Rattani.
Supplemental Information
Online-Only Content
Supplemental material is available with the online version of the
article.
Appendix. https://thejns.org/doi/suppl/10.3171/2017.11.
JNS171500.
Correspondence
Michael C. Dewan: Vanderbilt University Medical Center, Nash-
ville, TN. dewan.michael@gmail.com.
... Approximately 22.6 million patients, including 13.8 million who ultimately require surgery, experience neurological disorders or injuries that benefit from neurosurgical consultation annually. 1 Over 5 million surgical cases are unmet per year, all in lowand middle-income countries (LMICs), necessitating an additional 23,300 neurosurgeons. 1 Although the proportion of cases that are within the domain pediatric neurosurgery is unclear, there are an estimated 2,297 pediatric neurosurgeons in practice worldwide, of whom 85.6% operate in high-income and upper-middle income countries. 2 In total, 330 pediatric neurosurgeons care for 1.2 children in lowermiddle and low-income countries. ...
... 1 Over 5 million surgical cases are unmet per year, all in lowand middle-income countries (LMICs), necessitating an additional 23,300 neurosurgeons. 1 Although the proportion of cases that are within the domain pediatric neurosurgery is unclear, there are an estimated 2,297 pediatric neurosurgeons in practice worldwide, of whom 85.6% operate in high-income and upper-middle income countries. 2 In total, 330 pediatric neurosurgeons care for 1.2 children in lowermiddle and low-income countries. ...
... 3 Global neurosurgery is an emerging subfield at the intersection of neurosurgical care and public health that seeks to address the global deficit in neurosurgical care and associated disparities. 1,4,5 Domains of global neurosurgery include practice, research, health systems strengthening, advocacy, and education. 6 Education has been recognized as a particularly important element to ensure sustainability in global neurosurgical care through the expansion of local neurosurgical capacity. ...
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Objective: Education is a critical component of global pediatric neurosurgery with increasing attention being placed on the role of medical students in global neurosurgery. We provide a background of education for medical students interested in global pediatric neurosurgery, present existing pediatric neurosurgery resources with a focus on virtual modalities, and describe the need to create accessible resources for medical students. Methods: A narrative and anecdotal review was performed. Results: Education of medical students regarding pediatric neurosurgery is particularly important due to multidisciplinary collaboration and advocacy. Benefits of virtual education include accessibility across the world, convenience, easily updatable nature, incorporation of multimedia, minimal cost, and personalization. Existing online resources include courses focused on medical webinars, general courses, on-demand content, journals, online simulation, and social media. Few resources focused exclusively on medical students exist in pediatric neurosurgery, and none address the intersection of pediatric neurosurgery and global neurosurgery. Additional educational resources that incorporate neurosurgical knowledge with special applicability to the medical student population will capture the interest of medical students, while those incorporating global health elements will develop a commitment to global neurosurgery. Conclusion: Education of medical students is important for the sustainability of global pediatric neurosurgery. The development of educational resources for medical students interested in global pediatric neurosurgery should be encouraged.
... 5 The greatest deficit of neurosurgeons is seen in Southeast Asia. 6 Limited resources, poor healthcare infrastructure, and few sustainable training programs all pose barriers to neurosurgery in LMICs. These barriers are even higher for pediatric neurosurgery, as the development of surgical care for children often lags behind that of adults. ...
... Generally, the trained neurosurgeons treat both children and adults as the number of neurosurgeons in LMICs is limited, although some subspecialty fellowships exist. 6,16 For this reason, training non-neurosurgeons to treat conditions like traumatic brain injuries has been suggested. While training general surgeons to do simpler neurosurgical procedures would expand the capacity for treating neurosurgical cases, opponents suggest that this may do more harm than good. ...
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The recent emphasis on surgery as an essential yet neglected component of global health care has drawn attention to the lack of pediatric neurosurgery in low- and middle-income countries (LMICs). Most LMICs have very few neurosurgeons able or willing to care for children, leaving few access to care for readily treatable conditions, like pediatric hydrocephalus and spina bifida. Herein, we review the role of pediatric neurosurgeons to improve hydrocephalus management and medical education in LMICs. A literature search on global pediatric neurosurgery was performed using the Pubmed database from the year 2000 to October 5th, 2021. The majority of current pediatric neurosurgical efforts focus on the management of hydrocephalus. Endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization (CPC) has emerged as an effective alternative to ventriculoperitoneal (VP) shunting for CSF diversion in LMICs. Neurosurgical programs in LMICs are most successful when twinning is used to pair the program with an established center in a high-income country (HIC). Multiple international pediatric neurosurgical efforts aim to provide medical expertise, infrastructure, and surgical education to LMICs. The next step in developing sustainable surgery programs in LMICs includes establishing local training programs. Existing global pediatric neurosurgery programs are most successful when partnered to an experienced center in a HIC. A lack of funding, resources, and training programs all pose barriers to increasing the pediatric neurosurgical capacity in LMICs. Future global neurosurgery efforts may look to other neurosurgical conditions with high burdens of disease in LMICs, like epilepsy.
... If possible, triage facilities should be distributed so that 80% of the population lives within two hours of a facility. More trained healthcare workers are needed globally to properly care for the SB/HCP population, and task sharing/task shifting or telemedicine technology are acceptable options to help fill the existing gaps [37][38][39]. To alleviate the financial burden of SB/HCP care, the cost of treatment needs to be embedded into the universal health coverage package. ...
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In November 2020, the Member States of the World Health Organization (WHO) adopted the World Health Assembly resolution 73.10, asking the Director-General to develop an Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders. Notably, the action plan aims to use ”an integrated, person-centered framework for the prevention, diagnosis, treatment, and care of people with neurological disorders” and asks the Member States to develop “policies, plans, and legislation relating to neurological disorders, whether as separate instruments or integrated into other planned multisectoral actions”. Accordingly, these recommendations for the comprehensive management of spina bifida and hydrocephalus for low-and middle-income countries (LMICs) represent the collective effort of a group of advocates, and experts from around the world to compile the best evidence to date. They utilize the WHO health systems and person-centered framework used by many ministries of health to facilitate their integration. We intentionally chose two pediatric neurosurgical conditions, spina bifida and hydrocephalus, to highlight the massive pediatric surgical needs in LMICs as well as the paucity of prevention efforts despite overwhelming supporting scientific evidence. While the strengthening of capacity to detect and holistically treat spina bifida and hydrocephalus are crucial, strategies to prevent these conditions are indispensable to the overall disease management and cost effective. Contributions from members of the International Society for Pediatric Neurosurgery and the Global Alliance for the Prevention of Spina Bifida proved to be especially valuable. Healthcare workers, researchers, and public health practitioners came together for this project in providing strategic guidance and technical support to policymakers. Accordingly, the research team, with guidance from the advisory group of experts, initially reviewed the available literature to develop a comprehensive set of recommendations for the management of spina bifida and hydrocephalus in LMICs. The advisory group, especially its members living and working in LMICs, helped with contextualizing the recommendations. The goal of this document is not limited to just raising awareness of the unmet pediatric neurosurgical needs and the importance of prevention. We envision the inclusion of the recommendations in the WHO’s Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders. Additionally, it is our hope that LMICs adopt the recommendations into their national surgical system strengthening efforts pursuant to the World Health Assembly resolution 68.15, “Strengthening of Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage”. Furthermore, the team of contributors to this document stand ready to support the country-led implementation of these policies to reduce death and disabilities from spina bifida and hydrocephalus among children living in LMICs.
... 1 Global neurosurgery is a subfield at the intersection of neurosurgical care that seeks to address the global burden of neurosurgical disease, workforce and equipment deficits, and access to timely and affordable neurosurgical care through provision of neurosurgical care, research, advocacy, policy, and education and training. [2][3][4] Global pediatric neurosurgery seeks to mobilize these initiatives within the context of pediatric neurosurgical care. 5 Although most efforts within global pediatric neurosurgery have focused on trainees and attending neurosurgeons given their ability to provide direct neurosurgical care, [6][7][8] medical students are important for the longterm efficacy of global pediatric neurosurgery initiatives. ...
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Objective: Medical students are important for the long-term efficacy of global pediatric neurosurgery initiatives. In this manuscript, we describe the rationale for mobilizing medical students in global pediatric neurosurgery, delineate the potential impact of this mobilization, and detail how to increase exposure of medical students to global pediatric neurosurgery. Methods: A narrative review was conducted and supplemented with an anecdotal review. Results: Medical students are a critical asset for global pediatric neurosurgery due to their motivation and diligence, time management and organizational skills, technological proficiency, innovative perspective, and resourcefulness. Fostering the next generation of global pediatric neurosurgeons is important to facilitate long-term engagement in pediatric neurosurgery, ensure the sustainability of global pediatric neurosurgery, develop capacities to collaborate with diverse partners, teach knowledge and skills for engaging in advocacy and capacity-building, and facilitate determination of effective strategies for making progress in global pediatric neurosurgery. Opportunities for medical student involvement include reading key manuscripts; finding mentors; becoming involved in university-based global neurosurgery groups, auxiliary organizations, World Federation of Neurosurgical Societies Global Neurosurgery Committee, InciSion, or general neurosurgery medical student and trainee interest groups. Conclusion: Medical students represent a valuable asset for addressing the global burden of pediatric neurosurgical disease, ameliorating workforce and equipment deficits, and facilitating access to timely and affordable pediatric neurosurgical care. Involving medical students through existing opportunities and developing additional pathways specific to medical students will strengthen the impact and reach of global pediatric neurosurgical initiatives.
... Approximately 5 million essential neurosurgical cases are unmet each year, all in low-and middle-income countries (1). After the Lancet Commission on Global Surgery described the absence of global surgery from global health discourse in January 2014 (2), the field of neurosurgery quickly recognized the importance of increasing equity in care globally (3)(4)(5). ...
Article
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pproximately 5 million essential neurosurgical cases are unmet each year, all in low- and middle-income countries (1). After the LancetCommission on Global Surgery described the absence of global surgery from global health discourse in January 2014 (2), the field of neurosurgery quickly recognized the importance of increasing equity in care globally (3-5). Although existing initiatives in globalneurosurgery have focused on neurosurgeons and trainees, medical students represent a promising group for sustainable long-termengagement. We characterize why medical students are fundamental to success, outline the importance of incorporating medicalstudents, and delineate how to increase medical student interest and participation in global neurosurgery.
... The field of global neurosurgery has arisen to address the global burden of neurosurgical disease by mobilizing practice, research, policy, advocacy, and education at the intersection of neurosurgical care and public health. [41][42][43] Pediatric neurosurgeons in highincome and upper-middle-income countries account for 85.6% of all pediatric neurosurgeons. 44 In low-and lower-middle income countries, 330 pediatric neurosurgeons care for 1.2 billion children. ...
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Objetivo: Aproximadamente el 70-80% de los defectos del tubo neural (DTN) responden al folato. El mioinositol se ha identificado cada vez más como una posible solución para tratar los defectos del tubo neural que no responden al folato. Brindamos una breve reseña de la evidencia existente sobre el papel del mioinositol en la prevención de los NTD y describimos su papel en los esfuerzos de promoción centrados en la prevención de los NTD. Métodos: Se realizó una revisión narrativa. Resultados:Los datos existentes sobre la eficacia de la suplementación con inositol están limitados por los tamaños de muestra bajos y los diseños de estudio principalmente observacionales. Aunque los esfuerzos de promoción con respecto a las NTD se han centrado en la fortificación y la suplementación con folato, vale la pena examinar los datos sobre la ingesta de inositol. Después de revisar los datos, planteamos que sería necesario cumplir una serie de criterios incluso antes de considerar la promoción y la política. Primero, el peso de la evidencia debe favorecer el aumento de la ingesta de inositol. En segundo lugar, debe demostrarse la rentabilidad de la política de inositol. Tercero, la política debe ser políticamente viable. En cuarto lugar, se debe generar prioridad política para la política. En quinto lugar, se debe generar una sinergia entre los esfuerzos de política de folato existentes y los esfuerzos de política de inositol. Después de examinar esa serie de criterios, Conclusión: el inositol puede representar una vía para reducir la prevalencia de nacimientos de defectos del tubo neural que no responden al folato. Dadas sus funciones clínicas en el tratamiento de la espina bífida y los defectos del tubo neural, los neurocirujanos también son fundamentales para los esfuerzos de promoción en la prevención.
Article
Background Childhood neurosurgical conditions such as hydrocephalus and spina bifida represent a significant burden of death and disability worldwide, particularly in low and middle-income countries. However, there are limited data on the disease prevalence and delays in care for pediatric neurosurgical conditions in very low-resource settings. This study aims to characterize the delays in access to care for pediatric neurosurgical conditions in Somaliland. Methods We performed a retrospective review of all children with congenital hydrocephalus and spina bifida admitted to the Edna University Hospital (EAUH) in Somaliland between 2011 and 2018. Patient demographics were analyzed with descriptive statistics and χ ² test statistics. We defined delays in care for each condition based on standard care in high-income settings. Univariate and multivariate logistic regression were performed to evaluate predictors of delay in care. Statistical significance was set at p<0.05. Results A total of 344 children were admitted to EAUH with neurosurgical conditions from 2011 to 2018. The most common condition was congenital hydrocephalus (62%). Delays in care were found for 90% of patients and were associated with the type of diagnosis and region. The longest delay among children with spina bifida was 60 months, while the longest delay for children with congenital hydrocephalus was 36 months. Children with congenital hydrocephalus or spina bifida traveling from foreign countries had the highest waiting time to receive care, with a median delay of 8 months (IQR: 5–11 months) and 4 months (IQR: 3–7 months), respectively. Conclusion We found significant delays in care for children with neurosurgical conditions in Somaliland. This country has an urgent need to scale up its surgical infrastructure, workforce, and referral pathways to address the needs of children with hydrocephalus and spina bifida.
Article
Introduction Spina bifida (SB) is one of the common birth defects of the spinal cord and leads to permanent disability for newborns and young children. The management of this condition has faced barriers in the Republic of Benin. We aimed to assess the current prevalence of SB, management, in Benin, as well as the availability of pediatric neurosurgery in Benin. Methods SB patients admitted at the authors’ institution between January 2018 and August 2021 were included. Demographics, access to care, and therapeutic data were extracted from patient records. Results Forty patients aged 99 days (95% CI:5.9-192.1) were included. Most were male (24, 60%), 23 (57.5%) experienced a delay in diagnosis after birth ranged from 5 days - 7months and 28 (70%) could not afford neuroimaging. Most lesions were lumbosacral (n=23, 57.5%). Five patients had comorbidities, the most prevalent of which was club foot (4, 10%). Twenty-two patients (55%) had surgery repair, and the admission-to-surgery delay ranged from 2 days - 2 years. Sixteen patients (40%) required a ventriculoperitoneal shunt, and they were more likely to experience delays (OR=11.67, 95% CI:2.14-63.64, p=0.02). Three patients died (7.5%), and one developed meningitis (2.5%). Conclusion SB care in Benin remains suboptimal due to the lack of access to care, and cultural barriers like the belief in a curse of the gods, or infidelity of the woman. The delay between care and the diagnosis is long because of the unavailability of time and cost of neuro-imaging, cost of the device, and consumables for surgery.
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Robots in neurosurgery hold vast potential and has been a growing field since 1985. To date, there are numerous devices approved by the Food and Drug Administration for neurosurgical operations. The subsections that have the most prevalent robotic usage are: spine, cranial, and endovascular neurosurgery. Currently, robotic precision allows for improved patient outcomes compared to conventional methods. These robots are capable of superior spatial resolution, geometric accuracy, and faster implant placement. The most prevalent FDA-approved robotics in various neurosurgical subspecialities are outlined in this paper. The initial design process and various stages of development are discussed, and a comprehensive historical synopsis of robotics in neurosurgery is provided.
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Hydrocephalus is a pathological state affecting all age groups, which is characterised by the accumulation of intracranial CSF under pressure, with or without distension of the cerebral ventricles. There are a multitude of underlying aetiologies. The development of CSF shunt surgery 70 years ago revolutionised management and converted a very morbid and frequently fatal condition to an eminently manageable one, albeit management is frequently complicated. Given its prevalence and association with other childhood conditions, it is important for all paediatric specialists to have at least a basic working knowledge of its management.
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OBJECTIVE Traumatic brain injury (TBI)—the “silent epidemic”—contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups. METHODS Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group. RESULTS Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64–74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650–1947) and Europe (1012 cases, 95% CI 911–1113) and least in Africa (801 cases, 95% CI 732–871) and the Eastern Mediterranean (897 cases, 95% CI 771–1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs. CONCLUSIONS Sixty-nine million (95% CI 64–74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.
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Study Design Meta-analysis-based calculation. Objectives Lumbar degenerative spine disease (DSD) is a common cause of disability, yet a reliable measure of its global burden does not exist. We sought to quantify the incidence of lumbar DSD to determine the overall worldwide burden of symptomatic lumbar DSD across World Health Organization regions and World Bank income groups. Methods We used a meta-analysis to create a single proportion of cases of DSD in patients with low back pain (LBP). Using this information in conjunction with LBP incidence rates, we calculated the global incidence of individuals who have DSD and LBP (ie, their DSD has neurosurgical relevance) based on the Global Burden of Disease 2015 database. Results We found that 266 million individuals (3.63%) worldwide have DSD and LBP each year; the highest and lowest estimated incidences were found in Europe (5.7%) and Africa (2.4%), respectively. Based on population sizes, low- and middle-income countries have 4 times as many cases as high-income countries. Thirty-nine million individuals (0.53%) worldwide were found to have spondylolisthesis, 403 million (5.5%) individuals worldwide with symptomatic disc degeneration, and 103 million (1.41%) individuals worldwide with spinal stenosis annually. Conclusions A total of 266 million individuals (3.63%) worldwide were found to have DSD and LBP annually. Significantly, data quality is higher in high-income countries, making overall quantification in low- and middle-income countries less complete. A global effort to address degenerative conditions of the lumbar spine in regions with high demand is important to reduce disability.
Article
OBJECTIVE Epilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation. METHODS The authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence. RESULTS This systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources. CONCLUSIONS Understanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.
Article
OBJECTIVE The global magnitude of neurosurgical disease is unknown. The authors sought to estimate the surgical and consultative proportion of diseases commonly encountered by neurosurgeons, as well as surgeon case volume and perceived workload.METHODS An electronic survey was sent to 193 neurosurgeons previously identified via a global surgeon mapping initiative. The survey consisted of three sections aimed at quantifying surgical incidence of neurological disease, consultation incidence, and surgeon demographic data. Surgeons were asked to estimate the proportion of 11 neurological disorders that, in an ideal world, would indicate either neurosurgical operation or neurosurgical consultation. Respondent surgeons indicated their confidence level in each estimate. Demographic and surgical practice characteristics-including case volume and perceived workload-were also captured.RESULTSEighty-five neurosurgeons from 57 countries, representing all WHO regions and World Bank income levels, completed the survey. Neurological conditions estimated to warrant neurosurgical consultation with the highest frequency were brain tumors (96%), spinal tumors (95%), hydrocephalus (94%), and neural tube defects (92%), whereas stroke (54%), central nervous system infection (58%), and epilepsy (40%) carried the lowest frequency. Similarly, surgery was deemed necessary for an average of 88% cases of hydrocephalus, 82% of spinal tumors and neural tube defects, and 78% of brain tumors. Degenerative spine disease (42%), stroke (31%), and epilepsy (24%) were found to warrant surgical intervention less frequently. Confidence levels were consistently high among respondents (lower quartile > 70/100 for 90% of questions), and estimates did not vary significantly across WHO regions or among income levels. Surgeons reported performing a mean of 245 cases annually (median 190). On a 100-point scale indicating a surgeon's perceived workload (0-not busy, 100-overworked), respondents selected a mean workload of 75 (median 79).CONCLUSIONS With a high level of confidence and strong concordance, neurosurgeons estimated that the vast majority of patients with central nervous system tumors, hydrocephalus, or neural tube defects mandate neurosurgical involvement. A significant proportion of other common neurological diseases, such as traumatic brain and spinal injury, vascular anomalies, and degenerative spine disease, demand the attention of a neurosurgeon-whether via operative intervention or expert counsel. These estimates facilitate measurement of the expected annual volume of neurosurgical disease globally.
Article
OBJECTIVE Hydrocephalus is one of the most common brain disorders, yet a reliable assessment of the global burden of disease is lacking. The authors sought a reliable estimate of the prevalence and annual incidence of hydrocephalus worldwide. METHODS The authors performed a systematic literature review and meta-analysis to estimate the incidence of congenital hydrocephalus by WHO region and World Bank income level using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. A global estimate of pediatric hydrocephalus was obtained by adding acquired forms of childhood hydrocephalus to the baseline congenital figures using neural tube defect (NTD) registry data and known proportions of posthemorrhagic and postinfectious cases. Adult forms of hydrocephalus were also examined qualitatively. RESULTS Seventy-eight articles were included from the systematic review, representative of all WHO regions and each income level. The pooled incidence of congenital hydrocephalus was highest in Africa and Latin America (145 and 316 per 100,000 births, respectively) and lowest in the United States/Canada (68 per 100,000 births) (p for interaction < 0.1). The incidence was higher in low- and middle-income countries (123 per 100,000 births; 95% CI 98–152 births) than in high-income countries (79 per 100,000 births; 95% CI 68–90 births) (p for interaction < 0.01). While likely representing an underestimate, this model predicts that each year, nearly 400,000 new cases of pediatric hydrocephalus will develop worldwide. The greatest burden of disease falls on the African, Latin American, and Southeast Asian regions, accounting for three-quarters of the total volume of new cases. The high crude birth rate, greater proportion of patients with postinfectious etiology, and higher incidence of NTDs all contribute to a case volume in low- and middle-income countries that outweighs that in high-income countries by more than 20-fold. Global estimates of adult and other forms of acquired hydrocephalus are lacking. CONCLUSIONS For the first time in a global model, the annual incidence of pediatric hydrocephalus is estimated. Low- and middle-income countries incur the greatest burden of disease, particularly those within the African and Latin American regions. Reliable incidence and burden figures for adult forms of hydrocephalus are absent in the literature and warrant specific investigation. A global effort to address hydrocephalus in regions with the greatest demand is imperative to reduce disease incidence, morbidity, mortality, and disparities of access to treatment.
Article
Introduction: There is increasing acknowledgement that surgical care is important in global health initiatives. In particular, neurosurgical care is as limited as 1-to-10 million people in parts of the world. We performed a systematic literature review to examine the worldwide incidence of central nervous system vascular lesions (CNS-VL) and a meta-analysis of aneurysmal subarachnoid hemorrhage (ASAH) in order to define the disease burden and inform neurosurgical global health efforts. Methods: A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to estimate the global epidemiology of CNS-VL, including unruptured and ruptured aneurysms, arteriovenous malformations, cavernous malformations, dural arteriovenous fistulas, developmental venous anomalies, and vein of Galen malformation. Results were organized by WHO regions. After literature review, due to a lack of data from particular WHO regions, we determined we could only provide an estimate ASAH. Using data from studies with ASAH and twelve high-quality stroke studies from regions lacking data, we meta-analyzed the yearly crude incidence of ASAH per 100,000 persons. Estimates were generated using random-effects models. Results: From an initial yield of 1,492 studies, 46 manuscripts on ASAH incidence included. The final meta-analysis included 58 studies from 31 different countries. We estimated the global crude incidence for ASAH to be 6.67 per 100,000 persons with a wide variation across WHO regions from 0.71 to 12.38 per 100,000 persons. Conclusion: Worldwide, almost 500,000 individuals will suffer from ASAH each year, with almost two-thirds in low and middle income countries.
Article
Background: Traumatic spinal injury (TSI) results from injury to bony, ligamentous and/or neurological structures of the spinal column and can cause significant morbidity and mortality. The global burden of TSI is poorly understood, so we performed a systematic review and meta-analysis to estimate the global volume of TSI. Methods: We performed a systematic review through PubMed, Embase and Cochrane Databases on TSI studies published from 2000 to 2016. Collected data were used to perform a meta-analysis to estimate the annual incidence of TSI across World Health Organization (WHO) regions and World Bank income groups using random effect models. Incorporating global population figures, the annual worldwide volume of TSI was estimated. Results: A total of 102 studies were included in the systematic review and 19 studies in the meta-analysis. The overall global incidence of TSI was 10.5 cases per 100,000 persons, resulting in an estimated 768,473 [95% CI: 597,213 - 939,732] new cases of TSI annually worldwide. The incidence of TSI was higher in low- and middle-income countries (LMICs) (8.72 per 100,000 persons) compared to high income countries (HICs) (13.69 per 100,000 persons). Road traffic accidents, followed by falls, were the most common mechanism of TSI worldwide. Overall, 48.8% of patients suffering from TSI required a surgery. Conclusion: TSI is a major source of morbidity and mortality throughout the world. Largely preventable mechanisms, including road traffic accidents and falls, are main causes of TSI globally. Further investigation is needed to delineate local and regional TSI incidences and causes, especially in LMICs.
Article
Background: An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low- 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 CT and MRI imaging and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons (WFNS) classifications were used to stratify cities based on the level of neurosurgical care that could be provided. Data was geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a two-hour travel time of a city offering differing levels of neurosurgical care RESULTS: 68 countries provided complete data (response rate, 48.2%). Eleven (11) 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 Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia. Conclusions: There are a number of challenges to the provision of adequate neurosurgical services in low resource settings. This study has 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.
Article
Spina bifida is a serious and largely preventable neural tube birth defect and an important cause of mortality and lifelong disability. The People and Organizations United for Spina Bifida and Hydrocephalus (PUSH!) Global Alliance was formed in 2014 to provide a common platform for various organizations worldwide to raise the visibility of spina bifida and hydrocephalus. In its formative phase, the alliance recognized that in order to accelerate surveillance, prevention, and care for these conditions, there was a need to provide an evidence-based assessment of how nations are performing in specific areas. In this paper, we describe the impetus for, and the process of, developing country-level scorecards for spina bifida surveillance, prevention and care. The PUSH! Executive Committee formulated a comprehensive list of six actionable indicators measuring availability of published studies on population-based folate studies; surveillance of prevalence and mortality; prevention-based policies; access to care; and quality of life associated with spina bifida. Rubrics were developed to score each country on the aforementioned indicators. Country scores were pooled across each indicator and the composite scores ranged between zero and three if there was a need for improvement, four and five if they were in good standing, or six for an excellent status. The scorecard included country-specific recommendations assimilated from the literature and published guidelines to aid policy makers in accelerating surveillance and prevention, and improving the care and quality of life indicators. For comparison, country-level scorecards were grouped by WHO-regions. Score cards were made available publicly through the website "www.pu-sh.org".