Addressing global disparities in neurosurgical workforce and access to care

Governance Challenges to the Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review

The Role of the WFSA in Reaching the Goals of the Lancet Commission on Global Surgery.

Letter: Global Neurosurgery: The Pakistani Perspective.

We read the letter from Coonan et al1 with interest and appreciate the opportunity to make some comments. Coonan et al1 are concerned that authors from low- and middle-income countries (LMICs) are not sufficiently represented in this special edition on Global Anesthesia and Surgery.2 We agree that there is a need “to hear more from the health professionals who provide the essential anesthesia in the least developed countries.” Only 3 of the 15 articles do not have an author from an LMIC, and they include our lead editorial,3 the article from Kassebaum and McQueen,4 and the vision for the future article by Hendel and Absalom.5 All other presentations have authors from LMICs, and they are the lead authors in 4 of them. LMICs represented include Ethiopia, India, Zimbabwe, Thailand, Mongolia, Zambia, Serbia, Venezuela, Honduras, Pakistan, Benin, Tonga, and Uruguay—thus presenting opinions from Asia, Africa, Eastern Europe, the Pacific Islands, and Central and South America. Also included are opinions from surgeons and obstetricians from all income areas, thus giving a wide representation of regions and specialties. The reports on the programs from Mongolia6 and Benin7 clearly illustrate what local anesthesia providers can do when given appropriate long-term support and mentorship. Morris et al8 describe the anesthesia program in Fiji (now a high middle-income country), which is led by Pacific Islanders and has developed with support from many sources. Graduates from Fiji and Benin are now the leaders and teachers throughout their regions, many in low-income and low- to middle-income countries. Surely, this is the ultimate goal? It is certainly what we wished to highlight. We agree with Coonan et al1 that more data are needed on all aspects of anesthesia and surgery in LMICs. However, we recognize how difficult they are to obtain. Evans et al9 note that fact in their article on short subspecialty courses. They present evidence of practice improvement and knowledge translation from Rwanda.10 One might further assume that the propagation of all of these short courses by local anesthesia providers would provide evidence of their value. Primary trauma care, for example, has been taught in >70 countries, has been translated into 14 languages, and has trained tens of thousands of people in Asia, Africa, and Latin America.9 This propagation has been driven predominantly by local health care providers rather than visiting teams. McQueen et al11 previously criticized the World Federation of Societies of Anaesthesiologists (WFSA) Standards for the Safe Practice of Anaesthesia. They reiterate here their theory that the “bare minimum” is all that is necessary. Not everyone supports their opinion.12 One might agree that, for lifesaving surgery in the poorest of environments, the bare minimum might be acceptable, but we doubt anyone would agree that all anesthesia providers should not aspire to more. That is what the standards are about, and while it is recognized that many places in LMICs are “not there yet,” those of us in more fortunate situations should be assisting colleagues to use the standards to advocate for what they require. Often, those most in need are least able to articulate that need and advocate for themselves. The World Health Organization (WHO)–WFSA Standards for the Safe Practice of Anaesthesia have recently been updated and published.13 The involvement of the WHO in the development and approval of these standards speaks volumes for their importance. As countries all over the world develop their National Surgical, Obstetric and Anesthesia Plans in concert with the Lancet Commission recommendations14 and the World Health Assembly motion of 2015,15 it is vital that anesthesia leaders everywhere have a seat at the table and an equal voice in the advocacy. Angela Enright, MB, FRCPCDepartment of AnesthesiaUniversity of British ColumbiaRoyal Jubilee HospitalVictoria, British Columbia, Canada[email protected] Robert McDougall, MBBS, FANZCADepartment of AnesthesiaAnaesthesia and Pain ManagementUniversity of MelbourneThe Royal Children’s HospitalMelbourne, Victoria, Australia

The transformative power of telemedicine in delivering effective neurosurgical care in low and middle-income countries: A review

Exploratory Analysis into Reasonable Timeframes for the Provision of Neurosurgical Care in Low- and Middle-Income Countries

Background: Worldwide, neurological disorders are the leading cause of disability-adjusted life years lost and the second leading cause of death. Despite global health capacity-building efforts, each year, 22.6 million individuals worldwide require neurosurgeon's care due to diseases such as traumatic brain injury and hydrocephalus, and 13.8 million of these individuals require surgery. It is clear that neurosurgical care is indispensable in both national and international public health discussions. This study highlights the role neurosurgeons can play in supporting the global health agenda, national surgical plans, and health strengthening systems (HSS) interventions.Methods: Guided by a literature review, the authors discuss key topics such as the global burden of neurosurgical diseases, the current state of neurosurgical care around the world and the inherent benefits of strong neurosurgical capability for health systems.Results: Neurosurgical diseases make up an important part of the global burden of diseases. Many neurosurgeons possess the sustained passion, resilience, and leadership needed to advocate for improved neurosurgical care worldwide. Neurosurgical care has been linked to 14 of the 17 Sustainable Development Goals (SDGs), thus highlighting the tremendous impact neurosurgeons can have upon HSS initiatives.Conclusion: We recommend policymakers and global health actors to: (i) increase the involvement of neurosurgeons within the global health dialogue; (ii) involve neurosurgeons in the national surgical system strengthening process; (iii) integrate neurosurgical care within the global surgery movement; and (iv) promote the training and education of neurosurgeons, especially those residing in Low-and middle-income countries, in the field of global public health.

BACKGROUND AND OBJECTIVES: As the global neurosurgical workforce expands, so do the contributions of women neurosurgeons. Recent studies highlighted pioneering women leaders in neurosurgery and provided invaluable perspectives into the proportion of women neurosurgeons in regions across the world. To provide a broad perspective of global trends, this study aims to characterize the global female neurosurgical workforce and evaluate its association with countries' economic status, broader physician workforce, and global gender gap index (GGGI). METHODS: A literature search included studies dated 2016–2023 characterizing the neurosurgical workforce. Total neurosurgeons, neurosurgeons per capita, and percent of women neurosurgeons by country were collected or calculated from available data. Countries were stratified by World Health Organization (WHO) region, World Bank economic classification, WHO physician workforce, and GGGI. Poisson regressions and Spearman correlation tests were performed to evaluate the association between each country's percent of women neurosurgeons and their economic classification, WHO physician workforce, and GGGI. RESULTS: Neurosurgical workforce data were obtained for 210 nations; world maps were created demonstrating neurosurgeons per capita and proportion of women neurosurgeons. Africa had the fewest neurosurgeons (1296) yet highest percentage of women neurosurgeons (15%). A total of 94 of 210 (45%) countries met the minimum requirement of neurosurgeons needed to address neurotrauma. Compared with low-income countries, upper-middle–income and high-income countries had 27.5 times greater the rate of neurosurgeons per capita but only 1.02 and 2.57 times greater percentage of women neurosurgeons, respectively (P < .001). There was a statistically significant association between GGI and women neurosurgeons (P < .001) and a weak correlation between proportion of women in physician workforce and women neurosurgeons (P = .019, rho = 0.33). CONCLUSION: Much progress has been made in expanding the neurosurgical workforce and the proportion of women within it, but disparities remain. As we address the global neurosurgeon deficit, improving recruitment and retention of women neurosurgeons through mentorship, collaboration, and structural support is essential.

This study explores the integration of cerebrovascular neurosurgery into Nigeria's national health policies, aiming to enhance the accessibility, quality, and sustainability of neurosurgical care. With a focus on Nigeria’s challenges due to a high prevalence of cerebrovascular diseases (CVDs), this research identifies critical gaps in healthcare delivery and proposes comprehensive reforms. The study employed a systematic review of existing literature with thematic analysis to identify barriers to neurosurgical care and evaluate the effectiveness of current national health policies. Key barriers identified include severe shortages in the neurosurgical workforce, inadequate medical infrastructure, financial constraints, geographic disparities, and a general lack of public awareness about cerebrovascular diseases. The analysis also highlights the fragmented nature of the healthcare system and the inadequacy of current health policies to support neurosurgical needs effectively. In response to these challenges, the study proposes the Systems Integration Framework for Cerebrovascular Neurosurgery (SIF-CN), a framework designed to address these issues through strategic policy recommendations. The framework emphasizes workforce expansion, infrastructure enhancement, better integration of neurosurgical care within national health policies, improved financing mechanisms, and enhanced public awareness programs. The findings suggest that implementing the SIF-CN could significantly improve health outcomes by increasing the availability and quality of neurosurgical care, thus reducing the mortality and disability associated with cerebrovascular diseases. Economically, better neurosurgical care could decrease the long-term healthcare costs and enhance productivity by reducing the burden of disability. Socially, the proposed framework aims to ensure equitable access to care and enhance the overall public health infrastructure. The study concludes that urgent, collaborative action is required to overhaul the existing framework and implement the proposed model, which could lead to substantial improvements in the health and well-being of Nigeria's population.

INTRODUCTION: War has influenced the development of neurosurgery. Armed conflict and mass casualty events, including Humanitarian Assistance Disaster Relief (HADR) missions, require military surgeons to innovate to meet extreme demands. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses METHODS: We performed a narrative review of the literature examining the influence of wars and mass casualty disasters on contemporary global neurosurgery practices. RESULTS: Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, use of combat body armor, and the rise of damage control neurosurgery. Workforce shortages during wars and disasters have promoted task-shifting and task-sharing in low-resource settings that catalyzed the establishment of the physician associate profession in the United States (US). Neurosurgical care has been utilized by the US as a form of "soft power" during natural and humanitarian disasters. Low-and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges— ubiquitous in low-resource settings— have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk. CONCLUSIONS: War and mass casualty disasters have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military with subsequent spread to the civilian sector as military neurosurgeons and civilian neurosurgeons, who are military reservists, returned from the battlefront or other low-resource locations. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

Brain tumors have a poor prognosis and a high death rate. Sufficient aftercare is necessary to enhance patient results. But follow-up care provision is fraught with difficulties in low- and middle-income countries (LMICs), where a variety of variables can impede access to care. Therefore, our systematic review aimed to identify challenges to follow-up care for brain tumors and possible solutions in LMICs. A thorough search of the literature was performed from the beginning until October 20, 2022, using Google Scholar, PubMed, Scopus, and CINAHL. Studies focusing on the aftercare of brain tumors in LMICs met the inclusion criteria. Two reviewers used the National Surgical, Obstetric, and Anesthesia Plan categories to identify themes, extract relevant data, and evaluate individual articles. After being discovered, these themes were arranged in Microsoft Excel to make reporting and comprehension simpler. A total of 27 studies were included in the review. Among the studies included, the most frequently cited barriers to follow-up care were financial constraints (54%), long-distance travel (42%), and a lack of awareness about the importance of follow-up care (25%). Other challenges included preference for traditional or alternative medications (4%) and high treatment costs (8%). Proposed strategies included implementing mobile clinics (20%), establishing a documentation system (13%), and educating patients about the importance of follow-up care (7%). In LMICs, several issues pertaining to personnel, infrastructure, service delivery, financing, information management, and governance impede the provision of follow-up treatment for patients with brain tumors. As established by the suggested techniques found in the literature, addressing these issues will necessitate concurrent action by stakeholders, legislators, health ministries, and government agencies.

The global healthcare workforce is facing an unprecedented crisis characterized by shortages, uneven distribution, and increasing burnout, particularly in low- and middle-income countries (LMICs). These challenges threaten healthcare delivery, deepen health disparities, and restrict access to essential services, especially in rural and underserved regions. With an estimated shortfall of 18 million healthcare workers by 2030, urgent action is needed to build a resilient and sustainable workforce. This review examines strategies to strengthen the healthcare workforce by highlighting evidence-based approaches that enhance retention, professional development, and mental well-being. Key areas of focus include workforce education and training, fair compensation, mental health support, and the integration of digital health technologies like telemedicine. Additionally, international collaboration and public-private partnerships (PPPs) play a crucial role in mobilizing resources and driving healthcare innovation. To provide a comprehensive analysis, this study employs a systematic review methodology, synthesizing peer-reviewed literature, policy reports, and case studies from various regions. The research primarily focuses on LMICs, where workforce shortages are most severe, while drawing comparisons from high-income countries to identify adaptable best practices. Thematic analysis categorizes findings into key intervention areas, including workforce training, retention strategies, digital health adoption, and governance reforms. By evaluating successful models and identifying gaps in current workforce strategies, this review offers practical, evidence-based recommendations to guide policymakers and healthcare leaders in building a more resilient and equitable healthcare workforce. Addressing these pressing issues is essential for ensuring that health systems can withstand future global health challenges.

War has influenced the evolution of global neurosurgery throughout the past century. Armed conflict and mass casualty disasters (MCDs), including Humanitarian Assistance Disaster Relief missions, require military surgeons to innovate to meet extreme demands. However, the military medical apparatus is seldom integrated into the civilian health care sector. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses. In this paper, we explore how wars and MCD have influenced innovations of growing interest in the resource-limited settings of global neurosurgery. We performed a narrative review of the literature examining the influence of wars and MCD on contemporary global neurosurgery practices. Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, the implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, the use of combat body armor, and the rise of damage control neurosurgery. In addition to promoting task-shifting and task-sharing, workforce shortages during wars and disasters contributed to the establishment of the physician assistant/physician associate profession in the USA. Low- and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges-ubiquitous in low-resource settings-have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk. War and MCDs have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military and subsequently spread to the civilian sector as military neurosurgeons and reservist civilian neurosurgeons returned from the battlefront or other low-resource locations. Military neurosurgeons have utilized their experience in low-resource settings to make volunteer global neurosurgery efforts in LMICs successful. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

Neurosurgery has experienced significant growth over the past century, but much of that development has been centralized in Europe and North America. Despite their high burden of neurosurgical conditions, African countries like The Gambia continue to face barriers in accessing neurosurgical care. We intend to accentuate the barriers to neurosurgical care in The Gambia, elucidate pragmatic ways of improving this issue, and highlight models of sustainable neurosurgical development that have been used in similar lower- and middle-income countries. Our study analyzed the limited literature available on The Gambia's neurosurgical capabilities, disease burden, and outcomes. The keywords "Gambia" and "Neurosurgery" were searched on PubMed, from inception to July 1, 2024. Then, a complementary search was performed on Google using the keywords "The Gambia," "Healthcare," "Neurosurgery," and "Africa." The pertinent data from our search were collected and composed into a review. Neurosurgery in The Gambia is still in its infancy. Although several domestic general surgeons and a few visiting neurosurgeons have performed neurosurgical procedures in the past, the country did not have a designated neurosurgical department until 2018. Although neurosurgical activity has ramped up in The Gambia recently, the country continues to trail behind both regionally and internationally in neurosurgical care capacity. While the shortage of a neurosurgical workforce is the core of this issue, paucity of neurosurgical research and training and the limited availability of neuroimaging also amplify this problem. Neurosurgery in The Gambia is plodding because of workforce shortage, paucity of research, and inadequate neuroimaging. Eradicating these barriers would be salient in attaining sustainable neurosurgical development. With the devotion of the local team and the philanthropic efforts of international partners, The Gambia can experience similar advances seen in other lower- and middle-income countries.

Cervical cancer is preventable; however, it remains the leading cause of death in low‐ and middle‐income countries (LMICs). Women with HIV (WWHs) have a sixfold higher risk of developing and dying from cervical cancer than women without HIV. Cervical cancer can be prevented by vaccination against high‐risk human papillomaviruses (hrHPVs) and by screening for and treating precancer cervical lesions. While these preventive measures are routinely available to WWHs in developed countries, they are lacking in most LMICs, where the burden of HIV and cervical cancer is the highest. To prevent cervical cancer deaths among WWHs in LMICs, it is imperative to determine the dual burden of HIV and cervical cancer in LMICs. This narrative review synthesized scientific papers and policy documents on the intersection of HIV and cervical cancer in LMICs published between August 2006 and July 2025. We searched PubMed, Scopus, Web of Science, and Google Scholar for articles and official reports from the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) on cervical cancer burden, prevention strategies, barriers, and outcomes among WWHs. Despite its proven effectiveness, HPV vaccination coverage in LMICs is under 30%, and screening uptake is below 20%. Weak health systems, workforce shortages, stigma, reliance on donor funding, and late‐stage case presentation are major challenges in curbing cervical cancer in LMICs. Urgent political commitment is required to integrate precancer screening and HPV testing into routine HIV care and scale‐up HPV vaccination to achieve the WHO′s triple‐intervention targets to eliminate cervical cancer among WWHs in LMICs.