Capacity In Low-income Countries Research Articles

Making a Difference: 5 Years of Cardiac Surgery Intersociety Alliance (CSIA)

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA).

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA).

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, it's 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Using a consensus meeting to enhance fracture care education in low income countries

BackgroundA key strategy to building surgical capacity in low income countries involves training care providers, particularly in the interventions highlighted by the Lancet Commission for Global Surgery, including the management of open fractures. This is a common injury, especially in areas with a high incidence of road traffic incidents. The aim of this study was to use a nominal group consensus method to design a course on open fracture management for clinical officers in Malawi.MethodsThe nominal group meeting was held over two days, including clinical officers and surgeons from Malawi and the UK with various levels of expertise in the fields of global surgery, orthopaedics and education. The group was posed with questions on course content, delivery and evaluation. Each participant was encouraged to suggest an answer and the advantages and disadvantages of each suggestion were discussed before voting through an anonymous online platform. Voting included use of a Likert scale or ranking available options. Ethical approval for this process was obtained from the College of Medicine Research and Ethics Committee Malawi and the Liverpool School of Tropical Medicine.ResultsAll suggested course topics received an average score of greater than 8 out of 10 on a Likert scale and were included in the final programme. Videos was the highest ranking option as a method for delivering pre-course material. The highest ranking methods for each course topic included lectures, videos and practicals. When asked what practical skill should be tested at the end of the course, the highest ranking option was “initial assessment”.ConclusionThis work outlines how a consensus meeting can be used to design an educational intervention to improve patient care and outcomes. Through combining the perspectives of both the trainer and trainee, the course aligns both agendas so that it is relevant and sustainable.

Authorship Patterns in the Orthopaedic Journals of Low-Income and Lower-Middle-Income Countries.

Extensive research collaborations exist between researchers from high-income countries (HICs) and those from low-income countries (LICs) and lower-middle-income countries (LMICs). Previous research has suggested that authors from LICs and LMICs are underrepresented as first and last authors in the orthopaedic literature on local populations, particularly in LICs. We present a bibliometric analysis of authorship solely in studies published in orthopaedic journals that are based in LICs and LMICs. The Global Index Medicus was queried, and all articles published from January 1, 2010, to December 31, 2021, in journals with a focus on orthopaedic surgery that were based in an LIC or an LMIC were included. Logistic regressions were calculated to assess the predictors of local authorship. Over 92% of studies included in our analysis had first or last authors from LICs or LMICs. In terms of study type, the majority (89%) of studies were clinical, although largely of low-level evidence (78% of clinical studies were case reports, case series, or descriptive studies). None received funding. LIC or LMIC first authorship and last authorship were less likely for most types of nonclinical studies. LIC or LMIC first authorship was more likely when there were more study authors. LIC or LMIC first authorship and last authorship were less likely when there were more countries affiliated with the study authors. Finally, when compared with studies with only LIC or LMIC authors, those with a combination of HIC and LIC or LMIC authors had significantly lower rates of LIC or LMIC first authorship (93.3% versus 62.5%) and last authorship (97.7% versus 70.8%). Our study presents one of the first analyses to assess authorship patterns in the orthopaedic literature of locally published journals in LICs and LMICs. Future studies are needed to contextualize our findings within a broader bibliometric landscape in order to better address the ongoing challenges to building research capacity in LICs and LMICs. Our study highlights important observations regarding authorship in international, collaborative research in orthopaedics.

Transforming or tinkering: the world remains unprepared for the next pandemic threat

Transforming or tinkering: the world remains unprepared for the next pandemic threat

Vaccine apartheid: global cooperation and equity

Vaccine apartheid: global cooperation and equity

The Malawi emergency and critical care survey: A cross-sectional national facility assessment.

SummaryBackgroundData on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage.MethodsWe developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility.FindingsA total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80–0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021).InterpretationThis is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts.FundingDivision of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

A North\u2013South-South partnership in higher education to develop health research capacity in the Democratic Republic of the Congo: the challenge of finding a common language

BackgroundGlobally, increasing numbers of higher education institutions (HEIs) in non-English-speaking countries have adopted English as a medium of instruction (EMI), because of the perception that this provides opportunities to attract high-calibre students and academic staff, and engage with the international research community. We report an evaluation of a North–South-South collaboration to develop health research capacity in the Democratic Republic of the Congo (DRC) by establishing a postgraduate programme in nutritional epidemiology at the Kinshasa School of Public Health (KSPH), where EMI was adopted. We report experiences and perceptions of stakeholders, facilitators and students about using EMI.MethodsIn-depth qualitative interviews were conducted between October and December 2019 among convenience sampled stakeholders (8), facilitators (11) and students (12) involved in the programme from all three partner institutions (University of Kinshasa; University of KwaZulu-Natal, South Africa; University of Bergen, Norway). Interviews were conducted in participants’ language of preference (English or French), audio-recorded, transcribed verbatim and translated into English when required. Analysis employed a thematic approach.ResultsMost participants viewed EMI positively, reporting that studying in English created opportunities to access relevant literature, improve interactions with the scientific community and advance their careers. As a result of adopting EMI, some students had opportunities to present research findings at international conferences and publish their research in English. English-speaking researchers from partner institutions were able to participate in supervision of students’ research. However, inadequate English competency, particularly among students, was challenging, with some students reporting being unable to understand or interact in class, which negatively affected their academic performance. Further, EMI created barriers at KSPH among academic staff who were not proficient in English, leading to poor participation among non-English-speaking staff and lack of integration with other postgraduate programmes. Participants suggested additional English language support for EMI.ConclusionPartnerships between HEIs could be a powerful tool to develop research capacity in low-income countries in line with United Nations Sustainable Development Goals. EMI could be a solution to language barriers faced by many such partnerships, but wide-ranging support to develop English proficiency among staff and students is essential to ensure that the challenges do not outweigh the benefits.

Experience with an ultrasound donation program in a low-income country

Increasing radiology capacity in low-income countries (LIC) can improve clinicians’ access to diagnostic imaging tools and improve patient care. Ultrasound (US) is important in LIC due to its lower cost compared to that of CT or MRI scans and its excellent diagnostic ability. The relative portability of the equipment makes it ideal for donation by charitable organizations. We describe our experience as a radiology-capacity-focused charity working with the Haitian healthcare system and propose strategies to increase ultrasound capacity in other poor countries.

Outcomes of Nonoperatively Treated Pediatric Supracondylar Humeral Fractures at the Nkhotakota District Hospital, Malawi.

Background:Displaced supracondylar humeral fractures (SCHFs) benefit from closed reduction and percutaneous pinning. In Malawi, many SCHFs are treated nonoperatively because of limited surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively treated SCHFs in a resource-limited setting.Methods:We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital (NKKDH) in Malawi between January 2014 and December 2016. Patients subsequently underwent clinical and functional follow-up assessment.Results:We identified 182 children (54% male, mean age of 7 years) with an SCHF; 151 (83%) of the fractures were due to a fall, and 178 (98%) were extension-type (Gartland class distribution: 63 [35%] type I, 52 [29%] type II, and 63 [35%] type III). Four patients with type-I fractures were treated with an arm sling alone, and 59 were treated with straight-arm traction to reduce swelling and then splint immobilization until union. All 119 of the patients with Gartland type-II and III or flexion-type injuries were treated with straight-arm traction, manipulation under anesthesia without fluoroscopy, and then splint immobilization until union. A total of 137 (75%) of the patients were available for follow-up, at a mean of 3.9 years after injury. The Flynn functional outcome was excellent for 39 (95%) with a type-I fracture, 30 (70%) with type-II, and 14 (29%) with type-III. The Flynn cosmetic outcome was excellent for 40 (98%) with a type-I fracture, 42 (98%) with type-II, and 41 (84%) with type-III. Forty (98%) of the children with a type-I fracture, 41 (95%) with type-II, and 32 (65%) with type-III returned to school without limitation. Controlling for sex, delayed presentation, medical comorbidities, injury mechanism, and skin blistering/superinfection during traction, patients with type-II fractures were 5.82-times more likely (95% confidence interval [CI], 1.71 to 19.85) and those with type-III fractures were 9.81-times more likely (95% CI, 3.00 to 32.04), to have a clinical complication or functional limitation compared with patients with type-I fractures.Conclusions:Nonoperative treatment of type-III SCHFs resulted in a high risk of clinical complications or functional impairment. These results illustrate the urgent need to increase surgical capacity in low-income countries like Malawi to improve pediatric fracture care.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

International migration and climate adaptation in an era of hardening borders

Climate change will almost certainly generate higher rates of migration and displacement within low-income countries, but will it also generate more international migration? This depends on the receptiveness of destination countries, many of which are currently restricting immigration, criminalizing asylum seekers and using emergent technologies to tighten borders. Should these trends persist, migration to higher-income countries will decline, trapping people in deteriorating situations and reducing adaptive capacity in low-income countries. The United Nations Global Compact for Safe, Orderly and Regular Migration provides an alternative pathway for international migration that builds capacity and sustainability for a climate-disrupted future. The implications of current trends for migrants, policymakers and researchers are detailed in this Perspective. Climate change is likely to increase human migration, but future climate-related migration flows will depend heavily on the adaptive capacity of people living in vulnerable regions and on the border policies of potential destination countries. Current opportunities for mobility are constrained by increasingly strict border enforcement and the securitization of international migration.

1669. Trends in Authorship for Infectious Disease Research Conducted in Low-Income Countries

BackgroundResearch capacity in low-income countries (LICs) plays an important role in strengthening national healthcare systems and addressing local health priorities. Research in infectious diseases is especially important as they comprise five of the top 10 causes of death in LICs. While academic collaborations between high-income countries (HICs) and LICs offer many benefits, they also risk structural and professional imbalances. This study explores research capacity as a function of first or last authorship and funding for research conducted in LICs that is published in high-impact infectious disease journals.MethodsA literature search using the abstract database Scopus was completed for original research conducted within LICs or using samples collected from LIC subjects published between 1998 – 2017 in Clinical Infectious Diseases, Journal of Infectious Diseases, and Open Forum Infectious Diseases. Primary outcomes included the number of LIC first and last authors compared with HIC authors over time. Secondary outcomes included the geographic distribution of research and the proportion of research financed by LICs.ResultsA total of 1380 articles were identified of which 20% had LIC first authors and 21% had first authors with dual LIC/HIC affiliations. For last authors, 13% were affiliated with a LIC and 15% had dual LIC/HIC affiliation. HIC researchers compiled the majority of first and last authors regardless of geography (Figure 1). The number of studies conducted in LICs increased over the 20-year timeframe (Figure 2) but is attributed to an increase in articles with HIC authors. The number of LIC authors remained unchanged resulting in a decreasing proportion of LIC authors. Only 4% of articles received funding from a LIC; however, 79% of these studies were authored by LIC researchers vs. 39% of studies funded by HIC sources.ConclusionThere is a growing appreciation for international HIC/LIC research collaborations with the objective to reduce the burden of infectious diseases that disproportionately affect low-income settings. However, with this increased attention comes the responsibility to improve LIC research capacity. This includes promoting LIC researchers via authorship and supporting sustainability with funding that highlights LIC priorities. Disclosures All authors: No reported disclosures.

Technological capacity building through energy aid: Empirical evidence from renewable energy sector

This study looks at foreign aid as a channel to transfer clean technologies to developing countries, including those with smaller economies. The focus is on the technological knowledge transfer through the technical cooperation of foreign aid. As transferred knowledge accumulates, the recipient country's technological capacity increases. To better understand this accumulating capacity, this study explores the effect of foreign aid as a channel of technology transfer on the recipients’ technological capacity in the renewable energy sector. To investigate the effect of hands-on assistance, the empirical model estimates the long-term effects of foreign-aid disbursements for non-hydro renewable energy (NHRE) projects. I find that foreign aid for technical cooperation in NHRE projects catalyzes investments in NHRE capacity in low-income countries with a long incubation period. The findings confirm that hands-on cooperation, as emphasized by developing countries, contributes to their capacity building, although only in countries with low capacity to begin with. This study contributes to the ongoing discussions on the effectiveness of technology transfer channels for clean energy.

What drives failed policy at the World Bank? An inside account of new aid modalities to higher education: context, blame, and infallibility

ABSTRACTThis article analyses recent World Bank interventions aimed at improving higher education and local research capacity in low-income countries. Our empirical entry point is a critical analysis of the Development and Innovation Grant (DIG) scheme the Bank rolled out in Cambodia (2010–2015), a virtual carbon copy export of its Academic Initiative Fund in Bangladesh. Offering a rare insider perspective, we argue that the DIG scheme ultimately failed because the Bank so glaringly misunderstood the Cambodian context. We use this case to contemplate the deeper flaws in how the Bank ‘thinks’, highlighting how the world’s most powerful development institution manages to maintain faith in its own infallibility despite failure.

Prof. Fiemu Nwariaku: capacity building in low-resource settings is critical to address the disparity in burden of disease

Prof. Fiemu Nwariaku ( Figure 1 ) is a professor of surgery in the Department of General Surgery at the University of Texas Southwestern Medical Center. He holds the Malcolm O. Perry, MD, Professorship in Surgery and specialized in endocrinology. Prof. Nwariaku treats diseases and disorders of the pancreas and thyroid, parathyroid, and adrenal glands with minimally invasive and robotic-assisted procedures. His research focuses on building capacity in low-income countries and specially addressing the burden of injury in low and middle income countries (LMICs).

International consultation on long-term global health research priorities, research capacity and research uptake in developing countries

BackgroundIn recognition of the need for long-term planning for global health research, and to inform future global health research priorities, the United Kingdom Department for International Development (DfID) carried out a public consultation between May and June 2015. The consultation aimed to elicit views on the (1) the long-term future global health research priorities; (2) areas likely to be less important over time; (3) how to improve research uptake in low-income countries; and (4) how to build research capacity in low-income countries.MethodsAn online consultation was used to survey a wide range of participants on global health research priorities. The qualitative data was analysed using a thematic analysis, with frequency of codes in responses tabulated to approximate relative importance of themes and sub-themes.ResultsThe public consultation yielded 421 responses. The survey responses confirmed the growing importance of non-communicable disease as a global health research priority, being placed above infectious diseases. Participants felt that the key area for reducing funding prioritisation was infectious diseases. The involvement of policymakers and other key stakeholders was seen as critical to drive research uptake, as was collaboration and partnership. Several methods to build research capacity in low-income countries were described, including capacity building educational programmes, mentorship programmes and research institution collaboration and partnership.ConclusionsThe outcomes from this consultation survey provide valuable insights into how DfID stakeholders prioritise research. The outcomes from this survey were reviewed alongside other elements of a wider DfID consultation process to help inform long-term research prioritisation of global health research. There are limitations in this approach; the opportunistic nature of the survey’s dissemination means the findings presented may not be representative of the full range of stakeholders or views.

Telemedicine, Anesthesia, and Global Health

Telemedicine, the practice of medicine over a distance, is a potential tool to address the worldwide disparities in health care. The lack of anesthetic capacity in low-income countries contributes substantially to the worldwide toll of preventable deaths from surgical diseases. Distance anesthetic education between high- and low-income countries can supplement the existing educational institutions in low-income countries, as well as promote communities of practice dedicated to quality anesthetic care.

Retrospective Descriptive Study of an Intensive Care Unit at a Ugandan Regional Referral Hospital.

We describe delivery and outcomes of critical care at Mbarara Regional Referral Hospital, a Ugandan secondary referral hospital serving a large, widely dispersed rural population. Retrospective observational study of ICU admissions was performed from January 2008 to December 2011. Of 431 admissions, 239 (55.4%) were female, and 142 (33.2%) were children (<18years). The median length of stay was 2 (IQR 1-4) days, with 365 patients (85%) staying less than 8days. Indications for admission were surgical 49.3% (n=213), medical/pediatric 27.4% (n=118), or obstetrical/gynecological 22.3% (n=96). The overall mortality rate was 37.6% (162/431) [adults 39.3% (n=113/287), children 33.5% (n=48/143), unspecified age 100% (n=1/1)]. Of the 162 deaths, 76 (46.9%) occurred on the first, 20 (12.3%) on the second, 23 (14.2%) on the third, and 43 (26.5%) on a subsequent day of admission. Mortality rates for common diagnoses were surgical abdomen 31.9% (n=29/91), trauma 45.5% (n=30/66), head trauma 59.6% (n=28/47), and poisoning 28.6% (n=10/35). The rate of mechanical ventilation was 49.7% (n=214/431). The mortality rate of ventilated patients was 73.5% (n=119/224). The multivariate odd ratio estimates of mortality were significant for ventilation [aOR 6.15 (95% CI 3.83-9.87), p<0.0001] and for length of stay beyond seven days [aOR 0.37 (95% CI 0.19-0.70), p=0.0021], but not significant for decade of age [aOR 1.06 (95% CI 0.94-1.20), p=0.33], gender [aOR 0.61(95% CI 0.38-0.99), p=0.07], or diagnosis type [medical vs. surgical aOR 1.08 (95% CI 0. 63-1.84), medical vs. obstetric/gynecology aOR 0.73 (95% CI 0.37-1.43), p=0.49]. The ICU predominantly functions as an acute care unit for critically ill young patients, with most deaths occurring within the first 48h of admission. Expansion of critical care capacity in low-income countries should be accompanied by measurement of the nature and impact of this intervention.

Barriers to Neurosurgical Training in Sub-Saharan Africa: The Need for a Phased Approach to Global Surgery Efforts to Improve Neurosurgical Care

Neurosurgery in low-income countries is faced with multiple challenges. Although the most common challenges include infrastructure and physical resource deficits, an underemphasized barrier relates to the methods and components of surgical training. The roleof important aspects, including didactic surgical training, surgical decision-making, workshops, conferences, and assessment methods, has not been duly studied. Knowledge of these issues is a crucial step to move closer to strengthening surgical capacity in low-income countries. We designed an online survey to assess self-perceived and objectively measured barriers to neurosurgical training in various Sub-Saharan African countries. Key outcomes included perception toward adequacy of neurosurgery training and barriers to neurosurgical training at each individual site. Only 37% of responders felt that their training program adequately prepared them for handling incoming neurosurgical cases. Top perceived limitations of neurosurgery training included lack of physical resources (25% of all responses), lack of practical workshops (22%), lack of program structure (18%), and lack of topic-specific lectures (10%). Our results show that most responders believe their training program is inadequate and are interested in improving it through international collaborations. This implies that activities directed at strengthening surgical capacity must address this important necessity. One important strategy is the use of online educational tools. In consideration of the observed limitations in care, resources, and training, we recommend a phased approach to neurosurgical growth in low-income settings.