The challenges and Opportunities of Global Neurosurgery in East Africa

The Neurosurgery Education and Development Model

Andreas Leidinger, MD; Pablo Extremera, MD; Eliana E. Kim, BA; Mahmood M. Qureshi, FRCSEd(SN); Paul H. Young, MD, PhD; José Piquer, MD, PhD


Neurosurg Focus. 2018;45(4):E8 

In This Article

Abstract and Introduction


Objective: The objective of this study was to describe the experience of a volunteering neurosurgeon during an 18-week stay at the Neurosurgery Education and Development (NED) Institute and to report the general situation regarding the development of neurosurgery in Zanzibar, identifying the challenges and opportunities and explaining the NED Foundation's model for safe practice and sustainability.

Methods: The NED Foundation deployed the volunteer neurosurgeon coordinator (NC) for an 18-week stay at the NED Institute at the Mnazi Mmoja Hospital, Stonetown, Zanzibar. The main roles of the NC were as follows: management of patients, reinforcement of weekly academic activities, coordination of international surgical camps, and identification of opportunities for improvement. The improvement opportunities were categorized as clinical, administrative, and sociocultural and were based on observations made by the NC as well as on interviews with local doctors, administrators, and government officials.

Results: During the 18-week period, the NC visited 460 patients and performed 85 surgical procedures. Four surgical camps were coordinated on-site. Academic activities were conducted weekly. The most significant challenges encountered were an intense workload, deficient infrastructure, lack of self-confidence among local physicians, deficiencies in technical support and repairs of broken equipment, and lack of guidelines. Through a series of interviews, the sociocultural factors influencing the NED Foundation's intervention were determined. Factors identified for success were the activity of neurosurgical societies in East Africa; structured pan-African neurosurgical training; the support of the Foundation for International Education in Neurological Surgery (FIENS) and the College of Surgeons of East, Central and Southern Africa (COSECSA); motivated personnel; and the Revolutionary Government of Zanzibar's willingness to collaborate with the NED Foundation.

Conclusions: International collaboration programs should balance local challenges and opportunities in order to effectively promote the development of neurosurgery in East Africa. Support and endorsement should be sought to harness shared resources and experience. Determining the caregiving and educational objectives within the logistic, administrative, social, and cultural framework of the target hospital is paramount to success.


Since 2014, the World Bank has exhorted the medical community to design a global strategy that promotes universal access to basic surgical services.[4] A report from the Lancet Commission on Global Surgery (Global Surgery 2030) concluded that the progressive growth of surgery in low- and middle-income countries improves general health and promotes economic growth.[14] The development of surgical subspecialties, including neurosurgery, and their widespread availability are among the main objectives of the international community for global surgery.[22]

Many factors hamper the structured growth of surgical subspecialties in East Africa: geographic isolation of many communities, bureaucratic resistance, political instability, constant socioeconomic changes, high rates of poverty and illiteracy, and rapidly growing population.[4,5] Undoubtedly, the complex situation in East Africa hinders the growth of neurosurgery,[7] but this reality should not be perceived as an insurmountable obstacle; rather, it is an inevitable challenge that African physicians and global surgeons must tackle in the 21st century.[14,17]

Several international collaboration programs (ICPs), most of which are directed from less developed countries, have partnered with African hospitals using diverse methodologies toward training African specialists.[10,15,18,19] These organizations have been clustered around institutions such as the World Federation of Neurosurgical Societies (WFNS; and the Foundation for International Education in Neurological Surgery (FIENS;, which, in association with the Lancet Commission on Global Surgery[14] and the World Health Organization (WHO), act as global coordinators and leaders of ICPs in Africa.[6]

Among these ICPs, the Neurosurgery Education and Development (NED) Foundation (NEDF) has conducted surgical camps (e.g., neuroendoscopy unit) in East Africa since 2006.[18] The two main purposes of the NEDF are to provide neurosurgical care in East Africa and to improve neurosurgical education for physicians and nurses. Since the establishment of the NED Institute (NEDI) in Zanzibar in 2014,[10] the NEDF has focused on consolidating an autonomous neurosurgical center.[20,22] The NEDI hosts monthly surgical camps, organizes international academic activities, and is a potential center for training African residents.

The main objective of this study is to describe the clinical experience obtained by a volunteer neurosurgeon during an 18-week stay at the NEDI and to describe the most relevant opportunities for improvement. Finally, we wish to describe the economic, social, and cultural situation of medical practice in Zanzibar and its effects on ICPs.