In recent years, there has been increased attention to the public health needs of Africa. However, most interventions have focused on infectious and noncommunicable diseases. Low- and middle-income countries (LMICs) account for about 18 million deaths yearly from the absence of essential and emergency surgical capacity and infrastructure1. Africa accounts for 15% of the unmet global neurosurgical need, but African patients have access to only 1% of the neurosurgical workforce2. If this burden is not attended to, there is a risk that overwhelmed health care systems would result in erosion in efforts to improve the provision of essential neurosurgical services.
Neurosurgical service is an essential component of tertiary health care. However, in many African countries, the field is still evolving and is laden with a lack of human resources and resources. Neurosurgeons based in Africa attend to a high number of patients. Coupled with this high workload is the distance barrier between patients and doctors. In Africa, most patients live about 2 hours away from access to neurosurgical services.
The current state of neurosurgical services and barriers
Barriers to seeking neurosurgical services in Africa are mainly due to socioeconomic factors of cost, lack of infrastructure, and human resources, which continue to be at the heart of poor delivery of health care generally in the region. These barriers are more profound because neurosurgery is highly specialized and relies on a web of interrelating processes, including neuroimaging, neuro-anesthesia, operating room peculiarities, specialized nursing care, and rehabilitation services.
Few published papers address the average cost implication of neurosurgical services on consumers, but generally, neurosurgical care costs between tens of thousands to hundreds of thousands of dollars in developed countries but is far cheaper in LMICs3. Despite the apparent discrepancy, access to neurosurgical services is paradoxically lesser in many regions of Africa because of the apparent gross discrepancy in income. Eighty-five percent of Africans live on <6 dollars a day, and because the payments for surgical care are mainly out of pocket, the burden of neurosurgical care potentially contributes to financial impoverishment4. The cost of neurosurgical care remains a significant barrier, albeit relatively cheaper but significantly costing as high as 40.18% of GDP per capita5. However, in some cases, patients do not seek neurological services because of the existent perception that these services are too expensive to afford6. This misconception may appear inconsequential but no less contributes to barriers to accessing neurosurgical services.
Lack of governmental will in terms of health financing and the high poverty rate in Africa fuel this lack of access to funding. Most African countries spend <5% of their annual budget on health, a figure that is far behind the recommended 15% by the World Health Organization (WHO)3.
The number of neurosurgeons in most African countries falls short of the optimum ratio, with all African countries having <0.5 neurosurgeons per 100,000 population, while some others do not have a single practising neurosurgeon in the country7. Several factors are responsible for this. There is inadequate training facility and resources for neurosurgery education in Africa as more than half of the countries lack specialized postgraduate training programs for neurosurgeons. A disproportionate geographical localization of the available centers leaves some regions at a more significant disadvantage than others. For the existing centers, the quality of training is adjured suboptimal, with a lack of program structure, physical resources, and practical workshops forming the bulk of the program’s limitations.
Furthermore, the annual intake of 168 trainees per annum is insufficient to meet the 9000 neurosurgeon deficit on the continent8,9. In addition, training as a neurosurgeon comes at a personal cost to trainees at about 20%–30% higher than other specialities, and these costs include those for educational courses, conference attendance, speciality membership fees, and collegiate board exams10. This may be a deterrent from pursuing specialized training for medical graduates with interests. The inadequacy in training is also present during undergraduate training as many students are not exposed to neurosurgery, with only 25% of accredited Nigerian medical schools offering the subject11. In addition, the age-long state of poor working conditions and enumeration for staff has led to increased emigration of health care workers to more economically favorable countries, which translates not only to loss of workforce but of resources most governments spend on basic medical training of students. The inadequate human resources are, however, unlimited to neurosurgeons. The paucity of medical staff specially trained in neurosurgical care, including specialist nurses, neuro-anesthetists and physiotherapists, contribute to the human resource deficit of neurosurgical care.
Deficits funding for health care in many African Countries are grossly insufficient as many countries budget <15% of revenue to health, and this is not enough for primary care, staffing, research and policy development11. Consequently, specialized health services delivered by sophisticated equipment and capital incentives are usually entirely neglected. Poor maintenance culture coupled with a lack of resources contributes to the dearth of neurosurgical infrastructure and further raises a barrier to accessing neurosurgical services12.
Perhaps the essential way of increasing access to neurological services in Africa is to improve funding. This is especially important as funding is necessary for training, staffing and infrastructure development, especially in the amounts required to serve the deficits. Endowment funds should be established specifically for training neurosurgeons so they can access the tools and materials needed for skill development as it applies in many countries. Attractive remuneration packages and improved service conditions should be funded to stimulate interest and strengthen the existing workforce. Likewise, funding for infrastructure is essential. The establishment of central neurosurgical centers in countries rather than several substandard neurosurgical units in tertiary institutions would cut costs and improve the quality of service. There is no objective evidence for the cost of setting up neurosurgical centers5. However, the cost will be predicated upon three factors; human resources, finance, and equipment. Africa currently lacks these 3. Ultimately, there is a need for improved commitment by the states, and they should be encouraged that funding for neurosurgical services could be achievable. An inclusive private-public partnership should likewise be promoted to alleviate funding barriers.
Currently, there is no external funding for neurosurgical care. Most of the support has been within Africa. These measures have been in form of raising awareness of the need for more neurosurgeons in Africa4. Several aspects of neurosurgery are complex and can be executed appropriately with practical collaborative efforts in clinical service and training, especially as recent technologies give room for intraoperative guidance and knowledge exchange13. Foreign exchange programs to fill training gaps with technical assistance are provided by more capable institutions to African centers with visiting surgeons sharing knowledge and skills by providing didactic lectures and assisting and training during operations. Goals must be clearly stated to ensure sustainable and compelling collaborations, and the partnership work frame and implementation context must be delineated. There is a need for proper project design with the needs of the local institutions at the heart of the project to ensure that mutual expectations are met. Effective communication at every stage of program implementation is likewise essential. Such collaboration could also include waivers for updated courses, publishing fees and skills upgrades. Neurosurgical societies in Africa should support the local community of neurosurgeons to improve neurosurgical care by continuing education, scientific exchange, mobilization for international funding initiatives and soliciting the government’s support.
The burden of neurosurgical conditions and needs is enormous in Africa. Most neurosurgical needs in Africa are unmet due to delays in seeking, reaching and receiving care with little or no efforts directed toward understanding or reducing the barriers to seeking care and accessing neurological services. While most efforts at improving the health needs of Africans have been tailored toward battling infectious diseases, health stakeholders in Africa must look towards improving the current state of access to neurosurgical services.
Sources of funding
N.A. and J.O.: conceptualization, project administration, writing-review and designing. N.A.: collection and assembly of data; reviewed and edited the final draft.
Conflicts of interest disclosure
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
1. Feigin VL, Nicholas E, Alan T, et al. Global, regional and national burden of neurological disorders1990-2016. A systematic analysis of the global burden of disease study. 2016. Lancet Neurol 2019;18:459–80.
2. Ikwuegbuenyi C, Adegboyega G, Nyalundja AD, et al. Public awareness, knowledge of availability, and willingness to use neurosurgical care services in Africa: a cross-sectional e-survey protocol. Int J Surg Protoc 2021;25:123–8.
3. CostHelper. Cost of brain surgery—2022 Healthcare Costs. Available at: https://health.costhelper.com/brain-surgery.html
. Accessed August 20, 2022.
4. Abdelgadir J, Tran T, Muhindo A, et al. Estimating the cost of neurosurgical procedures in a low-income setting: an observational economic analysis. World Neurosurg 2017;101:651–7.
5. 85% of Africans live on less than $5.50 per day. Available at: https://blogs.worldbank.org/opendata/85-africans-live-less-550-day
. Acceessed August 20, 2022.
6. El-Ghandour NMF. Neurosurgical education in Egypt and Africa. Neurosurg Focus 2020;48:E12.
7. Rosman J, Slane S, Dery B, et al. Is there a shortage of neurosurgeons in the United States? Neurosurgery 2013;73:354–65.
8. Sader E, Yee P, Hodaie M. Barriers to neurosurgical training in Sub-Saharan Africa: the need for a phased approach to global surgery efforts to improve neurosurgical care. World Neurosurg 2017;98:397–402.
9. Dada OE, Karekezi C, Mbangtang CB, et al. State of neurosurgical education in Africa: a narrative review. World Neurosurg 2021;151:172–81.
10. O’Callaghan J, Mohan HM, Sharrock A, et al. Cross-sectional study of the financial cost of training to the surgical trainee in the UK and Ireland. BMJ Open 2017;7:e018086.
11. Earley H, Mealy K. An analysis of the cost of postgraduate training in surgery in Ireland compared to other specialties. Ir J Med Sci 2022;191:945–50.
12. Emejulu JKC. Neurosurgery in Nigeria II—evaluation of the perceptions of health personnel after the commencement of services in a new centre. Nigerian Med J 2010;51:177.
13. Nicholas A, Joshua O, Elizabeth O. Accessing Mental Health Services
in Africa: current state, efforts, challenges and recommendation. Ann Med Surg 2022;81:104421.