Fulfilling the Specialist Neurosurgery Workforce Needs in Africa: a SWOT Analysis of Training Programs and Projection Towards 2030 by Alvan-Emeka Kelechi Ukachukwu Duke Global Health Institute Duke University Date:_______________________ Approved: ___________________________ Michael M. Haglund, Advisor ___________________________ Joseph R. Egger ___________________________ Anthony T. Fuller Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Global Health in the Duke Global Health Institute in the Graduate School of Duke University 2021 ABSTRACT Fulfilling the Specialist Neurosurgery Workforce Needs in Africa: a SWOT Analysis of Training Programs and Projection Towards 2030 by Alvan-Emeka Kelechi Ukachukwu Duke Global Health Institute Duke University Date:_______________________ Approved: ___________________________ Michael M. Haglund, Advisor ___________________________ Joseph R. Egger ___________________________ Anthony T. Fuller An abstract of a thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Global Health in the Duke Global Health Institute in the Graduate School of Duke University 2021 Copyright by Alvan-Emeka Kelechi Ukachukwu 2021 Abstract Background/Objectives Africa has only 1% of the global neurosurgery workforce, despite having 14% of the global population and 15% of the global neurosurgical disease burden. Also, neurosurgical training is hampered by paucity of training institutions, dearth of training faculty, and deficiency of optimal training resources. The study appraises the current specialist neurosurgical workforce in Africa, evaluates the major neurosurgery training programs, and projects the 2030 workforce capacity using current growth trends. Methods The study involved systematic and gray literature search, with quantitative analysis of retrospective data on the neurosurgery workforce, qualitative evaluation of the major neurosurgery training programs for their strength, weaknesses, opportunities, and threats, and projection modeling of the workforce capacity up to year 2030. Results 1,974 neurosurgeons serve 1.3 billion people (density 0.15/100,000; ratio 1:678,740), in Africa, with the majority (1,271; 64.39%) in North Africa. There are 106 specialist neurosurgery training institutions in 26 African countries, with North Africa having 52 (49.05%) of the training centers. Training is heterogenous; the major programs being the West African College of Surgeons (WACS) - 24 centers across 7 countries, and iv the College of Surgeons of East, Central and Southern Africa (COSECSA) - 17 centers in 8 countries. At the current linear growth rate of 74.2 neurosurgeons/year or exponential growth rate of 6.81% per annum, Africa will have 2,716 - 3,813 neurosurgeons by 2030, and a deficit of 4,795 - 11,953 neurosurgeons. The continent requires a scale-up of its linear growth rate to 663.4 - 1269.5 neurosurgeons/year, or exponential growth rate to 15.87% - 22.21% per annum to meet its needs. While North African countries will likely meet their 2030 workforce requirements, sub-Saharan African countries will have significant workforce deficits. Conclusion Despite a recent surge in neurosurgery residency training, the current state of Africa’s neurosurgery workforce is dire, and many countries will be unable to meet their workforce requirements by 2030 at current growth trends. A significant scale-up of the neurosurgery workforce is required in order to meet these targets. v Dedication For Nena and Kosi, “…follow knowledge like a sinking star, beyond the utmost bounds of human thought, …strive, …seek, …find, and never …yield.” - Alfred, Lord Tennyson; Ulysses vi Contents Abstract .......................................................................................................................................... iv Background/Objectives ......................................................................................................... iv Methods ................................................................................................................................... iv Results ..................................................................................................................................... iv Conclusion ............................................................................................................................... v List of Tables .................................................................................................................................. x List of Figures ............................................................................................................................... xi Acknowledgements .................................................................................................................... xii 1. Introduction ........................................................................................................................... 1 1.1 State of global neurosurgery workforce ........................................................................ 2 1.2 State of neurosurgery workforce in Africa ................................................................... 4 1.3 Brief history of modern neurosurgery in Africa .......................................................... 5 1.4 Neurosurgery training in Africa ..................................................................................... 7 1.5 Need to evaluate the specialist neurosurgery workforce and training programs in Africa ...................................................................................................................................... 11 1.6 Study purpose ................................................................................................................. 12 1.7 Study objectives/aims ..................................................................................................... 12 2. Methods ............................................................................................................................... 14 2.1 Setting ............................................................................................................................... 14 2.2 Sample .............................................................................................................................. 15 2.3 Procedures ....................................................................................................................... 15 vii 2.4 Data management ........................................................................................................... 17 2.5 Ethical approval .............................................................................................................. 18 2.6 Measures .......................................................................................................................... 18 2.7 Data analysis .................................................................................................................... 20 3. Results .................................................................................................................................. 22 3.1 Literature search results ................................................................................................. 22 3.2 Aim 1: To appraise the current specialist neurosurgeon workforce and availability of neurosurgery residency training programs in Africa. ........................... 23 3.2.1 Specialist neurosurgeon workforce ......................................................................... 23 3.2.2 Specialist neurosurgery training centers ................................................................ 24 3.3 Aim 2: To evaluate the neurosurgery residency training programs in Africa for their contents, strengths, weaknesses, opportunities, and threats. ............................... 32 3.3.1 Neurosurgery residency training programs .......................................................... 32 3.3.2 S.W.O.T. analysis of training programs ................................................................. 38 3.4 Aim 3: To estimate the specialist neurosurgeon capacity and coverage in Africa by 2030, if current training rates are sustained. ............................................................... 46 4. Discussion ............................................................................................................................ 63 4.1 General ............................................................................................................................. 63 4.2 Current specialist neurosurgery workforce ................................................................ 63 4.3 Specialist neurosurgery training capacity ................................................................... 65 4.4 Neurosurgery residency training programs ............................................................... 67 4.4.1 General training ......................................................................................................... 67 4.4.2 Subspecialty training ................................................................................................. 68 viii 4.4.3 Role of neurosurgical associations and prominent individuals ......................... 70 4.4.4 Role of collaborative neurosurgical partnerships ................................................. 71 4.5 Neurosurgery workforce projections to 2030 ............................................................. 74 4.6