Access to training in neurosurgery (Part 2): The costs of pursuing neurosurgical training

Opportunities for in-country neurosurgical training are severely limited in LMICs, particularly due to rigorous educational requirements and prohibitive upfront costs.

Research question
This study aims to evaluate financial barriers aspiring neurosurgeons face in accessing and completing neurosurgical training, specifically in LMICs, in order to determine the barriers to equitable access to training.

Material and methods
In order to assess the financial costs of accessing and completing neurosurgery residency, an electronic survey was administered to those with the most recent experience with the process: aspiring neurosurgeons, neurosurgical trainees, and recent neurosurgery graduates. We attempted to include a broad representation of World Health Organization (WHO) geographic regions and World Bank income classifications in order to determine differences among regions and countries of different income levels.

Our survey resulted in 198 unique responses (response rate 31.3%), of which 83% (n ​= ​165) were from LMICs. Cost data were reported for 48 individual countries, of which 26.2% were reported to require trainees to pay for their neurosurgical training. Payment amounts varied amongst countries, with multiple countries having costs that surpassed their annual gross national income as defined by the World Bank.

Discussion and conclusions
Opportunities for formal neurosurgical training are severely limited, especially in LMICs. Cost is an important barrier that can not only limit the capacity to train neurosurgeons but can also perpetuate inequitable access to training. Additional investment by governments and other stakeholders can help develop a sufficient workforce and reduce inequality for the next generation of neurosurgeons worldwide.

Establishing Sustainable Arthroscopy Capacity in Low- and Middle-Income Countries (LMICs) through High-Income Country/LMIC Partnerships

Disparities exist in treatment modalities, including arthroscopic surgery, for orthopaedic injuries between high-income countries (HICs) and low- and middle-income countries (LMICs). Arthroscopy training is a self-identified goal of LMIC surgeons to meet the burden of musculoskeletal injury. The aim of this study was to determine the necessary “key ingredients” for establishing arthroscopy centers in LMICs in order to build capacity and expand training in arthroscopy in lower-resource settings.

This study utilized semi-structured interviews with orthopaedic surgeons from both HICs and LMICs who had prior experience establishing arthroscopy efforts in LMICs. Participants were recruited via referral sampling. Interviews were qualitatively analyzed in duplicate via a coding schema based on repeated themes from preliminary interview review. Subgroup analysis was conducted between HIC and LMIC respondents.

We identified perspectives shared between HIC and LMIC stakeholders and perspectives unique to 1 group. Both groups were motivated by opportunities to improve patients’ lives; the LMIC respondents were also motivated by access to skills and equipment, and the HIC respondents were motivated by teaching opportunities. Key ingredients identified by both groups included an emphasis on teaching and the need for high-cost equipment, such as arthroscopy towers. The LMIC respondents reported single-use materials as a key ingredient, while the HIC respondents reported local champions as crucial. The LMIC respondents cited the scarcity of implants and shaver blades as a barrier to the continuity of arthroscopy efforts.

Incorporation of the identified key ingredients, along with leveraging the motivations of the host and the visiting participant, will allow future international arthroscopy partnerships to better match proposed interventions with the host-identified needs.

Paediatric anaesthesia care in Africa: challenges and opportunities

In 2015, the World Health Organization and member states recognised surgery and anaesthesia care as a component of universal health coverage, yet 1.7 billion children and adolescents continue to lack access to safe surgical care. An overwhelming proportion of these children are from low- and middle-income countries (LMICs).1,2 In Africa, where almost 50% of the population is under the age of 15, children are disproportionately affected. Without sustained global efforts, these inequities and injustices will persist.1 Findings from previous studies suggest a 10–100 times increase in paediatric perioperative mortality in children in LMICs as compared to high-income countries (HICs).3,4 While pieces of the puzzle may be missing, it is clear that not only is access a problem, but also the safety and quality of the perioperative care provided is of concern.

Think global, act local: Burn care in a resource-limited setting

The burden of burn injuries remains a major global health issue.1,2 Worldwide,millions of people suffer from burns and burn-related disabilities and deformities. Every year over 8 million people require medical attention due to burns. Burns cause an estimated loss of 8.5 million disability-adjusted life years (DALYs) each year due to premature death and disability.3 Five per cent of all injury-related deaths are caused by burns, which amounts to an estimated 120,000 deaths annually.4 Non-fatal burns are a leading cause of disability, which cause long-term physical and psychological problems.5,6 There are large differences in burn care worldwide.1 In high-income countries (HICs) major progress has been made in acute burn care over the past decades. With advancements made in the prevention of burns and treatments of wounds, the incidence of burns has decreased and the survival rate of patients has increased. The current mortality reported by HICs is 1.5%.7 This is in stark contrast to low- and middle-income countries (LMICs). In these countries the burden of burn incidence, mortality and morbidity remains high.1,8,9 The vast majority of all burns globally occur in LMICs. This is because people use open fires in daily life, for example for cooking, heating and agriculture. The incidence of burns in these countries is estimated to be 1.3 per 100,000 people, compared to 0.14 per 100,000 people in HICs.8,10 The few existing studies from LMICs show that poor populations are most at risk of sustaining burns, and that the majority of patients are children.1,2,9,11,12 The higher morbidity and mortality is a consequence of the fact that geographically isolated and economically disadvantaged populations have limited access to safe and timely burn care.2 Due to this lack of care, 95% of all fatal fire-related cases of mortality due to burns occurs in LMICs. Studies have estimated that the risk of child mortality due to burns is currently over seven times
higher in LMICs compared to HICs