Introduction: In Tanzania, there are 4 neurosurgeons for 46 million people. To address this shortage, we collaborated with the Tanzanian government to develop a train-forward program for sustainable, self-propagating neurosurgery in resource-poor settings. The program utilizes intensive hands-on, one-to-one, bedside teaching, with local health workers trained to perform neurosurgical procedures independently and then trained to train others. This report quantifies increasing self-sufficiency with increasing case complexity over 6 years.
Methods: The program was introduced in 2006 at a remote, rural hospital in northern Tanzania. Outcome information was collected retrospectively from hospital records for the period 2005-2010. De-identified data was analyzed for changes in number and complexity of procedures, degree of Tanzanian independence, and impact on post-surgical complications. Surgery was considered “independent” if performed by a Tanzanian alone or with a Tanzanian trainer. Case “complexity” was categorized as simple (ventricular drain, exploratory burr holes or burr holes for evacuation of epidural or subdural hemorrhage, traumatic head wound repair without skull fractures), complex (shunt placement/revision, burr holes for tumor biopsy, craniotomies, myelomeningocele or encephalocele repair, spinal decompressions, diskectomy, fusions), and moderate (other).
Results: By 2010, three generations of Tanzanian health workers had been trained, with number of procedures increasing from 18 in 2005 to an average of 92 per year in the last 3 years. Independence increased significantly from 44% in 2005 to 86% in 2010 (p<0.001), with number of complex cases performed independently also increasing from 34% to 83% (p<0.001). Patients admitted as training progressed were 29% less likely to experience post-operative complications (multivariable odds ratio 0.71, p=0.03); this decrease in post-operative complications was more pronounced (48%) when restricted to pediatric patients (<= 17 years).
Conclusions: This intensive hands-on bedside training program is an effective approach to increasing self-sufficiency in specialized care in resource-poor settings.
Patient Care: This training program has been shown to increase the ability of health care providers in resource-poor settings to perform independently, not only more procedures, but more complex procedures with reduced post-operative complications.
Learning Objectives: By the conclusion of this session, participants should be familiar with an effective training program to increase neurosurgical self-sufficiency in a resource-poor setting.