Evaluating the Effectiveness and the Impact of Donated Neurosurgical Equipment on Neurosurgical Units in Low- and Middle-Income Countries: The World Federation of Neurosurgical Societies Experience

doi:10.1016/j.wneu.2017.09.117

World Neurosurgery

Volume 109, January 2018, Pages 98-109

https://doi.org/10.1016/j.wneu.2017.09.117 Get rights and content

Background

Surgical practice highly depends on the availability of surgical equipment; this is particularly relevant to low- and middle-income countries (LMICs), where resources are limited. A key part of the efforts to improve surgical provision globally include providing affordable equipment to LMICs; however, the effectiveness and the impact of these initiatives have not yet been assessed. We aimed to evaluate the World Federation of Neurosurgical Societies neurosurgical equipment program in this context.

Methods

Recipients were identified from the World Federation of Neurosurgical Societies records; contact details were gathered. An online survey was used to collect data on equipment, including its current use, any malfunctioning issues, suitability, reliability, serviceability, and the impact it has had on the unit.

Results

Responses were received from 16 units, totaling 28 pieces of equipment. A total of 75% of the equipment is still in use; of this, 57% is fully functioning, and 43% is used despite some malfunction. We found that 25% of the equipment is broken and unusable; high-maintenance items, such as high-speed drills, feature in this category (100% broken, n = 3). Units reported an increase in number of operation performed in 74% cases, improved surgery quality in 78%, and breadth of operations in 44%. Satisfaction, equipment suitability, reliability, and serviceability scored highly, with median values of 9 for all fields on a 10-point scale.

Conclusions

Equipment donation positively impacts neurosurgical units in LMICs by allowing expansion of neurosurgical practice, improved safety and quality, and affordability. Adequate follow-up, considerations regarding equipment durability and maintenance needs, and improved support for repairs should be prioritized to ensure maximal benefit.

Introduction

Surgical practice is dependent on the availability of adequate, functioning surgical equipment. This applies to all countries worldwide; however, it is especially relevant to hospitals in low- and middle-income countries (LMICs), where infrastructure and access to funding are limited. LMICs are defined in accordance with the World Bank calculations by using the Atlas method; countries with a gross national income (GNI) per capita of $1005 or less are defined low-income, and those with a GNI per capita between $1005 and $12,235 are middle-income (GNI per capita $1005–3955: lower-middle income; GNI per capita $3956–12,235: higher-middle income).¹

Infrastructure, workforce, and training are 3 domains that have been identified as priorities to be targeted to build surgical capacities in LMICs.² In recent years, efforts have been made to tackle all 3 areas though surgical missions, partnership building, technology, and academic endeavors. Infrastructure encompasses both the operating theater and hospital capacity and availability of equipment needed to carry out operations. Thus, one method to improve surgical provision in LMICs includes the provision of affordable surgical equipment to hospitals in such areas. Equipment-donation initiatives exist in various forms, both as part of specific partnerships between institutions such as that between Duke University Medical Center, USA and Mulago Hospital Department of Neurosurgery, Uganda,³ and as standalone projects as in the case presented here. However, to this date, the impact of such initiatives has not yet been quantified.

Specific to neurosurgery, the World Federation of Neurosurgical Societies (WFNS) has been coordinating a surgical equipment donation scheme since the early 2000s, where essential neurosurgical equipment is donated to units in LMICs that would otherwise not be able to afford their cost. Enabling LMICs to perform neurosurgical operations should not be treated as a luxury as it had previously been thought, as both congenital and traumatic neurologic disorders represent a substantial burden of disease.4, 5, 6

In this report, we aim to describe the effectiveness and the impact that the WFNS neurosurgical equipment donation scheme has had on recipient units in LMICs for the first time. We aim to focus on the benefits of the scheme as reported by responders of our online survey but also describe the challenges encountered during the process and areas in which donation programs can be improved. Finally, we wish to offer some recommendations for optimization of this and similar programs, so that their positive impact can be maximized in the future.

Section snippets

Donated Equipment

A list of donated equipment items was identified from the WFNS records database. These records contained information about the equipment piece that had been donated, as well as the destination either in the form of a hospital and neurosurgical department or a specific clinician. Contact detail information, such as e-mail addresses, were not available from the records. An online search for contact details was conducted; this included searching for hospital and neurosurgical department e-mail

Donated Equipment Items

From the WFNS records, we identified 172 pieces of equipment that had been donated between 2000 and 2016. These included several categories, summarized in Table 1, and a list of instruments in each set is available in Appendix B. Equipment items were donated to neurosurgical centers in 52 countries (Appendix C).

Contacts

Obtaining up-to-date and valid contact details for the equipment recipients proved difficult; we were able to identify potential contact details for 76 of 172 equipment pieces (44%),

Discussion

In this online survey–based study, we aimed to describe the impact of the WFNS-coordinated equipment donation program on participating neurosurgical units in LMICs. We set out to contact all recipients of equipment pieces since the scheme was started in the early 2000s. Establishing contact with recipients proved difficult, and the response rate obtained (16% of total equipment items donated, and 37% of identified contacts) was lower than initially hoped. This is likely multifactorial, caused

Conclusions

Our online survey is the first to follow up the impact that a surgical equipment donation scheme has had on the recipient units over the years. This is particularly relevant to specialized areas such as neurosurgery, where adequate equipment is vital to perform operations. We described an overall positive impact on recipient centers in LMICs, showing initiatives of this kind are valuable. However, further steps as listed in our recommendations can be taken to reach the full potential of this

References (16)

J.G. Meara et al.
Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development
Lancet
(2015)
A. Fuller et al.
Building neurosurgical capacity in low and middle income countries
eNeurologicalSci
(2016)
C.J.L. Murray et al.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Lancet
(2012)
K.B. Park et al.
Global neurosurgery: the unmet need
World Neurosurg
(2016)
M. El-Fiki et al.
African neurosurgery, the 21st-century challenge
World Neurosurg
(2010)
E. Sader et al.
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)
E. Sader et al.
Assessing barriers to neurosurgical care in Sub-Saharan Africa: the role of resources and infrastructure
World Neurosurg
(2017)
C.L. Karras et al.
Inside Vietnam’s largest neurosurgery department
World Neurosurg
(2017)

There are more references available in the full text version of this article.

Cited by (15)

Cranioplasty Using Customized 3-Dimensional–Printed Titanium Implants: An International Collaboration Effort to Improve Neurosurgical Care
2021, World Neurosurgery
Citation Excerpt :
A shortage of equipment such as microscopes, endoscopes, and high-speed drills has been cited as one of the primary factors in limiting neurosurgical access in LMICs across the globe.25-27 Venturini et al.28 reported on outcomes in countries that had been donated neurosurgical equipment. The authors noted that in hospitals that had received surgical provisions, there had been in increase in the number of cases, breadth of operations, and quality of surgery, demonstrating the impact that donated equipment can have in LMICs.
Evolutions in cranioplasty have allowed for the creation of customized implants via advances in 3-dimensional (3D) printing technology, although the high cost associated with this technique presents a barrier for low-income countries. Through an international collaboration, our team in Da Nang, Vietnam is able to create low-cost, customized titanium implants for patients with skull defects. We discuss the details of our collaboration and present our experience with this procedure.
We conducted a retrospective review of 35 patients who underwent cranioplasty using custom-made titanium implants. The molding and implant making processes were performed by our neurosurgeons using a 3D printer donated by the United Kingdom–based nongovernmental organization Facing the World. We obtained demographic and preoperative data (reason for skull defect, location, surface area measurement of defect) and postoperative data (complications, cosmetic outcome, and patient satisfaction).
The median patient age was 27 years (range, 16–60 years). Primary indications for craniectomy included traumatic brain injury from motor vehicle accident (77.1%), cerebrovascular disease (11.4%), implant failure following previous cranioplasty (5.7%), and fall (5.7%). Postoperatively, all implants were found to have an excellent fit; at 6-month follow-up, none of the implants required removal. Complications included 4 postoperative hematomas and 1 surgical site infection. All the patients had improved aesthetic appearance and high satisfaction.
Cranioplasty using customized titanium implants yields excellent results for patients with skull defects, demonstrating the practicality of this technique for cranioplasty in low-income countries. Our experience highlights the importance of ongoing international collaboration to improve neurosurgical care in these countries.
Cohesion Between Research Literature and Health System Level Efforts to Address Global Neurosurgical Inequity: A Scoping Review
2020, World Neurosurgery
Citation Excerpt :
Organizations such as the WFNS have worked diligently to donate equipment to these countries. However, long-term technical assistance should be provided to ensure the longevity of these donations.51 An ideal strategy would include training biomedical engineers in LMICs to manage the surgical equipment.
Research output on global neurosurgery (GNS) has exponentially increased in recent years. As research efforts increase, we must first analyze how the current body of GNS literature fits into the macroscopic schema of systems-based policies. The aim of this study was to identify and categorize GNS research based on health system domains.
PubMed, CINAHL, and Embase were searched for GNS literature published from 1999 to 2019. Then, health system domains were defined and itemized based on publicly available documents from the Program in Global Surgery and Social Change. This items chart was subsequently used to categorize the GNS literature into health system domains.
A total 63 articles were determined to focus on a health system domain. Of these articles, 6 focused on multiple domains, yielding an adjusted total of 70 articles. Overall, the most represented health system domain was service delivery (21 articles), followed by workforce (19), infrastructure (15), financing (12) and information management (3). A total of 30 low- and middle-income countries (LMICs) were represented across all articles. In addition, the first author was affiliated with an institution from a high-income country for 71.4% of the articles.
This review highlighted the pressing need for more research into information management in the context of GNS. In addition, health system–focused GNS literature represented only 20% of all LMICs (30/143). The trends in authorship should be noted, because many ethical (and practical) issues may arise if there is a disconnect in the objectives of the authors and the neurosurgeons in LMICs.
Traumatic Spine Injury: Which Discrepancy Between the Research Output and the Actual Burden of the Disease?
2020, World Neurosurgery
Citation Excerpt :
Unfortunately, a computed tomography scan was available in 80% of the hospitals, magnetic resonance imaging only in less than 40%, and a surgical microscope in 33%. Some sets of instruments including those for spine surgery were donated by the WFNS,41 but no center had an intraoperative computed tomography scan, and only a few had a 2D intraoperative radiological instrument. Furthermore, as reported above,26,29,36 in many LMICs, the family has to bear the cost of the surgical devices.
Traumatic spinal injury (TSI) is a global health issue contributing to morbidity and mortality, especially in low- and middle-income countries. The aim of this study is to compare the epidemiological estimates of TSI with the corresponding amount of published papers for different regions.
A bibliometric analysis was performed by collecting the number of publications concerning TSI from the PubMed database. Results were sorted according to the different geographical World Health Organization regions. A “publication-to-volume ratio” was obtained by comparing the average number of documents per year with the number of TSI cases across each region.
A total of 2304 articles were detected from 2008 to 2018. The major publishing regions were North America (AMR-US/Can: 843 articles, 36.6%) and Europe (EUR: 833, 36.2%), then Western Pacific (WPR: 410, 17.8%), Eastern Mediterranean (EMR: 73, 3.2%), South-East Asia (SEAR: 71, 3.1%), Latin America (AMR-L: 55, 2.4%), Africa (AFR: 19, 0.8%). The United States is the most publishing country in AMR-US/Can (86.0%), and Germany in EUR (22.4%). In 2018, EUR published 36.6% of papers versus AMR-US/Can 26.5% and WPR 25.7%, thanks to an increase in Chinese publications. The highest publication ratios of 4.63 and 2.68 were found for AMR-US/Can and EUR, respectively. The other were EMR (0.22), WPR (0.18), AMR-L (0.07), SEAR (0.03), and AFR (0.01).
A marked divide is currently found between countries with a high burden of TSI and those where there is most research interest, estimated as amount of publications. Data demonstrate the need for increased inclusiveness in guidelines generation from high-income countries including collection and analysis from low- and middle-income countries.
Takeoff of African Neurosurgery and the World Federation of Neurosurgical Societies Rabat Training Center Alumni
2019, World Neurosurgery
Citation Excerpt :
Drs. Youssouf Sogoba and Oumar Coulibaly (Mali) finished their 5-year training in Rabat in 2009 and 2011, respectively, and returned to their country as the first 2 neurosurgeons. Together with local neurosurgeons, they have been able to setup a unique neurosurgical team in Gabriel Toure Hospital, Bamako, and received a number of basic neurosurgical instrument sets and a microscope kindly offered by the WFNS Foundation.3,4 Mali is a West African country with a population of 18 million, of which a large part is still lacking access to basic neurosurgical care.
The World Federation of Neurosurgical Societies (WFNS) Rabat Training Center was established in 2002 following the efforts of Dr. Abdeslam El Khamlichi. This institution has paved the way to guide tremendous change and to improve neurosurgery training in Africa, especially Sub-Saharan Africa (SSA). The center has enabled so far the training of more than 58 neurosurgical candidates, from approximately 18 countries in SSA, including 30 neurosurgeons who are already back in their respective countries, establishing and improving neurosurgical care. It is clear that this is the first successful example of the WFNS in increasing the neurosurgical workforce in SSA by well-trained and competent neurosurgeons. Consequently, this experience is worth depicting. We reviewed the profile of the neurosurgeons trained in this center and shortly summarized their reestablishment in their respective countries and their challenges to provide neurosurgical care in such source-limited countries.
Predictive Factors of Spine Surgery Complications at a Major Government Hospital in Cambodia
2019, World Neurosurgery
Citation Excerpt :
Lack of quality home care, infrequent access to clean running water, and inconsistent postoperative follow-up is also a concern for the majority of patients, and also likely contributes to the infection rate. Although many operative suites in low-resource areas have intra-operative x-ray capabilities, many locations, including the one studied here, struggle with the maintenance and repair of these technologies, and thus are not able to use them regularly.7 In PKH, x-ray was rarely used for preoperative marking; rather, spine levels were identified by palpation of local anatomical landmarks.
Spine pathology is a common reason for admission to neurosurgical units in low- and middle-income countries (LMICs) and can have high morbidity rates from lack of specialized institutes. However, good surgical outcomes and quality-of-life scores have been reported in LMICs.
This study details the complication rates and predictive factors from spine surgery at a large hospital in Cambodia, aiming to identify high-risk patients to improve surgeon understanding of these complications for improved pre-operative planning and patient counseling.
This is a retrospective review of patients admitted for spine conditions to Preah Kossamak Hospital in Phnom Penh, Cambodia (2013-2017). Univariate analysis was conducted on potential predictive factors; variables with P < 0.1 were entered into multivariate logistic regression models.
Seven hundred seventy-three patients were included. Forty-six patients had complications including wrong level surgery, hardware failure, and infection. On multivariate analysis, patients from the provinces of Kratie (P = 0.009) or Sihanoukville (P = 0.036), and those that delayed seeking care for more than 1 year after injury (P = 0.027), were significant predictive factors of postoperative complications, and American Spinal Injury Association grade A injury (P = 0.020) was a predictive factor of poor outcome.
Many factors play a role in spine surgery complications in LMICs, including limited access to intra-operative technology, low follow-up rates, and minimal physiotherapy and rehabilitation capabilities. Patients with long delays in presentation, American Spinal Injury Association grade A injuries, and lumbar-level surgery may be especially susceptible to complications and postoperative morbidity. Despite this, institutions have reported encouraging spine trauma outcomes, and spine surgeries are becoming more accepted and safe operations in many LMICs.
Insights into craniosynostosis management in low- and middle-income countries: A narrative review of outcomes, shortcomings and paediatric neurosurgery capacity
2024, SAGE Open Medicine

View all citing articles on Scopus

: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

View full text

Doing More with LessEvaluating the Effectiveness and the Impact of Donated Neurosurgical Equipment on Neurosurgical Units in Low- and Middle-Income Countries: The World Federation of Neurosurgical Societies Experience

Background

Methods

Results

Conclusions

Introduction

Section snippets

Donated Equipment

Donated Equipment Items

Contacts

Discussion

Conclusions

Lancet

eNeurologicalSci

Lancet

World Neurosurg

World Neurosurg

World Neurosurg

World Neurosurg

World Neurosurg

Doing More with Less
Evaluating the Effectiveness and the Impact of Donated Neurosurgical Equipment on Neurosurgical Units in Low- and Middle-Income Countries: The World Federation of Neurosurgical Societies Experience