Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries

Faith C Robertson; Ignatius N Esene; Angelos G Kolias; Patrick Kamalo; Graham Fieggen; William B Gormley; Marike L D Broekman; Kee B Park; Collaborative Working Group

doi:10.1016/j.wnsx.2019.100059

Task-Shifting and Task-Sharing in Neurosurgery: An International Survey of Current Practices in Low- and Middle-Income Countries

World Neurosurg X. 2019 Sep 9:6:100059. doi: 10.1016/j.wnsx.2019.100059. eCollection 2020 Apr.

Authors

Faith C Robertson^{1

2}, Ignatius N Esene³, Angelos G Kolias^{4

5}, Patrick Kamalo^{6

7}, Graham Fieggen⁸, William B Gormley^{1

2

9}, Marike L D Broekman^{10

11}, Kee B Park¹²; Collaborative Working Group

Collaborators

Collaborative Working Group:
Jeffrey Rosenfeld, Naci Balak, Ahmed Ammar, Magnus Tisel, Michael Haglund, Timothy Smith, Ivar Mendez, Jannick Brennum, Stephen Honeybul, Akira Matsumara, Severien Muneza, Andres Rubiano, Gail Rosseau, Tariq Khan, Basant Misra, Gene Bolles, David Adelson, Robert Dempsey, Peter Hutchinson, Abenezer Aklilu, Abigail Javier-Lizan, Adil Belhachmi, Ahtesham Khizar, Alexandru Tascu, Ali Yalcinkaya, Aliyu Baba Ndajiwo, Alvan-Emeka Ukacjukwu, Amit Agrawal, Amit Thapa, Ana Cv Silva, Armin Gretschel, Arvind Sukumaran, Atul Vats, Bakr Abo Jarad, Balgopal Karmacharya, Bipin Chaurasia, Boon Seng Liew, Carlos A Rodriguez Arias, Claire Karekezi, Cohen-Inbar Or, Danjuma Sale, Davendran Kanesen, Djula Djilvesi, Evarsitus Nwaribe, M Elhaj Mahmoud, Mian Awais, Sanjay Kumar, Amos O Adeleye, Manish Agarwal, Menelas Nkeshimana, Sunday David Ndubuisi Achebe, Walid El Gaddafi, Ece Uysal, Eghosa Morgan, Elubabor Buno, Emmanuel Sunday, Esayas Adefris, Fayez Alelyani, Felipe Constanzo, Gabriel Longo, Ghulam Farooq, Goertz Mirenge Dunia, Gyang Markus Bot, Hamisi K Shabani, Harch Deora, Hassan Almenshawy, Hazem Kuheil, Igor Lima Maldonado, Ionut Negoi, Irfan Yousaf, Jafri Malin Abdullah, Jagos Golubovic, Khalil Ayadi, Kriengsak Limpastan, Luxwell Jokonya, Mirsad Hodzic, Mohamed Kassem, Mohammed Al-Rawi, Muhammad Tariq, Mykola Vyval, Naci Balak, Nidal Abuhadrous, Nikolaos Syrmos, Osaid Alser, Paul H Young, Petra Wahjoepramono, Prabu Rau Sriram, Rafik Ouchetati, Recep Basaran, Ritesh Bhoot, Robson Amorim, Rosanda Iliƒá, Saman Wadanamby, Samuel M Fetene, Sanjay Behari, Satish Babu, Tariq Khan, Trung Kien Duong, Tsegazeab Laeke, Ulrick S Kanmounye, Vladimir Komar, Ipe Vazheeparambil George, Zahid Hussain, Lynne Lourdes N Lucena, Hugues Brieux Ekouele Mbaki, Ken-Keller Kumwenda, Djvnaba Bah, Ibrahim E Efe, Dickson Bandoh, Yunus Kuntawi Aji, Thomas Dakurah

Affiliations

¹ Harvard Medical School, Boston, Massachusetts, USA.
² Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.
³ Neurosurgery Division, Department of Surgery, University of Bamenda, Cameroon.
⁴ Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom.
⁵ NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.
⁶ University of Malawi, College of Medicine, Department of Surgery, Blantyre, Malawi.
⁷ Stellenbosch University, Centre for Medical Ethics and Law, Cape Town, South Africa.
⁸ Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa.
⁹ Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
¹⁰ Leiden University Medical Center, Neurosurgery, Leiden, Netherlands.
¹¹ Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands.
¹² Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

Background: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs.

Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics.

Results: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%).

Conclusions: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce.

Keywords: Capacity; DRC, Democratic Republic of the Congo; Global health; Global neurosurgery; LMIC; LMIC, Low- and middle-income country; MOH, Ministry of Health; TS/S, Task-shifting and task-sharing; Task-sharing; Task-shifting; Workforce.