title: Neurosurgical capacity building in the developing world through focused training.
abstract: OBJECTIVE
  In Tanzania, there are 4 neurosurgeons for a population of 46 million. To address this critical shortage of neurosurgical care, the authors worked with local Tanzanian health care workers, neurosurgeons, the Ministry of Health and Social Welfare, and the Office of the President of Tanzania to develop a train-forward method for sustainable, self-propagating basic and emergency neurosurgery in resource-poor settings. The goal of this study was to assess the safety and effectiveness of this method over a 6-year period.
  
  
  METHODS
  The training method utilizes a hands-on bedside teaching technique and was introduced in 2006 at a remote rural hospital in northern Tanzania. Local health care workers were trained to perform basic and emergency neurosurgical procedures independently and then were taught to train others. Outcome information was retrospectively collected from hospital records for the period from 2005 (1 year before method implementation) through 2010. Analysis of de-identified data included descriptive statistics and multivariable assessment of independent predictors of complications following a patient's first neurosurgical procedure.
  
  
  RESULTS
  By 2010, the initial Tanzanian trainee had trained a second Tanzanian health care worker, who in turn had trained a third. The number of neurosurgical procedures performed increased from 18 in 2005 to an average of 92 per year in the last 3 years of the study period. Additionally, the number of neurosurgical cases performed independently by Tanzanian health care providers increased significantly from 44% in 2005 to 86% in 2010 (p < 0.001), with the number of complex cases independently performed also increasing over the same time period from 34% to 83% (p < 0.001). Multivariable analysis of clinical patient outcome information to assess safety indicated that postoperative complications decreased significantly from 2005 through 2010, with patients who had been admitted as training progressed being 29% less likely to have postoperative complications (OR 0.71, 95% CI 0.52-0.96, p = 0.03).
  
  
  CONCLUSIONS
  The Madaktari Africa train-forward method is a reasonable and sustainable approach to improving specialized care in a resource-poor setting.
authors.affiliation: Centra Neuroscience Institute;
authors.forename: Dilantha B
authors.initials: DB
authors.lastname: Ellegala
authors.forename: Lauren
authors.initials: L
authors.lastname: Simpson
authors.forename: Emanuel
authors.initials: E
authors.lastname: Mayegga
authors.forename: Emanuel
authors.initials: E
authors.lastname: Nuwas
authors.forename: Hayte
authors.initials: H
authors.lastname: Samo
authors.forename: Naftal
authors.initials: N
authors.lastname: Naman
authors.forename: Doyle B
authors.initials: DB
authors.lastname: Word
authors.forename: Joyce S
authors.initials: JS
authors.lastname: Nicholas
mesh_terms: D000293:Adolescent; D000328:Adult; D057191:Capacity Building / Q000379:methods* / Q000458:organization & administration; D003906:Developing Countries; D004503:Education, Medical, Graduate / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D009493:Neurosurgery / Q000193:education*; D019035:Rural Health Services / Q000458:organization & administration / Q000706:statistics & numerical data; D012946:Social Welfare; D013636:Tanzania; D000078329:Workforce; D055815:Young Adult
keywords: AMO = assistant medical officer; HLH = Haydom Lutheran Hospital; MD = medical doctor; global neurosurgery; self-sufficiency; training