Thank you Isabella, it's a pleasure to be able to speak on the neurosurgery training current structure, limitations and future trends as regards the Continental Association of African Neurosurgical Societies. Programs across Africa essentially are spread out in almost all the regions except the central African region. Programs in North Africa are well established programs, particularly in Egypt, Algeria and Morocco. In West Africa we have programs that are run through the West African College of Surgeons in Nigeria and Ghana. These are anglophone programs and in Senegal, Niger, Mali we have francophone programs. These are not as developed as in North Africa. In the central African region there are no established programs which are reliant mainly on North African programs. In East Africa since 2006 we have two types of programs. One is run by the university and the other the regional college COSEXA and in Southern Africa we have programs in Zimbabwe and the Republic of South Africa. The five regions of the continent have diverse training structures. Training within programs is different in its curriculum content, duration, quality of resources and the academic staffing of these programs. This has resulted in a diverse range of competences as well as their capacity to develop quality training programs that are consistent across the continent. The Egyptian training program is an example of the North African training. Over the past 50 years Egypt has developed a very good neurosurgical training system. There are two main types of certification in Egypt. One is a university based training which offers an MD in neurosurgery and the other is the Ministry of Health training programs which lead to a fellow of neurosurgery. Graduates from either program then provide services in military and private hospitals which may be accredited to conduct training. Other North African programs of repute are the Moroccan and the Algerian programs. These are the leading programs in that region and they are primarily university based and conducted over a five to six year period. They participate in training of neurosurgeons from countries where there are no training programs in Africa. In the West African region we have Nigeria as an example. The first training center in Ibadan, Nigeria was established in 1962. Typically these are four year training programs. The first year being conducted in a regional university or public hospital and the second and third year at a central university hospital and the final year the resident goes back to his original or her original base hospital for completion of training and following which they are able to sit for the final fellowship exam of the West African College of Surgeons in Neurosurgery. Training in South Africa involves a six year program incorporating a one year primary, a second 18 months conducting an intermediate training and then a dedicated neurosurgical fellowship over three to four years. Typically it is three but candidates can go up to four years to train. This leads to an examination for an award of the fellowship of the South African College in Neurosurgery which is then required to achieve board accreditation. South African training is recognized on the continent as to be amongst the leading program. How do we then develop a neurosurgery training program in a resource challenge environment such as Sub-Saharan Africa? As this map illustrates, when you look at the population, graphs, maps as opposed to the burden of disease, the density of medical schools and the density of workforce, there is a huge discrepancy between the capacity to train and the need for training. How do we develop neurosurgical training in such regions where, as you can see from the map of Africa, there are skimpy centers for training with huge amounts of patient workload? We've done our programs through establishing initially mission sites that help patients and trained various cadres of surgeons, anesthesiologists and nurses in various parts of the hospital. This was done essentially through a volunteer humanitarian neurosurgery approach. This is a setup in one of the regional hospitals in Tanzania. These outreach neurosurgery programs have been conducted in various parts of the region – in Zimbabwe, in Sudan, in the coastal province of part of Kenya – and essentially these centers have been involved in humanitarian mission site training and provision of care in the countries that are outlined in that map. These visits then took place all across parts of the East, Central and Southern African region, which was basically a humanitarian mission work to try and develop neurosurgical capacity in these regions. The sites that have been impacted since 2001 are outlined on the slide above – essentially a whole array of hospitals in the various countries of the region. This then allowed us to start contemplating the commencement of a regional training program. This was initially initiated by two individuals affiliated with the Foundation for International Neurosurgery. Following many months of meetings with the leadership in the region, the initiative was born out of the need to train neurosurgeons within the region and to address the very poor neurosurgeon to population ratio in this part of the world. Prior to 2006, this region did not have any formal neurosurgical training program. What happened was that general surgeons were sent through government support for varying periods of training abroad, usually a one or two year period of observerships with centers in the UK, Norway, India, Australia, Germany, South Africa and Israel. The formal neurosurgical training followed those discussions that I mentioned earlier and the centers in the region were visited with that in mind. This led to a stakeholders meeting in Nairobi, Kenya on the 29th of March 2004. In this slide it shows several colleagues who you may recognize. We have Paul Young from St. Louis, Missouri in the back row. There is Ben Wolfe looking much younger in 2004 and Bert Park who was a missionary neurosurgeon who would visit Kenya and work in Tenwek in the Rift Valley. These hospitals were all visited and discussions held to start up a regional training program in Ethiopia, in Uganda, in Zimbabwe, in Rwanda and centers in Kenya. A training curriculum, a regional training curriculum, was developed through efforts of the Neurological Society of Kenya. It was initially the Neurosurgical Training Program of Kenya but then incorporated the other East African countries and then East and Central African countries. This was also promoted in Ethiopia by Mervyn Began, the chairman of FIANS at the time. The curriculum was then received and accepted by the College of Surgeons of East, Central and Southern Africa at a meeting in Blantyre, Malawi in 2004. The CCNS-XR or the Consortium of Collaborative Sites of Neurosurgical Training in this region is at the moment the premier academic program in neurosurgery in this part of Africa. It's a four-year training program developed with collaboration with FIANS, the Neurological Society of Kenya and the College of Surgeons of East, Central and Southern Africa. The key institutions have been evaluated and accredited by the program and this then was formalized as a consortium program in 2006. The accredited sites are in Kenya, Uganda, Tanzania, Ethiopia, Zambia, Rwanda and more recently in Malawi. This consortium has various hospitals in the region and those are outlined in this slide and you will see there are hospitals that have been accredited in various parts of the region in Eastern Africa. What has helped is the forging of international collaborations. We've been working very closely with the Foundation for International Education in Neurosurgery, the Neurosurgical Education Development Foundation, which is based in Valencia, Spain. Through Yoko Kato, we have collaborated with the Asian Congress of Neurological Surgeons, through Roger Hartle with Weill Cornell University and with Mike Hagglund with Duke University. The Ethiopian program has a close association with Bergen University in Norway. This is of real value because this provides mentorship for the young African-American neurosurgeons through working with senior international faculty. They get training opportunities both locally and through training programs abroad. They ensure personal skill development and the availability of modern technology that is often brought along by the visiting colleagues from these twinning sites. The WFNS Foundation has been a key promoter of programs in the consortium and here we see folks from FIANDS, the World Federation and the Asian Congress interacting with colleagues in Mombasa, Kenya in 2014. The organizations that have continued to assist the development of neurosurgery in this region have, as I mentioned, the WFNS Foundation, the Majid Sami Foundation, the Yoko Kato Foundation and others that I mentioned earlier. The Neurosurgical Education Development Foundation was formed in 2006 primarily for the development of neurosurgery in the East-Central-Southern African region. It initially was the pioneer in mobile outreach neuroendoscopy, which then initiated the training programs and then this gradually grew into the full-blown neurosurgical training program that I talked to you about earlier. Roger Hartle has been a huge supporter, particularly of the program in Tanzania, which is part of the consortium. Roger holds weekly Skype conferences and has developed a well-structured research and publication program with primarily the hospitals of the consortium in Tanzania. He also offers a global fellowship. Ben Worf has been hugely supportive in the development of the CURE Children's Hospital in Bali, Uganda, where a huge amount of research on hydrocephalus has come out from. The Foundation for International Education has been a key partner, as I mentioned, and Bob Dempsey is seen here during one of those visits teaching at the hospital in Tanzania. Mike Hagglund, with his huge entourage of volunteers, comes regularly to Uganda, particularly the Mulago National Hospital and Barara Hospital, and his program is based on the paradigms of twinning technology training and top-down development. The Yoko Kata Foundation has been a huge supporter, regularly coming for courses that have been conducted in our region. There have been collaborations with universities in Egypt. This is one where a memorandum was being signed with Cairo University through the faculty and dean of university there. The consortium of collaborative neurosurgical sites of the East-Central-Southern African became a reference training site, an anglophone reference training site within the African region in 2012, and from that period onwards there have been several residents that have been trained, seven Kenyans, seven Ugandans, Ethiopians, and there are some at the moment in training within the region. The WFNS Foundation currently offers four scholarships for the period of training. The site was also recognized as a reference site for the Africa 100 training program, which was initiated by Professor Majid Sami, inaugurated in 2012, and this program has become one of the training sites for Africa 100 since 2017. The WFNS Foundation has had a huge amount of impact in our region, and this impact has seen the development of locally trained neurosurgeons in our region, and as I mentioned, they received the WFNS sponsorship during their training. This is an image of the 2018 graduation ceremony where 10 East-Central-Southern African region neurosurgeons graduated from this reference site program, which was a huge moment of pride for us all. The numbers of neurosurgeons as a result of these initiatives have increased significantly. Here is a slide that shows the difference between the numbers and the ratio of neurosurgeon to population in 1992, and within a period of 20-odd years, we've managed to reduce that ratio to 1 in 3 million. Still a significant gap, but I think we're heading in the right direction. What do we hope to achieve in the future? We would like to enhance the quality of our training, increase the number of locally trained neurosurgeons, increase the number of training sites where such training can take place, and we would love to have the harmonization of training standards across the African continent. Such an approach to standardized training was published in World Neurosurgery, authored by the past president of the WFNS Foundation, Peter Black, and this essentially was a fairly detailed scoring system where he scored various programs internationally and found that in Africa, we weren't doing too badly. South Africa was leading, followed by Egypt, the Gulf region, and the new program in East-Central-Southern Africa was actually matching some of the established. This is a slide showing the global ranking that Peter Black outlined. This showed where we stand compared to the rest of the world. Malaysia and South Korea were doing very well, followed by the USA and Brazil, and then UK and South Africa, followed by Egypt, and then East Africa. There is a global ranking system that we've been trying to follow and would want to achieve. The role that CANS can play to enhance African neurosurgery is move towards an African Board of Neurological Surgeons, and this is what we would like to seek the help of the WNS with its track record of the American Board of Neurological Surgery as the template to emulate. This is the recommended board structure, and we would love to have the support of international partners, particularly the WNS, which is well-placed to partner with us in CANS to achieve this goal. Thank you very much.

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Continental Association of African Neurosurgical Societies

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resource-challenged regions

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