Neurologic services in the nations of Africa

In 1996, the Global Burden of Disease study found that the burden of neurologic disease was increasing in both the developed and developing world.¹ Most disorders of the nervous system occur in developing countries.² In spite of this, little is known about the state of neurologic services in the majority of the continent of Africa. The current status of neurosurgical availability in Africa was reported³ but not neurologic services. In the World Federation of Neurology’s (WFN) 2002 survey of the worldwide distribution of neurologists, only five African nations responded.⁴ The World Health Organization (WHO) reported the distribution of neurologists worldwide, including most of the nations of Africa, but this documented the number of neurologists only.⁵ We designed this study to gather data on the number of neurologists in the nations of Africa, their level and type of training, their practice characteristics, and the ancillary equipment available.

Methods.

We expanded a survey prepared by the WFN⁴ to collect information on the number of neurologists, definition of neurologist, level of training, training programs, practice characteristics, and ancillary equipment available (see the survey on the Neurology Web site at www.neurology.org). Surveys were prepared in English, French, and Portuguese and sent to representatives of all 53 African nations.

We used a stepwise method in attempting to identify that representative for each nation who would be most accurate in completing the survey. The first representative was one identified as a member of the Pan African Association of Neurologic Sciences (PAANS). The PAANS was created in 1972 to bring together national African societies of neurology and neurosurgery and is most analogous to the American Academy of Neurology for North America and the European Federation of Neurologic Societies for Europe. If we could not identify a PAANS representative, we contacted a local representative from the WFN, followed by a local official from the WHO. We made three attempts to obtain the survey results from each representative. If these representatives did not return the surveys, we contacted officials from the nation’s embassy in Washington, DC, or Addis Ababa, Ethiopia, or their local ministry of health in an attempt to obtain survey results. If these attempts were all unsuccessful, we used published results from the WHO on the number of neurologists per nation.⁵ Under the WHO definition, a neurologist was considered a medical doctor with at least 2 years of postgraduate training in neurology at a recognized teaching institution.

As this study is descriptive, statistical tests were not necessary. The nations were divided into four groups according to the number of neurologists in each country. This was done for simplicity of analysis. Classifying by ratio of neurologist to population was another possibility, and these numbers were included in the results.

Results.

Survey results were received from representatives of 38 (71.7%) of 53 African nations. Data from the WHO on the number of neurologists was added for 12 countries, resulting in information on 50 (94.3%) of 53 nations. No information was obtained for the nations of Libya, Somalia, or Sudan.

The nations were divided into four groups, according to the number of neurologists in each country. The table compares these groups with other common measures of health care.⁶ Table E-1 (on the Neurology Web site at www.neurology.org) lists the number of neurologists, description of neurologists, and ancillary equipment per country. Table E-2 lists the practice characteristics for each group.

Group A consists of 11 nations who reported having >10 neurologists per country. This covers a total population of 462,706,800, averaging 711,856 population per neurologist (compared with 26,200 population per neurologist in the United States). Of those reporting, 8 (80%) of 10 countries required neurologists to pass a specialty examination, with only two defining neurologists as a generalist with a special interest in neurology. Ninety percent reported having a local training program, with 50% reporting that all neurology training was done locally in the country.

Group B consists of five nations who reported having 5 to 10 neurologists per country. This covers a total population of 53,197,300, averaging 1,612,039 population per neurologist. Of those reporting, 4 (100%) of 4 required neurologists to have extensive training or pass a specialty examination, but only 1 (25%) of 4 had a local training program.

Group C consists of 23 nations who reported having one to four neurologists per country. This covers a total population of 270,295,100, averaging 5,099,908 population per neurologist. Of those reporting, 10 (59%) of 17 required neurologists to have extensive training or pass a specialty examination, whereas 7 (41%) of 17 defined neurologists as those having some training (<3 years) or an interest only in neurology. Only 3 (18%) of 17 had a local training program, with two of those three reporting that at least some of the training had to be done in a foreign country.

Group D consists of 11 nations, covering a total population of 25,939,273, who reported having no neurologists. Two of those nations reported having a CT scan, and one reported having an EEG.

The figure shows the average population per neurologist for each group as compared with the United States, Canada, the United Kingdom, and other regions of the world.⁴

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Figure. Average population per neurologist for each group as compared with the United States, Canada, the United Kingdom, and other regions of the world.

Discussion.

At least 250 million people are affected by brain disorders in the developing world. Epilepsy alone affects 40 million of these people, approximately 80% of all those affected by epilepsy worldwide.⁷ In developing countries, neuropsychiatric diseases account for 15% of the burden of disability and death.⁷ Although the incidence of some infectious diseases such as tetanus, polio, and leprosy should decrease, the incidence of other neuroinfectious diseases such as HIV, arboviruses, and bacterial meningitis as well as noncommunicable neurodegenerative diseases will increase.^1,2,8,9 Contrary to popular belief, the death rates from noncommunicable diseases are higher in the developing world than in market economies.^1,10 It is important to understand the current state of neurologic services in these areas of the world to plan for their future needs.

The biggest limitation of this study is the variability in reliability of the representatives returning the surveys. The infrastructure of the health care systems in these nations varies tremendously and is not as advanced as those in the developed world. For many of the African nations, official data on the survey questions do not exist. However, 24 (63.2%) of 38 of the survey respondents reported that the stated number of neurologists was derived from national health care statistics or a membership list from a specialist society or specialist board. Other questions were answered with estimates. Of the 38 surveys returned, only 13 were from an official with a neurologic background (PAANS or WFN), representatives whom we considered most reliable in responding accurately to the survey. Fourteen were from an official from the WHO, and 11 were from a governmental official. It is not surprising that of the nations with more advanced neurologic services (Groups A and B), 8 of 16 surveys were from the more reliable neurologic sources. Because of the limited reliability of some of the sources, these data should be considered as estimates only, albeit the best estimates to date.

Another limitation of the study is a possible overestimation of the number of neurologists available to the population in Africa compared with other populations in the world. The definition of neurologist varied from country to country. In Groups A and B, the vast majority of the nations required neurologists to have extensive training or pass a specialty examination, whereas in Group C, a sizable minority (41%) required only some training or an interest in the field. In the 2000 census of the American Academy of Neurology 99.7% of neurologists completed neurology training, and 82.1% were board certified.¹¹ This variability in definition makes it difficult to compare countries. Furthermore, the location of the neurologists distorts the reporting of averages. Twenty-five (81%) of 31 of the nations reported that most of their neurologists practice in large cities, whereas 23 (85%) of 27 reported that no neurologist practices in the rural areas. The calculation of an average population per neurologist may deceptively overestimate the actual population with access to a neurologist. It was beyond the scope of this study to investigate this distribution in a more detailed manner.

Reflecting the enormous geographic, cultural, and economic differences in this continent, the neurologic services among each nation is equally diverse. This is most reflected in the differences in ancillary equipment, training location, and practice settings. The availability of ancillary equipment in each country decreased steadily from that in Group A to Group D. The availability of local neurology training also decreased from 80% in Group A to 25% in Group B to 18% in Group C. Similarly, the options for a practice setting differed among the nations. For those nations in Group A or B, all neurologists have the option of practicing in an academic setting, a private practice, or a national health service. For those neurologists in the Group C nations, the options are more limited. A large minority of those nations had no university setting or offered no choice between private or governmental practice.

The scope of practice of neurologists in Africa does not, however, vary greatly among the nations. Only 24% to 30% of the nations in Groups A to C reported that neurologists practice only neurology. Forty percent to 71% of the nations reported that most neurologists also practice general medicine, and 25% to 50% of the nations reported that most neurologists also practice psychiatry. There is no clear pattern between those in the more neurologically advanced nations vs those in the neurologically limited ones, but their scope of practice stands in contrast to that of neurologists in developed nations.

The number of neurologists per country should be seen in the greater context of that nation’s health care services. One would expect that those nations with a more developed health care infrastructure would have more medical specialists. Not surprisingly, the median life expectancy at birth decreased steadily from Group A to Group D. The median number of physicians per capita, gross domestic product per capita, and total health expenditures per capita decreased steadily from Group A to Group C but increased in those nations with no neurologists. This suggests that wealthier African nations spending more money on health care with more general physicians do not necessarily produce a population with a higher life expectancy. We have no clear explanation for this intriguing finding. Further health economic analysis is warranted.

With limited local training programs, physicians desiring neurologic training must travel to a foreign country. Twenty-eight African nations reported that their neurologists receive training in Europe, eight in North America, eight in other African nations, two in Russia, and one in China and Ukraine. The predominance of foreign training raises the question of training suitability.

Although African physicians receiving neurologic training in developed countries have greatly enhanced their neurologic services, it has also created new problems. The outside training may not be appropriate for the local pathology or the local equipment that they will encounter in practice.¹² The training may encourage them to divert scarce resources into ill-suited local conditions.⁴ Outside training may also increase the problems of “brain drain.” Although overseas training is intellectually satisfying, it is very expensive. The development of local training programs could address many of these issues.

The correct population/neurologist ratio is controversial. Some believe that a ratio of 27,000 per neurologist in the United States is appropriate.¹³ Health maintenance organizations in the United States use an average of 59,000 per neurologist.¹⁴ The recommendation in the United Kingdom and by the WHO is 100,000 per neurologist.^15,16 The current ratios in the African nations range from 1.6 to 175 times that recommended by the WHO in the countries that have neurologists. Furthermore, 12 nations have no neurologists at all.

Correcting these ratios will not be accomplished soon. It is even debatable whether this is appropriate in nations with limited health resources and overwhelming nonneurologic health needs. The most important role for a neurologist in many of these nations may be that of a teacher rather than a primary care provider. Rather than trying to match the ratio of developed nations, using neurologists to train primary physicians and non-MD practitioners in neurologic disease may be a more pragmatic solution.^8,17,18

Many neurologists in developed nations have a fatalistic attitude when considering methods to assist these nations. Their own training is usually ill suited for direct patient care in these countries. There are also multiple nonmedical causes for poor neurologic health in developing nations, including poverty, illiteracy, social instability, war, and underdeveloped transportation and health care infrastructures.^9,18,19 The Institute of Medicine of the National Academy of Sciences released a report in 2001 presenting a comprehensive plan to help remedy this problem. One recommendation was to “extend and strengthen existing systems of primary care to deliver health services for brain disorders.”⁷ Other recommendations include several for which neurologists in developed nations could contribute:

• Increase professional awareness and understanding of brain disorders in developing countries.

• Conduct operational research to monitor the incidence, prevalence, and burden of brain disorders in developing countries.

• Link national centers for training in and research on brain disorders with institutions in high-income countries through multicenter research projects, staff exchanges and training, and Internet communication.

• Create a program to facilitate competitive funding for research devoted to brain disorders in developing countries.⁷

These suggestions would lead to increased publication in mainstream journals of scientific research in developing nations. This is important if the goal is to “increase the awareness and understanding” of their neurologic health needs and, thus, broaden the overall field of clinical neurology. Further support that the international neurology community could give the local African neurologist includes supplying travel stipends to international meetings, enhancing their access to medical literature through the Internet, delivering short-term local educational courses, and supplying resources for new training programs in neurology.