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Up to 2013, Tanzania was a country without a national neurology training programme with arguably the lowest number of neurologists per 100,000 population (0.009/100,000; a total of 4 neurologists). All current Tanzanian neurologists were trained abroad, but the only viable solution in the future will be training within the country.
To develop a post-graduate neurology training programme within Tanzania would be a long-lasting investment in improving ‘brain health’ in one of the world’s lowest-income countries.

Background

Neurological disorders are an important source of morbidity and mortality [1]. They account for 7% of the burden of disease worldwide, which is only slightly less than the combination of HIV/AIDS, Malaria and Tuberculosis [1,2]. Likewise, neurological disease makes up a significant proportion of in-patient hospitalizations. Among neurological conditions, stroke, migraine and epilepsy are responsible for the largest burden of disease. Despite this substantial disease burden, the necessary human resources to solve this major health problem are still almost entirely lacking.

THE WHO RECOMMENDS A RATIO OF BETWEEN 1 AND 5 NEUROLOGISTS PER 100,000 POPULATION

Also, as in various other low-resource countries, the overall lack of diagnostic and therapeutic resources in Tanzania severely limits quality of health. For example, epilepsy is a prevalent disorder in Eastern Africa, but in a large survey the majority of individuals with epilepsy in the East African Community (EAC) was not on any anti-epileptic drug [1,3,4]. However, it is reasonable to assume that as soon as adequate human resources are available, epilepsy treatment rates will improve substantially [5].

Neurology capacity in East Africa: present and future

To date, prospects for improving the number of neurologists in the EAC have been poor: presently there are no nationwide neurology training programmes in all of East Africa, which is directly reflected by the number of neurologists. The geographically nearest adult and child neurology post-graduate training programmes are in South Africa. Neurologists who are currently in practice in the EAC have all been trained in South Africa, Europe and the United States. The World Health Organization (WHO) recommends a ratio of between 1 and 5 neurologists per 100,000 population [6,7,8]. Whereas for instance the United States and many European countries have >5 neurologists per 100,000 population, Kenya has 0.025 neurologists per 100,000 population (a total of 10 neurologists in active clinical practice). Similarly, Uganda has 0.018 neurologists per 100,000 population (a total of 5 in clinical practice) [6,7,8] and Tanzania only 0.009 per 100,000 population (a total of 4 in clinical practice).

In Tanzania, all neurologists work in the two academic centres of the country, being Muhimbili University School of Health and Associated Sciences (MUHAS) in Dar-es-Salaam, and Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Northern Tanzania. Two neurologists have passed retirement age but continue to work, partly because there is simply no one to take over. Three more internal medicine specialists are in various stages of neurology training, which is an ad hoc programme driven by the availability of temporary funds. Paediatric neurology remains out of the focus of this description, but is even worse off in terms of capacity.

As mentioned before the WHO recommends a ratio of between 1 and 5 neurologists per 100,000 population [6,7,8]. Thus in Kenya, between 400 and 2,000 neurologists would be needed and in Uganda, between 330 and 1,650. According to this calculation, Tanzania with even fewer neurologists and the largest population of the EAC, will require anywhere between 500 and 2,500 neurologists. These goals are high, yet every new neurologist would mean a significant gain to Tanzanian health care.

Programme planning of postgraduate neurology training

We propose to set up the Tanzanian Postgraduate Neurology Training, which will consist of an additional two years of neurology training for General Medicine specialists (these individuals have already received 3-4 years of specialist training). The first year of training will take place internally in Tanzania, consisting of specific clinical neurological patient care and becoming familiar with neurophysiological and neuroradiological diagnostic procedures. The second year of training will be spent in an academic hospital equipped with neurophysiological (EEG, EMG), neuroradiological (CT, MRI) and neurosurgery facilities, which will have to take place in a higher-resource country. Other regional training sites in East Africa such as relatively affluent Nairobi or even Addis Abeba are attractive in this respect and are ‘African Neurology-proof’ venues. Muhimbili University in Dar-es-Salaam, the country’s largest city, has already entered a pilot MSc Clinical Neurology programme in collaboration with Vellore, India. In order to optimalize training capacity, we intend to make this a nationwide programme.

Conclusion

As yet, there are no financial resources for the programme. Efforts are made in Tanzania but also EAC wide to reinforce this initiative, which has become an important focus in world neurology. The World Federation of Neurology is now involved and further discussion about the current situation has taken place during the World Conference on Neurology (Vienna, Austria Sept 21-26). After all, Tanzania is still the world’s last large country without national neurology training facilities. If there is no first structural step towards future home-trained neurologists in a country like Tanzania, there will never be viable neurological patient care.

References

  1. Howlett W. Neurology in Africa. University of Bergen/Kilimanjaro Christian Medical centre, Moshi, 2012. Free download available. http://www.uib.no/cih/en/resources/neurology-in-africa
  2. Murray C, Vos T, Lozano R, 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;380:2197-2223.
  3. Meyer A-C, Dua T, Ma J, Saxena S, Birbeck G. Global disparities in the epilepsy treatment gap: a systematic review. Bulletin of the World Health Organization 2010;80:260-266.
  4. Mbuba C, Ngugi A, Newton C, Carter J. The epilepsy treatment gap in developing countries: A systematic review of the magnitude, causes and intervention strategies. Epilepsia 2008:vol; 1-13.
  5. Feksi A. Epilepsy: A community approach. Tropical and Geographical Medicine 1993;45:221-222.
  6. World Health Organization, World Federation of Neurology. Atlas: Country Resources for Neurological Disorders. Geneva, 2004.
  7. Jowi J. Provision of Care to People with Epilepsy in Kenya. East African Medical Journal 2007;84:97-99.
  8. Hooker J. Nurturing Neurology and Neuroscience in Kenya and East Africa – Some Reflections. Paper presented at: Kenya Association of Physicians Annual Scientific Conference 2013; Nairobi, Kenya.