NED Model: Equip, Treat and Educate

An innovative model for transforming healthcare systems through the development of surgical specialties

The surgical needs of the world’s poorest people are being neglected. In 2015 the Lancet Commission on Global Surgery put numbers to this reality. 

It is estimated that nearly 5 billion people worldwide do not have access to safe, timely and financially secure surgical and anaesthetic care when they need it. Most of these people live in the world’s poorest regions.

In low- and middle-income countries, for example, 9 out of 10 people do not have access to safe surgical care. And in most African countries, more than 90% of the population lacks access to such care. Worldwide, lack of access to surgery causes almost three times as many deaths as HIV/AIDS, tuberculosis and malaria.

World populition without access to surgery (%)

This reality must change. Global health policies must prioritise the development of surgery to strengthen national health systems. Surgical care is essential for the treatment of many conditions, from infectious, maternal and neonatal diseases to traumatic injuries and cancer. This investment saves lives, prevents disability, and promotes economic growth.

Over the past decade, the NED Foundation has sought to contribute to this effort. To this end, we have developed a collaborative model that allows us to provide more people with the opportunity for (neuro)surgical treatment by investing in equipment, ensuring quality medical care, and prioritising the training of health professionals. This model has a clear ambition: Equip, Treat and Educate (ETE) to transform health systems in low-income countries.

The NED Model: Equip, Treat and Educate

Promoting a medical or surgical specialty in a low-resource healthcare context must take into account two factors: the difficulty of the interventions required to develop the specialty (its level of complexity) and the capacity of healthcare professionals to perform them successfully (their level of autonomy). Based on these two parameters, the NED Foundation has developed a tiered model of collaboration according to the infrastructure, resources and expertise required to reach each milestone.

The NED model identifies three stages of development with increasing complexity in each area. As the development of the specialty progresses, the complexity of the interventions increases, as does the autonomy of the local team to implement them. External support may be required throughout the process, but the aim is to gradually reduce external support until the local team is fully autonomous.

The key to this is to rely on what we call the ETE method: Equip, Treat and Educate. At each level, interventions will be needed in all three areas. As far as possible, all interventions will aim to equip, treat and educate at the same time. This method can be applied to almost any type of intervention. For example, the planning of a surgical mission may include actions in all three areas: transport and donation of equipment, materials and consumables; medical assistance to patients together with local professionals (consultations, operations); and training sessions given by volunteers (monographic sessions on specific pathologies, surgical techniques or protocols).

In the case of the NED Institute in Zanzibar, the aim of our cooperation is to create the necessary conditions for our colleagues to be able to provide neurosurgical services autonomously once they have reached level 3.

From the point of view of the external organisations, the aim is to no longer be needed. For the centres, units or systems supported, the aim is to achieve full autonomy in the provision, management and financing of medical-surgical care.

Applying the model: Global Neurosurgery in Zanzibar

Since 2008, the foundation has been promoting global neurosurgery in Africa through various initiatives. However, none has had a greater impact than our cooperation in Zanzibar. The NED Mnazi Mmoja Institute, which we created and co-direct, is the most ambitious project in terms of scope and resources dedicated to its development. This centre is the best illustration of how we have applied our model.

In 2008, when a team of volunteers arrived in Zanzibar, there were no neurosurgeons on the island, and the Mnazi Mmoja hospital could not treat newborns with hydrocephalus. Additionally, there were no admission protocols, and no staff were trained in the treatment of head trauma. Consequently, most patients admitted with severe head trauma did not survive.

Following this initial trip, the Zanzibar health authorities requested the foundation’s long-term collaboration. Their goal was to comprehensively develop neurosurgery. We started by organizing short-term surgical missions and adapting a technology used in European hospitals to treat certain pathologies. The portable neuroendoscope allows for local treatment of patients without the need for having this technology locally. Two doctors received accelerated training to handle neurosurgical emergencies and simpler surgeries.

From 2013 onwards, the foundation scaled up its interventions. We funded the construction of the first neurosurgical monographic institute within the grounds of the Mnazi Mmoja Hospital. The centre was granted autonomy to hire its own staff and function as a specialty centre. This made it possible to comprehensively develop neurosurgical care and training.

NED Model: Equip, Treat and Educate

Our interventions have been designed to align with the various stages of development, as outlined in the table. According to the model, physicians focus on treating less complex pathologies at the first level, while educational interventions prioritise the search for, motivation and empowerment of local talent. As each stage is reached, progress will be made in promoting the speciality.

Reaching the third level is a significant milestone in itself. Local specialists should be able to handle complex pathologies at this stage. This will require advanced infrastructure and experienced specialists capable of training new residents.

We collaborated with local authorities at each stage to address infrastructure, care, and training needs. The NED Institute is now capable of achieving the milestones outlined in the second level.

Our experience suggests that this model can benefit other organizations seeking to improve global health and social change. To this end, we have published a report that explains the model and situates it within a broader context. You can download the report and a template to plan interventions based on the model in English and Spanish if you are interested.

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