The Future of Global Neurosurgery and the Peshawar Declaration

Abstract

Background

The Peshawar Declaration reinforces the critical need for equitable access to neurosurgical care, especially in the low- and middle-income countries (LMICs). With most of the people requiring neurosurgical care living in resource-constrained settings, the field faces significant challenges, such as a lack of trained neurosurgeons, poor infrastructure, and disparity in accessing care. The Peshawar Declaration presents a unified vision for addressing these gaps, building on previous efforts, including the Bogota Declaration (2016) and the establishment of the Global Neurosurgery Committee (2019).

Material and Methods

More than 800 people attended the Global Neurosurgery Conference 2024 in Peshawar, including neurosurgeons, policymakers, researchers, and patient advocates, to discuss the latest developments and challenges in neurosurgical care.

Results

The main outcome was the adoption of a unified definition of global neurosurgery encompassing both clinical practice and public health. The integration of neurosurgery into global health systems, capacity building, strategic partnerships, and the role of advocacy in policy formation were the key topics of debate. The declaration focused on national neurosurgical champions, task-sharing models, multidisciplinary collaboration, and young neurosurgeons' involvement in governance. For sustaining neurosurgical programs, the declaration calls for the development of advocacy toolkits, community-driven initiatives, and research-based residency tracks.

Conclusion

The Peshawar Declaration calls on policymakers, healthcare professionals, and global health organizations to work together to reiterate the commitment to timely, safe, and equitable global neurosurgical care. The declaration sets the stage for sustainable progress in global neurosurgery by fostering an inclusive and collaborative approach.

 

Scroll to top

Keywords

global neurosurgery - Peshawar declaration - advancement - future

Introduction

Significant disparities exist in the global distribution of healthcare, particularly affecting lower and middle-income (LMIC) countries.[1] Even though the medical field has made remarkable progress, adequate access to necessary services—particularly surgical care—remains a major obstacle.[2] [3] Although the importance of surgery in global health has been acknowledged in the past 10 years,[4] [5] there are still striking differences, particularly in specialist fields like neurosurgery. The lack of surgeons, in addition to poor infrastructure and scarce resources,[1] emphasizes how urgent these discrepancies must be addressed worldwide.

Neurosurgery, being a resource-intensive field, confronts significant problems in LMICs, with 80% of the 13.5 million people who require neurosurgical intervention each year living in places with limited access.[6] The number of neurosurgeons available for their growing populations is extremely low, with only 56% of the neurosurgeons residing in LMICS; some suffer ratios of one neurosurgeon for every 10 million people, due to which morbidity and mortality rates are on the rise.[6] [7] [8] This underscores the critical need for more inclusive efforts to close the survival gap and improve access to surgical care.

Motivated by a dedication to equity, global neurosurgery aims to address these discrepancies by providing multifaceted solutions that differ depending on the geopolitical context and lessen the toll that neurosurgical illness takes. The movement seeks to bridge the significant divide through global cooperation, advocacy, and locally specific, sustainable solutions. Recent initiatives have centered on moving toward more robust frameworks prioritizing long-term capacity building and sustainable development.[9] Through academic collaborations, multinational coalitions, and policy-level involvement, the discipline is gradually establishing itself as a crucial component of global health.[10]

The groundwork for modern global neurosurgery advocacy in LMICs was laid by the Lancet Commission on Global Surgery (2015) by identifying surgical care as a critical public health necessity.[4] [5] It also sheds light on the disparities in global health, influences future policy directions and international collaborations, and establishes a unified front in the fight for universal surgical access. The first World Health Assembly (WHA) resolution, WHA68.15, addressing public health gaps resulting from surgical disparities, from infection control to surgeon training, was unanimously endorsed by the WHO shortly after the commission.[11] [12] Following this, there has been a surge in the scope of global enterprises such as the Foundation for International Education in Neurological Surgery and World Federation of Neurosurgical Societies (WFNS), launching comprehensive initiatives like the International Conference for Recent Advances in Neurotraumatology (ICRAN), Bogota Declaration, which formalized a global agenda for equitable neurosurgical care.

 

Scroll to top

Evolution of Global Neurosurgery: From ICRAN 2016 to GNC 2024

The ICRAN, which was led by the WFNS Neurotraumatology Committee, proposed the Bogotá Declaration of 2016, a significant advocacy document that formally acknowledged the severe deficiencies in neurosurgical care, especially in LMICs.[13] The Bogota Declaration laid the groundwork for sustained, organized, and collective efforts to increase access to neurosurgery care worldwide by highlighting the professional duty of the neurosurgical community to come together and create a cooperative international response.

Soon after, prominent neurosurgical journals like World Neurosurgery and Neurosurgery began to include sections on global neurosurgery.[14] [15] The field's dedication to the fair distribution of research and knowledge is further demonstrated by the establishment of the Journal of Global Neurosurgery, an open-access platform that has no fee and prioritizes LMIC researchers.[16]

Other notable successes include the growth of the neurosurgical workforce and the establishment of coordination teams in various countries. Today, more than 70,000 neurosurgeons are working worldwide, with Africa, strikingly Ethiopia, and South East Asia having made remarkable progress, as evidenced by > 20-fold rise in neurosurgeons.[17] [18] [19] The Global Neurosurgery Committee (GNC) has launched country coordination teams in Afghanistan and Sierra Leone to improve neurosurgical capacity in resource-limited areas as part of its broader initiative to mitigate disparities in neurosurgical care with a focus on policy proposals for important issues like hydrocephalus, spina bifida, and traumatic brain injury (TBI). In Sierra Leone, a neurosurgeon practicing in the United States, contacted the GNC to address the critical deficiency of neurosurgical services. A preliminary evaluation at Connaught Hospital revealed significant deficiencies in neurosurgical capabilities due to the high burden of road traffic incidents, causing increased neurosurgical case load. The GNC orchestrated the training of two medical practitioners in neurosurgery at the WFNS training facility in Rabat, Morocco. Mission Brain took on financial responsibility for the training, and a trainee completed a 12-month fellowship and returned to Sierra Leone in November 2024. The Sierra Leonean government has concurrently shown dedication to enhancing neurosurgical services by upgrading operating room facilities and acquiring a new CT scanner for Connaught Hospital. The Sierra Leone initiative exemplifies a systematic, cooperative framework for addressing surgical care deficiencies through data-informed advocacy, capacity enhancement, and government involvement.

In Afghanistan, the GNC initiated outreach to Afghan neurosurgeons in 2020, but faced infrastructural challenges like inadequate internet connectivity. After the political transition in 2021, the GNC, in partnership with collaborators, donated neurosurgical apparatus to ten facilities throughout Afghanistan. This was facilitated by contributions from Pakistan and the WFNS, along with supplementary assistance from the WFNS Foundation. High-speed internet access was facilitated by a Boston-based neurosurgeon from Afghanistan, enhancing communication and capacity-building initiatives. This led to organized neurosurgical training programs, telemedicine partnerships, and virtual mentoring using Ohana-1 smart glasses technology. A strategic planning framework was established, focusing on workforce development, infrastructure enhancement, and surgical training. A formal needs assessment was performed, leading to the publication of an academic paper on the status of neurosurgery in Afghanistan in 2023. Afghanistan recently convened its inaugural international neurotrauma symposium, reinforcing its role in global neurosurgery endeavors.

The organized initiatives in Sierra Leone and Afghanistan illustrate how strategic coordination teams, enhanced by international collaborations and national policy involvement, can convert advocacy into enduring neurosurgical programs. By cultivating local leaders, utilizing global training opportunities, and incorporating digital health innovations, these initiatives function as scalable frameworks for enhancing neurosurgical systems in other resource-limited environments.

By 2019, the WFNS created its first-ever GNC. The committee established a unified definition of global neurosurgery and implemented the global action plan on global neurosurgery.[20] Global neurosurgery centers, such as the Harvard Program in Global Surgery and Social Change Global Neurosurgery Initiative, were established and played a crucial role in strengthening global surgical systems and producing leaders in global health systems. The program's graduates have established neurosurgical departments in their home countries, contributing to the global advancement of neurosurgery.

Significant progress was made after WFNS formed the GNC. The committee made resolving neurosurgical inequities a top priority by advocating for universal health coverage, expanding training programs, and developing infrastructure. Afterward, key organizations such as the European Association of Neurosurgical Societies, the Congress of Neurological Surgeons, and the British Society of Neurological Surgeons established committees and supported global neurosurgery fellowships to foster leadership within LMICs. This collaborative framework has been transformative, marking a significant shift in the global health landscape since the Bogota Declaration in 2016 and setting the stage for the Global Neurosurgery Conference (GNC) in 2024.

 

Scroll to top

Global Neurosurgery Conference 2024

The First WFNS International GNC commenced on February 23, 2024, in Peshawar, Pakistan, and marked a pivotal event in the evolution of global neurosurgery. The conference brought together leaders, advocates, and neurosurgical professionals from around the world to address the pressing challenges in neurosurgical care. The conference drew participation from a diverse audience of 800 professionals, with 150 in-training participants. This ground-breaking event broadcast an insightful scientific program, featuring seminars, workshops, and courses, plenary sessions, multiple scientific sessions, and discussions led by esteemed neurosurgical experts. The conference proceedings were live telecast on Neurosurgery TV. The 3-day activities are presented in [Table 1].

Table 1 First WFNS global neurosurgery conference (February 2024, Peshawar, Pakistan)

Day 1—public awareness seminars, courses, and workshops
Public awareness seminars	• Seminar on prevention of neurotrauma, featuring a head injury patient and expert personnel from Rescue 1,122 and Traffic Police • Roundtable discussion on the “Decolonization of Neurosurgery,” focusing on lived experiences, Pan-Africanism, and postcolonial realities in Asia and Africa • Seminar on “Prevention of Spina Bifida and Folate Fortification,” with a parent sharing their struggle of raising a child with spina bifida
Courses and workshops	• Global Neuro-Nursing Course on neurological surgery nursing; panel on unified neurosurgical care for nurses, physicians, and critical care staff • Neuromonitoring course on intracranial pressure, cerebral compliance, and monitoring techniques, with hands-on training for neurosurgeons, residents, and critical care nurses • Advances in Neuro-Oncology Workshop on brain tumor surgical planning, awake craniotomy, and stereotactic neurosurgery, aimed at neurosurgeons and neuro-oncology professionals • Dorsolumbar/Iliac Fixation and Osteotomy Techniques: Hands-on workshop on cadaver training for neurosurgeons and residents on fixation, osteotomies, and deformity corrections • Hands-On Endoscopic Skull Base Workshop on endoscopic skull base surgery with live surgery demonstrations for neurosurgeons and healthcare professionals • Neurorehabilitation Workshop on neurorehabilitation strategies, interdisciplinary collaboration, and community health for neurosurgeons, physicians, physical therapists, and community health workers
Day 2: plenary sessions
Plenary session 1	• Global Neurosurgery session focusing on the evolution, challenges, and development of global neurosurgery; emphasized the need for sustainable funding models • Neurotrauma and Rehabilitation session discussing unmet neurotrauma needs, policy recommendations, and TBI research; highlighted the need for comprehensive neurotrauma protocols and HIC-LMIC collaborations • Spine session addressing acute spinal cord injuries, outcomes, innovative injection techniques, and strategies for reducing chronic back pain globally • Pediatrics and Congenital Anomalies session covering pediatric neurosurgery topics, including spinal issues in neonates, BELA-TRIPP Pediatric RCT, pediatric functional neurosurgery, and spina bifida management
Plenary session 2	• Parallel discussions on neurotrauma and rehabilitation and neuro-oncology/miscellaneous topics included TBI management protocols, giant pituitary macroadenoma, ICP hydrostatic features, endoscopic brain tumor surgery, and awake vs. general anesthesia craniotomy outcomes • Focused on neuro-oncology/miscellaneous and vascular/stroke and intracranial hemorrhage (ICH); discussed ethical considerations in gene therapy, complex brain tumor management, stroke and cerebrovascular program development in Paraguay, and the ethics of gene therapy advocacy. Neurotrauma topics included the life of neurosurgeons in peripheral areas, spinal trauma from gunshots in conflict zones, and the Journal of Korean Neurosurgical Society
Day 3—plenary and miscellaneous sessions
Plenary session 1	• Global Neurosurgery session on neurotechnology ethics, stroke updates in developing regions, and global neurosurgical training perspectives • Neurotrauma and Peripheral Nerves session on brachial plexus palsies, redo surgery in peripheral nerves, lower limb nerve injuries, and a novel technique for restoring peripheral nerve function. Discussed neurotrauma as a notifiable condition globally
Plenary session 2	• Spine session on advancements in spine-related topics, including posterior wiring for C2 fractures and challenges in establishing spine trauma care in LMICs • Capacity Building in LMICs) session on neurosurgery challenges, the impact of prehospital care on TBI, and the state of neurosurgery in Afghanistan • Pediatrics and Congenital Anomalies session on surgical outcomes in drug-resistant epilepsy, cerebral endoscopy, neural tube defect impact in sub-Saharan Africa, and building epilepsy surgery services
Miscellaneous sessions	• Neuro-oncology session on policy recommendations, epilepsy surgery programs, judicious use of radiosurgery, and a panel on brain tumor management, AI in glioma management, surgical approaches for pineal lesions, vision preservation in parasellar tumors, and brain tumor guidelines from GNO supplement • Neurotrauma session on neurotrauma outcomes, traumatic brain injury, and the increasing impact of trauma on morbidity and mortality, structural violence in neurotrauma, task sharing, surgical treatment of ruptured dural arteriovenous fistula, and lumbar surgery under regional anesthesia in developing countries • Discussions on trans-sensual frontal approach, delayed cerebrospinal fluid leaks, vagus nerve stimulation, efforts to establish neurosurgery societies in the Philippines, and open surgery in the AI era, low-cost spinal fusion, MMA embolization, and photodynamic therapy for malignant tumors
Future of global neurosurgery	Future of Global Neurosurgery session on the future trajectory, challenges, and innovations in global neurosurgery

 

Scroll to top

Future of Global Neurosurgery: The Peshawar Declaration

After acknowledging prior successes, it was underlined—using examples of Afghanistan and Sierra Leone—that national champions are needed to promote global neurosurgery. This approach entails locating leaders capable of obtaining government backing without the need for traditional aid. The importance of collaboration in advancing neurosurgery was emphasized, highlighting the fact that progress cannot be made in isolation. It was proposed to collaborate with surgical societies to create transitional task-sharing systems until official neurosurgery training programs could be set up. It was reaffirmed how important nurses and rehabilitation specialists are within global neuro initiatives.

Engaging community leaders, authorities, and decision-makers in global meetings was discussed as essential to enhancing the effectiveness of implementation. Encouraging attendance from sociologists, anthropologists, historians, and politicians in LMIC conferences could ensure a more inclusive approach. Collaboration with local governments and policymakers is essential to expanding neurosurgery programs. To ensure effective approaches, cultural sensitivity and community involvement were emphasized.

Young neurosurgeons and medical students have a key role in supporting neurosurgical development; hence, training courses, roundtable talks, and knowledge exchanges were advised to nurture future leaders, with technology aiding multilingual communication and collaboration. Residents' research is recommended to highlight contributions, with young neurosurgeons adopting active governance roles in projects, as seen in initiatives like the Cape Town Congress. It was proposed that young neurosurgeons be involved as observers on the WFNS AC, underlining the necessity of their participation in governance and decision-making processes. It was suggested that efforts be made to equalize training standards and that residents of LMICs be provided with opportunities for international exposure.

It was reinforced that global neurosurgery initiatives must continue to advocate for policy reforms, use telemedicine to improve access in remote places, and document results to guide future developments. Sharing best practices, introducing research tracks in residency programs, and encouraging international collaborations are critical for knowledge exchange and enhanced learning opportunities. Empowering local surgeons to lead and establishing resilient healthcare systems through grassroots campaigning is critical for long-term success. Addressing discrepancies in research data between HICs and LMICs remains a key priority.

The conference culminated in the Peshawar Declaration, outlining the shared vision and strategies necessary to advance neurosurgical care globally for equitable healthcare. The statement is built on the foundation laid by earlier declarations and plans, with a renewed focus on multidisciplinary collaboration and youth engagement.

With the shared commitment to advance global neurosurgery in the spirit of collaboration, we issued The Peshawar Declaration. The statement comes from the insights of the conference participants, collective wisdom, and actionable items from engaging discussions to focus on shaping the future of global neurosurgery.

Recognizing the constantly evolving landscape of global neurosurgery, we have transitioned from multiple definitions 3 to 5 years ago to an agreed-upon, One Definition of Global Neurosurgery during this conference: Global Neurosurgery is the field of neurosurgery integrating clinical care, research, advocacy, capacity building, and health systems strengthening with the primary purpose of ensuring access to safe, affordable, and timely neurosurgical care to all who need it globally. This unified understanding emphasizes not only better surgical practices but also adds a public health dimension. Our common understanding recognizes global neurosurgery as a social justice issue as well.

Acknowledging the challenges faced by underprivileged nations lacking neurosurgical infrastructure and the absence of neurotrauma programs, we endorse the need for promoting efforts with Neurosurgical Champions and their Advocacy Goals in each country. Inspired by successful initiatives in Sierra Leone and Afghanistan, we encourage the identification and support of champions who can secure government support and foster sustainable progress without having to rely on traditional international aid. Highlighting the role of collective efforts in the progress of global neurosurgery, we suggest collaborations with other surgical societies as well as other stakeholders to develop high-quality task-sharing systems in countries currently lacking neurosurgeons. Champions could emerge from general surgeons performing neurosurgical tasks until the gap is bridged in establishing proper neurosurgery training programs.

Acknowledging the roles of nurses, students, and other allied health professionals, we aim to strengthen advocacy, grassroots efforts, and support for surgical system strengthening. A more inclusive perspective and multidisciplinary collaboration are important, including sociologists, anthropologists, historians, bureaucrats, and politicians, for advancing global neurosurgery. Recognizing the importance of strategic partnerships, we need to carefully select and engage partners, including nutritionists, lawyers, army personnel, and government officials. The involvement of decision-makers, authorities, and ministries of health in global meetings, conferences, and discussions will enrich our endeavors; building and developing on their expertise will make our efforts more inclusive and impactful, especially in low and middle-income countries.

Building on the insights shared by various conference participants, we encourage young and diverse neurosurgeons' engagement in global neurosurgery. Acknowledging the successful initiatives in the Global North, we can explore similar models for other regions as well. The involvement of residents in a research track in residency programs focusing on global health policies will provide a valuable plan to create a broader research enterprise in global neurosurgery. We emphasize the integration of young neurosurgeons at governance levels in our professional activities and encourage their participation in shaping the future of global neurosurgery.

Some of the strategies and ways to engage young professionals, nurses, and allied health workers include encouraging medical students and residents to participate in global neurosurgery research, conferences, and policy deliberations. Nurses and allied health professionals should be educated and trained in neurocritical care and postoperative rehabilitation through global neuro-nursing courses. Young and emerging neurosurgeons should be designated as observers in policy groups, advocacy committees, and neurosurgical societies to foster early leadership involvement in global neurosurgery. Other strategies include forming student-led research groups, promoting community outreach and public awareness, and offering practical hands-on training in low-cost surgical simulation laboratories to improve skill development.

Celebrating the unity and diversity of global neurosurgery, we call upon leaders in each country, irrespective of linguistic backgrounds, to collaborate and exhibit unity in our collective efforts. We call for community involvement and recognize the need for an implementation science approach in growing neurosurgical services. We endorse the creation of an advocacy toolkit for global neurosurgery, facilitating the development of surgical plans and empowering professionals across linguistic and cultural diversities.

Concluding, we reiterate our commitment to inclusivity, excellent communication, regular meetings, and conferences, growing and guiding the young neurosurgeons, and the weaving of neurosurgical initiatives around existing agendas with the governments. We emphasize the global neurosurgery's nature as a forum with an inclusive space for all, including neurosurgeons, nonneurosurgeons, nurses, young people, medical students, and advocates.

This Peshawar Declaration represents our shared vision for an inclusive, impactful, and collaborative future in global neurosurgery.

 

Scroll to top

 

Scroll to top

Conflict of Interest

None declared.

• References

• 1 Dewan MC, Rattani A, Fieggen G. et al; Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. J Neurosurg 2018; 130 (04) 1055-1064
• 2 Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN. Eds. Disease control priorities, (Volume 1): essential surgery. World Bank Publications; 2015
• 3 Meara JG, Leather AJ, Hagander L. et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386 (9993): 569-624
• 4 Meara JG, Greenberg SL. The Lancet Commission on Global Surgery 2030: Evidence and solutions for achieving health, welfare and economic development. Surgery 2015; 157 (05) 834-835
• 5 Grimes CE, Bowman KG, Dodgion CM, Lavy CBD. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg 2011; 35 (05) 941-950
• 6 Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: the unmet need. World Neurosurg 2016; 88: 32-35
• 7 El Khamlichi A. Neurosurgery in Africa. Clin Neurosurg 2005; 52: 214-217
• 8 Haglund MM, Fuller AT. Global neurosurgery: innovators, strategies, and the way forward. J Neurosurg 2019; 131 (04) 993-999
• 9 Uche EO, Sundblom J, Uko UK. et al. Global neurosurgery over a 60-year period: conceptual foundations, time reference, emerging co-ordinates and prospects for collaborative interventions in low and middle income countries. Brain Spine 2022; 2: 101187
• 10 Price R, Makasa E, Hollands M. World Health Assembly Resolution WHA68.15: “strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage”—addressing the public health gaps arising from lack of safe, affordable and accessible surgical and anesthetic services. World J Surg 2015; 39 (09) 2115-2125
• 11 Rosseau G, Johnson WD, Park KB. et al. Global neurosurgery: continued momentum at the 72nd World Health Assembly. J Neurosurg 2020; 132 (04) 1256-1260
• 12 WFNS. (2017, February 3). The report of ICRAN 2016. WFNS Newsletter. Accessed October 28, 2024 at: http://wfns.org/newsletter/6
• 13 Rosseau G. Global neurosurgery section introduction—neurosurgery's “moon shot”. Neurosurgery 2022; 91 (04) 527-528
• 14 Rosseau G. Introduction: global neurosurgery: the new frontier. Neurosurgery 2024; 95 (03) 499-500
• 15 Esene I, Park KB. The journal of global neurosurgery. JOURNAL OF GLOBAL NEUROSURGERY 2021; 1 (01) 10-12
• 16 Asfaw ZK, Tirsit A, Barthélemy EJ. et al. Neurosurgery in Ethiopia: a new chapter and prospects. World Neurosurg 2021; 152: e175-e183
• 17 World Federation of Neurosurgical Societies WFNS. Global Neurosurgical Workforce Map - about WFNS | WFNS. Accessed October 28, 2024 at: https://wfns.org/menu/61/global-neurosurgical-workforce-map
• 18 Mukhopadhyay S, Punchak M, Rattani A. et al. The global neurosurgical workforce: a mixed-methods assessment of density and growth. J Neurosurg 2019; 130 (04) 1142-1148
• 19 World Federation of Neurosurgical Societies WFNS. (2020, February 18). WFNS-WHO Liaison Committee Report | WFNS. Accessed October 6, 2025 at: https://wfns.org/newsletter/160
• 20 Rolle M, Ammar A, Park KB. Global neurosurgery: A call to action. J Global Neurosurg 2021; 1 (01) 86-88

Publikationsverlauf

Accepted Manuscript online:
30. September 2025

Artikel online veröffentlicht:
14. Oktober 2025