From Flying Surgeon to Permanent Hub: A Historical Vignette of Decentralised Neurosurgical Service Development in Rural East Coast Sabah
Main Article Content
Abstract
Background: Access to neurosurgical care in remote regions remains challenging because of the uneven distribution of specialists, transportation limitations, and infrastructure constraints. For many years, patients from East Coast Sabah relied on transfer to Queen Elizabeth Hospital, Kota Kinabalu, for emergency and elective neurosurgical care, often requiring long-distance evacuation. This study describes the phased development of a decentralised neurosurgical service in Tawau and evaluates associated regional service trends.
Methods: This descriptive historical vignette and service evaluation reviewed aggregated neurosurgical data from Tawau Hospital, Duchess of Kent Hospital (Sandakan), and Lahad Datu Hospital from 2019 through April 2026. Service activity was analysed across three phases: the flying surgeon model, rotational specialist postings, and permanent specialist deployment. Referrals, admissions, outpatient attendance, operative activity, interhospital transfers, and mortality were evaluated descriptively.
Results: The East Coast Sabah Neurosurgical Service evolved from a monthly visiting service to rotational specialist coverage and, ultimately, a permanent Tawau-based hub in 2025. Referrals, outpatient attendance, and operative workload increased progressively across the three phases. Mean annual referrals increased from 1,388 to 1,802 and reached an annualised 2,130 during early Phase 3. Annual outpatient attendance increased from 1,117 to 1,675, with an annualised total of 2,526 visits. Operative volume increased from 202 to 366, with an annualised total of 374 procedures, while the proportion of elective procedures rose from 1.9% to 16.5%. Crude inpatient mortality rates were 5.8%, 4.9%, and 3.2% across the three phases. Following establishment of the permanent hub, emergency transfers from Tawau decreased from approximately 35 per year during Phase 2 to an annualised 18 per year during early Phase 3, corresponding to a crude administrative estimate of annual government cost avoidance of approximately RM425,000 to RM680,000 through reduced emergency air evacuations.
Conclusion: The phased decentralisation of neurosurgical services in Tawau was associated with expanded local capacity, improved continuity of care, and reduced reliance on transfers to a tertiary referral centre for selected neurosurgical conditions.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Servadei F, Rossini Z, Nicolosi F, Morselli C, Park KB. The role of neurosurgery in countries with limited facilities: facts and challenges. World Neurosurg. 2018;112:315–321. https://doi.org/10.1016/j.wneu.2018.01.047
Lee KE, McMullen N, Kota H, Peterson K, Oravec CS, Frey C, et al. Predictors of citations in neurosurgical research: a 5-year follow-up. World Neurosurg. 2021;153:e66–e75. https://doi.org/10.1016/j.wneu.2021.06.029
Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624. https://doi.org/10.1016/S0140-6736(15)60160-X
Alkire BC, Raykar N, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316–e323. https://doi.org/10.1016/S2214-109X(15)70115-4
García RM, Williams AL, Niquen-Jimenez M, Benllochpiquer V, Durand W, Reynolds R, et al. A mixed-methods evaluation of neurosurgical care in the public sector in Peru. Res Sq. 2023. https://doi.org/10.21203/rs.3.rs-3724636/v1
Tong L, Medeiros L, Moen EL, Dhand A, Bi WL. Dissecting patterns and predictors of interhospital transfers for patients with brain metastasis. J Neurosurg. 2024;140(1):27–37. https://doi.org/10.3171/2023.5.JNS222922
Tung WY, Chang JCY, Deng CY, Shih YS, Yen DHT. Impact of routine neurosurgical dispatch on emergency air transport and outcomes of patients with intracranial hemorrhage. J Formos Med Assoc. 2020;119(1):524–531. https://doi.org/10.1016/j.jfma.2019.07.018
Tasíou A, Tzerefos C, Karagianni M, Tsianaka E, Jarratt M, Gazioğlu N, et al. The complexities of aeronautical transfer of acutely unwell neurosurgical patients. World Neurosurg. 2025;195:123692. https://doi.org/10.1016/j.wneu.2025.123692
Lippa L, Cadieux M, Barthélemy EJ, Baticulon RE, Ghotme KA, Shlobin NA, et al. Clinical capacity building through partnerships: boots on the ground in global neurosurgery. Neurosurgery. 2024;95(4):728–739. https://doi.org/10.1227/neu.0000000000003129
Iqbal J, Naseem A, Bashir MA, Yangı K, Bozkurt İ, Chaurasia B. Global perspective of neurosurgery practice in lower-middle-income countries: challenges, opportunities, and the path forward. Ann Med Surg. 2025;87(5):2532–2536. https://doi.org/10.1097/MS9.0000000000003221
Calderon C, dos Santos Rubio EJ, Negida A, Park KB. Neurosurgical training in the Caribbean. Brain Spine. 2022;2:101691. https://doi.org/10.1016/j.bas.2022.101691
Tenkorang PO, Awuah WA, Mannan KM, Roy S, Boateng PAN, Asiedu O, et al. The transformative power of telemedicine in delivering effective neurosurgical care in LMICs: a review. Brain Spine. 2025;5:104269. https://doi.org/10.1016/j.bas.2025.104269
Fong SY, Mori D, Rundi C, Yap JF, Jikal M, Abd Latip ALL, et al. Five-year retrospective study on hand-foot-mouth disease epidemiology in Sabah, Malaysia. Sci Rep. 2021;11:17814. https://doi.org/10.1038/s41598-021-96083-3
Kaur N, Syed Abdul Rahim SS, Jaimin JJ, Dony JJF, Khoon KT, Ahmed K. The East Coast districts as possible epicentre of severe dengue in Sabah. J Physiol Anthropol. 2020;39:19. https://doi.org/10.1186/s40101-020-00230-0
Harris H, Ooi YBH, Lee JS, Matanjun P. Non-communicable diseases in low-income adults in rural coastal communities in Eastern Sabah, Malaysia. BMC Public Health. 2019;19:554. https://doi.org/10.1186/s12889-019-6854-6
Peters D, Omar MA, Dollah R, Wan Hassan WS. Undocumented workers during Malaysia’s Movement Control Order. Migr Lett. 2022;19(2):107–121. https://doi.org/10.33182/ml.v19i2.1280
Mohd Khatib MA. Present status of marine fisheries in Sabah, Malaysia. J Aquac Mar Biol. 2015;2(4):00033. https://doi.org/10.15406/jamb.2015.02.00033
Frank S. Project Mahathir: ‘extraordinary’ population growth in Sabah. J Curr Southeast Asian Aff. 2006;25(5):71–80.
Freeman M, Savva N, Scholtes S. Economies of scale and scope in hospitals: an empirical study of volume spillovers. Manag Sci. 2021;67(2):673–697. https://doi.org/10.1287/mnsc.2019.3572
Abdelgadir J, Tran T, Muhindo A, Obiga D, Mukasa J, Ssenyonjo H, et al. Estimating the cost of neurosurgical procedures in a low-income setting: an observational economic analysis. World Neurosurg. 2017;101:651–657. https://doi.org/10.1016/j.wneu.2017.02.048
Leal-Méndez F, Holmberg L, Enblad P, Lewén A, Linder F, Wettervik TS. Emergency neurosurgery for traumatic brain injury by general surgeons at local hospitals in Sweden: a viable option when time is brain. Scand J Trauma Resusc Emerg Med. 2024;32:115. https://doi.org/10.1186/s13049-024-01290-2
Merakis MP, Weaver N, Fischer A, Balogh ZJ. Time to traumatic hematoma evacuation: contemporary standard and room for improvement. Eur J Trauma Emerg Surg. 2024;50:2181–2189. https://doi.org/10.1007/s00068-024-02573-0
Grevfors N, Lindblad C, Nelson DW, Svensson M, Thelin EP, Wahlin RR. Delayed neurosurgical intervention in traumatic brain injury patients referred from primary hospitals is not associated with an unfavorable outcome. Front Neurol. 2020;11:610192. https://doi.org/10.3389/fneur.2020.610192
Upadhyayula PS, Yue JK, Yang J, Birk HS, Ciacci JD. The current state of rural neurosurgical practice: an international perspective. J Neurosci Rural Pract. 2018;9(1):123–131. https://doi.org/10.4103/jnrp.jnrp_273_17
Fezeu F, Ramesh A, Melmer PD, Moosa S, Larson PS, Henderson F. Challenges and solutions for functional neurosurgery in developing countries. Cureus. 2018;10(9):e3314. https://doi.org/10.7759/cureus.3314
Fan JS, Chen YC, Huang HH, Yen DHT, How CK, Huang MS. Interhospital transfer neurological deterioration in patients with spontaneous intracerebral haemorrhage: incidence and risk factors. Postgrad Med J. 2017;93(1100):349–353. https://doi.org/10.1136/postgradmedj-2016-134463
Kasputytė G, Jakiševaitė M, Žurauskaitė A, Karbonskienė A, Švagždienė M, Kumpaitienė B, et al. The impact of neurocritical patient transfer on outcomes: retrospective analysis of practice in the largest neurosurgical centre in Lithuania. Anaesthesiol Intensive Ther. 2024;56(2):146–150. https://doi.org/10.5114/ait.2024.141342
Muili AO, Adrien TDE, Nicholas A, Shariff S, Florence AO, Awad F, et al. Advancing neurosurgery in Africa: the impact of telemedicine and capacity building. Egypt J Neurosurg. 2025;40:51. https://doi.org/10.1186/s41984-025-00397-7
Chetcuti K, Chilingulo C, Goyal MS, Vidal L, O’Brien NF, Postels DG, et al. Implementation of a low-field portable MRI scanner in a resource-constrained environment: our experience in Malawi. AJNR Am J Neuroradiol. 2022;43(5):670–674. https://doi.org/10.3174/ajnr.A7494
Shen FX, Wolf SM, Bhavnani S, Deoni S, Elison JT, Fair D, et al. Emerging ethical issues raised by highly portable MRI research in remote and resource-limited international settings. Neuroimage. 2021;238:118210. https://doi.org/10.1016/j.neuroimage.2021.118210
Peselzon O, Tole DT, Rissel C, Kamat A, Maclachlan L, Redmond M. Neurosurgery in Australia’s Top End: the lifesaving advantages of developing sustainable neurosurgical care in rural and remote regions. J Neurosurg. 2024;142(4):1176–1183. https://doi.org/10.3171/2024.6.JNS232599
Kanmounye US, Ammar A, Rolle M, El Ouahabi A, Park KB. Global neurosurgical workforce density—you cannot improve what you do not measure. Chin Neurosurg J. 2021;7:33. https://doi.org/10.1186/s41016-021-00252-2
Kato Y, Liew BS, Sufianov AA, Rasulić L, Arnautović KI, Dong VH, et al. Review of global neurosurgery education: horizon of neurosurgery in the developing countries. Chin Neurosurg J. 2020;6:19. https://doi.org/10.1186/s41016-020-00194-1
Nugroho AW. The start-up of a neurosurgical service in an East Indonesian archipelagic province: the first 2-year experience of North Maluku Database in Neurosurgery (NOMADEN). Surg Neurol Int. 2024;15:53. https://doi.org/10.25259/SNI_1026_2023
Rosseau G, Shlobin NA, Baticulon RE, Ghotme KA, García RM. Global neurosurgery: a path forward through health system strengthening. Neurosurgery. 2025;96(2):251–258. https://doi.org/10.1227/neu.0000000000003106
Sekhon MS, Gooderham P, Toyota B, Kherzi N, Hu V, Dhingra VK, et al. Implementation of neurocritical care is associated with improved outcomes in traumatic brain injury. Can J Neurol Sci. 2017;44(4):350–357. https://doi.org/10.1017/cjn.2017.25
Karanjia N, Dugyala V, Olm-Shipman C, Lele AV. Quality improvement in neurocritical care: a review of the current landscape and best practices. Curr Treat Options Neurol. 2022;24:533–549. https://doi.org/10.1007/s11940-022-00734-3
Giugni A, Gamberini L, Carrara G, Antiga L, Brissy O, Buldini V, et al. Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury. Scand J Trauma Resusc Emerg Med. 2021;29:158. https://doi.org/10.1186/s13049-021-00959-2
Balogun JA. Situating Sub-Saharan Africa within intra-operative innovations in neurooncology. Front Surg. 2022;9:889965. https://doi.org/10.3389/fsurg.2022.889965
McGirt MJ, Speroff T, Dittus RS, Harrell FE, Asher AL. The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description. Neurosurg Focus. 2013;34(1):E6. https://doi.org/10.3171/2012.10.FOCUS12297
Barthélemy EJ, Hackenberg AEC, Lepard JR, Ashby J, Baron RB, Cohen E, et al. Neurotrauma surveillance in national registries of low- and middle-income countries: a scoping review and comparative analysis of data dictionaries. Int J Health Policy Manag. 2022;11(11):2373–2380. https://doi.org/10.34172/ijhpm.2021.167
Asher AL, Sammak SE, Michalopoulos GD, Yolcu YU, Alexander AY, Knightly JJ, et al. Time trend analysis of database and registry use in the neurosurgical literature: evidence for the advance of registry science. J Neurosurg. 2021;136(6):1804–1809. https://doi.org/10.3171/2021.9.JNS212153
Hoffman C, Härtl R, Shlobin NA, Tshimbombu TN, Elbabaa SK, Haglund MM, et al. Future directions in global neurosurgical training: challenges and opportunities. World Neurosurg. 2022;166:e404–e418. https://doi.org/10.1016/j.wneu.2022.07.030
AbuAlrob MA, Mesraoua B. Harnessing artificial intelligence for the diagnosis and treatment of neurological emergencies: a comprehensive review of recent advances and future directions. Front Neurol. 2024;15:1485799. https://doi.org/10.3389/fneur.2024.1485799
Kotovich D, Twig G, Itsekson-Hayosh Z, Klug M, Simon AB, Yaniv G, et al. The impact on clinical outcomes after 1 year of implementation of an artificial intelligence solution for the detection of intracranial hemorrhage. Int J Emerg Med. 2023;16(1):50. https://doi.org/10.1186/s12245-023-00523-y
Monsour R, Dutta M, Mohamed AZ, Borkowski A, Viswanadhan NA. Neuroimaging in the era of artificial intelligence: current applications. Fed Pract. 2022;39(1):S14–S20. https://doi.org/10.12788/fp.0231
Zhu G, Jiang B, Tong L, Xie Y, Zaharchuk G, Wintermark M. Applications of deep learning to neuro-imaging techniques. Front Neurol. 2019;10:869. https://doi.org/10.3389/fneur.2019.00869
Onciul R, Tătaru CI, Dumitru AV, Crivoi C, Șerban M, Covache-Busuioc RA, et al. Artificial intelligence and neuroscience: transformative synergies in brain research and clinical applications. J Clin Med. 2025;14(2):550. https://doi.org/10.3390/jcm14020550
Rafiei S, Arab M, Rashidian A, Mahmoudi M, Rahimi-Movaghar V. Policy interventions to improve rural retention among neurosurgeons in Iran: a discrete choice experiment. Iran J Neurol. 2015;14(4):211–218.
Veerappan VR, Gabriel PJ, Shlobin NA, Marks K, Ooi SZY, Aukrust CG, et al. Global neurosurgery in the context of global public health practice–a literature review of case studies. World Neurosurg. 2022;165:20–26. https://doi.org/10.1016/j.wneu.2022.06.022