Problem: As identified in the Global Burden of Disease report (2012), spine disorders present an enormous burden on individuals, their families, communities and societies and are the leading cause of disability worldwide. In Botswana, the burden of low back pain has been estimated to be the 5th leading cause of disability adjusted life years (DALYS) in 2013 and neck and back pain combined is ranked as the number 1 cause of years lived with disability (YLDs), increasing from the third position in 1990 to the first position in 2013.  In the developing world the burden of spine disorders is expected to be higher than in high income countries; there is a critical lack of access to patient-centred, evidence based spine care in low income countries due to poor prioritization and integration of spine services and lack of available trained health workforce to manage these conditions
Solution highlights: Visionary leadership and reaching out globally to like-minded volunteers led to development of an innovative, patient-centred, model of spine care in collaboration with the government in Botswana; integrating spine services across primary care settings (within the Shoshong community health centre), in secondary care level with the local district hospital in Mahalapye for advanced testing and treatment as needed, and collaboration at the tertiary care level with spine surgical services in Gaborone; active and ongoing engagement of patients, community and all health team members in program design, delivery and evaluation; partnerships with local community, government and academic institutions support long-term sustainability
Description of practice
Although low back pain and neck pain are among the leading causes of disability worldwide, there is a critical lack of access to spine care health services especially in low income countries. Access to spine care is often limited or non-existent due to lack of prioritization of spine disorders and a severe shortage of trained health workers to deliver primary, secondary and tertiary spine care. With the increasing recognition of the burden of spine disability, initiatives to reduce disability have raised the profile of these disorders as an important global and community burden and have stressed the recognition that spine care has to be delivered in such a way as to:
- Be patient-centered and culturally appropriate for the community in which the services are provided
- Be integrated within the existing local health system levels and coordinated
- Be evidence informed At the initiation of this pilot project there were no conservative spine care clinical services available in the village of Shoshong, Botswana other than the prescription of medication to help manage pain.
- To date, however, there is a lack of any sustainable model of care for the management of spinal disorders that could be recommended or implemented in poor and underserved communities in the world. 
At the initiation of this pilot project there were no conservative spine care clinical services available in the village of Shoshong, Botswana other than the prescription of medication to help manage pain.
World Spine Care (WSC) was founded to address the profound gap in care for the management of these types of conditions in developing countries. As an global network of experts in the fields of medicine (orthopaedics, neurology and rheumatology), chiropractic, physiotherapy and nursing, WSC developed an inter-professional, evidence-based, sustainable model of care for the management of spinal disorders in underserved regions and tested this in a pilot project based in Botswana. The overarching aim was to develop a model for the primary care of spinal disorders, fully integrated with the local health host health care system, and with the goal of building capacity to the point where the entire program is locally run and sustainable. All of the clinical service provision is underpinned by local community involvement, government engagement, and education and research. WSC’s model of care incorporates patient-, family-, and community-centered values; interprofessional collaboration and education; use of advanced communication technology where possible; and accessible evidence-based care that is supported by ongoing evaluation and research.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
Unique partnerships with academic institutions, community organizations, the local government and funding agencies have facilitated the development of WSC’s model of care. The government of Botswana, the local government of Mahalapye and the hospital leadership, community leaders in Shoshong and the community all contributed to the development and implementation of the model. Local health workers were engaged to help identify people needing care and to work with local community agencies to implement the services. Researchers have been engaged on an ongoing basis from multiple academic institutions to evaluate the program. An advisory committee, that includes Archbishop Desmond Tutu, advises World Spine Care. Current governance of WSC is by an international board with clinical, educational and research committees. Local people are actively engaged on an ongoing basis with program delivery, sustainability and evolution. Sustainability of the practice is enabled by the development of a local health work force trained to oversee the clinical and community-based operations over the long run.
Between 2012 to 2014 the Botswana program provided spine care services to over 1,000 patients, 90% of which were managed with conservative care. Approximately 10% required referral for more serious pathology. In the past year, WSC developed a new clinical outcome measure and tested this in the Botswana clinics in early 2016. During pilot testing, the Clinical Follow-Up Questionnaire (CFQ) was administered to 57 consecutive patients. The great majority presented (68.4%) with a primary complaint of low back pain with neck and upper back pain as the second most common area of complaint (17.5%). Initial data from the CFQ with respect to pain and disability indicated good improvement in both indices in the pilot study group. Further data analysis is currently in process regarding the validation of this novel clinical outcome measure and the outcomes of the treatment patients are receiving.
Feedback from patients and local community members and health providers has indicated very high satisfaction and consistently high utilization of the services. Engagement by the communities has been high and community members are trained and involved in several public health programs. The government of Botswana renewed the Memorandum of Understanding on the program, allowing a continuation of the practice that has now been established in Botswana for over 5 years. The government also supports a cooperative educational sponsorship program whereby local individuals are offered scholarships in academic institutions abroad to study chiropractic, physiotherapy and spine surgery. All three students are committed to returning to the WSC program in Botswana to oversee service delivery, program evaluation and research.
The practice has been scaled up to other jurisdictions with programs now established in the Dominican Republic, in the process of being set up in Ghana since 2016 and in the final stages of negotiation in India. Programs have been requested in several other countries.
- Vos T, Flaxman AD, Naghavi M, Lozano R et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 2012. 380(9859):2163-2196.
- Botswana. Institute for Health Metrics and Evaluation. Available at www.healthdata.org/botswana. Accessed on August 2, 2016.
- Haldeman S, Kopansky-Giles D, Hurwitz E, Hoy D, Erwin M, Dagenais S, Kawchuk G, Strömqvist B, Walsh N. Bone and Joint Decade report: Moving together beyond the decade – Advancements in the Management of Spinal Disorders. Best Practice & Research Clinical Rheumatology 2012;6:263-280.
- Scott Haldeman and Deborah Kopansky-Giles
- World Spine Care
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