Irrua Specialist Teaching Hospital is geographically located in a rural community with a population of about 200,000. Starting a neurosurgical service in a rural setting portend a great challenge and it is tasking, our setup has also been likened to other similar settings as seen in the research by Rabiu et al.  at Oshogbo, Nigeria, where the following were also encountered.
The challenges of starting a neurosurgical center in the rural area are quite enormous, though there are paucity of literature [2, 8, 11] on these challenges. These challenges include, ineffective coordination between all health care staffs with significant time wasted in attending to patients, manpower, critical care, materials for intervention, limited theater space, and post-operative care and which can result in significant mortality due to a variety of factors discussed below:
There are few neurosurgeon practicing in the rural area in Nigeria, and this is the usual trend worldwide as earlier pointed out in literatures [2, 3, 8]. As earlier studies have identified, resulting in the referral of complex cases to urban area which has a poor transportation network and communication facilities with the rural area with significant chances of morbidity/mortality. In our rural setup, there is only one neurosurgeon attending to a population of over 200 thousand people with no trained support staffs such as neuro nurses, neuro physiotherapist, and neuro physiology. This creates a cumbersome work environment for the neurosurgeon who must interface among this specialties and in turn train local manpower to meet up with need. Studies from several low income countries have also pointed out this factor as responsible for great death of morbidity and mortality , even leading to the instance of training general surgeons and orthopedic surgeons to be able to handle some neurosurgical cases. Our experience of the need for manpower stemmed from a situation where long waiting list with paucity of support staffs and other relevant specialist unavailability due to their limited number, and attending to other cases.
The lack of resources to offer a succinct critical care is the first among the numerous challenges in our setting. These include human resources, equipment, and intensive care unit. Our intensive care unit for instance has only two ventilators which sometimes are non-functional. We do not have a mobile X-ray making unstable patients to be wheeled some meters away from the emergency point to get radiological investigations. Oxygen pipeline not guaranteed. It can be interrupted anytime. Mobile oxygen is not readily available. These problems have also been identified in other low income countries , and thus correlate with morbidity and mortality. These are also the absence of post-operative neuromonitoring and haemodynamic device, and thus has great impact on patients care. These issues were also noted some literature [8, 11]. This sometimes endangers the patient, worsens neurological state of the patient, and overall outcome.
Materials for surgical intervention
The materials for neurosurgical procedures are not readily available in the rural setting with ours not been an exception. Most are gotten from the city. This eventually causes delay in intervention predisposing to a frequency of mortality as recorded in Tables 3 and 4. The cost of the items is further increased as well as putting strain on these local inhabitant who live in less than 2 dollars per day.
Only three suits are available for both elective and emergency cases. With busy elective list, emergency cases are occasionally delayed and (in few cases are done in suite where other procedure which are however not for clean cases as shown in Table 3 where we had three cases of shunt tract infection out of which two died), thus resulting in morbidity and mortality. Another confounding factor is the non-availability of operating day for neurosurgery in our center causing significant delay in the review and intervention of neurosurgical patients. This leaves the unit with very few elective cases. Appropriate surgical instruments are not provided by the hospital in the government extension. This leaves the surgeon with no choice but to acquire his own equipment to ease his services which thus affects patient care.
The role of the intensive care unit and functional mechanical ventilator in the post-operative management of neurosurgical patients cannot be over emphasize, few ventilator support thus resulting in the hospital prolong waiting list, makes optimal emergency care unattainable, and increases the chances of morbidity and mortality In the same vein, absent neuromonitoring devices and lack of neurosurgical trained support staffs affect the outcome of management of patients in the rural community.