Groundbreaking Perspective on Epilepsy Surgery Systems in Africa
In June 2026, Aayesha J Soni published a compelling perspective piece titled "Beyond aspiration: a systems model for adult epilepsy surgery in sub-Saharan Africa" in The Lancet Regional Health – Africa. The work details the establishment of the first documented state-sector adult epilepsy surgery service at Groote Schuur Hospital in Cape Town, South Africa. This service addresses a critical gap in care for people living with drug-resistant focal epilepsy across the region. Soni, an adult neurologist and epileptologist affiliated with the University of Cape Town and the Neuroscience Institute, draws on real-world experience to argue that the primary barrier is not technology but the lack of organized systems to mobilize existing resources.
The publication highlights how epilepsy surgery represents the most effective treatment for drug-resistant focal epilepsy, yet access remains severely limited. In sub-Saharan Africa, only a handful of countries offer any form of such surgery, leaving the vast majority of patients without viable options beyond repeated medication trials that often fail. Soni's account moves beyond statistics to emphasize patient stories and practical implementation steps that can be replicated in similar resource-constrained settings.
The Human Cost of Delayed Care and the Shift to Systems Thinking
Soni opens with the story of a young man who became the first patient operated on by the new service in December 2020. Living with frequent seizures that disrupted his education, he achieved seizure freedom after surgery and returned to complete secondary school. This outcome underscores the transformative potential of timely intervention. Another patient, a woman in her thirties with clear mesial temporal lobe scarring, had been told nothing more could be done despite being an ideal candidate. Such cases illustrate the ethical weight of prolonged delays, which contribute to increased morbidity, mortality, psychosocial harm, and economic exclusion.
The perspective reframes the challenge as a systems issue rather than a purely technological one. While high-income countries advance with stereo-EEG and neuromodulation, many African settings possess foundational elements like EEG equipment, MRI scanners, and neurosurgical expertise that simply require better coordination. The state sector in South Africa serves about 85 percent of the population, yet until recently offered no sustained adult epilepsy surgery pathway. Soni demonstrates that building a service involves protecting resources, standardizing workflows, and fostering cross-departmental and cross-sector collaboration.
Core Components of a Sustainable Service Model
The paper outlines essential elements for a viable state-sector adult epilepsy surgery service. These include patient identification through routine EEG screening and outpatient clinics, long-term video-EEG monitoring, standardized MRI protocols, neuropsychological assessment, multidisciplinary team decision-making, and structured follow-up. Sustainability relies on workflow standardization, virtual specialist input, institutional commitment, data collection, and incremental expansion.
At Groote Schuur Hospital, the process began with securing a single protected video-EEG bed amid competing demands on inpatient resources. Existing EEG screening databases were reviewed to identify overlooked candidates with focal abnormalities. Early cases focused on clear unilateral temporal lobe epilepsy to build confidence and refine processes before tackling more complex presentations. Standardized ten-day admissions allowed completion of investigations in one visit, benefiting patients traveling long distances and providing predictability for staff in an emergency-pressured environment.
Multidisciplinary collaboration proved vital. Radiology colleagues adopted international epilepsy imaging protocols. Neuropsychology teams developed expertise in pre-surgical assessments. Nuclear medicine incorporated additional modalities. Neurosurgeons, including trainees eager to gain experience with procedures like anterior temporal lobectomy, committed early. Monthly multidisciplinary team meetings incorporated virtual input from a fellowship-trained epileptologist in the private sector, enabling expert review without new referral pathways.
Photo by Robina Weermeijer on Unsplash
Implications for Academic Research and Capacity Building
This systems model carries significant implications for academic neurology programs and research training across sub-Saharan Africa. Universities and teaching hospitals can integrate similar workflows into curricula, preparing the next generation of neurologists and neurosurgeons for context-appropriate practice. Soni's work at the University of Cape Town exemplifies how academic centers can lead in translating global standards into local realities, fostering research on outcomes, cost-effectiveness, and scalability.
Training pipelines remain limited, with few dedicated epilepsy fellowships in the region. The paper suggests interim models like cross-sector virtual collaboration while local capacity matures. Academic institutions are positioned to develop modular training programs, simulation-based education, and international partnerships that emphasize systems thinking alongside technical skills. Such efforts could expand the pool of specialists capable of leading services in other countries.
Research opportunities abound in documenting long-term seizure and quality-of-life outcomes, refining patient selection criteria for resource-limited environments, and evaluating the economic impact of seizure freedom on individuals and health systems. The perspective encourages data collection as a core component, supporting evidence-based advocacy for sustained funding and policy support.
Broader Regional Context and Global Equity in Neurological Care
Epilepsy affects millions across sub-Saharan Africa, with high treatment gaps driven by stigma, limited specialist access, and fragmented care pathways. The publication aligns with global calls for equitable distribution of advanced interventions. By showing that organized systems can deliver results using existing infrastructure, it challenges assumptions that epilepsy surgery is a luxury in low-resource settings.
Similar initiatives could emerge in other tertiary centers across the continent, tailored to local referral patterns and specialist availability. The model prioritizes starting small, winning early cases, and defending dedicated resources against daily pressures. This approach offers a blueprint for other neurological conditions requiring coordinated multidisciplinary care.
Academic and research communities worldwide can draw lessons on implementation science, health systems strengthening, and the role of narrative in driving change. Soni's emphasis on patient-centered outcomes reinforces the value of qualitative insights alongside quantitative metrics in medical research.
Future Outlook and Actionable Pathways Forward
The publication concludes that adult epilepsy surgery in sub-Saharan Africa is no longer hypothetical but achievable through deliberate systems design. As global neurology prioritizes equity, persistent disparities become increasingly difficult to justify. The components exist; the task is assembling them with institutional courage and conviction that patients deserve the attempt.
Stakeholders including university leaders, hospital administrators, neurologists, neurosurgeons, and policymakers can advance this work by auditing existing resources, piloting protected monitoring beds, establishing standardized protocols, and building virtual networks for specialist input. Incremental expansion, supported by ongoing data collection and outcome tracking, can demonstrate value and attract further investment.
For academics and early-career researchers, this opens avenues in health services research, implementation studies, and capacity development projects. Institutions seeking to strengthen neurology programs may find inspiration in the collaborative, pragmatic approach detailed here.
Photo by Robina Weermeijer on Unsplash
Readers interested in the full details can access the original publication directly at https://www.sciencedirect.com/science/article/pii/S3050501126000763. Additional context on epilepsy care in Africa is available through resources from the World Health Organization and regional neurology associations.
