Neurology and headache medicine in Malawi: territory, education, and the path to strengthening primary care in sub-Saharan Africa.

Sub-Saharan Africa (SSA) bears a disproportionate burden of neurological and pain-related diseases while facing a severe shortage of trained specialists. In this context, expanding neurology and, particularly, headache medicine, through education and integration within primary care represents both a necessity and an opportunity. This Perspective proposes a context-sensitive framework in which three interconnected domains-territory, culture, and capacity-shape the accessibility, acceptability, and sustainability of neurological care. Drawing on the experience of the International Headache Society (IHS)-DREAM healthcare network partnership in Malawi, we examine how locally adapted education, task-shifting and task-sharing can contribute to capacity building while highlighting the limitations of approaches that focus on training alone. We argue that closing the neurological treatment gap requires a shift from specialist-centred to system-centred neurology, integrating workforce development with primary care, culturally grounded community engagement, appropriate supervision and referral pathways, supportive national health policies, and equitable access to essential medicines. Task shifting and task sharing between physicians and non-physician clinicians may constitute a sustainable component of this model when appropriately regulated, supervised, remunerated, and integrated with specialist support and referral pathways. Rather than proposing a model for direct transfer across SSA, this Perspective advocates locally led, context-dependent implementation strategies capable of adapting to diverse health systems. Such an approach reframes global neurological capacity building from the episodic transfer of expertise towards the development of resilient and sustainable systems of care.