Keywords
cardiac surgery in Africa - rheumatic and congenital heart surgery - development models
for cardiac programs - pioneers in cardiac surgery
Background
Pioneering of cardiac surgery in north and sub-Saharan African regions began in the
1950s and 1960s.[1]
[2]
[3]
[4]
[5]
[6]
[7] Sustainability of the programs in sub-Saharan Africa (SSA) was confounded by multiple
problems. It demanded the highest level governmental support, a dedicated multidisciplinary
team approach, leadership, and profound know-how which were not adequately available
in those days.[8]
[9]
Cardiac surgery capacity in Africa was reviewed almost 15 years ago by Unger and Turina,
and they reported 18 open heart operations per million and 1 cardiothoracic surgeon
(CS) per 4 million people.[10]
[11] In response to this alarming situation, several visiting cardiac teams went to Africa
to establish humanitarian cardiac programs or to aid the local cardiothoracic surgical
teams who had limited or no capability to perform open heart surgery.[8]
The objectives of the study were to provide baseline data on current cardiac surgery
capacity to enable effective concepts to be designed within the priority health care
agenda for developing sustainable programs in SSA.
The article will attempt to “formulate new solutions for these very old problems”[11] for colleagues in developing countries, particularly in SSA. It will describe the
current role of visiting humanitarian heart teams who come to SSA for 10 to 14 days
and the Ghanaian/German and Namibian models for developing cardiac surgery in SSA.
Methods
Participants in the Study
A retrospective survey on cardiac surgery capacity was conducted in 2011 and 2012
in 21 countries in Africa with open heart surgery capability. Survey questions included
number of cardiac centers or units in each country, local and visiting surgeons performing
open heart and closed heart procedures, diagnostic possibilities, and hospital mortality
rates.
Colleagues practicing in these countries were invited to participate in the study.
There were six countries in North Africa: Algeria, Morocco, Tunisia (the Maghreb states),
Egypt, Libya, and Sudan and 15 countries in SSA: Central Africa: Angola; East Africa:
Kenya, Rwanda, Tanzania, Uganda; West Africa: Côte d'Ivoire, Ghana, Nigeria, Senegal;
The Horn: Eritrea, Ethiopia; Southern Africa: Mauritius, Mozambique, Namibia, South
Africa (Republic of South Africa [RSA]). Mauritius and Nigeria were also invited but
did not have the capability to perform regular open heart surgery in 2012.
Finally, 29 senior colleagues (3 cardiologists and 26 cardiac and CSs) representing
16 countries with open heart surgery capability participated in the study. The distribution
by regions was as follows: North Africa, n = 5; Central Africa, n = 1; East Africa, n = 10; West Africa, n = 7; The Horn, n = 2; and Southern Africa, n = 4. The database of the Cardiothoracic Surgery Network (CTSNet, www.ctsnet.org) was searched for 933 listed CSs in Africa in April 2013. The data were verified
by the executive director, CTSNet. The study differentiated in the listed CS in Africa
between surgeons who perform open heart surgery or pure thoracic surgery. The CTSNet
registry does not represent the number of global practicing CS; however, it demonstrates
the approximate density of CS in various regions.
The principal author of this article undertook exploratory visits to interact with
colleagues in Ghana, Libya, Tunisia, Rwanda, South Africa, and Uganda in conjunction
with educational meetings. He conducted interviews during the Pan-African Society
for Cardiology meeting in Kampala, Uganda in 2011 and at video conferences with colleagues
in Kenya and Nigeria during the Pan-African/World Health Summit Global Forum in Berlin
in 2012 and 2013. Three models for developing cardiac surgery in SSA were reviewed.
Model 1: Ghanaian–German and Namibian models are associated with an integrated health
care system with part government and part private funding managed by a senior local
consultant CS. The Ghanaian program, for example, is independent, has political support,
has trained more than 20 local and foreign CS, maintains stable surgical load though
lower than that of its counterparts in Europe, and produces scientific works. The
model requires 7 to 10 years for infrastructure development and stability and 3 more
years for the mixed team until the unit becomes independent.[5]
[9]
Model 2 is practiced in many countries in SSA: Visiting teams (1–2 missions a year)
who come for 10 to 14 days are not integrated into the health care system and not
fully supported by the host health care policy makers due to economic constraints.
This model is solely dependent on foreign donors and would require at least 10 years
for developing a proper infrastructure with the local teams. An additional 3 to 5
more years would be required to mentor the local teams as a mixed team until unit
independence at 15 years. The expatriate teams commit themselves to teaching the local
staff and additionally arrange scholarships with the local health authorities for
the local physicians to be sent to high-volume centers for postgraduate training.
This has happened in Mozambique where the foreign surgeons have trained a native team
including surgeons who now perform more than 100 open heart cases per year.
Model 3 is practiced in Kenya: Senior expatriate CS on contract is paid by the host
government to develop a cardiac surgery program and organize capacity building. This
is similar to the cooperation between Deutsches Herzzentrum Berlin and Sarajevo Heart
Centre.
Sources of Statistical Data
Annual reports on cardiovascular diseases, data on global population, and health care
expenditure statistics were obtained from the Web sites of the World Bank (WB), World
Health Organization (WHO) and analyzed. Further data were retrieved from the annual
statistical reports of the German Society for Thoracic and Cardiovascular Surgery,
Deutscher Herzbericht 2013, p. 202 (Publisher: Deutsche Herzstiftung—German Heart
Foundation: www.herzstiftung.de/herzbericht) and a presentation by Prof. Wei Wang, Fuwai Hospital, Beijing, China on behalf of
the Chinese Society for Cardiothoracic Surgery during the International Telemedicine
Forum held in Berlin on October 23, 2013, in conjunction with the fifth World Health
Summit. The gross domestic product (GDP) and GDP per capita of Africa and sub-Saharan
African countries were obtained from WB data published in 2012. Global and national
mortality data were sourced from the WHO publication 2012.[12]
[13]
[14]
[15]
[16]
[17]
Figures on population of Africa and SSA were used to calculate ratios of (1) cardiothoracic
surgeons (CSs), (2) cardiac centers, (3) open heart surgery to population, (4) pediatric
cardiologists to population under 15 years, and (5) percentage of pediatric population
in SSA that had access to open heart surgery.
The populations of nonparticipating countries were not included in the calculation
for heart centers, cardiac surgeons, and open heart surgeries to million population
ratios. The population of Africa in 2012 was 1.1 billion. Without Egypt (80.7 million),
Sudan (37.2 million), and South Africa (51.2 million), the population was 912.3 million.
North Africa has a population of 221 million, without Egypt and Sudan 103.1 million.
The population of the Maghreb states was 81.7 million. SSA has a population of 860.4
million, without the RSA (809.2 million).
Hoffman formula was used for calculations to predict the incidence of congenital heart
disease (CHD)/1,000 live births, which estimates 4 to 5/1,000 live births. Severe
CHD requiring cardiological care occurs in 2.5 to 3/1,000 live births.[18]
Exclusion Criteria
Surgeons who were performing open heart operations irregularly—less than 10 a year—and
had not operated in the last 3 consecutive years (2010–2012) were not included in
the study. Hospitals or units with a local CS which had limited open heart surgery
capability, performing less than 10 operations a year, or no capability for open heart
surgery were excluded.
Results
Data were obtained from 25 respondents of the 29 colleagues who were invited for the
study, yielding a response rate of 86.2%. Four of the six North African countries
(Algeria, Morocco, Tunisia, and Libya) participated in the study yielding a response
rate of 66.7%. In SSA, the response rate was 91.3% (21/23).
Using Hoffman model, an estimate of 4.42 to 6 million children in SSA are born with
CHD. Of these, an estimated 1.7 to 2.6 million children will require cardiac surgery
in SSA. In East Africa, The Horn, and Ghana, 0.5 to 3.4% of the estimated number of
children younger than 15 years of age requiring surgery had access to open heart surgery.
There were 78 cardiac centers or units which were performing regular open heart operations
in Africa. Distribution by region is as follows: 56 centers in North Africa (the Maghreb
states: Algeria, Morocco, and Tunisia) and Libya and 22 in SSA. West Africa, n = 5; Central Africa, n = 1; East Africa, n = 12; The Horn, n = 2; and Southern Africa, n = 2 ([Table 1]).
Table 1
Regional distribution of cardiac centers with capability to perform regular open heart
operations in 2012 in North and sub-Saharan Africa
|
Regions
|
Cardiac centers (n)
|
Cardiac center per million (n)
|
|
Africa[a]
|
113
|
1:8.5
|
|
Africa[b]
|
78
|
1:12.5
|
|
Sub‐Saharan Africa + RSA
|
57
|
1:15.1
|
|
Sub-Saharan Africa[c]
|
22
|
1:33.3
|
|
Central Africa
|
1
|
1:132
|
|
East Africa
|
12
|
1:12.4
|
|
The Horn
|
2
|
1:54.4
|
|
West Africa
|
5
|
1:63.7
|
|
Southern Africa[c]
|
2
|
1:50.5
|
|
Southern Africa + RSA
|
37
|
1:2.7
|
|
North Africa
|
56
|
1:1.8
|
Abbreviation: RSA, Republic of South Africa.
a Excluding Egypt and Sudan.
b Excluding Egypt, Sudan, and RSA.
c Excluding RSA.
A total of 933 CS in Africa were listed in the CTSNet registry, which translates into
one surgeon to 1.3 million people. CS to population ratio was three surgeons per 1
million for North Africa and one surgeon per 3.3 million for SSA ([Table 2]).
Table 2
A summary of cardiac surgery capacity in African regions in 2012
|
(A) Regional distribution of cardiothoracic surgeons and cardiothoracic surgeon to
population ratios (CTSNet registry)
|
|
Region
|
Cardiothoracic surgeons (CTSNet)
|
Cardiothoracic surgeons per million (CTSNet)
|
|
Africa
|
933
|
1:1.3
|
|
Sub-Saharan Africa
|
265
|
1:3.3
|
|
North Africa
|
668
|
3:1
|
|
(B) Regional distribution of cardiac centers, cardiac center to population ratios,
and cardiac surgeons with capability to perform open heart surgery
|
|
Regions
|
Cardiac centers
n, n per million
|
Cardiac surgeons with capability to perform open heart operation
n, n per million
|
|
Africa[a]
|
113, 1:8.5
|
206, 1:5
|
|
Africa[b]
|
78, 1:12.5
|
156, 1:5.9
|
|
Sub-Saharan Africa[c]
|
22, 1:33.3
|
57, 1:14.3
|
|
+ RSA
|
57, 1:15.1
|
107, 1:8
|
|
North Africa
|
56, 1:1.8
|
99, 1:1.1
|
|
(C) Regional distribution of open heart operations and open heart operations to population
ratios
|
|
Regions
|
Open heart operations
|
Open heart operations per million
|
|
Africa[a]
|
14,802
|
18.6:1
|
|
Africa[b]
|
10,725
|
11.8:1
|
|
Sub-Saharan Africa[c]
|
1,277
|
1.6:1
|
|
+ RSA (public sector)
|
4,077
|
4.7:1
|
|
North Africa
|
9,448
|
91.6:1
|
Abbreviations: CTSNet, Cardiothoracic Surgery Network; RSA, Republic of South Africa.
a Excluding Egypt and Sudan.
b Excluding Egypt, Sudan, and RSA.
c Excluding RSA.
Of the 668 CS in North Africa registered with the CTSNet, 510 originate from Egypt
and Sudan. The remaining 158 CSs are practicing in the Maghreb states (Algeria, Morocco,
and Tunisia) and Libya.
The number of CS in Africa registered with the CTSNet has increased from 1% of the
global population of CS to 2.7% (in figures: from 210 in 2002 to 933 in 2013) during
the past ([Figs. 1]
[2]
[3]
[4]) decade. About 67% of the CS are practicing general thoracic surgery or have no
capability to perform open heart surgery. In North Africa (Maghreb states and Libya),
36% are practicing general thoracic surgery ([Fig. 3]).
Fig. 1 Global distribution of cardiothoracic surgeons registered with the CTSNet, the Cardiothoracic
Surgery Network in April 2013 (n = 34,251).
Fig. 2 Global distribution of cardiothoracic surgeons registered with the CTSNet in 2002
(n = 210) and 2013 (n = 933). CTSNet, Cardiothoracic Surgery Network.
Fig. 3 Cardiothoracic surgeons (CSs) in North Africa registered with the CTSNet in 2013.
CS, n = 668. CSs with capability to perform open heart surgery (OHS): n = 99 (the Maghreb states: n = 90, Libya: n = 9). Data from Egypt and Sudan were not available (na).
Fig. 4 Regional distribution of cardiothoracic surgeons in sub-Saharan Africa registered
with the CTSNet in 2013 (n = 265). CTSNet, Cardiothoracic Surgery Network.
There were 156 CS (99 in North Africa and 57 in SSA) identified as having capability
to perform open heart surgery in Africa.
Cardiac surgeons in North Africa with capability to perform open heart surgery: In
North Africa, 99 CS were performing open heart operations ([Fig. 3]). CS to population ratio in the North African region was one surgeon per 1 million
people ([Table 2]). In the Maghreb states, it was one surgeon per 1.1 million people.
Cardiac surgeons in SSA with capability to perform open heart surgery: With the exclusion
of RSA, a nonparticipant country there remains 97 local CS from SSA registered with
the CTSNet ([Fig. 5]). Of these 97 CS, 32 had capability to perform regular open heart surgery ([Figs. 5] and [6], [Table 2]). An additional 25 expatriate cardiac surgeons were practicing with the local teams
in SSA. The 57 CS practicing in SSA were defined as mixed teams. Cardiac surgeon to
population ratio in SSA was 1:14.3 million for the mixed team and 1:25 million people
for local cardiac surgeons ([Fig. 7]).
Fig. 5 Cardiothoracic surgeons registered with the CTSNet in Africa in 2013. North Africa
(the Maghreb states): n = 142. Thoracic surgeons (TS): n = 52, cardiac surgeons (CS): n = 90. Sub-Saharan Africa excluding RSA: n = 97, TS: n = 65, CS: n = 32. CTSNet, Cardiothoracic Surgery Network; RSA, Republic of South Africa.
Fig. 6 Local cardiothoracic surgeons in sub-Saharan Africa listed in the CTSNet registry
(n = 97). Regional distribution of the local cardiothoracic surgeons with capability
(n = 32) and without capability (n = 65) to perform open heart surgery in sub-Saharan Africa excluding RSA*. CTSNet,
Cardiothoracic Surgery Network; RSA, Republic of South Africa.
Fig. 7 Population in million per cardiac surgeon. Africa: one cardiac surgeon per 5.9 million
people. Sub-Saharan Africa I (SSA I): one local cardiac surgeon per 25 million people,
sub-Saharan Africa II (SSA II): local and visiting cardiac surgeons (mixed teams).
One cardiac surgeon per 14.3 million people. North Africa: one cardiac surgeon per
1.1 million people. Distribution by regions: Central Africa 1:33 million, East Africa
1:5.1 million, The Horn 1:18.1 million, West Africa 1:26.5 million, Southern Africa
1:16.8 million. China: one cardiac surgeon per 0.208 million (208,333 people), Germany:
one cardiac surgeon per 0.087 million (87,723 people).
In 2012, 78 centers performed an estimated 10,725 open heart operations in Africa,
which translates into 11.8 open heart operations per million people in Africa. Twenty-two
centers in SSA and 56 in North Africa performed 1,277 and 9,448 open heart operations,
respectively ([Fig. 8], [Table 2]). In the Maghreb states, it was 110 open heart operations per million people.
Fig. 8 Regional distribution of open heart operations to population ratio in Africa, China,
and Germany in 2012.
Distribution of open heart operations by regions in SSA was as follows: Central Africa,
n = 255; East Africa, n = 362; The Horn, n = 81; West Africa, n = 377; and Southern Africa, n = 202 ([Figs. 8] and [9]). Most of the procedures (70%) were performed by the visiting teams.
Fig. 9 Distribution of open heart operations to population ratio by countries: (1) Tunisia,
(2) Morocco, (3) Algeria, (4) Libya, (5) Namibia, (6) Angola, (7)Eritrea, (8) Senegal,
(9) Côte d'Ivoire, (10) Rwanda, (11) Ghana, (12) Kenya, (13) Mozambique, (14) Tanzania,
(15) Uganda, (16) Ethiopia, and (17) Nigeria.
In East Africa (Kenya, Rwanda, Tanzania, Uganda), 29 CSs (19 locals and 10 expatriates)
performed open heart surgery on 362 patients in 2012. In the Horn (Eritrea, Ethiopia),
six surgeons operated on 81 patients in 2012. There were 12 open heart operations
per million in Eritrea ([Figs. 8] and [9]). In West Africa, 12 CSs (10 local and 2 expatriate surgeons) were serving a population
of 318.6 million and performed 377 open heart operations in 2012 ([Figs. 8] and [9]).
Central Africa has a population of 132 million and there was no local CS identified.
Four visiting cardiac surgeons were practicing in Angola, and performed 255 open heart
operations in 2012. This means a CS to population ratio in Central Africa of one per
33 million people ([Figs. 8] and [9]).
There were six CSs practicing in Southern Africa (excluding RSA). Of these, five visiting
cardiac surgeons were practicing in Mozambique and one local surgeon in Namibia. The
two institutions performed 202 open heart operations in 2012 in the region ([Figs. 8] and [9]).
RSA is a continental referral center with approximately 35 heart centers and 50 cardiac
surgeons performing approximately 2,800 open heart operations in the public and 5,480
in the private sector a year (data from Prof. Francis Smit, Bloemfontein, South Africa).
The estimated data of the public sector in SSA translate into a ratio of five open
heart operations per million, one cardiac surgeon per 8 million, and one center per
15 million people. Adding the figures for RSA distorts the data of SSA considerably;
their inclusion produces an overall ratio of 20 open heart operations per million
people in Africa as a whole.
On the basis of the data from China and Germany, CS-to-population ratio was one per
208,333 and one per 87,723 people, respectively. China performed 158 and Germany 1,038
open heart operations per million people ([Figs. 7] and [8]).
The most frequent cardiac procedure performed in 2012 in East Africa and The Horn
was congenital heart surgery followed by rheumatic heart valve surgery (10% repair
and 90% replacement) and coronary artery bypass surgery ([Fig. 10]). Among the congenital heart patients, 12% were adults. In the pediatric population,
the valve repair rate was 76%.
Fig. 10 Distribution of cardiovascular surgical procedures in East Africa and The Horn in
2012, n = 443. CABG, coronary artery bypass grafting.
Early (30-day) mortality: The overall mortality of the pediatric cases of the visiting
teams in SSA ranged from 2 to 4%.
The three models were used for developing cardiac programs in SSA. In Model 1 (Ghanaian–German,
Namibian), a senior local consultant CS with governmental and private foundation funding
developed national capacity building programs. Model 2 has been used in 21 centers.
Visiting teams are funded by NGOs and charged with local staff training. Model 3 is
used in Kenya. It is a modification of Model 1 where in the absence of an indigenous
senior local consultant CS with managerial talent, the senior CS is an expatriate
on contract.
Discussion
The study results represent the most comprehensive data till date on the current state
and practice of cardiac surgery in SSA. RSA is a total outlier vis-a-vis the rest
of SSA with respect to availability of cardiac surgery services. Inclusion of its
data would have distorted the data of SSA considerably and is not really relevant
to the main point of the publication.
Twenty-two centers in SSA performed 1,277 open heart operations in 2012 which translated
to 1.6 (approximately two operations) per 1 million people. Most of the centers offer
open heart surgery to pediatric patients in collaboration with foreign visiting teams
who come for 10 to 14 days with the exception of units in Ghana, Namibia, and RSA
which are operated independently by local staff.
The data published in this article proclaim an urgent need for long-term strategic
plans to train local surgeons and allied personnel at home and abroad for developing
existing cardiac programs. Currently, except in Ghana the accredited institutions
of the West African College of Surgeons in Liberia, Nigeria, Sierra Leone, and the
Gambia would need foreign support to facilitate cardiothoracic surgery training programs.[5]
[19] Cardiac and thoracic surgeries are regarded as one specialty; therefore, the College
facilitates combined training and certification. In order not to repeat the mistakes
made in the developed countries, catheter-based interventional procedures and echocardiography
courses should be part of the curriculum which will prepare trainees to be integrated
into a heart team working group. In East Africa, there is an accredited teaching hospital
for cardiothoracic surgery training only in Kenya. The median length of cardiothoracic
surgery training in West Africa is 6 years. West African residents obtain much less
hands-on experience compared with their European and American counterparts.[20] A young cardiothoracic surgeon in SSA therefore does not meet the requirements for
board certification in Europe and therefore might need to go elsewhere for additional
surgical skill training. This critical situation can be improved by developing close
collaboration with visiting teams in various African regions and encouraging them
to become involved in the cardiac surgery training programs. Unfortunately, the fellowship
programs in cardiothoracic surgery in India and RSA for trainees from SSA which began
with great enthusiasm and promise have lost their momentum and practical value and
need to be revisited on a governmental level. The flaw is attributed to lack of strategic
planning with the policy makers and bench marking of the training program.
In Africa, only 51.4% of the CS registered with the CTSNet performed open heart surgery
in 2012. In North Africa, it was 62.6% and in the SSA, it was 33%. The CS in SSA are
challenged with a high number of patients and late referrals requiring surgery for
congenital heart, rheumatic heart valve, and coronary artery diseases.[5]
[21]
[22]
[23]
[24]
The Ghanaian–German model has demonstrated that the determinant factor for sustainability
of a cardiac surgery program in SSA is leadership rather than the distribution of
health expenditure per capita income and the GDP. The density of the CSs could be
directly related to the distribution of GDP and the health budget, but it was not
a determinant factor for sustainability and success of the cardiac programs.[5]
[11]
In some regions, there is currently no substitute for visiting heart teams and this
is not likely to change in the near future. Aldo Castaneda properly defined the efficiency
of visiting heart teams: “It helps if an experienced ( ± senior/retired) surgeon
leads these efforts on a full time, pro bono basis.”[8] The model is similar to that initiated in 1989 by Frimpong-Boateng in Ghana under
the mentorship and sponsorship of Hans Borst and the former President of Ghana, Jerry
Rawlings.[5] This Ghanaian/German model has proved to be a successful program in the long term
and could inspire health care policy makers in SSA and senior colleagues planning
to establish cardiac programs in their home countries. Ghana cannot currently afford
a second independent cardiac center for its 25 million population for economic reasons
although it is urgently needed. It is therefore applying Model 2 to develop a second
center in Kumasi which is completely dependent on two visiting teams (adult and pediatric)
from United States. This model is being practiced in Kenya as well with a team from
the United Kingdom.
One solution to the acute shortage of cardiac surgical services in SSA is to engage
foreign teams to support the local teams to develop a program on a “twinning” basis.[25] Critics of humanitarian surgery emphasize the challenges facing the local teams
after departure of the visiting teams.[9]
[11] Late postoperative care has proved to be one of the biggest challenges because many
of the adult patients are taking warfarin for anticoagulation after receiving mechanical
heart valves. Financial constraints around clinic and hospital visits and admission
have prevented some patients from receiving appropriate care in a timely fashion,
again, most critically, in the vulnerable first few weeks after surgery. Alternative
biological valves should be considered in a selected group of patients in such situations.[26]
[27]
A long-term solution to this problem is to convince the ministers of health and education
to commit the deans of the national university medical schools to begin putting together
resources for more robust postoperative care, to include (1) training of nurses and
general practitioners in basic cardiology concepts and warfarin management, (2) echocardiography
courses for personnel from provincial and district hospitals where cardiac patients
are being seen, to improve cardiac care in the country. The Berlin initiative of monthly
international video clinical conferences with African countries which are practicing
cardiac surgery can strengthen the networking and collaboration in continuing education
with centers in Africa.
The data provided in [Figs. 6]
[7]
[8] demonstrate the great difference in cardiac surgery services between the emerging,
developed and developing economies.[17] The figures from the Maghreb countries in North Africa (Algeria, Morocco, and Tunisia)
could inspire the policy makers and the colleagues in SSA to target at least 92 to
110 open heart operations per million in the future. Nigeria has a population of 168.8
million and if it completes the reactivation of its five to seven existing centers
in the next 10 years, West Africa will possess 12 centers to serve the region of 318.4
million. Ghana and Nigeria could aim at performing 30% of the projected 2,500 and
17,000 open heart operations per annum in the next decade, respectively. Kenya could
aim at performing 30% of the projected 4,400 open heart operations per annum. The
cardiac team in Eritrea could plan for 500 open heart operations a year in the Horn
region in the next decade. The 12 centers in East Africa (Kenya, Rwanda, Tanzania,
Uganda), the two centers in the Horn (Eritrea, Ethiopia), and the two other centers
in Southern Africa (Mozambique, Namibia) could aim at performing 30 to 50 open heart
operations per million in the next two decades.
Limitations of the Study
Patients' demographics were not available. The high-volume centers in Egypt and Sudan
which perform more than 1,000 to 1,500 cases each per year did not participate in
the study. The data presented in the study contain no late clinical results.
Conclusion
Cardiothoracic health care delivery would worsen in certain regions in SSA without
the support of humanitarian teams. The Ghanaian/German model has proved to be a successful
program in the long term and could inspire health care policy makers in SSA and senior
colleagues planning to establish cardiac programs in Africa.
Strategic plans for training programs in high-volume centers are critical to populate
SSA with adequate CS in the next three decades with international support.
The programs should aim at developing a database to support clinical research and
educational programs. An endowment of a heart foundation to supplement the government's
budget for maintaining the infrastructure of the program is the driving force for
sustainability of the cardiac program.
A sustainable cardiac program demands highest level governmental support, leadership,
and a dedicated multidisciplinary team with profound know-how.
The length of time for cardiac missions should be extended to 21 days and this is
desirable to integrate a special “task force” for postoperative management and skill
training programs.
