Global Cardiac Surgery: Access & Disparities

Vervoort et al
Miscellaneous
Global cardiac surgery: Access to cardiac surgical care
around the world
Dominique Vervoort, MD,a Bart Meuris, MD, PhD,b Bart Meyns, MD, PhD,b and
Peter Verbrugghe, MD, PhDb
ABSTRACT
Methods: A scoping review was done on access to cardiac surgery for an undifferentiated population. Workforce data were collected from the Cardiothoracic
Surgery Network database and used to calculate numbers and ratios of adult
and pediatric cardiac surgeons to population.
Results: A total of 12,180 adult cardiac surgeons and 3858 pediatric cardiac surgeons were listed in the Cardiothoracic Surgery Network in August 2017,
equaling 1.64 (0-181.82) adult cardiac surgeons and 0.52 (0-25.97) pediatric cardiac surgeons per million population globally. Large disparities existed between
regions, ranging from 0.12 adult cardiac surgeons and 0.08 pediatric cardiac surgeons per million population (sub-Saharan Africa) to 11.12 adult cardiac surgeons
and 2.08 pediatric cardiac surgeons (North America). Low-income countries
possessed 0.04 adult cardiac surgeons and 0.03 pediatric cardiac surgeons per
million population, compared with 7.15 adult cardiac surgeons and 1.67 pediatric
cardiac surgeons in high-income countries.
Conclusions: This study maps the current global state of access to cardiac surgery. Disparities exist between and within world regions, with a positive correlation between a nation’s economic status and access to cardiac surgery. Low early
mortality rates in low-resource settings suggest the possibility of high-quality cardiac surgery in low- and middle-income countries. There is the need to increase
human and physical resources, while focusing on safety, quality, and efficiency
to improve access to cardiac surgery for the 4.5 billion people without. (J Thorac
Cardiovasc Surg 2019;-:1-10)
Cardiovascular disease (CVD) is the leading cause of death
in the world, accounting for approximately 17.5 million
deaths worldwide every year, of which 80% occur in lowand middle-income countries.1 This burden is increasing
because of the epidemiologic transition from
From the aProgram in Global Surgery and Social Change, Harvard Medical School,
Boston, Mass; and bDepartment of Cardiac Surgery, UZ Leuven, Leuven, Belgium.
Received for publication Nov 11, 2018; revisions received April 2, 2019; accepted for
publication April 10, 2019.
Address for reprints: Dominique Vervoort, MD, Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, 02115 Boston, MA
(E-mail: [email protected]).
0022-5223/$36.00
Copyright Ó 2019 by The American Association for Thoracic Surgery
https://doi.org/10.1016/j.jtcvs.2019.04.039
Cardiac surgeon density worldwide exacerbates disparities in access to cardiac surgery.
Central Message
Some 4.5 billion people lack access to cardiac
surgery when needed. Availability of adult
and pediatric cardiac surgical workforce is
scarce in low- and middle-income countries,
and disparities are widespread.
MIS
Objective: Cardiovascular disease is the leading cause of death worldwide,
responsible for 17.5 million deaths every year, of which 80% occur in low- and
middle-income countries. Some 75% of the world does not have access to cardiac
surgery when needed because of lack of infrastructure, human resources, and
financial coverage. This study aims to map access to cardiac surgery around the
world.
Perspective
Global cardiac surgery addresses the lack of
cardiac surgical care for the majority of the
world. CVDs remain the leading cause of mortality globally, with surgical conditions such as
rheumatic and congenital heart disease significant in low- and middle-income countries.
Knowing the availability of specialist cardiac
surgical workforce allows for targeted policy
interventions.
See Commentary on page XXX.
communicable to noncommunicable diseases in low- and
middle-income countries, with CVD and stroke mortality
increasing rapidly. Despite the high prevalence of CVD in
low- and middle-income countries, exact, high-quality
data and imaging are scarce, thus potentially underestimating the true global state.
Scanning this QR code will
take you to the article title
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information.
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Miscellaneous
Abbreviations and Acronyms
CTSNet ¼ Cardiothoracic Surgery Network
CVD ¼ cardiovascular disease
DALY ¼ disability-adjusted life-year
GDP
¼ gross domestic product
NGO ¼ nongovernmental organization
RHD ¼ rheumatic heart disease
MIS
Surgery has recently been recognized as an integral part
of national health systems, yet approximately 5 billion people remain without timely access to safe and affordable surgical care when needed.2 More than 17 million people die of
surgically preventable conditions every year, and only 6%
of the 313 million surgical interventions taking place every
year occurs in the poorest one-third of the world’s population, in whom the need for surgical care is highest. Unlike
previous misconceptions about the costs of investing in surgical systems, emergency and essential surgical services are
cost-effective on an individual and macro-economic level.2
Global cardiac surgery can be defined as an area for
study, research, practice, and advocacy that places priority
on improving health outcomes and achieving health equity
for all people worldwide who are affected by cardiac surgical conditions or have the need for cardiac surgical care.3 In
sub-Saharan Africa, excluding South Africa, there is only 1
cardiac surgery center per 38 million inhabitants.4 In Asia,
there is only 1 per 25 million. In contrast, North America
and Europe have 1 per 120,000 people.5 For cardiothoracic
surgeons, a similar maldistribution follows gross domestic
product (GDP) differences: With 27 and 28 cardiothoracic
surgeons per million population, North America and Western Europe have 42% and 32% of the world’s capacity,
respectively. Africa, with only 1 cardiothoracic surgeon
per 4 million population, accounts for only 1% of the total
global capacity.6 On a population level, ready access to
cardiothoracic surgery is proportional to the economic status of the patient. As a result, approximately 4.5 billion people do not have access to cardiac surgery.7
In low- to middle-income countries, rheumatic heart disease (RHD) and congenital heart disease are the most common CVDs requiring surgical care. RHD affects 33.4
million people worldwide, yet 97% occurs in low- and
middle-income countries and indigenous populations in
high-income countries.8 In low-income countries, only
11% of patients undergo operation, underlining the fact
that RHD is a disease of social injustice.9 Recently, the
Cape Town Declaration on Access to Cardiac Surgery in
the Developing World was released as an attempt to unite
all stakeholders to tackle the global burden of RHD.10
Meanwhile, congenital heart disease affects 1 million babies or 1 in 125 live births per year, of which approximately
2
Vervoort et al
70% will require medical or surgical treatment in the first
year of life.11 Some 90% are denied treatment or receive
suboptimal care, and up to 80% of cases are not diagnosed
until advanced or irreversible stages of heart failure.12 With
treatment, 85% of cases are expected to survive to adult
life. Without treatment, 1 in 3 babies will die within their
first month.13 The remaining patients are faced with multiple complications, including frequent pulmonary infections, bacterial endocarditis, irreversible pulmonary
changes, myocardial fibrosis, neurologic events, increased
operative risks, and an impaired functional status. In lowto middle-income countries, 66% of preventable deaths
and 58% of disability-adjusted life-years (DALYs) due to
congenital malformations are related to congenital heart defects, which could be averted by scaling up surgical care.14
In sub-Saharan Africa, CVD is responsible for 45 per 1000
DALYs, compared with 15 per 1000 for trauma.15,16
Although the cost-effectiveness of cardiac surgical care in
low- and middle-income countries has not been studied
widely, a recent cost-effectiveness analysis has proposed
favorable cost-effectiveness of pediatric cardiac surgery in
low- and middle-income countries ($171 per DALY
averted) compared with other surgical (eg, trauma centers:
$100-300 per DALY averted) and public health interventions (eg, antiretroviral therapy for human immunodeficiency virus: $800-1000 per DALY averted).17,18
Overall, the pediatric population in low- and middleincome countries has a higher incidence and prevalence
of cardiac diseases requiring surgical care than children in
industrialized countries.19 Developed countries are estimated to require 1 cardiac center performing 300 to 500 pediatric cardiac surgeries per year per 2 million population,
whereas low- and middle-income countries are estimated
to require 1 per 1 million population, although the exact
need is still unknown.19 Nevertheless, many countries
with populations up to 70 million people still remain
without a single pediatric cardiac center. As a result, an estimated 15 million children die or become debilitated annually by potentially treatable or preventable cardiac
diseases.19 With 47% of the population in sub-Saharan Africa being younger than 15 years old, global upscaling of
pediatric cardiac surgery is highly needed.
This study attempts to map the current global cardiac surgery capacity, to support health system strengthening, and
to establish a framework to develop sustainable programs
to scale up access to cardiac surgery on a global level.
MATERIALS AND METHODS
Literature Search
A scoping review was done to identify quantitative data and descriptive
studies on access to cardiac surgical care with a focus on cardiac surgical
workforce, infrastructure, capacity, and quality. Literature searches were
performed between August 1, 2018, and October 1, 2018, in the medical
database PubMed using the search string below to identify articles
describing the state of and disparities in accessing cardiac surgical care
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Search String
The search string was as follows: ("Cardiac Surgical Procedures"[mh]
OR "cardiac surgery"[tiab] OR "cardiothoracic surgery"[tiab] OR "heart
surgery"[tiab] OR "interventional cardiology"[tiab] OR "interventional
cardiology"[mh]) AND ("humanitarian"[tiab] OR "low-income"[tiab] OR
"low income"[tiab] OR "middle-income"[tiab] OR "middle income"[tiab]
OR "developing country"[tiab] OR "developing countries"[tiab] OR
"developing nation"[tiab] OR "developing nations"[tiab] OR "developing
world"[tiab] OR "Africa"[tiab] OR "Africa"[mh] OR "developing countries"[mh] OR "relief work"[mh] OR "global health"[mh]) NOT
(Comment[ptyp] OR Editorial[ptyp] OR Letter[ptyp] OR Case Reports
[ptyp] OR News[ptyp]).
Data
Identification
Countries are stratified as defined by the World Bank regions: East Asia
and Pacific, Europe and Central Asia, Latin America and the Caribbean,
Middle East and North Africa, North America, South Asia, and subSaharan Africa. On the basis of the World Bank income groups, countries
are further divided in low-, middle-, and high-income countries.
Records identified through
database searching
(n = 903)
Numbers of adult and pediatric cardiac surgeons per country were independently obtained from the registry of the Cardiothoracic Surgery
Network (CTSNet, http://www.ctsnet.org) in August 2017 and checked
for duplicates. The CTSNet database is overseen by the Society of Thoracic
Surgeons, the American Association for Thoracic Surgery, and the European Association for Cardio-Thoracic Surgery and includes the membership registries of 29 cardiothoracic surgical societies from around the
world. Cardiac surgeons not affiliated with these societies are invited,
but not obliged, to join CTSNet independently. Pediatric cardiac surgeons
were also registered as adult cardiac surgeons in the database, but no information on caseload or operative focus was available. The collected data
were used to calculate numbers and ratios of adult and pediatric cardiac surgeons to population. Although available data did not provide details on surgeons practicing abroad, they demonstrate approximate densities of cardiac
surgeons around the world. Pure thoracic or vascular surgeons registered
with CTSNet and cardiac surgeons who were indicated to have retired
were excluded. A sample of the data from low-, middle-, and highincome countries was validated against external data, including a subset
analysis for English-speaking versus non–English-speaking countries
(Appendix E1).
RESULTS
Literature Search
Of the 903 identified articles, 15 were included in the
study (Figure 1). The main findings are summarized in the
Table E1.
Additional records identified
through other sources
(n = 2)
Eligibility
Records screened
(n = 896)
Full-text articles assessed
for eligibility
(n = 34)
Included
Screening
Records after duplicates removed
(n = 896)
Studies included in
qualitative synthesis
(n = 15)
Records excluded
(n = 862)
Full-text articles excluded,
with reasons
(n = 19)
(Personal and regional
perspectives n = 19,
editorial n = 4, letter n = 1)
FIGURE 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
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in low- and middle-income countries. There were no restrictions to language or publication status. Commentaries, editorials, letters, and case reports were excluded. Articles describing novel procedures, outcomes,
personal experiences, or perspectives; articles that are not related to cardiac
surgery or interventional cardiology; and articles more than 20 years old
(published before 1998) were excluded.
Miscellaneous
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Adult Cardiac Surgeons
A total of 12,180 adult cardiac surgeons were listed in the
CTSNet registry, which translates to 1 adult cardiac surgeons per 0.61 million people globally, or, conversely,
1.64 adult cardiac surgeons per million people (Figure 2).
Regional distribution ranged from 11.12 adult cardiac surgeons per million population (32.82% of total) in North
America to 0.12 adult cardiac surgeons per million
(1.05% of total) in sub-Saharan Africa (Figure 3). Furthermore, large disparities were found within regions. In subSaharan Africa, no cardiac surgeon in the Democratic
Republic of the Congo and Ethiopia was registered for a
population of 78.7 million and 102.4 million people, respectively. The other regional spectrum was South Africa, with
58 adult cardiac surgeons for a population of 55.9 million
people, or 1.04 adult cardiac surgeons per million population. In contrast, the United States had 11.54 adult cardiac
surgeons per million, whereas the highest density was found
in Monaco, with 181.82 adult cardiac surgeons per million
(7 adult cardiac surgeons covering 38,500).
Similar disparities existed when dividing countries per
income group (Figure 3). Low-income countries possessed
0.04 adult cardiac surgeons per million population,
compared with 7.15 adult cardiac surgeons per million people in high-income countries. Regional distribution of adult
cardiac surgeons was correlated with GDP per capita, with
sub-Saharan Africa ($1450 GDP per capita) on the lower
end of the spectrum, and North America ($55,928 GDP
per capita) on the higher end of the spectrum (Figure 4).
Vervoort et al
Pediatric Cardiac Surgeons
A total of 3858 pediatric cardiac surgeons were registered
in the CTSNet database, equaling 0.52 pediatric cardiac surgeons per million population (Figure 5). Disparities in distribution of pediatric cardiac surgeons were similar to those
for adult cardiac surgeons, ranging from a minimum of 0.08
pediatric cardiac surgeons per million population (2.20% of
total) in sub-Saharan Africa to 2.08 pediatric cardiac surgeons per million (19.37% of total) in North America. On
a country level, registered numbers varied from no pediatric
cardiac surgeons in Ethiopia (102.4 million people) and the
Democratic Republic of the Congo (78.7 million people) to
2.12 per million population in the United States and the
United Kingdom, with Monaco (1 pediatric cardiac surgeons for 38,500 people, or 25.97 per million) at the higher
end of the spectrum. Based on income groups, distribution
ranged from 0.071 pediatric cardiac surgeons per million
in low-income countries up to 9.505 pediatric cardiac surgeons per million in high-income countries (Figure 3).
Similar to adult cardiac surgeons, lower and upper
middle-income countries did not significantly differ from
each other in the numbers of pediatric cardiac surgeons
per population. Regional distribution of pediatric cardiac
surgeons was also correlated with GDP per capita
(Figure 4).
When adjusting for the pediatric (<15 years old) population, there were 1.99 pediatric cardiac surgeons per million
population. Sub-Saharan Africa and South Asia possessed
0.19 and 1.16 pediatric cardiac surgeons per million
FIGURE 2. Adult cardiac surgeons per million population registered with the CTSNet in August 2017 (n ¼ 12,180). Map created at www.mapchart.net.
CTSNet, Cardiothoracic Surgery Network.
4
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Miscellaneous
8
7
6
5
4
3
2
1
0
Lower
Middle-Income
Countries
Upper
Middle-Income
Countries
ACS
High-Income
Countries
PCS
FIGURE 3. Adult and pediatric cardiac surgeons per million population for the different World Bank Income Groups registered with the CTSNet in 2017.
ACS, Adult cardiac surgeon; PCS, pediatric cardiac surgeon.
population, respectively, compared with 11.1 and 6.28 pediatric cardiac surgeons per million population in North
America and Europe and Central Asia. Disparities of pediatric cardiac surgeons distribution between regions are
more apparent when adjusting for pediatric population,
with a difference in density of pediatric cardiac surgeons
per million population of factor 25.3 between North
America and sub-Saharan Africa, running up to a difference
factor of 57.9 between North America and sub-Saharan Africa for pediatric cardiac surgeons per million population
aged less than 15 years. These differences can be due to
higher relative pediatric populations in sub-Saharan Africa
(42.88% of total population) compared with North America
(18.72% of total population).
100000
10000
1000
100
10
1
0.1
Sub-Saharan
Africa
South Asia
Middle East & Latin America &
Caribbean
North Africa
East Asia &
Pacific
Europe &
Central Asia
North America
0.01
GDP per capita (in USD)
Adult cardiac surgeons per million population
Pediatric cardiac surgeons per million population
FIGURE 4. Regional correlation between GDP per capita and distribution of adult and pediatric cardiac surgeons registered with the CTSNet in 2017.
GDP, Gross domestic product.
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Low-Income
Countries
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FIGURE 5. Pediatric cardiac surgeons per million population registered with the CTSNet in August 2017 (n ¼ 3858). Map created at www.mapchart.net.
CTSNet, Cardiothoracic Surgery Network.
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Data validation highlighted valid data for the majority of
sampled countries not covered by societies participating in
CTSNet. Data validity was comparable across countries
from different income groups and countries with official
languages other than English (Appendix E1).
Cardiac Centers
Several low- and middle-income countries have established cardiac surgical centers of excellence for their country or region in an attempt to effectively centralize the
scarcely available resources. These dedicated centers of
excellence form centralized hubs providing clinical,
educational, research, and administrative support to local
cardiac centers in their respective regions, as well as direct
domestic and foreign patient care. In the Asian region, centers of excellence exist in Malaysia, Singapore, South Korea, Japan, Australia, and New Zealand, supporting
neighboring and nearby countries lacking (complex) cardiac surgical care. If restarted, Ghana (5 centers) and
Nigeria (7 centers) could provide West Africa with 12 centers covering a population of 376.3 million people.4 Likewise, in the next 20 years, the 12 centers in East Africa
(Kenya, Rwanda, Tanzania, and Uganda), 2 centers in
Southern Africa (Mozambique, Namibia), and 2 centers
in Eritrea and Ethiopia could aim at performing at least
30 open surgeries per million people.4 However, disparities may exist within countries. For example, the availability of cardiac surgical care in China is particularly
prominent in the East of the country (eg, Beijing and
Shanghai), whereas availability thereof in the West is
scarce.20 Likewise, many countries only have centers in
6
the capital, limiting access to care for patients living far
away.21
DISCUSSION
Global surgery is a relatively new field, and subspecialization with a focus on specific surgical subdisciplines is
limited. This study is a comprehensive review of the global
state of access to cardiac surgery. Tables 1 and 2 provide a
summary of the current state and ways forward for cardiac
surgery in low- and lower middle-income, upper middleincome, and high-income countries.
CVDs have a 32% chance of requiring a surgical intervention in low- and middle-income countries.22 However,
93% of the population in low- and middle-income countries
do not have access to cardiac surgery, leaving approximately 2.5 million people in need of cardiac surgery untreated. Although costs for cardiac surgery are lower in
low- and middle-income countries, open surgery is relatively expensive as GDP per capita income is low compared
with high-income countries.23 Generally, low- and middleincome countries do not possess universal health coverage
packages, and thus rely on sponsoring or out-of-pocket payments. If open surgery is not performed in that country,
costs are even higher, requiring surgery abroad. In the Pacific region, island nations spend between 4% and 12%
of their total health budget on sending patients with RHD
to other countries for the needed surgery.24 Patients without
health insurance have to find alternate sources of financing
to meet surgical costs, including borrowing from friends
and relatives, and pledging or selling assets such as their
property.25
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Miscellaneous
Income group
Burden of cardiac disease
Workforce
Infrastructure and medicines
Access to care
Low- and lower
middle-income
countries
High burden of RHD
Unmet burden of
CHD, CMP, EMF
Growing burden of IHD
(epidemiologic
transition)
Low density or absence of
cardiac surgeons and
anesthesiologists
No or few cardiac surgery
residency and fellowship
programs
Shortages of ancillary staff
Low numbers or complete
absence of cardiac centers
Frequent stockouts of essential
medicines and
anticoagulation
Lack of (functional) equipment
(eg, electrocardiograph)
Limited or no health insurance
coverage for cardiac surgery
Long waiting lists where
cardiac centers exist
High relative costs for patient, if
surgery performed
Upper
middle-income
countries
Lower, rural or
poverty-linked burden
of RHD
Lower unmet burden
of CHD, CMP
Growing burden of IHD
(epidemiologic
transition)
Low density of cardiac surgeons
and anesthesiologists
No or few cardiac surgery
residency and fellowship
programs
Shortages of ancillary staff
Inadequate numbers and
distribution of cardiac centers
Few stockouts of essential
medicines and
anticoagulation
Limited (functional) equipment
(eg, CT scan)
Public (universal) or private
health insurance coverage for
cardiac surgery
Long waiting lists
High relative costs for patient, if
surgery performed
High-income
countries
Absence of RHD
Met burden of
CHD, CMP
High burden of
IHD
Adequate numbers of cardiac
surgical workforce
Adequate numbers of cardiac
surgery residency and
fellowship programs
Adequate numbers and
distribution of cardiac centers
Availability of essential
medicines and
anticoagulation
Adequate availability of
functional equipment
Public (universal) or private
health insurance coverage for
cardiac surgery
Short to medium waiting lists
Low or high relative costs for
patient
RHD, Rheumatic heart disease; CHD, congenital heart disease; CMP, cardiomyopathy; EMF, endomyocardial fibrosis; IHD, ischemic heart disease; CT, computed tomography.
In most countries, healthcare expenditure, including the
growth of cardiac surgery, parallels GDP. High-income
countries spend an average of 11.8% of GDP on health,
compared with just 5.8% of GDP in low- and middleincome countries, severely restricting health services to
essential priorities in those countries.26 Despite lacking sufficient access to cardiac surgery services, delivery thereof
has proven to be as effective and efficient as high-income
countries. For example, the Narayana Hrudayalaya Heart
Hospital in India provides cost-effective and high-quality
cardiac surgical care in India, including in areas without established programs.27 Early mortality of pediatric cases
operated on by visiting teams in sub-Saharan Africa ranged
from 2% to 4%.4 Outcomes in Samoa, Fiji, Pakistan,
Cambodia, and Mozambique further show that early mortality rates after open surgery in low-resource settings can
be low and comparable to outcomes in the rest of the world,
suggesting the possibility of performing high-quality cardiac surgery in low- and middle-income countries.24,28,29
In an attempt to bridge the gap in existing fragile health
systems, humanitarian efforts have led 77 nongovernmental
organizations (NGOs) to develop cardiac surgical programs
in low- and middle-income countries.30 These programs
range from overseas treatment to fly-in fly-out missions.
However, no comprehensive quality control or impact
assessment is in place to evaluate the benefit or harm introduced by surgical NGOs. It is important to recognize that
some fly-in fly-out organizations may not take into account
the postoperative care of patients, leaving a setting after
operating without knowledge of follow-up care or availability and monitoring of anticoagulation. We propose the
adoption of capacity-building programs for local care teams
and the establishment of sustainable preoperative and postoperative frameworks to enable timely, quality, and holistic
cardiac care.
NGOs increasingly collaborate with each other, whereas
the European Union reaches out to Eastern Europe and
former colonies.31 Likewise, China, India, Mexico, Brazil,
and Russia have developed satellite programs in rural areas,
ensuring widespread upscaling around the world.5 Maghreb
countries have taken the lead in open surgery in the African
region, which could inspire sub-Saharan African countries
to follow the example.4 Twinning programs pair 2 cardiac
programs in the world, an established center of excellence
and an evolving program, to teach cardiac surgery locally.31
As a result, Mozambique, Sudan, and Ethiopia have seen
open surgery introduced through collaborative programs
between local institutions and NGOs from Europe and
North America.
We mapped existing disparities between and within
regions with regard to cardiac surgeons based on data available by CTSNet. Relative shortages are highest in subSaharan Africa, with 0.12 adult cardiac surgeons per
million population and 0.19 pediatric cardiac surgeons per
million pediatric population. In comparison, North America
possesses 11.12 adult cardiac surgeons per million
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TABLE 1. Current state of the provision of cardiac surgical care in low-, lower middle-, upper middle-, and high-income countries
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TABLE 2. Proposed way forward for low-, lower middle-, upper middle-, and high-income countries in the provision of cardiac surgical care
Infrastructure and
medicines
MIS
Income group
Burden of cardiac disease
Workforce
Access to care
Low- and lower
middle-income
countries
Increased surveillance of
rheumatic fever, RHD,
CHD, and other cardiac
diseases
Introduce public campaigns
and patient counseling to
empower lifestyle changes
to reduce IHD
Expand South-South
partnerships
Regulate task-sharing for
nonsurgical care (eg, nurse
anesthetist)
Establish or increase national
or regional cardiac surgery
residency and fellowship
programs
Train ancillary health staff
Establish fewer, but highvolume cardiac centers
Establish public-private
partnerships
Regulate and standardize
cardiac surgical supply
chain
Establish or expand public
insurance schemes
Increase government spending
on health
Introduce economies of scale
Upper
middle-income
countries
Increased surveillance of
rheumatic fever, RHD,
CHD, and other cardiac
diseases
Introduce public campaigns
and patient counseling to
empower lifestyle changes
to reduce IHD
Expand South-South
partnerships
Regulate task-sharing for
nonsurgical care (eg, nurse
anesthetist)
Establish or increase national
or regional cardiac surgery
residency and fellowship
programs
Train ancillary health staff
Strengthen existing cardiac
centers to become highvolume centers of
excellence
Establish public-private
partnerships
Regulate and standardize
cardiac surgical supply
chain
Establish or expand public
insurance schemes
Increase government spending
on health
Introduce economies of scale
High-income
countries
Introduce public campaigns
and patient counseling to
empower lifestyle changes
to reduce IHD
Expand North-South
partnerships
Establish team training
programs for cardiac
surgery teams from low- and
lower middle-income
countries
Regulate quality of
procurement of functional
cardiac surgical equipment
and consumables
Increase developmental aid
Introduce economies of scale
RHD, Rheumatic heart disease; CHD, congenital heart disease; IHD, ischemic heart disease.
population and 11.1 pediatric cardiac surgeons per million
pediatric population. Disparities are even clearer when
comparing World Bank income groups. Low-income countries possess 0.04 adult cardiac surgeons per million population and 0.07 pediatric cardiac surgeons per million
pediatric population, compared with 7.15 adult cardiac surgeons per million population and 9.51 pediatric cardiac surgeons per million pediatric population in high-income
countries. Because of the complexity of interventions, cardiac surgeons are concentrated in large urban areas, limiting
available services for rural populations.
However, it is important to recognize that mere availability of cardiac surgeons does not necessarily translate to access to cardiac surgery. Adequate preoperative (eg,
imaging, laboratory services, cardiology, general medical
care), intraoperative (eg, blood banking, cardiopulmonary
bypass equipment, perfusionists, technicians), and postoperative services (eg, intensive care unit, follow-up cardiology services, anticoagulation) are essential to facilitate
true access. Central to the human resources crisis underlying cardiac surgical care, the need arises for high-volume
and high-quality training facilities adapted to local needs.
Budding centers and visiting surgeons have to be fully
8
capable of handling, among others, the higher prevalence
of endomyocardial fibrosis in equatorial African countries,
the widespread prevalence of RHD, conditions with more
advanced disease processes due to delayed diagnosis or access to care, and the use of materials that are low cost and
easily accessible, which are notable challenges in lowand middle-income countries. Accordingly, the establishment of centers of excellence and training centers should
include a focus on training of surgeons and supporting staff
on the management of the regionally prevalent and growing
cardiac disease burden.
Increasing cardiac surgical workforce in low- and
middle-income countries without parallel increase in financial risk protection (ie, health insurance coverage) will have
limited effects on access. The high costs for patients to pay
for the procedure (direct costs) and indirect costs related to
the visit to the hospital (eg, transportation and food costs)
further limit access to care through imposed catastrophic
expenditure for patients and their families.32 Traditionally,
cardiac surgery has been perceived as a high-cost luxury
lacking priority in low- and middle-income countries.
Nevertheless, although cost-effectiveness analyses on cardiac surgery are scarce in low- and middle-income
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Miscellaneous
Study Limitations
Data presented in this article have important limitations.
The database of the CTSNet was not fully up-to-date with
some errors in country allocation and thus only provides
an estimate of the exact number of cardiac surgeons in
each country. The CTSNet database combines databases
of regional cardiac societies, in addition to voluntary participation by professionals not registered with other societies.
Because of less accurate registration of surgeons in low- and
middle-income countries (eg, Papua New Guinea) and
countries where the English language is not widespread
(eg, Japan), these numbers were particularly underestimated. Unregistered surgeons may exist and operate
through alternative circuits. For example, CTSNet did not
register any cardiac surgeon in the Democratic Republic
of Congo and Ethiopia, even though cardiac centers exist
in Kinshasa and Addis Ababa, respectively. A follow-up
study aims to include a worldwide survey among registered
surgeons to assess current and recent work commitment to
further specify availability of cardiac surgery. Moreover,
surgeons registered as pure thoracic surgeons and general
surgeons should be inquired about the number of cardiac interventions they perform in areas lacking pure cardiac surgeons. Last, because of the lack of a database and available
literature for the number of interventional cardiologists and
surgical and minimally invasive interventions, the establishment of global inclusive databases is warranted.
CONCLUSIONS
This is a comprehensive study mapping the global state of
access to cardiac surgery. Disparities in distribution of cardiac surgical workforce and availability of open surgery
exist between and within world regions. The establishment
of centralized, high-volume centers providing high-quality
training programs adapted to local needs is essential to
populate low- and middle-income countries with adequate
numbers of skilled native cardiac surgeons and other cardiac surgical workforce in the next decades. International
support from international bodies and NGOs is critical to
create a sustainable framework supporting clinical research
and educational programs contextualized within existing
socioeconomic and political systems. There is the need to
increase human and physical resources, while focusing on
safety, quality, and efficiency to improve access to cardiac
surgery for the 4.5 billion people without.
Conflict of Interest Statement
B.M. is a consultant for Edwards and LivaNova. All other
authors have nothing to disclose with regard to commercial
support.
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systems strengthening within wider surgical and health
systems strengthening through National Surgical,
Obstetric, and Anesthesia Plans, strategic and
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Altogether, scaling cardiac services support and rely on
efforts toward universal health coverage.
Miscellaneous
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et al. Economic analysis of children’s surgical care in low- and
middle-income countries: a systematic review and analysis. PLoS One.
2016;11:e0165480.
Key Words: global health, health policy, education
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10
The Journal of Thoracic and Cardiovascular Surgery c - 2019
Miscellaneous
APPENDIX E1. SUPPLEMENTAL VALIDATION
Supplemental Document: Cardiothoracic Surgery
Network Data Validation
Validation of data obtained on the number of cardiac surgeons registered with the CTSNet database was done for a
sample of countries whose national societies are not participating organizations of CTSNet (and thus not automatically
register with CTSNet), using data from Fellow registries,
national and regional public databases, national health reports, and academic literature. Sample low-, middle-, and
high-income countries were validated. A subset analysis
of English-speaking and non–English-speaking countries
was performed.
Low-Income Countries
Ethiopia
COSECSA Member/Fellow DirectoryE1: 8 cardiothoracic surgeons
CTSNet database: 0 cardiac surgeons, 0 thoracic surgeons (0 total)
Mozambique
COSECSA Member/Fellow DirectoryE1: 1 cardiothoracic surgeon
CTSNet database: 0 cardiac surgeons, 1 thoracic surgeon
(1 total)
Nepal
Hosain and colleaguesE2: 15 cardiac surgeons
CTSNet database: 16 cardiac surgeons
Tanzania
COSECSA Member/Fellow DirectoryE1: 5 cardiothoracic surgeons
CTSNet database: 3 cardiac surgeons, 2 of which
thoracic surgeons (3 total)
Uganda
COSECSA Member/Fellow DirectoryE1: 3 cardiothoracic surgeons
CTSNet database: 2 cardiac surgeons, 2 thoracic surgeons (2 total)
Zimbabwe
COSECSA Member/Fellow DirectoryE1: 2 cardiothoracic surgeons
CTSNet database: 2 cardiac surgeons, 1 thoracic surgeon
(3 total)
Middle-Income Countries
Bolivia
Sandoval and colleaguesE3: 6 pediatric cardiac surgeons
CTSNet database: 6 pediatric cardiac surgeons
Colombia
Sandoval and colleaguesE3: 24 pediatric cardiac surgeons
CTSNet database: 23 pediatric cardiac surgeons
Ghana
Edwin and colleaguesE4: 6 cardiothoracic surgeons
CTSNet database: 5 cardiac surgeons, 5 thoracic surgeons (6 total)
Kenya
COSECSA Member/Fellow DirectoryE1: 5 cardiothoracic surgeons
CTSNet database: 5 cardiac surgeons, 5 thoracic surgeons (5 total)
Nigeria
Ekure and colleaguesE5: 31 cardiac surgeons
CTSNet database: 29 cardiac surgeons
Pakistan
Hosain and colleaguesE2: 140 cardiac surgeons
CTSNet database: 84 cardiac surgeons
Paraguay
Sandoval and colleaguesE3: 5 pediatric cardiac surgeons
CTSNet database: 3 pediatric cardiac surgeons
Peru
Sandoval and colleaguesE3: 8 pediatric cardiac surgeons
CTSNet database: 13 pediatric cardiac surgeons
Sri Lanka
Hosain and colleaguesE2: 24 cardiac surgeons
CTSNet database: 19 cardiac surgeons
Zambia
COSECSA Member/Fellow DirectoryE1: 0 cardiothoracic surgeons
CTSNet database: 0 cardiac surgeons, 0 thoracic surgeons (0 total)
High-Income Countries
Canada
Royal College Directory of FellowsE6: 267 active cardiac
surgeons
CTSNet database: 267 cardiac surgeons
Singapore
College of Surgeons Singapore Chapter of Cardiothoracic Surgeons Annual Report 2016E7: 36 local cardiac
surgeons
CTSNet database: 31 cardiac surgeons
Subset Analysis
A subset analysis of English-speaking versus non–English-speaking countries included above to assess whether
the CTSNet database is biased toward higher inclusion of
English-speaking cardiac surgeons indicates comparable
accuracy of data among countries from different language
groups. However, it is reiterated that data from most other
countries are not readily available beyond the CTSNet
database.
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
10.e1
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Vervoort et al
Miscellaneous
E-References
E1. College of Surgeons of Eastern Central and Southern Africa. COSECSA Members and Fellows Directory. Available at: http://www.cosecsa.org/membersfellows-directory. Accessed January 15, 2019.
E2. Hosain N, Amin F, Rehman S, Koirala B. Know thy neighbors: the status of cardiac surgery in the South Asian countries around India. Indian Heart J. 2017;
69:790-6.
E3. Sandoval N, Kreutzer C, Jatene M, Sessa T Di, Novick W, Jacobs JP, et al. Pediatric cardiovascular surgery in South America: current status and regional differences. World J Pediatr Congenit Heart Surg. 2010;1:321-7.
E4. Edwin F, Tettey M, Aniteye E, Tamatey M, Sereboe L, Entsua-Mensah K, et al.
The development of cardiac surgery in West Africa–the case of Ghana. Pan Afr
Med J. 2011;9:15.
E5. Ekure EN, Sadoh WE, Bode-Thomas F, Orogade AA, Animasahun AB,
Ogunkunle OO, et al. Audit of availability and distribution of paediatric cardiology services and facilities in Nigeria. Cardiovasc J Afr. 2017;28:54-9.
E6. Royal College of Physicians and Surgeons of Canada. Royal College Directory.
Available at: https://rclogin.royalcollege.ca/webcenter/portal/rcdirectory_en.
Accessed January 15, 2019.
E7. College of Surgeons Singapore. Chapter of Cardiothoracic Surgeons College of
Surgeons Singapore Annual Report 2016. Available at: https://ams.edu.sg/
view-pdf.aspx?file¼media%5C4701_fi_488.pdf&ofile¼ChapterþReport
þ2016þ-þCTS.pdf. Accessed January 15, 2019.
E8. Pezzella AT. Global aspects of cardiothoracic surgery with focus on developing
countries. Asian Cardiovasc Thorac Ann. 2010;18:299-310.
E9. Doherty C, Holtby H. Pediatric cardiac anesthesia in the developing world. Paediatr Anaesth. 2011;21:609-14.
Vervoort et al
E10. Yacoub M, ElGuindy A, Afifi A, Yacoub L, Wright G. Taking cardiac surgery to
the people. J Cardiovasc Transl Res. 2014;7:797-802.
E11. Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S,
et al. Cardiac surgery capacity in sub-Saharan Africa: Quo vadis? J Thorac Cardiovasc Surg. 2014;62:393-401.
E12. Edwin F, Entsua-Mensah K, Sereboe LA, Tettey MM, Aniteye EA,
Tamatey MM, et al. Conotruncal heart defect repair in Sub-Saharan Africa:
remarkable outcomes despite poor access to treatment. World J Pediatr Congenit Heart Surg. 2016;7:592-9.
E13. Okwuosa IS, Lewsey SC, Adesiyun T, Blumenthal RS, Yancy CW. Worldwide
disparities in cardiovascular disease: challenges and solutions. Int J Cardiol.
2016;202:433-40.
E14. Kwan GF, Mayosi BM, Mocumbi AO, Miranda JJ, Ezzati M, Jain Y, et al.
Endemic cardiovascular diseases of the poorest billion. Circulation. 2016;
133:2561-75.
E15. Mirabel M, Lachaud M, Offredo L, Lachaud C, Zuschmidt B, Ferreira B, et al.
Cardiac surgery in low-income settings: 10 years of experience from two countries. Arch Cardiovasc Dis. 2017;110:82-90.
E16. Reichert HA, Rath TE. Cardiac surgery in developing countries. J Extra Corpor
Technol. 2017;49:98-106.
E17. Edwin F, Zuhlke L, Farouk H, Mocumbi AO, Entsua-Mensah K, DelsolGyan D, et al. Status and challenges of care in Africa for adults with
congenital heart defects. World J Pediatr Congenit Heart Surg. 2017;8:
495-501.
E18. Zilla P, Bolman RM, Yacoub MH, Beyersdorf F, Sliwa K, Z€uhlke L, et al. The
Cape Town Declaration on access to cardiac surgery in the developing world.
Eur J Cardiothorac Surg. 2018;54:407-10.
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10.e2
The Journal of Thoracic and Cardiovascular Surgery c - 2019
Author(s)
Year
Country/region
Data source
Surgical
infrastructure
Surgical workforce
Surgical capacity
>6000 cardiac centers >2 million open
surgeries per year
Surgical quality
Additional findings
Pezzella
2010 Global
Literature review
>10,000
cardiothoracic
surgeons
Sandoval and
colleaguesE3
2010 South America
Primary survey data
Literature review
>195 cardiac surgeons 138 cardiac centers
41% (24,081) of CHD Not specified
cases per year left
untreated
Edwin and
colleaguesE4
2011 National CardioPrimary institutional
thoracic Center, Korle data
Bu, Accra, Ghana
Literature review
6 cardiothoracic
surgeons
2 operating rooms
1 catheterization lab
464 cardiac surgeries 5.3% in-hospital
Open surgery spans
(2008)
mortality for pediatric decades in West
mechanical valve
Africa
replacement
Cardiac surgery relies
on stable political
climate, economic
growth, leadership,
and prudent fiscal
management
Doherty and
colleaguesE9
2011 Global
Literature review
NA
NA
NA
Yacoub and
colleaguesE10
2014 Aswan Heart Center,
Egypt
Primary institutional
data
Literature review
Not specified
752 cardiac surgeries 5% in-hospital
2 cardiac operating
(2013)
mortality
rooms
2 catheterization labs
Advanced imaging
suite
Yankah and
colleaguesE11
2014 Africa (excluding South Primary survey data
Africa)
CTSNet
South Africa
E8
NA
NA
Descriptive capacity
summary
CHD prevalence 58,718
cases per year
No training and
qualifications
consensus for
pediatric cardiac
anesthesia; often
nonexistent in lowand middle-income
countries
Need for local staff
trained in pediatric
cardiac anesthesia for
safer surgery for more
children
Descriptive comparison
and sustainable
model of cardiac
programs
75% of world does not
have access to cardiac
surgery
10.e3
China: 158 open
surgeries per million
population
Germany: 1038 open
(Continued)
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Miscellaneous
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
Africa (excluding
Africa (excluding
Africa (excluding
South Africa): 156
South Africa): 78
South Africa):
cardiac surgeons
cardiac centers (22
10,725 open
(57 in sub-Saharan
in sub-Saharan
operations (2012):
NA
Vervoort et al
TABLE E1. Global cardiac surgery capacity studies
MIS
TABLE E1. Continued
Year
Country/region
Data source
Surgical
infrastructure
Surgical workforce
Surgical capacity
The Journal of Thoracic and Cardiovascular Surgery c - 2019
Africa; 56 in North
Africa; 99 in North
Africa)
Africa)
South Africa: 35
South Africa: 50
cardiac centers
cardiac surgeons
1277 in subSaharan Africa;
9448 in North
Africa
South Africa: 8280
open surgeries
Surgical quality
Additional findings
surgeries per million
population
In Africa, only 51.4% of
cardiac surgeons
registered with
CTSNet performed
open surgery in 2012
Primary institutional
2016 National Cardiothoracic Center, Korle data
Bu, Accra, Ghana
Not specified
1 cardiac center
Nigeria, Democratic
Access to surgery for Modified Blalock–
Republic of the
conotruncal
Taussig shunt: 0%
Congo, Ethiopia,
anomalies within
30-d mortality
Tanzania, Uganda,
2 y of birth <1% Intracardiac repair: 4%
and Kenya account
30-d mortality
for 53.5% of CHD
cases in sub-Saharan
Africa
Okwuosa and
colleaguesE13
2016 Global
Literature review
NA
NA
NA
NA
Descriptive summary of
social determinants of
health and global
disparities to cardiac
care
Kwan and
colleaguesE14
2016 Global
NA
Primary data
Global Burden of
Disease study 2013
NA
NA
NA
Ischemic heart disease
12% of total CVD
burden in poorest
countries; 51% in
high-income
countries
53% of CVD burden
attributed to
behavioral or
metabolic risk factors
in poorest countries;
85% in high-income
countries
34% of CVD burden in
people aged <30 y in
poorest countries; 3%
in people aged <30 y
in high-income
countries
(Continued)
Vervoort et al
Edwin and
colleaguesE12
Miscellaneous
10.e4
Author(s)
Author(s)
Year
Country/region
Data source
Surgical
infrastructure
Surgical workforce
Surgical capacity
Surgical quality
Additional findings
2017 MozambiqueCambodia Primary institutional
data
NA
NA
NA
55.63% of patients in
Mozambique: 6.10%
Cambodia and 14.6%
early (30-d)
in Mozambique lost
postoperative
to follow-up at 30 d
mortality rate
Cambodia: 3.05% early due to remoteness
postoperative
mortality rate
Ekure and
colleaguesE5
2017 Nigeria
Primary institutional
and survey data
31 cardiac surgeons
6 cardiac centers
NA
NA
Hosain and
colleaguesE2
2017 Bangladesh
India
Nepal
Pakistan
Sri Lanka
Primary institutional
and survey data
Bangladesh: 80
cardiac surgeons
India: 700 cardiac
surgeons
Nepal: 15 cardiac
surgeons
Pakistan: 140 cardiac
surgeons
Sri Lanka: 24 cardiac
surgeons
Bangladesh: 25
cardiac centers
India: number not
specified
Nepal: number not
specified
Pakistan: over 40
cardiac centers
Sri Lanka: 11 cardiac
centers
Bangladesh: 11,121 NA
cardiac surgeries
(2012)
India: 150,000 cardiac
surgeries per year
Nepal: 2000 cardiac
surgeries (2016)
Pakistan: >20,000
cardiac surgeries
per year
Sri Lanka: 5500
cardiac surgeries
(2016)
Bangladesh, Nepal,
Pakistan, Sri Lanka
important sources of
medical tourism in
India; USD3 billion
annually
Reichert and
colleaguesE16
2017 Global
Literature review
NA
NA
NA
North America,
Australia, Europe:
860 cardiac
surgeries per
million people
South America, the
Russian Federation,
Asia, Africa: 60
cardiac surgeries
per million people
4.5 billion people in
low- and middleincome countries no
access to cardiac
surgery
Edwin and
colleaguesE17
2017 Africa
Previous estimates (7) NA
Literature review
South Africa: 35
cardiac centers
Egypt: 48 cardiac
centers
Shisong, Cameroon: NA
35-50 congenital
heart surgeries per
year
Africa cumulative CHD
prevalence 300,486
cases
Cost of open surgery
between US$6230
and US$11,200
10.e5
(Continued)
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Miscellaneous
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
Mirabel and
colleaguesE15
Vervoort et al
TABLE E1. Continued
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The Journal of Thoracic and Cardiovascular Surgery c - 2019
Author(s)
Year
Country/region
Data source
Surgical workforce
Surgical
infrastructure
Surgical capacity
South Africa: 8280
open surgeries per
year
Egypt: >16,000
procedures per year
Zilla and
colleaguesE18
2018 16 countries
Primary survey
National databases
Annual reports data
0.06 (Nigeria) to 11.5 0.08 (Nigeria) to 1.6 0.5 cardiac surgeries NA
per million in
(Brazil) public
(Germany) cardiac
assessed lowcardiac centers per
surgeons per
income countries
million population
million population
and lower-middlein assessed
in assessed
income countries to
countries
countries
500 per million in
upper-middleincome countries
Surgical quality
Additional findings
51.4% of total birth
prevalence in 7
countries
Increase in adult CHD
pool not met by care
capacity
Miscellaneous
10.e6
TABLE E1. Continued
Need estimates: 200
operations per million
in low-income
countries to >1000
per million in highincome countries
NA, Not available; CHD, congenital heart disease; CTSNet, Cardiothoracic Surgery Network; CVD, cardiovascular disease.
Vervoort et al
Vervoort et al
Global cardiac surgery: Access to cardiac surgical care around the world
Dominique Vervoort, MD, Bart Meuris, MD, PhD, Bart Meyns, MD, PhD, and Peter Verbrugghe,
MD, PhD, Boston, Mass, and Leuven, Belgium
Some 4.5 billion people lack access to cardiac surgery when needed. Availability of adult and
pediatric cardiac surgical workforce is scarce in low- and middle-income countries, and disparities
are widespread.
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000
Miscellaneous
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