The “The Nation’s Heart” series features a different country every week to highlight its current state of cardiac surgery, progress made, initiatives set, and prospects to come. Today, for the first blog of this series, Global Cardiac Surgery is featuring Ghana, a lower-middle-income country in West Africa with a strong history in the realms of cardiothoracic surgery.
Ghana (the Republic of Ghana) is a unitary presidential constitutional democracy located along the Gulf of Guinea and Atlantic Ocean in West Africa, after declaring independence from the United Kingdom in 1957 and transitioning into a Republic in 1960. With a GDP per capita of US$1,513, Ghana falls in the lower-middle-income group (US$996-US$3,895) spanning a population of 28.21 million people, with 10.95 million children (38.8% of total) under 15 years old. It has been reported that the estimated burden of congenital heart disease (CHD) in Ghana approximates 372 per million population, a disproportionally high number due to the higher fertility rate in the country relative to other countries in the Region. Nevertheless, with less than 20% of parents of children with CHD requiring surgical care able to cover the medical costs to undergo the operation within 12 months of diagnosis, access remains scarce.
Flag of Ghana: red represents the blood shed to fight for independence, gold represents the mineral wealth present in Ghana, green represents the nature and grasslands of Ghana, and the black star represents African emancipation.
Traditionally, West Africa has been one of the poorest regions in the world, limiting the financial scope to scale cardiac surgical care in the region. Some countries, however, including Ghana, have built a long and proud history establishing cardiac programs in their country. Documented reports in Ghana go back to 1964 with the use of surface cooling to close atrial septal defects (ASDs) and performing a closed mitral commissurotomy at the Korle-Bu Teaching Hospital in Accra, under Charles Easmon, general surgeon and head of the Surgery Department at the hospital. In the years that followed, due to political upheavals in the country putting cardiac development on hold, few cases were done by visiting surgeons and non-cardiac surgeons. In 1989, Dr. Frimpong-Boateng, trained in Hannover, Germany, returned to Ghana to found the National Cardiothoracic Center, the only tertiary center in the country, supported by the Ghanaian and German governments. In addition, Germany supported Ghana through initial equipment and medical personnel for up to ten years, to train the local workforce. In 1992, Dr. Frimpong-Boateng introduced the use of cardiopulmonary bypass (heart lung machine) in the country, replacing a mitral valve. The introduction of the Center allowed Ghana to treat patients in-country, saving up to US$44,000 per patient compared to sending patients to the United States, as was done prior.
Today, Ghana’s National Cardiothoracic Center remains active and is accredited by the West African College of Surgeons (WACS) for the training of cardiothoracic surgeons. The Center has a 30-bed ward, 2 operating theatres, a 6-bed intensive care unit, a 6-bed high dependency unit, a laboratory, catheterization lab, radiology, echocardiography services, and a renal dialysis unit. Dr. Frimpong-Boateng trained 7 cardiothoracic surgeons to serve as the permanent cardiac team, supported by cardiac anaesthesiologists, cardiologists, perfusionists, cardiac nurses, technicians, and other staff. Accordingly, the Center has grown to become a surgical hub for the West African region, with regular referrals from Sierra Leone, the Gambia, Liberia, Nigeria, and Togo. In addition, the Center has been able to withstand the widely perceived “brain drain” in other sectors, through ensuring opportunities for surgeons to academically advance, conduct research, integrate new technology in practice, and sustain international collaborations.
In Ghana, as in most sub-Saharan African countries, rheumatic heart disease has been the major indication for valve surgery (together, in terms of case load, with CHD), often presenting during advanced stages of pathology. This, in turn, leads to increased calcification and difficulty of operation, often requiring re-operation causing increased financial constraints for patients. To bridge this, the Center has traditionally opted to use bi-leaflet mechanical valves, committing patients to lifelong anticoagulation but better long-term outcomes, limiting reoperation and related costs. Nevertheless, this readily underlines the importance of early detection and prevention of cardiac pathology, as well as reducing the delay of seeking care, requiring efficient systems of community health workers and referral systems in place. In addition, the cost of open-heart surgery remains beyond the scope of 90% of the population, ranging from US$6,000 for ventricular septal defect (VSD) closure to US$10,000 for double valve replacement. The national health insurance does not cover cardiothoracic surgical interventions due to the high costs, limiting patients to out-of-pocket payments and philantropic support. In some cases, the Ghana Heart Foundation, supported by the government of Ghana, financially supports patients to receive the care they need. Nevertheless, care provided at the National Cardiothoracic Center has proven to approximate outcomes seen in developed countries and higher-volume hospitals, showing the feasibility of providing cardiac surgical care in developing nations.
Building on the expertise and foundation set forth by Dr. Frimpong Boateng and the National Cardiothoracic Centre at the Korle-Bu Teaching Hospital in Accra, Ghana could build upon a decades-long history to sustain its position as one of the leading countries in West Africa providing and scaling cardiac surgical care. Together with increased awareness and escalation of the pre-hospital chain and cardiac prevention and diagnosis, the increasing volume, and thus gradually reducing costs of procedures, will allow for broader coverage of its population and sustainability of the nation’s program.
Tettey M, Tamatey M, Edwin F. Cardiothoracic surgical experience in Ghana. Cardiovasc Diagn Ther. 2016. Open Access article.