|Year : 2016 | Volume
| Issue : 2 | Page : 104-106
Open-heart surgery programme in Nigeria: The good, the bad and the ugly
Babatunde Babasola Osinaike
Department of Anaesthesia, Cardiac Anaesthesia Unit, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||13-Jul-2016|
Babatunde Babasola Osinaike
Department of Anaesthesia, Cardiac Anaesthesia Unit, College of Medicine, University of Ibadan, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
The development of open-heart surgery (OHS) programme in Nigeria has followed the different economic phases. Starting from the oil boom era in the 70s to 80s when indigenous efforts led to the successful performance of the first set of OHS to the period of depressed economy in the 80s to 90s that witnessed a lull in the programme, the revamping of the programme that started in the mid-90s following intense collaboration with foreign groups is gradually being sustained. The aim of this article was to examine the current efforts at sustaining the development of OHS programme in Nigeria with a view to identifying various challenges and how such can be addressed.
Keywords: Nigeria, open-heart, surgery
|How to cite this article:|
Osinaike BB. Open-heart surgery programme in Nigeria: The good, the bad and the ugly. Niger Postgrad Med J 2016;23:104-6
| Introduction|| |
Individuals with acquired or congenital heart lesions often require palliative or definitive heart surgery to restore cardiopulmonary physiology. However, open-heart surgery (OHS) for treating congenital heart disease in resource-poor countries continues to be a major challenge, and in several Sub-Saharan countries like Nigeria, it is often unavailable or in its infancy. Lack or inadequate facilities required for cardiac surgery is responsible for large numbers of potentially preventable death and suffering.
In Nigeria, there are few options available to patients with potentially correctable congenital heart defects in view of the limited opportunity to have their surgery done locally. Some lucky ones may enjoy support from non-governmental agencies or philanthropists to support referrals abroad. Only few families can afford the referral expenses abroad, yet most charities that sponsor referrals abroad commonly take on those with good prognosis. This leaves other affected individuals continuing in suffering and preventable deaths.
This review seeks to highlight the various challenges inherent in the development of open-heart programmes in Nigeria and how such can be mitigated to bring relief to those involved.
| Brief History of Open-Heart Surgery Programme in Nigeria|| |
The first OHS (repair of calcified aneurysmal patent ductus arteriosus) was done at the University of Nigeria Teaching Hospital (UNTH), Enugu, in 1974, by a local joined by a visiting team from the United Kingdom. Subsequently, an indigenous team in Ibadan that collaborated with the Veterinary Surgical Department at the University of Ibadan, conducted cardiopulmonary bypass procedures on dogs in the early 70s. After rigorous local training of the cardiac team, the University College Hospital (UCH), Ibadan, Nigeria, had the first successful OHS done on 18th September 1979. The surgery was a pulmonary valvotomy done using cardiopulmonary bypass in a 16-year-old boy. Three other procedures which were done successfully during this session included repair of a secundum atrial septal defect, Fallot's tetralogy and pulmonary valve stenosis all between 1978 and 1982. There was a lull in OHS programmes in Nigeria for over a decade following dwindling healthcare financing as a result of poor national economy. Other factors included interpersonal and intra- and inter-institutional conflicts. The increased concern of the government about the state of facilities in teaching hospitals which led to better funding and determination of the local cardiac teams leading to collaboration with cardiac teams abroad in the mid-90s culminated in a resurgence of OHS programmes. This second phase was almost going to suffer the same fate as the first save the dogged determination of the UCH, Ibadan, UNTH, Enugu and Lagos State University Teaching Hospital teams that 'kept hope alive'. They engaged in staff training, development of necessary infrastructures such as cardiac catheterisation laboratory, efficient blood banking and laboratory services to enhance provision of standard care for patients with cardiac lesions. Extensive collaborations with international cardiac teams also occurred. Recently, more centres across the geopolitical zones are at different stages of development of the OHS programme. Some are with the capacity to provide surgical care for simple congenital cardiac lesions only to those able to provide interventional procedures for both congenital and acquired cardiac lesions and complex cardiac surgical procedures. Furthermore, many of these centres have established collaborations with centres in Asia, Europe and America.
| The Good|| |
There is no doubt that recent cardiac mission efforts to Nigeria by different teams across the globe are helping to reduce the burden of surgically correctable and intervention-required cardiac problems in Nigeria. In addition to the direct benefit to patients, this is helping to reduce medical tourism and demand for foreign currency that continues to put pressure on the economy. As at 2012, an estimated $500 million was said to be lost annually as over 5000 Nigerians travel overseas for medical interventions at a cost of $20,000–$40,000 per traveller. On-site capacity training is major benefit of cardiac mission efforts to Nigeria. Conducting OHS operations at local sites is said to positively impact on the ability of local cardiac teams to have hands on training and exposes them to quality skills and builds their confidence.
Capacity building of local cardiac teams and infrastructural development by different institutions are efforts to be applauded. Virtually all specialists required to run successful open-heart programme are regularly being supported by their institutions to acquire requisite training both locally and abroad. This includes, but not limited to cardiac surgeons, cardiac anaesthetists, intensivists, cardiopulmonary therapists, nurses and perfusionists. Similarly, important facilities such as cardiac catheterisation laboratory, cardiopulmonary bypass machine and cardiac intensive care are now regular features in some tertiary and private hospitals. These are obviously positive developments.
| The Bad|| |
A major threat to the steady development of OHS programmes in Nigeria is the lack of coordination between personnel and infrastructural development. Often, efforts are directed at training of personnel well ahead of provision of required facilities. This interval can be up to 5 years and a common consequence is skill attrition at the time facilities are provided. Re-training which should be the way-out is seen as double expenses and not usually favoured by the hospital administrators. This problem can be avoided if there is a better understanding between hospital management and cardiac team and engaging relevant professionals during the planning phase.
Despite support provided for personnel development, in most institutions, there remains a critical need for training more personnel who make up the cardiac team to enhance efficiency of the open-heart programmes, and perfusion technician and cardiopulmonary therapist seem to be worst hit. In addition to this, many centres are still without important facilities such as cardiac laboratory, to enhance delivery of comprehensive care. In view of inadequate personnel and limited funding, the OHS programme in Nigeria is still largely dependent on external support. This comes mostly in form of personnel support. This is often said to enhance the quality of the programme and improve acceptance. Unfortunately, lack of trust in the local programme remains a huge challenge as many still doubt the ability of these local programmes to offer successful care in this very special area of medicine. Advocacy and enlightenment programmes will be necessary to correct this impression.
| The Ugly|| |
Having identified some positive values and threats against a successful OHS programme in Nigeria, there are some negative trends which may spell doom for the programme if not checked. The first is the absence of national policy or plan with regards to the establishment of OHS programmes. This would have provided a framework for the different components which include actors (individuals and organisations that implement policy), processes (implementation and evaluation) and context (political, social and economic environment in which the actors work). The consequence of this is the 'proliferation' of OHS programmes in many institutions lacking the requisite personnel and facilities. One may be tempted to assume that the opportunity to attract fund from the Federal Government and the National Health Insurance Scheme may be responsible for this new drive instead of the genuine desire to offer relief to affected individuals. One would expect that a health facility offering OHS services should have attained some level of standard in the provision of quality health care; this is, however, not the case. Experience has shown that investigations such as full blood counts, clotting profiles, serum creatinine, liver function tests and arterial blood gases estimation are often unavailable after working hours in some of these centres. Most times, special arrangements are made during OHS sessions. Similarly, bedside radiological services are not readily available. This 'top to bottom' approach may not guarantee a sustainable future for the OHS programme.
The desire of each institution to grow their programme is also gradually leading to unhealthy competitions. Some manifestations of this include refusing to refer patients to other institutions even when the service is not readily available at such times, surgical fee undercutting to attract patients and unwillingness to share information that may be beneficial to all. All these are major threats capable of jeopardising the genuine growth of OHS programme in Nigeria. The Nigerian Cardiac Society (NCS) as an important stakeholders' forum has a great role to play in stemming this ugly trend. The NCS can facilitate interaction among different centres currently running the OHS programme and also help with the setting up of necessary guidelines.
There is no doubt that the OHS programme in most centres is not enjoying the needed support from the government, and this has been responsible for the lack or inadequate facilities observed in many institutions, thereby forcing them to seek ways of raising enough funds to sustain the programme. One of these is the public–private partnership initiative, an arrangement where a private establishment contributes to the development of the programme and profit is shared. Some other centres leverage on the procedure fee which sometimes is augmented by the payment from the National Health Insurance Scheme for registered individuals. This financial pressure may sometimes shift the focus of tertiary institutions providing OHS programme from training to fund generation to sustain the programme. This threatens the training component of the teaching hospital mandate and may end up making the services unaffordable by large percentage of individuals. The most recent study in Nigeria aimed at determining the cost of an average OHS in Nigeria by Falase et al. showed that the cost ranged between $6230 and $11,200. This still appears to be on the high side considering the low purchasing power of an average Nigerian.
| Conclusion|| |
Despite the increasing numbers of OHS performed in the country recently, almost none has been done by wholly indigenous team in the different centres, yet well-trained professionals in the different skill group who make up the cardiac team are available in the country. In view of this, collaboration among different institutions providing OHS services should be encouraged. Institutions can pool skilled personnel and resources together to make the programme fully home grown.
In view of the increasing requirement for interventional and/or surgical procedures for acquired or congenital cardiac lesions and many centres now providing these services, there is an urgent need for an encompassing national policy on cardiovascular care. This will help provide the needed coordination and chart a right course for the growth of OHS in Nigeria. Strong advocacy by the various stakeholders' societies will be required to make this a reality. Establishment of regional OHS programmes may also be a step in the right direction. This will allow for the concentration of skill and facilities in few centres initially, leading to development of expertise and ultimately improved care.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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