Discussion

The double burden of disease in developing countries or low-middle-income countries and emerging economies remains an obstacle for the development of increased medical access and care, especially for the increasing non-communicable diseases and the lingering communicable diseases.^{Reference Nguyenu, Leon-Wyss, Iyer and Pezzella8} 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.^{Reference Tchantchaleishvili, Mokashi, Rajab, Bolman, Chen and Schmitto9} A young cardiothoracic surgeon in sub-Saharan Africa, 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 cardiac teams in various African regions, including Nigeria and encouraging them to become involved in the cardiac surgery training programmes.^{Reference Yanka, Fynn-Thompson and Antune10}

The outcome of the mission programme in Nigeria (model A) is far from success. This is because, very few if any of the centres that engaged in cardiac missions are independent. A humanitarian surgeon’s focus will always be upon patient, but local health care providers and the community they serve can and should both benefit. Ultimately, success should not be measured by the number of successful operations of any given mission but by the successful operations that the local team performs after the visiting leave.^{Reference Maluf, Franzoni, Melgar, Hernandez and Perez11,Reference Corno12,Reference Pezzella13} In a similar study by Velebit et al., a team of fully trained specialists did a cardiac mission in Tbilis Georgia for a period of 5 years where the frequency was monthly of 1 week duration with an average of 10 times in a year, After 5 years, the local team was able to become independent and has performed 111 cases within the first 7 months in 2008 out of 204, while the remainder was done by foreign team during irregular support visits in relationship to difficult cases.^{Reference Velebit, Montessuit, BednarkKiewicz, Khatchatourian, Mueller and Neidhart14} In Nigeria, the mission programme can be described as surgical Safari type rather than educational. They are not regular and no targeted end point.^{Reference Nwafor and Eze15} This explains why it worked in other developing countries of the world but not Nigeria.

For example, at University of Nigeria Teaching Hospital, Enugu (SER), 30 mission trips took place between February 2013 and January 2019. During this period, about 209 cases were performed both in adults and children with a ratio of 34.2 cases per year. The ratio of the local/visiting surgeons as the primary surgeon is about 5/43 and the local surgeon given the opportunity as the primary surgeon happened during the mission trips of Cardiostart International and William Novick Cardiac Alliance.^{Reference Nwiloh, Smith and Mestress16} Some foreign surgeons do come with their foreign residents who displace the local surgeon as the first assistant surgeon. The local surgeon often becomes the second assistant or become an observer. They strive to do many cases on their own rather than teaching the local surgeon because as a surgical Safari type, the emphasis is on the number and not on skill transfer.

Model E involves individual member of cardiac team travelling abroad for training especially India and South Africa, but the fellowship programmes in cardiothoracic surgery in India and Republic of South Africa for trainees from sub-Saharan Africa 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 benchmarking of the training programme.^{Reference Yanka, Fynn-Thompson and Antune10} Despite this short coming, West African College of Surgeons and National Post Graduate Medical College of Nigeria have made it mandatory that a trainee cardiothoracic surgeon in Nigeria must undergo a year fellowship training in accredited centre either in India, South Africa, Europe, or America as one of the conditions for qualifying for part II or exit examination in cardiothoracic surgery.^{Reference Bode, Nwawolo and Giwa-Osagie17} In view of the afore-mentioned shortcoming, this model is a failure. See Table 2.

In view of the failure of models (A, E, F), the Ghana–German model (model B)^{Reference Yanka, Fynn-Thompson and Antune10}, successfully adopted by a small neighbouring country, Ghana became the cynosure of some centres. Unfortunately, no respective government, state or federal government has been convinced to support the programme and no highly skilled senior cardiac surgeon(s) among Nigerians in diaspora is willing to relocate home like the Frimpong Boateng did in Ghana.^{Reference Kwabena18} Rather, many highly skilled cardiac surgeons, cardiac anesthetists, perfusionists, and intensivists, all of Nigerians in diaspora believe that provision of special incentives by the Federal Government of Nigeria will enable them to return home and establish a successful and enviable open heart surgery programme in Nigeria^{Reference Bode, Michael, Adetinuwe, Ifeoluwa, Ariyo and David19} (model F). However, at this point in time, this idea as well intended as it is, has not well been packaged enough to sell successfully to the Federal Ministry of Health en route to the Federal Government of Nigeria.

Any model without governmental support is unlikely to succeed. In Nigeria, budgetary allocation to health is very low due to competing demands. Ironically, the amount of money government officials spent on medical tourism to treat heart-related diseases and other illnesses is very huge.^{Reference Leon-Wyss, Veshti and Veras20} This misplacement of priority makes it impossible for health insurance to cover patients needing open heart surgery.

Corruption, interprofessional conflicts, and nepotism create avenue for stealing public funds and stashing them away in foreign countries, thereby denying the poor masses access to basic health care. Inadequate remuneration of trained cardiac surgeons and other highly skilled ancillary staff created wave of brain drain syndrome of some of the staff to Europe and America, thereby making it impossible for the models A, E, and F to succeed.

Due to the failure of models A, E and F to produce independent local team in open heart surgery in almost all the centres, there is suggestion currently that the best method that will quickly establish the independence is the employment of expatriate consultant (model C). This model was practised in Kenya: senior expatriate cardiac surgeon on contract is paid by the host government to develop a cardiac surgery programme and organise capacity building. This is similar to the cooperation between Deutsches Herzzentrum Berlin and Sarajevo Heart Centre.^{Reference Ogundiya7} It is hoped that any interested state government within any given region aided by selfless non-governmental organizations will buy into this model.

The popular but almost impractical model (model F) is the provision of special incentives to highly skilled Nigerians in diaspora to relocate home and establish a sustainable open heart surgery programme via public–private partnership.^{Reference Bode, Michael, Adetinuwe, Ifeoluwa, Ariyo and David19} This is similar to Ghanaian–German and Namibian models. They are associated with an integrated health care system with part government and part private funding managed by a senior local consultant cardiac surgeon. The Ghanaian programme, for example, is independent, has political support, has trained more than 20 local and foreign cardiac surgeons, maintains stable surgical load though lower than that of its counterparts in Europe, and produces scientific works. The model requires 7–10 years for infrastructure development and stability and 3 more years for the mixed team until the unit becomes independent.^{Reference Edwin, Tettey and Aniteye1,Reference Turina21}

Prof Frimpong Boateng of Ghana upon completion of his training in Hannover, Germany, had a vision to return home against the wishes of his boss, to establish a sustainable open heart surgery programme in Ghana. While still in Germany, he made several frustrating trips to Ghana to get his governmental support but never gave up. By divine intervention, he was able to convince then head of state of Ghana, Frank Jerry Rawlings. By his in-depth knowledge of heart surgery coupled with his exemplary leadership, qualities, National Cardiothoracic Center Accra, Ghana was born in 1989. By the 20 years anniversary, the centre has not only become the only accredited place of training cardiothoracic surgeons by the West African College of surgeon, but has produced six extra cardiothoracic surgeons of Ghanian indigenes.^{Reference Edwin, Tettey and Aniteye1} The Ghanaian–German model has demonstrated that the determinant factor for sustainability of a cardiac surgery programme in sub-Saharan Africa is leadership rather than the distribution of health expenditure per capita income and the gross developmental product. The density of the cardiothoracic surgeons could be directly related to the distribution of gross developmental product and the health budget, but it was not a determinant factor for sustainability and success of the cardiac programmes.^{Reference Edwin, Tettey and Aniteye1,Reference Nwafor, Arua, Eze and Ezemba22}

Model D is largely practised in southwestern region and some centres there have transited to independence. See Table 2. However, their yearly output is still relatively low as a result of poor funding. See Table 3.

Table 3.

Limitations of different models based on the interviewees (ranked)

Currently, the Federal Ministry of Health indirectly supports the old fashioned but failed to thrive cardiac mission model of the Safari or Blitzer type.^{Reference Kwabena18}

To this end, highly skilled Nigerians in diaspora should emulate the pioneering leadership of Ghanian Frimpong Boateng. This Ghanaian–German model has proved to be a successful programme in the long term and could inspire health care policy-makers in sub-Saharan Africa and senior colleagues planning to establish cardiac programmes in their home countries.^{Reference Bode, Michael, Adetinuwe, Ifeoluwa, Ariyo and David19}

Even while practising model A, E, and F, there were limitations as obtained while interviewing the surgeons and the trainees. See Table 3. These limitations are ranked according to the respondents/interviewees. Funding of open heart surgery programme is a major limitation. Nigerian Heart Foundation is inefficient but Rotary Club of Nigeria, public spirited individuals, and occasionally governmental support have been helpful.

Private cardiac hospital either for adult or children in Nigeria with a large population is almost non-existent. Over-dependence on private power supply, inadequate national blood banks, and dependence on paid blood donors make cost of open heart surgery extremely unrealistic that such venture even if it is initiated from outside Nigeria is bound to fail.^{Reference Falase, Sanusi, Majekondunmi, Ajose, Idowu and Oke23}