1. After so many years of OHS in Kenya, what has slowed us down? S.W.O. Ogendo

2. Cardiac Surgery (World) 22/04/2015 4000 cardiac surgery units worldwide Surgeries per million and units per million (Reproduced from Unger F. Worldwide survey on cardiac interventions 1995. Cor Europaeum. 1999;7:128-46; )

3. Countries able to offer cardiac surgery Algeria Botswana Burkina-Faso Cameroon Egypt Eretria Ethiopia Ghana Ivory Coast Kenya Libya Mauritania Mauritius

4. Countries able to offer cardiac surgery  Morocco  Mozambique  Namibia  Nigeria  Rwanda  S. Africa  Senegal  Sudan  Tanzania  Tunisia  Uganda  Zambia  Zimbabwe  TOTAL = 26

5. Countries without ongoing resident programmes. Visiting teams  Botswana (Mauritian team)  Burkina Faso (French team)  Rwanda (American, Australian)  Zambia (Mutima)  Eritrea(Switzerland, Italian and German)

6. Countries not hosting visiting teams South Africa Sudan ?Egypt

7. Commencement of cardiac surgery AlgeriaUnknown LibyaUnknown MoroccoUnknown TunisiaUnknown S. Africa1958 Egypt1963 Ghana1964 Kenya1973 Nigeria1974 Sudan1977 Ivory Coast1978 Mauritius1984 Zimbabwe1988 Senegal1995 Mozambique1998 Mauritania2002 Ethiopia2003 Eritrea2004 Rwanda2006 Uganda2007 Tanzania2008 Cameroon2009 Burkina-Faso2010 Namibia2010 Botswana2011 Zambia2011

8. Distribution of facilities Egypt48 S. Africa30** Nigeria9 Tunisia11 Libya7 Morocco7 Sudan7 Kenya7 Algeria3** Tanzania3 Ivory Coast2 Mauritius2 Namibia2 Uganda2 Zambia2 Botswana1 Burkina-Faso1 Cameroon1 Ghana1 Mauritania1 Mozambique1 Rwanda1 Senegal1 Zimbabwe1 Eritrea1 Ethiopia1

9. 22/04/2015

10. Surgical output in Africa Country Number facilities Cardiac surgeons Operative numbers/year Algeria15353000 Botswana102 Burkina-Faso10100 Cameroon1 0 Egypt4810016000 Eritrea1060 Ethiopia1240

11. Ghana16100 Ivory Coast27250 Kenya411250 Libya7100 Mauritania1030 Mauritius22500 Morocco10 500 Mozambique1150 Namibia2210

12. Nigeria91512 Rwanda1060 S. Africa3012012,000 Senegal1540 Sudan5172000 Tanzania37105 Tunisia13802500 Uganda2350 Zambia2010 Zimbabwe210 TOTAL166 397 (933 CSTnet) 37,669

13. Cardiac surgery capacity in Africa. Yankah et. al

14. History cardiac surgery Kenya KNH - 1973 hypothermia KNH - 1975 CPB machine Nairobi Hospital - 1993 Mater Hospital - 1996 Karen Aga Khan Tenwek Mombasa (AGK)* - 2003 22/04/2015

15. Series 1 = KNH, 2 = Nairobi Hospital and 3 = Mater Hospital (2003) 22/04/2015

16. KHN figures last 10 years

17. Surgeries Per Population (?Needs) Average for Africa

18. What are the positive improvements?

19. Access to service Overall greater availability of cardiac services Wider distribution in country More personnel available Skills transfer

20. infrastructure

21. Training Training programme for surgeons ongoing Return of surgeons from outside the country Nursing staff

22. Challenges/obstacles

23. Decision to start a programme

24. Training challenges Nursing and other support staff for programme Support units must keep pace training opportunities Accreditation

25. Training Challenges (cont) Cross institution/border corporation (low)  Training programmes  Skills mix Public private collaborations Government prioritisation of training needs

26. Equipment challenges Lack of front line equipment. Maintenance of equipment Replacement of equipment (Inappropriate) Equipment donations

27. Financing challenges More private institutions Public institution more into cost sharing Down sizing of cardiac allocation in public institution Donor inclusion into programme Agenda maybe different

28. Treatment options outside Kenya Challenge as patients go out (e.g. India and South Africa)

29. Collective Effect of Challenges on Cardiac Surgery Services Nigeria: 1974 – 2000. Tex Heart Inst J. 2007; 34(1): 8–1 Kenya: Authors personal database

30. Management Personnel Equipment Finances Audit

31. Audit and research Audit and value (Operational research studies) Research collaborations

32. Addressing Challenges  Funding  Training  Sustainability plans  Collaborations

33. Mmed training programmes in Africa  South Africa. Universities of; Cape Town Stellenbosch KwaZulu-Natal Witwatersrand Pretoria Medunsa Free State Ethiopia Ghana Kenya

34. Way Forward Better manage what we have Improve services by address challenges Technology transfer Vertical Horizontal Government support Community confidence