1. Training Programs and Education in Africa Hannes Meyer 2015 Prof F E Smit University of the Free State, Bloemfontein, South Africa

2. Background 1.1 billion people lives in Africa with 860 million in Sub Saharan Africa ( World Bank 2013) 370 million below 15 years of age (43%) and 516,2 million under 25years (60%) Under 5 mortality decreased from 90/1000 in 1990 to 48/1000 in 2013 Congenital disease 2,7 – 3,4 million born per year 48,1% of infants with congenital heart defects die 1,7 – 2,6 million children require surgery with 0,5 – 3,4 % having access Health Expenditure in Sub Saharan Africa was 3,6% of GDP in 2013 Middle class expanded from 126 million (27%) in 1980 to 350 million (34%) in 2013

3. Background Changing epidemiology Projected fatalities due to CVD to reach 20 million per year in 2020 and 24 million per year by 2030 6,5 million men and 6,9 million females affected in 2000 Increased to 8,1 million men and 7,9 million women in 2010 RHD - over 1 million in Sub Saharan Africa

4. Perspective Cardiac Centers Cardiac center per Million Central Africa 1 1:132 East Africa 12 1:12.4 The Horn 2 1:54.4 West Africa 5 1:63.7 Southern Africa[c]2 1:50.5 Southern Africa + RSA37 1:2.7 North Africa 56 1:1.8

5. Funding Perspective - WHO 2012 USD per capita per annum Physicians per 1000 population Hospital beds per 1000 populkation World10301,5.. Euro zone38843,75,6 High Income46353,05,7 Low income310,2.. Middle Income2621,32,3 Sub Saharan Africa 950,2..

6. Funding

7. Challenges National budgets - 15% of GDP Abaju target not reached African funding needs to be seriously assessed and addressed - self, insurance, donor and state High percentage of state funding spend on salaries Low operating budget, Low infra structure budget Political will, responsibility and corruption Outsourcing of high tech and expensive treatment to high turnover regional units (to be identified and developed) will be cheaper than low volume local units

8. Cardiac Training Requirements USA - 150 cases Europe - 150 cases Australia – 100 cases Brazil – 100 cases South Africa – 70 ( aiming at 100) cases Africa – low volume units/undefined/impact of missions on volumes

9. ADULT CARDIAC SURGERY - SERVICE DELIVERY AND STAFFING – 2010/11 Population 15-+80 yr Public population 86% Surgery AdultSurgeonsRegistrarsMOSupernumerary GAUTENG Pretoria Steve Biko Medunsa Wits Baragwaneth TOTAL Activity Per Million 8 2545347 098899 138 101 200 439 62 3 4 10 0.0014 1 4 5 2 11 0.0015 2 1 0.0001 0 1 0.001 0 FREE STATE Universitas Activity Per Million 1 947 2471 674 632 384 0.2293 229 2 0.0012 1 2 0.0012 10 2 0.0012 1 KWAZULU NATAL Albert Lethuli Activity Per Million 7 157 5326 155 478 418 68 10 2 0.0006 1 0 0.0006 1 0.0006 1 EASTERN CAPE Port Elizabeth Activity Per million 4 586 9763 9447 99 116 0.029 29.41 3 0.001 1 0.0003 0.25 2 0.001 0.5071 0 0.000 WESTERN CAPE Stellenbosch UCT Groote Schuur TOTAL Activity Per Million 3 749 7573 224 791 390 250 640 0.1985 199 3 6 9 0.0028 3 4 8 0.0025 2 0 0.000 0 2 0.006 1 NORTHERN CAPE MPHUMALANGA NORTH WEST LIMPOPO TOTAL 764 437 2 468244 2 221010 3 624 752 657 416 2 122 690 1 910069 3 117 287 1 199734 57 TOTAL Activity 34 774 48929 906 061 0.0668 66.7759 0.0011 1.1369 0.0011 1.1369 0.0002 0.1672 0.0002 0.2341

10. Service and development options Private funding – medical insurance State funding Private Public Partnerships (PPP’s) Donors – full or partial funding/subsidy Out-sourcing surgery and interventions to regional major centers and development of diagnostic centers/expertise, peri-operative and long term care Missions to missions +

11. Opportunities in the Developing World Cardiac Interventions – Cath lab based or surgery Diseases - mitral stenosis, mitral regurgitation, coronary artery disease, aorta valve, pericardial disease Cardiac Interventionist – extended rotation in cardiology Imaging expertise – echo- cardiography Intensivist Thoracic Surgery

12. Our Plan - 1 Training models – Team Sports, Formula 1, Airline Industry, Military Models, Business Models Maximum Output, highest possible level, competitive (at international standard) Management of Risk Check lists Communication skills and strategy Personal Development (2013) Simulators / Wet labs / Video linked wet labs Systemic Challenges – Resource management

13. Our Plan - 2 Open hearts – 100 cases More valves than coronaries – 70 /30 Use step wise training – open and close, CPB, dissection of mammary/veins Learn to conduct the band ( integration) - check lists, communication, manage Simulators and wet labs Simple to complex Monitor progress regularly – cannot catch up Measure outcomes / International Benchmarking Expand case volumes

14. Interim Actions Political will to address health care per country determine success. No will, no success, no sustainability. Development of alternative funding models a priority Medical tourism – Consider channeling to regional or supra regional units with regional service, training, research and development responsibility to ensure viability Develop relationships with major units ( Regional or from Industrialized World) Support Missions to missions + with diagnostic and care programs

16. Pre-Requisites Standard project management/business management principles apply (and cannot be done in isolation) Clear Objectives – numbers /selection/service package Training objectives and arrangements Costs - actuarial analyses (requires information!) Funding Mechanism and Sustainability Ring fence funding Strong Leadership Planning and Execution

17. Perspective -1 Table 1 Regional distribution of cardiac centers with capability to perform regular open heart operations in 2012 in North and sub-Saharan Africa RegionsCardiac centers (n)Cardiac center per million (n) Africa[a] 113 1:8.5 Africa[b] 78 1:12.5 Sub ‐ Saharan Africa + RSA 57 1:15.1 Sub-Saharan Africa[c] 22 1:33.3 a Excluding Egypt and Sudan. b Excluding Egypt, Sudan, and RSA.

18. Cardiac Surgeons (CTS Net)