Introduction
In low- and middle-income countries, 93% of the population lacks access to safe, timely, and affordable cardiac surgical care as a result of geographic, infrastructure, quality, and financial barriers.¹ Traditionally, the scaling of advanced cardiac care has been neglected in low- and middle-income countries despite the global burden of cardiovascular disease.^2,3 There is growing recognition of the favorable cost-effectiveness of cardiac surgical care in low- and middle-income countries⁴ because cardiovascular disease is the leading cause of death worldwide and tends to affect people at younger ages in low- and middle-income countries.¹ More broadly, the financing of robust surgical ecosystems in low- and middle-income countries is not only feasible and affordable but urgently needed given the large burden of cardiovascular disease worldwide.⁵

The large and growing prevalence of non-communicable diseases, particularly cardiovascular diseases, results in major productivity losses and early morbidity and mortality across low- and middle-income countries.⁶ Investing in surgical care is expected to increase human capital in countries with limited access to such services.⁷ Nevertheless, access to cardiac surgery remains limited in low- and middle-income countries because many countries have limited numbers of trained cardiothoracic surgeons.⁸ Contemporary spending by low- and middle-income countries governments to send patients abroad for cardiac surgical care is high, representing over 10% of annual health spending in some low- and middle-income countries,^9,10 whereas visiting teams and non-governmental organizations help fill local gaps through various models. Meanwhile, the development of novel technologies and procedures, such as minimally invasive and transcatheter techniques, comes with an improvement of patient outcomes and short hospital lengths of stay, ultimately driving down costs for both patients and providers and ensuring a faster return to work for patients. The excellent results achieved by both visiting and local teams in the delivery of cardiac surgical and catheter-based cardiovascular treatments suggest the potential for low- and middle-income countries to leapfrog their way to sustainable and modern cardiac centers, provided that government-driven financial and political support is present.

Costs of Cardiac Surgery
Although the operative costs of open-heart surgery are extraordinarily high in the United States (up to US$100,000 per operation), costs are found to be as low as US$6,000-11,000 in Nigeria,¹¹ less than US$10,000 in Brazil,¹² US$2,000-5,000 in Vietnam,¹³ and less than US$2,000 in India.¹ Costs are particularly high for operating room and intensive care overhead and consumable costs in low- and middle-income countries, whereas visiting teams report the highest costs coming from surgical teams.^4,11 Leveraging a workforce microcosting model for congenital and rheumatic heart surgery in Kenya, an estimated US$899 is needed per year for total workforce costs for 2.5 heart surgeries per 1,000 people¹⁴ despite the high burden of (late-stage) congenital heart defects and rheumatic heart disease. Similar cost estimates are likely across low- and middle-income countries given the tens of millions of people living with cardiac conditions worldwide.¹⁵

Patient Funding
Although the procedural and total hospital costs associated with cardiac surgery are smaller in low- and middle-income countries in absolute value compared to high-income countries, the smaller proportion of health insurance coverage, higher out-of-pocket expenses for health services, and lower income and standard of living makes it disproportionally more difficult for patients and families in low- and middle-income countries to afford such services. In West Africa, fewer than 20% of patients are able to find funding for their cardiac surgery within a year of diagnosis, while the share of patients covered by government insurance has remained stable or even declined.¹¹ The majority of patients in low- and middle-income countries able to obtain cardiac surgical care secure funding through out-of-pocket payments, non-governmental organizations or visiting teams, or philanthropic support.¹⁶ Some countries, such as Nepal through the Poor Patients Relief program, have established governmental schemes for life-threatening cardiac conditions for the poor, the children, and the elderly, and parts of other countries, such as India through Narayana Health, have leveraged co-financing models whereby wealthier patients cover part of the costs for poorer patients.¹

Health Care Financing
The longstanding reliance on development assistance for health¹⁷ in low- and middle-income countries requires a shift from externally dominated funding streams—which are often earmarked and very rarely allocated to surgical care—to more domestic investments where possible.¹⁸ In 2001, all African countries signed the Abuja Declaration, committing to allocating 15% of annual government budgets to health care spending; however, the majority of countries have failed to fulfill this pledge as a result of both insufficient political will and competing priorities.⁵ Other low- and middle-income countries across the world have equally low domestic health care funding, with most spending less than 5% of total Gross Domestic Product on health. Because countries' budgets and, accordingly, government health spending are expected to grow in the coming years, opportunities arise to increase funding to support strengthening health systems rather than earmarked, vertical disease silos. Accordingly, the fiscal space, defined as the change of governments' public spending without affecting the macroeconomic stability, for health must and can be expanded,18 which will help to ensure the local expansion of cardiac care. The development of National Surgical, Obstetric, and Anesthesia Plans (long-term strategic plans to strengthen surgical ecosystems as part of national health plans) and the integration of cardiac surgical services therein will be necessary to move forward.¹⁹ Whether this occurs and to what extent allocation of funding to cardiac care takes place will rely on political will, strong governance at all layers of the health system, and cardiovascular voices at the table from physicians and patient advocates.

Innovative financing mechanisms have been successfully leveraged in various global health domains but are yet to be applied to global surgical contexts.¹⁸ Nationally, opportunities arise to increase health care budgets through financial pooling mechanisms—whether through domestic taxes, international levies, or non-earmarked foreign aid—and promoting value-based health care practices to minimize wasteful spending. At the facility and institutional level, resource mobilization and public-private partnerships should be leveraged to optimize surgical supply chains, regionalize specialized services, create economies of scale, and foster efficient referral networks. Such mechanisms can ensure that more resources can be allocated to the expansion of cardiac care through both top-down government insurance and microinsurance schemes and bottom-up community engagement, grassroots efforts, and collaborative co-financing models.

Conclusion
Cardiac surgical care remains expensive, but opportunities exist for countries and international organizations to sustainably and innovatively finance local cardiac centers in low- and middle-income countries, drive down costs, and support patients requiring specialty care (Figure 1). Such efforts must occur while minimizing opportunity and productivity costs for patients requiring cardiac surgery, which can ultimately promote socioeconomic growth through health system-wide ripple effects.

Figure 1: Financing, Costing, and Funding in Global Cardiac Surgery

References

1. Vervoort D, Swain JD, Pezzella AT, Kpodonu J. Cardiac Surgery in Low- and Middle-Income Countries: A State-of-the-Art Review. Ann Thorac Surg 2020;Aug 6:[Epub ahead of print].
2. Vervoort D, Parikh UM, Raj A, Swain JD. Global cardiovascular care: an overview of high-level political commitment. Asian Cardiovasc Thorac Ann 2020;28:258-65.
3. Vervoort D. The Neglected Component of Cardiovascular Care: Dispelling the Myths. Glob Heart 2019;14:281-3.
4. Cardarelli M, Vaikunth S, Mills K, et al. Cost-effectiveness of Humanitarian Pediatric Cardiac Surgery Programs in Low- and Middle-Income Countries. JAMA Netw Open 2018;1:e184707.
5. Jumbam DT, Reddy CL, Roa L, Meara JG. How much does it cost to scale up surgical systems in low-income and middle-income countries? BMJ Glob Health 2019;4:e001779.
6. Jumbam DT, Reddy CL, Makasa E, et al. Investing in surgery: a value proposition for African leaders. Lancet 2020;396:7-9.
7. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624.
8. Vervoort D, Meuris B, Meyns B, Verbrugghe P. Global cardiac surgery: Access to cardiac surgical care around the world. J Thorac Cardiovasc Surg 2020;159:987-996.e6.
9. Vinck EE, Vervoort D. Cardiac Surgery Air-Bridging in the Caribbean. Semin Thorac Cardiovasc Surg 2020;May 16:[Epub ahead of print].
10. Vervoort D, Vinck EE, Tiwari KK, Tapaua N. Cardiac Surgery and Small Island States: A Bridge Too Far? Ann Thorac Surg 2020;Jul 25:[Epub ahead of print].
11. Falase B, Sanusi M, Majekodunmi A, Ajose I, Idowu A, Oke D. The cost of open heart surgery in Nigeria. Pan Afr Med J. 2013;14:61.
12. Titinger DP, Lisboa LAF, Matrangolo BLR, et al. Cardiac surgery costs according to the preoperative risk in the Brazilian public health system. Arq Bras Cardiol 2015;105:130-8.
13. Pezzella AT. On Location – Vietnam (CTSNet website). October 16, 2017. Available at https://www.ctsnet.org/article/location-vietnam. Accessed September 1, 2020.
14. Kontchou NAT, McCrary AW, Schulman KA. Workforce Cost Model for Expanding Congenital and Rheumatic Heart Disease Services in Kenya. World J Pediatr Congenit Heart Surg 2019;10:321-7.
15. Roth GA, Johnson C, Abajobir A, et al. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol 2017;70:1-25.
16. Ekenze SO, Jac-Okereke CA, Nwankwo EP. Funding paediatric surgery procedures in sub-Saharan Africa. Malawi Med J 2019;31:233-40.
17. Jumbam DT, Vervoort D, Park KB. Development Assistance for Health in Low-Income Countries. JAMA 2019;322:1517-8.
18. Reddy CL, Peters AW, Jumbam DT, et al. Innovative financing to fund surgical systems and expand surgical care in low-income and middle-income countries. BMJ Glob Health 2020;5:e002375.
19. Vervoort D. National Surgical, Obstetric, and Anesthesia Plans: Bridging the Cardiac Surgery Gap. Thorac Cardiovasc Surg 2020;Mar 1:[Epub ahead of print].

Clinical Topics: Cardiac Surgery

Keywords: Health Expenditures, Developing Countries, Cost-Benefit Analysis, Cardiovascular Diseases, Gross Domestic Product, Rheumatic Heart Disease, Global Health, Prevalence, Hospital Costs, Public-Private Sector Partnerships, Operating Rooms, Developed Countries

< Back to Listings