**2. Historical aspects**

In Nigeria, a foreign cardiac team with a local team performed the first open heart surgery in our institution, University of Nigeria Teaching Hospital (UNTH), Enugu, in 1974. UNTH is the teaching hospital for the Federal Government of Nigeria and is affiliated to University of Nigeria, Nsukka. Foreign cardiac team was led by a British-Egyptian Surgeon, Sir (Dr) Magdi Yacoub, and indigenous team was led by late Professor Fabian Udekwu. This singular act added to many others attracted the attention of the Federal Military Government of Nigeria, which designated it the National Cardiothoracic Center of Excellence (NCTCE) in 1984.

Adult cardiac surgery was the main focus of the program. The hospital stood by her deeds and was able to establish itself, as the leader in open heart surgery not only in Nigeria but also in West African subregion [1]. Afterward, the center's activities decreased due to poor military governance and corruption. The near total neglect of healthcare system (HCS) in the country led to the collapse of the center due to brain drain and inadequate facilities such that between 1974 and 2000, only a total of 102 open heart operations were carried out, mainly by local team [1].

With return to civilian rule in Nigeria in 1999, efforts were made to improve the center through Foreign Cardiac Mission Model. The first mission was by International Children Heart Foundation (ICHF) in 2003 under the sponsorship of Kanu Heart Foundation. Incidentally, that mission was the first pediatric mission, and William Novick (International Cardiac Foundation) was the lead surgeon. The team visited once and performed mainly pediatric cases for the first time at the center. Other international cardiac missions started visiting 10 years later and became regular with more frequent visits every year [2]. Options considered toward sustenance of pediatric cardiac surgery were staff training and equipment procurement. One way to achieve the desired training in emerging country like ours is by regular and frequent visits to centers such as NCTCE by foreign cardiac teams and performing the surgery alongside the local team (cardiac mission model) [3–5]. Other options include sending the local team to established centers, for example, India for hands-on training for a period not less than 2 years. Furthermore, members of the local team individually went for training abroad on their personal arrangement at different times and in different established centers.

The cardiac mission model would not even have been possible without the aids from some agencies of the Federal Government of Nigeria, Nigerians in Diaspora, public spirited individuals, and foreign organizations as shown in **Table 1**. Most of the countries in West African subregion are very poor, and a study by Edwin F et al. showed that no existing cardiac center in the subregion came into being without huge governmental support [6].

Good things that go for foreign mission team include high technical skill and team work in contrast to what is obtainable on the ground. Treating patients locally in this method is cheaper and serves as workshop and training session for different categories of workers at minimal cost to the institution. However, model of cardiac missions is not a sustainable one because a lot of effort and expenditure are allocated toward surgery on a few patients [7].

The adoption of cardiac mission model by developing countries such as Nigeria as a way of helping indigent patients with both congenital and acquired heart diseases is good. However, that method is like giving someone a fish anytime he demands it. The best way is to incorporate teaching the person how to fish, that is, developing and equipping local team. It is only in this way will establishing pediatric cardiac center across the low- and middle-income countries become sustainable.

Pediatric cardiology and pediatric cardiac surgery practices in Nigeria are taxing [8, 9]. Getting all the requirements to cater for the surgical needs of a very *Establishing Sustainable Pediatric Cardiac Surgery Program in Nigeria: Challenges and Prospects DOI: http://dx.doi.org/10.5772/intechopen.102737*


#### **Table 1.**

*Some collaborations took place both locally or outside your country in helping capacity building but help will also be needed in some aspect.*

large number of children with congenital heart defects with its attendant financial constraints, poor funding from the government is really a huge task.

Pediatric cardiology and pediatric cardiac surgery training in Nigeria involve the management of different cardiac diseases in children. This covers children with both congenital and acquired heart disease [10]. This also includes arrhythmias and coronary heart diseases. Besides, interventional cardiology practice is really at the primordial phase with less than three teaching hospitals providing the skills and competences all over the country [10].

Even the foreign missions that come occasionally could not provide the necessary skills of all the surgical intervention as they spend few days and may not inculcate such skills to the local surgeons within few days of stay.

**Infrastructure problems, non-availability of high technology**: The equipment used for heart surgery in Nigeria is imported from other countries. Virtually all the drugs are also imported. Prostheses and other consumables are imported, and their cost is quoted in US Dollars or Naira equivalent. With the heavy devaluation of Nigerian currency, many of these items are lacking or beyond reach. Therefore, the team has to improvise, but this state of affairs leads to poor outcome.

**Human resources, team members**: The practice is a team work, and the team members include pediatric cardiac surgeons, pediatric cardiologists, pediatric cardiac anesthetists, cardiac interventional radiologists, clinical perfusionists, medical laboratory scientists, and pharmacists. Other members are physiotherapists, perioperative nurses, cardiothoracic nurses, intensive care unit nurses, and equipment technicians. Human resources are not adequate locally trained and pediatric cardiac surgeons are not sufficiently skilled to handle complex congenital cardiac defects.

**Training/skill acquisition**: Every member in this team requires some skill to fit into the team, but our local training program leaves room for vital overseas exposure. Currently, there is neither perfusion school nor equipment training center in Nigeria that will produce manpower that will operate high-tech equipment or trouble shoot malfunction, respectively. Surgical management of heart disease is not a trial-anderror program. Every member of the team is expected to be proficient in his/her area. If mistake is made, the patient suffers. Only correct actions at every stage of the management will produce good outcome. There is need for further training or continuing education, research, workshop, seminar, and recertification. In the absence of these, the workers will become outdated. No member of the team should grow weary of this exercise, and this is where a leader with vision is needed.

Pediatric cardiac surgery program requires enormous resources and commitment to establish. Training of cardiac anesthetist like every other personnel in the team requires enormous funds. This is because the training is done abroad [11].

Training and retraining are also necessary in order to prevent attrition. Attrition therefore constitutes a big problem as the volume of cardiac surgery carried out in Nigeria is very small compared with the burden of pediatric cardiac disease in the country. Training or upgrading the education of the pediatric cardiac team, massive training of core personnel for pediatric cardiac surgery and pediatric cardiologist will enable the work to be self-sustaining as their services will be patronized by both locals and foreigners. Funds will be generated as is done in other heart centers in India, America, etc.

There are three main methods of acquiring training. It could be by an institution sending a team to undergo training in another institution. The second option involves *Establishing Sustainable Pediatric Cardiac Surgery Program in Nigeria: Challenges and Prospects DOI: http://dx.doi.org/10.5772/intechopen.102737*

inviting experts to come and train the local personnel on the job while the third option is for individuals to scout for training positions anywhere by themselves.

Another good alternative is to engage a cardiac team from a good cardiac center to work with the locals on continuous basis until skill transfer is achieved. This will be cost-effective, and more patients will receive care while skill acquisition will take place smoothly [11].

**Financing of equipment/supply of equipment**. Equipment is usually procured through tenders by government, but one noticeable problem is the dumping of unserviceable and outdated equipment at the hospital, by fraudulent contractors and their collaborators. The end user more often than not is not in the picture although the pediatric cardiac surgery is equipment-driven. Many of the equipment in use now are computer-based, but computer illiteracy is pervasive, resulting in poor handling and subsequent breakdown of these sophisticated and expensive machines.

Monitoring in cardiac anesthesia is pivotal to the success of cardiac surgery [12]. Monitoring equipment is expensive, and for a country such as Nigeria, acquisition of these equipment is difficult to come by. This equipment ranges from anesthesia work station, ultrasound, transesophageal echocardiography, multiparameter monitor, cardiac output monitor, I-Stat machine for point of care test in the operation theater, and intensive care unit. Other equipment include syringe pump, infusion pumps, blood warmer, etc.

**Disposables/consumables** are equally as important as non-availability of central venous catheters, arterial cannula, transducers; pressure tubing, etc., can prevent successful surgery. These consumables can be secured by the hospital management if she is committed to the sustainability of the program. Non-availability of drugs is also an impediment to cardiac surgery in Nigeria as some of the required drugs are not approved by the National Food and Drug Administration agency (NAFDAC). Some opioids and inotropes are not readily available, and this makes patient management difficult**.**

Procurements through competitive bidding: The prices are usually overinflated owing to the fact that contractors are owed for a period between 1 and 2 years. This adds to the high cost of pediatric cardiac surgery in Nigeria. Some cardiac missions such as Cardiostart International, William Novick cardiac Alliance, VOOMF, Savea-heart Nigeria, ICHF/Kanu Heart foundation brought consumables during visits. These are, however, not usually enough.
