Global Cardiac Surgery Capacity Development in Low and Middle Income Countries

Foreword I: Duke Cameron
Foreword II: Thiery Folliguet
Preface
Acknowledgment
About the Book
Contents
About the Editor
Global Surgery as the Neglected Stepchild of Global Health
1 History of Global Surgery
	Abstract
	1.1 Introduction
	1.2 The Foundations of Medical Missions
		1.2.1 Faith-Based Missions
		1.2.2 Short-Term Reconstructive Missions
		1.2.3 Self-Contained Surgical Platforms
		1.2.4 Specialty Surgical Hospital Missions: The Barsky Model
	1.3 Early Institutional Global Surgery Efforts
		1.3.1 The International Committee of the Red Cross
		1.3.2 Médecine Sans Frontieres—The Beginnings
	1.4 Early Policy Milestones
	1.5 The Evolution of Academic Global Surgery
	1.6 History of Early Ethics in Global Surgery
	1.7 Recent Global Surgery Policy Shifts
	1.8 National Surgical, Obstetric, and Anesthesia Plans
	1.9 Regionalization of Surgical Strategy
		1.9.1 Standardization of Metrics and Data Collection
	1.10 Conclusion
	Acknowledgements
	References
2 Global Surgery: From Grassroots Movement to Global Momentum
	Abstract
	2.1 Introduction
	2.2 Partnerships and Advocacy Organizations in Global Surgery
		2.2.1 The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC)
		2.2.2 The Lancet Commission on Global Surgery
		2.2.3 The G4 Alliance
		2.2.4 World Federation of Societies of Anaesthesiologist (WFSA)
		2.2.5 South-South Partnerships
			2.2.5.1 The West African College of Surgeons (WACS)
			2.2.5.2 The College of Surgeons of East, Central, and Southern Africa (COSECSA)
		2.2.6 Educational and Grassroots Partnerships in Global Surgery
			2.2.6.1 Harvard Medical School’s Program in Global Surgery and Social Change (PGSSC)
			2.2.6.2 Other U.S.-Based Educational Partnerships
			2.2.6.3 Student Organisations
		2.2.7 Ethical Considerations in Global Surgery Partnerships
	2.3 National Surgical, Obstetric, and Anaesthesia Plans
		2.3.1 Framework and Process
		2.3.2 Principles and Purpose
		2.3.3 Global Momentum
		2.3.4 Regional Momentum Towards a Global Movement
	2.4 Conclusion
	References
3 UHC Surgery and Anesthesia as Essential Components of Universal Health Coverage (WHA 68.15)
	Abstract
	3.1 Introduction
	3.2 Universal Health Coverage
		3.2.1 History of UHC: A Transition from MDGs to SDGs and the Expansion of IHP + 
		3.2.2 UHC as a Means to an End
	3.3 Surgery as Part of UHC
	3.4 Strategies to Achieve Universal Surgical Coverage
	3.5 Health Financing and Surgery Under the Umbrella of UHC
		3.5.1 Micro Health Insurance Systems
		3.5.2 Innovative Financing
		3.5.3 Universal Surgical Coverage and Financial Risk Protection
	3.6 The Role of Academia in Achieving Universal Surgical Coverage
	3.7 Barriers Towards UHC Coverage
	3.8 Conclusion
	References
4 Global Surgery Financing, Challenges and Possibilities
	Abstract
	4.1 Health as a Right and the Movement Towards Universal Health Coverage
	4.2 Scarce Resources, Delivery Failure and the Global Cost of Lack of Access to Surgery
	4.3 How Is Health and Surgical Care Paid?
	4.4 The Spark: How Surgical Programs Can Advance in Low Resource Settings
	4.5 The Long Run: How to Sustain Efforts in Surgical Services Delivery
	4.6 The Ecosystem
	4.7 Conclusion
	References
5 Leveraging Data Science for Global Surgery
	Abstract
	5.1 Background
	5.2 Global Health and Global Surgery
	5.3 The Necessity of Data-Driven Strategies
	5.4 Challenges of Data Collection in LMICs
	5.5 Opportunities for Technology and Data Science Approaches in LMICs
	5.6 Future Possibilities with AI
	References
6 Global Surgery Innovation at Academic Medical Centers: Developing a Successful Innovation Ecosystem
	Abstract
	6.1 Introduction
	6.2 Global Cardiac Surgery and the Need for Medical Innovation
	6.3 Medical Innovation in Limited Resource Settings—An Overview of Relevant Terminology
	6.4 Centers for Medical Innovation at Academic Medical Centers and Innovation Ecosystems
		6.4.1 Trainees and Training Programs
		6.4.2 Infrastructure
		6.4.3 Partnerships
		6.4.4 Funding and Innovation Networks
	6.5 Common Challenges in Global Surgery Innovation—Manufacturing and Ethical Concerns
	6.6 Conclusion
	References
7 The Role of Social Impact Innovation and Entrepreneurship in Global Health
	Abstract
	7.1 Introduction
	7.2 Healthcare Innovation Context
		7.2.1 Emerging Market Operating Environments
		7.2.2 Challenges for Emerging Market Healthcare Ventures
		7.2.3 The Impact of the COVID-19 Pandemic
			7.2.3.1 Balancing Local Resilience and Globalization
			7.2.3.2 Necessity Spurs Technology Adoption
			7.2.3.3 Consumer Power Rising
	7.3 The Role of Innovation Ecosystems
	7.4 Health System Innovation in Emerging Markets
		7.4.1 Innovation in Action: Case Studies of Global Healthcare Innovators
			7.4.1.1 Proximie—Winning Hearts and Minds with Industry Allies Around the Globe
			7.4.1.2 Smart Medical Care Services—Finding the Right Investors
			7.4.1.3 Bloomer Tech—Building Entrepreneurship Capacity at Academic Institutions
			7.4.1.4 HM Habib Cardiac Endowment Fund—Measuring Quality for Sustainable Innovation
	7.5 Blueprint for Social Impact Ventures and Ecosystem Players
		7.5.1 Social Impact Entrepreneurs: Essential Ingredients
			7.5.1.1 Resilience
			7.5.1.2 Focus on Mission and Values
			7.5.1.3 Systems Orientation
			7.5.1.4 Personal Motivation
			7.5.1.5 Local Ties
			7.5.1.6 Global Reach
		7.5.2 Innovation-Driven Ventures: Blending Ingredients for Success
			7.5.2.1 Identify and Fill Systemic Gaps
			7.5.2.2 Invest in Local Capacity
			7.5.2.3 Blend Technology with Human Intervention
			7.5.2.4 Focus on Business Models with Social Purpose
			7.5.2.5 Blend Local and Global
			7.5.2.6 Embrace Consumers
		7.5.3 Accelerating Regional Innovation Ecosystems for Healthcare Innovation
			7.5.3.1 Collaborate to Build Needed Capacities
			7.5.3.2 Involve Stakeholders in a Collective Ecosystem Approach
			7.5.3.3 Adopt New Mindsets
	7.6 Conclusion: Collaborating for Sustainable Healthcare Impact
	References
Cardiac Surgery as an Indispensable Component of Health Systems Strengthening
8 Global Cardiac Surgery and the Global Burden of Disease
	Abstract
	8.1 Introduction
	8.2 Rheumatic Heart Disease
	8.3 Congenital Heart Defects
	8.4 Ischemic Heart Disease
	8.5 Aortic Pathologies
	8.6 Other Cardiovascular Diseases
	8.7 Conclusion
	References
9 Monitoring, Evaluation, and Disease Surveillance for Cardiovascular Surgical Disease
	Abstract
	9.1 Introduction
	9.2 Disease Surveillance
		9.2.1 Importance of Surveillance
		9.2.2 Community-Level Screening
	9.3 Monitoring and Evaluation
	9.4 Diagnostics
	9.5 Conclusion
	References
10 Global and National Advocacy for Cardiac Surgery—Start with the Children
	Abstract
	10.1 Burden of Heart Disease in Children
	10.2 What Is Advocacy
	10.3 Global and National/Subnational Advocacy
	10.4 Advocacy for Children with Heart Disease
	10.5 Collaboration
	10.6 Challenges
	10.7 The Invisible Child Series
	10.8 Conclusion
	References
11 Costing and Health Systems Financing of Global Cardiac Surgery
	Abstract
	11.1 Introduction
	11.2 Cost of Cardiac Surgery
	11.3 Health Systems Financing
	11.4 Innovative Financing Instruments
	11.5 Cost Reduction Opportunities
	11.6 Conclusion
	References
12 The Global Cardiothoracic Surgery Workforce in 2020
	Abstract
	12.1 Introduction
	12.2 Describing the Landscape
	12.3 Changing the Landscape
	12.4 Conclusion
	References
13 Team-Based Care Along the Cardiac Surgical Care Cascade
	Abstract
	13.1 Introduction
	13.2 Team-Based Approach to Care
		13.2.1 Cardiologists
		13.2.2 Internists and General Practitioners
		13.2.3 Advanced Practice Providers
		13.2.4 Pharmacists
		13.2.5 Nurses
		13.2.6 Community Health Workers
	13.3 The Care Cascade
		13.3.1 Chronic Disease Management
		13.3.2 Primordial Prevention
		13.3.3 Primary Prevention
		13.3.4 Secondary Prevention
		13.3.5 Tertiary Prevention
	13.4 Health Systems Strengthening to Support Surgical CVD Care
		13.4.1 Health Workforce
		13.4.2 Health Service Delivery
		13.4.3 Access to Essential Medicines
		13.4.4 Health Information Systems
		13.4.5 Leadership and Governance
		13.4.6 Health Systems Financing
	13.5 Summary
	References
14 An Advanced Heart Team Model: Can It Be Adapted to Africa?
	Abstract
	14.1 Introduction
	14.2 UOHI Advanced Heart Team Concept
	14.3 Three Pillars–Clinical, Research, Education
		14.3.1 Clinical Practice Initiatives
		14.3.2 Research
		14.3.3 Education
	14.4 High Performance Teams
	14.5 Heart Teams in Reducing the CVD Burden in Africa
	14.6 Conclusion
	References
Bioethics, Education and Role of Societies in Global Cardiac Surgery
15 Ethical Considerations in Global Heart Surgery
	Abstract
	15.1 Allocation of Scarce Resources to Cardiac Surgery: The Ethical Perspective
	15.2 How Can I Help? Ethical Guidelines for Assisting in the Establishment of Cardiac Surgical Programs
		15.2.1 Ethical Guidelines for Cardiothoracic Surgery Global Health Initiatives
	15.3 Interaction with Local Providers
	15.4 Navigating Differences in Cultural Norms
	15.5 Conclusion
	Conflict of Interest Disclosure
	References
16 Role of Humanitarian Cardiac Surgery Missions in Developing the Next Generation of Global Surgeons
	Abstract
	16.1 Background
	16.2 Challenges to Incorporating Medical Students
	16.3 Surgical Mission Trips as an Investment into the Next-Generation of Global Cardiac Surgeons
	16.4 How Best to Prepare for Mission Trips?
	References
17 Role of Cardiothoracic Surgery Societies in Global Health Disparities
	Abstract
	17.1 Current State of Cardiac Surgical Disparities
	17.2 Global Cardiac Surgery
	17.3 Pitfalls of Humanitarian Surgery
	17.4 Successful Programs
	17.5 Future Perspective and the Role of CT Surgery Societies
	References
18 Deconstruct One, Document One, Simulate Many, Assess Many. Role of Simulation in Cardiac Surgery
	Abstract
	18.1 Introduction
	18.2 The Science of Learning
	18.3 The Domains of the MVS Project
	18.4 The Format of the MVS Project
	18.5 The Simulators of the MVS Project
	18.6 The Online Platform of the MVS Project
	18.7 The Assessments of the MVS Project
	18.8 The Profile of the Participants
	18.9 The Future of Simulation Versus the Future of Cardiac Surgery
	References
19 Utility of Simulation in Transthoracic and Transesophageal Echocardiogram-Based Training of a Cardiovascular Workforce in Low and Middle-Income Countries (LMIC)
	Abstract
	19.1 Introduction
	19.2 Ultrasound
		19.2.1 Point of Care Ultrasound (POCUS)
		19.2.2 Training
	19.3 Role of Simulators
	19.4 Static Simulation
		19.4.1 Workflow
		19.4.2 Limitations
	19.5 Live TEE Simulation
		19.5.1 Modes
		19.5.2 Limitations
	19.6 3D TEE Simulator
	19.7 Augmented Reality (AR)
		19.7.1 Limitations
	19.8 Curricula for Application of Simulation Technology
	19.9 Future Applications
	19.10 Conclusion
	References
20 Developing a Web-Based Curriculum for Radiology Sub-Specialty Training in Emerging Countries
	Abstract
	20.1 Overview: The Greatest Problem
	20.2 What to Avoid
	20.3 The Digital Solution
	20.4 Case Example: Ethiopia
	20.5 A Note on Digital Colonialism
	20.6 More Than eLearning: “Project Nobel”, A Model for Healthcare Workforce Capacity Building
	20.7 Application to Cardiovascular Care (Cardiac Echo Curriculum) and Future Perspectives
	20.8 Summary
	Acknowledgements
	References
Strategies for the Implementation of Sustainable Cardiac Surgery Programs
21 Echocardiography for Cardiac Surgeons
	Abstract
	21.1 Overview
	Bibliography
22 Anesthesia Considerations in Global Cardiac Surgery Capacity Development in Emerging Countries
	Abstract
	22.1 Introduction
	22.2 Preoperative Anesthetic Management
		22.2.1 Preoperative History
			22.2.1.1 Diabetes Mellitus
			22.2.1.2 Systemic Hypertension
			22.2.1.3 Atherosclerotic Disease of the Carotid Arteries
			22.2.1.4 Pulmonary Disease
			22.2.1.5 Renal Insufficiency
			22.2.1.6 Anemia
		22.2.2 Preoperative Medications
		22.2.3 Physical Examination
		22.2.4 Preoperative Laboratory Evaluation
	22.3 Intraoperative Anesthetic Management
		22.3.1 Premedication
		22.3.2 Monitoring
			22.3.2.1 Standard Monitors
			22.3.2.2 Blood Pressure Monitoring
			22.3.2.3 Cardiac Output Monitoring
			22.3.2.4 Temperature Monitoring
			22.3.2.5 Brain Monitoring
		22.3.3 Induction and Maintenance of Anesthesia
		22.3.4 Intraoperative Anesthetic Management Prior to Cardiopulmonary Bypass
	22.4 Intraoperative Transesophageal Echocardiography
		22.4.1 Training Requirements for TEE Certification
			22.4.1.1 National Board of Echocardiography [46]
			22.4.1.2 European Association of Cardiovascular Imaging [47]
	22.5 Cardiopulmonary Bypass
		22.5.1 Weaning from Cardiopulmonary Bypass
		22.5.2 Intraoperative Problems After Cardiopulmonary Bypass
			22.5.2.1 Problems with Cardiac Function
			22.5.2.2 Hypotension and Hypertension
			22.5.2.3 Excessive Hemorrhage
			22.5.2.4 Metabolic Abnormalities
			22.5.2.5 Pulmonary Dysfunction
	22.6 Transport to ICU
	22.7 Pain Control
	22.8 Enhanced Recovery After Cardiac Surgery
	22.9 Future Perspectives
	References
23 Cardiopulmonary Considerations for Cardiac Surgery in Low and Middle Income Countries
	Abstract
	23.1 Brief History of CPB
	23.2 CPB Hardware Including Oxygenator and Pump
	23.3 Hemodilution and Priming Solutions
	23.4 Conduction of CPB
	23.5 Troubleshooting During CPB and Management
	23.6 Deep Circulatory Arrest
	23.7 Non-cardiac Use of CPB
	23.8 Heparin-Protamine Axis
	23.9 Perioperative Cell Salvage
	23.10 Brief: Off Pump CABG Role of a Perfusionist
	23.11 IABP, VADS, ECMO
	23.12 Checklists
	References
24 PEN-Plus Strategies I: Decentralizing and Integrating Preoperative Medical Management, Cardiac Surgery Screening, and Referral
	Abstract
	24.1 Introduction
	24.2 PEN-Plus Model for Decentralizing NCD Care Including Heart Failure and Cardiac Surgical Screening
	24.3 Preoperative Evaluation and Planning
	24.4 Procedural Considerations
	Acknowledgements
	References
25 PEN-Plus Strategies II: Decentralizing and Integrating Postoperative Management and Anticoagulation
	Abstract
	25.1 Introduction
	25.2 Routine Management
		25.2.1 Heart Failure
		25.2.2 Anticoagulation
			25.2.2.1 Initiating Warfarin
			25.2.2.2 Anticoagulation Monitoring and Titration in Rural LMIC Settings
		25.2.3 Penicillin Prophylaxis
		25.2.4 Family Planning
	25.3 Management of Ongoing Complications
		25.3.1 Endocarditis and Fever in Patients with Prosthetic Heart Valves
		25.3.2 Sternal Wound Infection and Dehiscence
		25.3.3 Pericardial and Pleural Effusions
		25.3.4 Atrial Fibrillation
		25.3.5 Valve Thrombosis
		25.3.6 Valve Dehiscence
		25.3.7 Hemolytic Anemia
	25.4 Other Considerations
		25.4.1 Cardiac Rehabilitation
		25.4.2 Nutritional Support
		25.4.3 Socioeconomic Support
		25.4.4 Mental Health Support
	Acknowledgements
	References
26 Establishing and Expanding Cardiac Surgery Centers
	Abstract
	26.1 Introduction
	26.2 Components of Cardiac Centers
	26.3 Existing Models to Establish Center
	26.4 Opportunities for New Models
	26.5 Conclusion
	References
27 Nuts and Bolts of Establishing a Contemporary Global Cardiac Surgery Program
	Abstract
	27.1 Introduction
	27.2 Identifying Need: Rules of Engagement
	27.3 Site Assessment and Scout Visit
	27.4 Team Composition and Logistics
	27.5 Before the First Surgery
	27.6 After the First Mission
	27.7 Conclusion and Key Points
	Acknowledgements
	References
28 Cardiac Surgery Capacity Development in Emerging Countries
	Abstract
	28.1 Introduction
	28.2 The Global Burden of Cardiac Disease
	28.3 Pulmonary Disease and the Unmet Need for Surgery
	28.4 Proposed Way Forward for Global Cardiothoracic Surgery in Low-and-Middle Income Countries
	28.5 Scaling Up Surgical Programmes
	28.6 Cardiothoracic Anaesthesia
	28.7 Continuity of Care
	28.8 Fellowship Programs, Collaboration and Education
	28.9 Research and Perioperative Databases
	28.10 Prevention
	28.11 Access to Care
	28.12 Simulation Laboratory
	28.13 Surgical Workforce, Diversity and Inclusion
	28.14 Conclusion
	References
29 Development of Sustainable Global Thoracic Surgery Programs in LMICs
	Abstract
	29.1 Burden of Thoracic Surgical Disease
		29.1.1 Chronic Respiratory Disease
		29.1.2 Pulmonary Infections
		29.1.3 Malignancy
		29.1.4 Trauma
	29.2 Current Barriers and Solutions
		29.2.1 Imaging Techniques
		29.2.2 Anesthesia Techniques
		29.2.3 Postoperative Care
		29.2.4 Pathology
		29.2.5 Workforce
	29.3 Existing Models for Thoracic Surgery Program Building
		29.3.1 Malawi Surgical Initiative
		29.3.2 Tenwek Hospital—Bomet, Kenya
		29.3.3 Human Resources for Health
	29.4 Future Directions
	References
Leveraging Digital Health Technologies in Augmenting Cardiac Surgery Capacity
30 Digital Technology’s Role in Addressing the Social Forces Impacting Cardiovascular Health
	Abstract
	30.1 Introduction
	30.2 Defining the Social Determinants of Health
	30.3 Factors Influencing Health Outcomes
	30.4 Healthcare Access and Quality
	30.5 Social and Community
	30.6 Economic Stability
	30.7 Education Access and Quality
	30.8 Environment
	30.9 Behaviour and Lifestyle
	30.10 Digital Behaviour
	30.11 Provider Perspectives on SDH
	30.12 Conclusions
	References
31 Emerging Opportunities for Sustainable Digital Health Enhanced Care Delivery Models for Improved Cardiovascular Surgery Outcomes
	Abstract
	31.1 Introduction
	31.2 Digital Health Overview
	31.3 Models of Digital Health Care Delivery
		31.3.1 Avatars for Preceptorship and Mentorship
		31.3.2 Portable Ultrasound and Hand-Held Electrocardiogram Imaging
		31.3.3 Robotic Cardiac Surgery
		31.3.4 Chronic Disease Management via Telehealth/ Telemedicine
	31.4 Conclusions and Discussion
	References
32 The Role of Technology and Innovation
	Abstract
	32.1 Introduction
		32.1.1 The Value of Technology and Innovation
		32.1.2 The Considerations and Challenges of Technology and Innovation
	32.2 Human Resources
		32.2.1 Improving the Minimum Quality Standard
		32.2.2 New Training Methods
		32.2.3 New Relationships
		32.2.4 New Career Opportunities
		32.2.5 Future Developments
		32.2.6 Improving the Maximum Quality Standard
	32.3 Physical Resources
		32.3.1 Technology Development
		32.3.2 Clues of Successful DevelopmentClues of Successful Development
		32.3.3 Helpful Resources and Support
		32.3.4 Where Does Development Occur?
		32.3.5 Who Is Involved in Development?
		32.3.6 How Does Development Occur?
		32.3.7 Technology Implementation
		32.3.8 Accreditation and Procurement
		32.3.9 User Uptake
	32.4 Summary
	References
33 Augmented, Virtual and Robotic Capabilities in Cardiovascular Program Capacity Building
	Abstract
	33.1 Capacity Building as a Part of Overall Health System Strengthening
	33.2 Examples of emerging technologies
		33.2.1 Extended Reality
			33.2.1.1 Extended Reality in Education and Training
			33.2.1.2 Extended Reality for Surgical and Interventional Procedures
			33.2.1.3 Robotics in Cardiovascular Care
	33.3 Acceleration of Technology Adoption for Capacity Building During Pandemic
	33.4 Technology Coupled with Ecosystem Partnerships
	References
34 Establishing National Telehealth Service in a Lower Middle-Income Country—the Ghana Model
	Abstract
	34.1 Definition
	34.2 Case Study One
		34.2.1 Ghana Telemedicine Project (GTP)
			34.2.1.1 Workflow of GTP
			34.2.1.2 Opportunities for Increased Access
		34.2.2 GHS Telehealth Program
			34.2.2.1 System Strengthening Using Ghana Telehealth Services
			34.2.2.2 Service Delivery Using Ghana Telehealth Services
			34.2.2.3 Components and Range of Telehealth Services
		34.2.3 Key Projects Under Ghana Telehealth Program
			34.2.3.1 Modalities for Telehealth Service Delivery
			34.2.3.2 Upgrade Implementation
			34.2.3.3 Implementation of Telehealth Service Delivery Technology Upgrade
			34.2.3.4 Clinical Decision Support System for Telehealth
		34.2.4 Reimbursement
			34.2.4.1 Health Insurance
			34.2.4.2 Micro Insurance in Healthcare
		34.2.5 The Way Forward in Telehealth Reimbursement
			34.2.5.1 NHIS Reimbursement of Telehealth Services
			34.2.5.2 Private Health Insurance Reimbursement of Telehealth Services
			34.2.5.3 Telehealth Reimbursement with Micro Health Insurance
			34.2.5.4 Reimbursing Telehealth with Payment for Services and Grant Support
		34.2.6 Evaluation of Telehealth in Ghana
	References
Cardiology and Cardiothoracic Surgery—A Global Perspective
35 The Story of Rheumatic Heart Disease in Rwanda: Capacity Building for Comprehensive Cardiovascular Care
	Abstract
	35.1 RHD as a Disease of Poverty
	35.2 Scope of the Disease
	35.3 The Genocide Against the Tutsi and the Rwandan Health System 
	35.4 Strategic Direction for Eradicating RHD in Rwanda
	35.5 Recommendations 
	35.6 Challenges 
	35.7 Innovation and Technology: Telemedicine as a Way Forward to Improve Cardiovascular Health in Resource-Constrained Settings 
	35.8  Team Heart and Rwanda’s Race to Establish Cardiac Surgery to Address the Surgical Burden of RHD; It Is Not Just About Surgery
	35.9 Conclusion
	References
36 Telecardiology in Ghana: Perspectives from Korle Bu Teaching Hospital and Cardiovascular Diagnotics Clinic
	Abstract
	36.1 Introduction
	36.2 History of Telecardiology in Ghana
	36.3 Technology
	36.4 Wearable Devices
	36.5 Teleechocardiography with Kosmos Echonous
	36.6 Artificial Intelligence Enabled Hand Held Tablet Echochardiography (KOSMOS ECHONOUS)
	36.7 Future Perspectives
	References
37 Developing a Sustainable High-End Cardiovascular Surgery Program in Emerging Economies: The Narayana Health (NH) Model Structured on Affordable, Accessible, Tertiary Level Care
	Abstract
	37.1 Introduction
	37.2 Economies of Scale (Micro Health Insurance, Assembly Line Surgery)
	37.3 Converting Atoms into Bytes (Telemedicine, Holter Monitoring and Portable EHR)
	37.4 Data Intelligence
	37.5 Electronic Health Systems (EHS)
	37.6 Training for the Future
	37.7 Scaling into Other Territories (the Caribbean Story)
	37.8 Conclusion
	Acknowledgements
	References
38 Cardiac Surgery and Interventional Cardiology Capacity Development: Insights from Ethiopia and Côte d’Ivoire
	Abstract
	38.1 Introduction
	38.2 Background: Ethiopia and Côte d’Ivoire at a Glance
	38.3 A Brief History and Current Status of Cardiac Service in Ethiopia and Côte d’Ivoire
	38.4 Implementation of a Team-Based Collaborative Capacity-Building Model
	38.5 A Team-Based Collaborative Capacity-Building Model in Ethiopia
	38.6 A Team-Based Collaborative Capacity-Building Model in Côte d’Ivoire
	38.7 Lessons and Challenges
	38.8 Future Direction
	Acknowledgements
	References
39 Global Cardiac Surgery in China: 23 Years of Mission Work
	Abstract
	39.1 Growth in China
	39.2 Cardiovascular Disease Burden
	39.3 First Visits
	39.4 Expanding the Scope
	39.5 Getting Organized
	39.6 Training in Cardiac Surgery
	39.7 Lessons Learned
	References
40 Establishing a Congenital Cardiac Program-Pakistan Model
	Abstract
	40.1 Introduction
	40.2 Burden of Disease
	40.3 Screening
	40.4 Diagnosis
	40.5 Limitations
	40.6 Current Model and Status of CHD Programs
	40.7 Interventional Program
	40.8 Cardiac Surgery
	40.9 Financial Model
	40.10 Brain Drain
	40.11 Capacity Building
	40.12 Challenge for the Future
	Acknowledgements
	References
Index