We read with great interest “The 2025 Accra Declaration on Upskilling & Low-Cost Cardiac Surgery in Africa” by Yankah et al., which summarizes the deliberations of the 1st Pan-African Cardiothoracic Surgery Summit organized by the Pan-African Society of Cardiothoracic Surgery (PASCaTS). The summit convened key cardiovascular stakeholders from across the globe to share their vision for addressing the growing burden of cardiovascular disease across Africa. The declaration highlights central obstacles to expanding access to cardiac surgical care on the continent and proposes an ambitious framework to overcome them. We believe this coordinated effort represents a meaningful step toward meeting global unmet needs in cardiac surgery, and we commend all participants for their commitment and impactful work.
For decades, expanding access to cardiac surgery in African low- and middle-income countries (LMICs) has relied on a patchwork of dedicated efforts, led by dozens of nongovernmental organizations (NGOs) and international partnerships committed to the cause. Most of these initiatives operated at a small scale, often centered on a single institution, and spanned the spectrum from short-term visiting teams to long-term “north-south” capacity-building partnerships intended to foster sustainable, independent cardiac programs. The 2018 Cape Town Declaration, backed by all major cardiothoracic societies, signaled a shift toward a coordinated global effort to advance cardiac care and strengthen the training of local surgeons in African LMICs. Nevertheless, as Yankah and colleagues note, substantial disparities in access to cardiac surgical care persist. The Accra Declaration, informed by the clinical experience of PASCaTS members, offers an actionable framework aligned with local needs and the realities of African health systems.
Global health initiatives often stall when faced with 2 stubborn realities: the difficulty of securing sustained funding and the complexity of coordinating the many actors needed for system-wide reform. With this in mind, we believe that securing early traction will be essential to the Accra Declaration’s success. In our view, this is best achieved by focusing initial investments on the bottlenecks along the care pathway most likely to produce meaningful early gains.
Africa’s cardiac surgical workforce is far too small to meet the needs of its growing population, and expanding training capacity will be central to any long-term solution. In the near term, however, training more surgeons alone may not meaningfully increase surgical volume. Reported surgical rates suggest that the average cardiac surgeon in African LMICs may perform as few as twenty operations per year, significantly fewer than their counterparts in high-income countries. This figure echoes reports indicating that many African heart centers are constrained by limited funding and inefficient surgical supply chains. Addressing these barriers may be an effective first step toward increasing surgical volume.
Yankah et al. rightly call for addressing the prohibitive cost of cardiac surgery through both diversified funding and reductions in surgical expenses. While broadening funding streams is essential, achieving this across the fragmented landscape of more than fifty health systems may prove especially difficult. In our view, cost reduction represents the most actionable point of intervention; with surgical supplies, which constitute the majority of procedural costs in Africa, being the most logical place to begin. Similar approaches in China and India have been incredibly effective at reducing surgical costs and expanding access to cardiac surgical care. Logistics, then, become a pivotal determinant of success. Consolidated procurement and coordinated supply-chain strategies have already been used to powerful effect by NGOs in Africa, most notably during the AIDS and COVID-19 pandemics. Cardiac surgery initiatives can adapt these proven models to streamline the procurement and delivery of surgical supplies, expanding the capacity of existing cardiac surgery programs.
The Accra Declaration is an important and commendable step toward addressing the long-standing disparities in cardiac surgical access across Africa. We believe that an early focus on cost reduction can trigger a reinforcing cycle in which increasing procedural volumes drive additional efficiencies through scale. Greater volumes would not only improve clinical outcomes but also provide the throughput necessary to train new surgeons and ensure adequate caseloads for those entering practice. Early progress may, in turn, catalyze the broader engagement needed for sustained growth, helping to turn the Accra Declaration from a visionary statement into a practical roadmap for expanding cardiac surgical care across Africa.
CRediT authorship contribution statement
Ely Erez: Conceptualization, Writing– original draft. Cody W. Dorton: Writing– review & editing. J. Michael DiMaio: Supervision, Writing– review & editing.
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