Abstract
The National Cardiothoracic Centre at the Korle Bu Teaching Hospital stands as a premier institution for cardiothoracic surgery in Ghana and West Africa. Established in 1989 under the leadership of Prof. Kwabena Frimpong-Boateng, the Centre recently celebrated 35 years of advancing modern cardiothoracic surgery in Ghana. The Centre also serves as an accredited training hub for cardiothoracic surgeons, critical care nurses and other allied health professionals in the West African sub-region. Over the past 35 years, the Centre has undertaken 14,981 surgeries and other cardiac procedures for Ghanaians and other African countries. The centre has also locally trained a total of 30 cardiothoracic surgeons for Ghana, Nigeria and Ethiopia, and has recently commenced training its first surgeon for the Gambia. Among the Centres’ challenges are infrastructural deficit, limited health financing, human resource deficit and technological gaps. This narrative review highlights the Centre’s 35 years of existence, its contributions to the cardiothoracic surgical landscape in West Africa, challenges and its future directions.
Background
Thirty-five years in the life of any institution represents a significant milestone, marking the transition from one generation of development to the next. The National Cardiothoracic Centre (NCTC) in Accra, Ghana, recently celebrated this milestone under the theme, ‘Cardio at 35 – A Legacy of Excellence, A Future of Perfection,’ highlighting the Centre’s evolution over the past 35 years. The occasion focused on the Centre’s development and its prospective position as a premier institution for cardiovascular care in the sub-region. This review encompasses the NCTC’s founding goals, operational challenges, institutional resilience and sustained commitment to advancing cardiothoracic surgery and related disciplines. 1 The narrative review also highlights the contributions of the Centre’s founder and first director, Prof. Kwabena Frimpong-Boateng, whose leadership was instrumental in the establishment and early development of cardiothoracic surgery in Ghana. 2
History of cardiothoracic surgery in Ghana
The history of cardiothoracic surgery in Ghana originates in the 1960s when Prof. Charles Easmon performed the inaugural closed mitral commissurotomy. This treatment was a pivotal achievement for the practice of medicine and surgery in Ghana.
Building on this foundation, Prof. Easmon performed Ghana’s first open-heart surgery utilising surface cooling to induce hypothermia. This opened new possibilities for treating more complex heart conditions in Ghana. 3
The period between 1972 and 1975 marked a significant expansion in thoracic surgical capabilities, driven by the contributions of multiple pioneering surgeons. Prof. Lade Wosornu, a general surgeon, performed oesophagectomies (removal of part of the oesophagus), pleural decortications (removal of scar tissue from the lungs) and thoracoplasties (surgical procedures to chest wall deformities resulting from lung disease). Around the same period, Prof. Edward D. Yeboah, a urologist with thoracic surgery experience, performed ligations of patent ductus arteriosus (PDA).
The arrival of Dr Seth Bekoe, Ghana’s first surgeon with specialised training in cardiothoracic surgery, marked further progress. After his training in Italy, Dr Bekoe performed coarctation repairs (correcting narrowed sections of the aorta), PDA ligations and the construction of Blalock-Taussig shunts – life-saving procedures for children with Tetralogy of Fallot, a complex congenital heart defect. These procedures represented a significant improvement in the complexity and sophistication of cardiac surgery available in Ghana at the time. 3
In 1989, Prof. Frimpong Boateng returned from his training in general, cardiothoracic and vascular surgery in Hanover, Germany. His return marked the beginning of modern cardiothoracic surgery in Ghana, culminating in the establishment of the NCTC – a dedicated facility that would serve as the hub for advanced cardiac care in Ghana. In 1992, he became the first surgeon in Ghana to use a heart–lung machine for cardiac surgery, performing Ghana’s first mitral valve replacement. 3 This achievement represented not just a surgical success but the arrival of Ghana into the realm of modern cardiac surgery. Table 1 provides a summary of key milestones in the history of cardiothoracic surgery in Ghana.
Annotated history of cardiothoracic surgery in Ghana.
Source: Extracts from Tettey et. al. (2016). 3
Honouring Prof. Kwabena Frimpong-Boateng
Prof. Kwabena Frimpong-Boateng is recognised for his role in establishing and developing the NCTC in Ghana in 1989.3,4 Through his leadership and dedication, the Centre has become a key institution for advancing cardiothoracic surgery and related medical training in the country. His contributions laid the foundations for the growth of modern cardiothoracic surgery in Ghana, providing opportunities for many medical professionals to enhance their skills and pursue specialist training. As one of Ghana’s prominent medical pioneers, his work has had a considerable impact on healthcare development from the 20th century into the early 21st century. Since its establishment 35 years ago, the NCTC has become a key centre in the Korle Bu Teaching Hospital.
In recognition of his contributions, the management and staff of the centre commissioned a bust in his honour at the NCTC (Figure 1).
Bust of Prof. Kwabena Frimpong-Boateng at the entrance of the national cardiothoracic centre unveiled during the 35th anniversary celebration.
Additionally, Prof. Frimpong-Boateng founded the Ghana Heart Foundation to provide financial assistance to patients requiring heart surgery. This initiative was introduced to address the economic barriers posed by the high cost of cardiothoracic procedures, a challenge faced globally and particularly significant in Ghana’s socioeconomic context.
Throughout its history, four (4) directors have guided the Centre’s operations. Table 2 provides details of the leadership of the centre since its inception.
Directors of the national cardiothoracic centre since its inception.
Source: National Cardiothoracic Centre: 35th anniversary brochure. 5
Political and administrative support
In the early years, the NCTC faced significant challenges in establishing itself within Ghana’s healthcare system. In this period, the then Head of State and Chairman of the Provisional National Defence Council (PNDC), Flt. Lt Jerry John Rawlings and his spouse, Her Excellency Nana Konadu Agyeman-Rawlings, provided political and financial support that facilitated the transformation of the Cardiothoracic Unit into an independent centre of excellence. Successive governments have continued to demonstrate commitment to the progress and sustainability of the Centre. The contributions of former presidents of Ghana – John Agyekum Kufour, the late John Evans Atta Mills, John Dramani Mahama and Nana Addo Danquah Akuffo Addo – have been instrumental in reinforcing institutional capacity and promoting the Centre’s growth.
A legacy of excellence
The NCTC has established a distinguished excellence over its 35 years of operational history. The institution’s trajectory from 1989 to 2024 highlights several important themes in medical development, including the catalytic role of pioneering clinical leadership, the strategic value of international training partnerships and collaborative networks, the steady expansion of institutional capacity and the essential contribution of governmental support in the development of specialised medical capabilities. This historical progression has yielded substantial public health impact through improved cardiovascular surgical outcomes and positioned Ghana as a regional centre of excellence in cardiothoracic surgery, inspiring similar developments across West Africa and beyond. 4 We examine the Centre’s accomplishments in workforce training and clinical service delivery, while critically assessing persistent operational challenges.
Training
The NCTC remains the only facility in West Africa fully accredited by the West African College of Surgeons (WACS) for cardiothoracic surgery training, serving as a regional hub for clinical services, education and research across neighbouring countries, including Nigeria, Sierra Leone, Gambia, Liberia, Burkina Faso and Togo.4,6,7 This status reflects the sustained excellence and discipline of its staff, establishing the NCTC as a leading academic and service institution in a resource-limited setting. 3 As of the April 2024 fellowship examinations of the West African College of Surgeons, the Centre had trained a total of 30 cardiothoracic surgeons: one surgeon for Ethiopia, 12 for Ghana and 17 for Nigeria (Table 3).
Surgeons trained since the establishment of the national cardiothoracic centre, as of April 2024 examination.
Courtesy: The West African College of Surgeons.
Currently, five Ghanaians and one Nigerian are in training, with regional expansion evidenced by the first Gambian trainee admitted in January 2024, and plans to train surgeons for Sierra Leone and Liberia. Beyond surgical training, the Centre also functions as the specialised training hub for cardiothoracic anaesthesia, critical care and peri-operative nursing in the sub-region. 4
Clinical services and impact
Since its establishment, the NCTC has made substantial contributions to addressing the burden of cardiovascular and thoracic disease, which represents the leading causes of morbidity and mortality in sub-Saharan Africa.8,9 As of 31st July 2024, the Centre had performed 14,981 surgical and other interventional procedures, served predominantly Ghanaian patients while also functioning as a regional referral centre for patients from neighbouring West African nations and countries as far as Ethiopia. This demonstrates the Centre’s critical role in filling a significant healthcare gap in the West African region, where access to specialised cardiovascular services remains very limited. Studies have documented that many African countries have fewer than one cardiac surgeon per million population, necessitating cross-border referrals for patients requiring specialised cardiac interventions.10,11
Vascular procedures constituted the largest proportion of the centre’s surgical activity, accounting for 5741 (38% of total procedures). This predominance reflects the substantial burden of peripheral vascular disease in Ghana and West Africa, driven by the increasing prevalence of cardiovascular risk factors including diabetes mellitus, hypertension and dyslipidaemia.8,12,13
By contrast, paediatric thoracic surgical procedures represented the smallest component of the Centre’s case volume, with 623 (4% of total procedures) (Figure 2). While this represents a relatively modest number in absolute terms, these procedures address critical conditions in children, including congenital thoracic malformations, chest wall deformities, empyema thoracis, mediastinal masses and thoracic trauma. The development of paediatric thoracic surgical capacity in sub-Saharan Africa has been identified as a priority area, given the substantial burden of childhood respiratory disease and the limited availability of specialised paediatric surgical services across the continent.14,15
Distribution of services rendered as of July 2024.
The remaining procedures – including adult cardiac surgery, paediatric cardiac surgery, cardiac catheterisation, interventional cardiology procedures and adult thoracic surgery – collectively account for approximately 58% of the Centre’s surgical and interventional volume. This diverse case mix reflects the comprehensive nature of cardiovascular and thoracic services provided at the NCTC, encompassing both congenital and acquired cardiovascular disease, structural heart interventions and thoracic oncological and infectious diseases. 3
In addition to the quantitative assessment of procedural volume, the NCTC has acted as a catalyst for healthcare innovation and capacity enhancement within Ghana’s health system. The Centre has initiated numerous specialised cardiovascular services that were previously inaccessible in Ghana and the wider West African region. This institutional innovation has produced multiplicative effects by training specialised healthcare professionals, developing clinical protocols and quality standards and illustrating the feasibility of providing intricate cardiovascular care in resource-limited African environments. 4 The establishment of subspecialised services, including interventional cardiology, electrophysiology, advanced heart failure management and minimally invasive cardiac surgery, signifies important milestones in the development of healthcare in Ghana. The expansion of these services has increased therapeutic options for Ghanaian patients, reduced reliance on international medical referrals and facilitated the retention of healthcare expenditure within the national economy. 3
Current challenges of the centre
Despite the achievements enumerated above, the Centre is plagued with significant challenges that impede its effective functioning. These include human resource deficits, small physical space, limited health financing and technology gaps.
Human resource deficits
The NCTC faces a significant shortage of human resources across all staff categories, a challenge consistent with broader patterns observed in healthcare systems across sub-Saharan Africa.16,17 Due in large part to a high attrition rate of highly skilled healthcare workers to high-income countries – a phenomenon that is well documented in the literature on medical brain drain from developing countries.17,18 The migration of skilled healthcare workers from low- and middle-income countries to Western nations has been identified as a critical factor undermining health system capacity in resource-limited settings.
Table 4 presents a comprehensive analysis of human resource deficits across key personnel categories at the NCTC, revealing substantial gaps between optimal staffing levels and current workforce capacity.
Statistics of key personnel at the national cardiothoracic centre 2024–2025.
Source: Human resource records at the National Cardiothoracic Centre, Accra.
The data reveal particularly concerning deficits in critical care nursing (70% shortfall), general nursing (63% shortfall) and specialist physician categories. The complete absence of paediatric anaesthesiologists and intensivists at the post represents a critical gap in service delivery capacity, particularly for high-acuity paediatric cardiac cases. These staff shortages are consistent with broader trends in sub-Saharan African cardiac surgery programmes, where inadequate human resources remain a primary barrier to expanding access to life-saving cardiovascular interventions.11,17,19
The magnitude of human resource deficits documented at the NCTC underscores the urgent need for innovative multi-faceted retention strategies that extend beyond conventional approaches. In response to these challenges, the NCTC has identified initiatives to enhance both monetary and non-monetary incentives for staff retention. Evidence suggests that effective retention strategies in resource-constrained healthcare settings must address multiple factors beyond salaries, including professional development opportunities, improved working conditions and career advancement pathways. 18 Non-financial incentives such as continuing education, recognition programmes and improved work environments can be particularly effective in retaining healthcare professionals in developing country contexts. 18
In lieu of this, the NCTC is actively sponsoring and supporting the training of personnel. This investment in human capital development aligns with WHO recommendations for strengthening workforce capacity through targeted training and education programmes. 20 Such capacity-building initiatives are essential for specialised tertiary care facilities, where highly trained personnel are required to deliver complex cardiovascular and thoracic surgical services.
Additionally, addressing these workplace challenges will require sustained investments in training programmes, improvements in working conditions and infrastructure and policy interventions at the national level to create an enabling environment for healthcare workforce retention. Without concerted efforts to address these human resource constraints, the Centre’s capacity to fulfil its mandate as a tertiary referral centre for cardiovascular and thoracic disease will remain significantly compromised.
Small physical space
The amount of space needed for patient care and the installation of new equipment, including magnetic resonance imaging, computed tomography scanners, electrophysiology laboratories, endoscopy and bronchoscopy units, is inadequate. There are also not enough spaces for offices, laboratories or consultation rooms. This national centre has a persistent shortage of bed spaces, with only 36 beds available. This limits the number of procedures performed as well as the number of patient admissions. The Centre has actively implemented measures that reduce bed occupancy, such as admitting patients close to surgery dates, adopting strategies that enhance recovery after anaesthesia and cutting down on the length of inpatient stays after surgery.
Limited health financing
The government of Ghana is responsible for staff salaries and emoluments of all staff. Beyond that, patients must either cover their own expenses or secure sponsorship, especially for major cardiothoracic surgeries, which cost more than one thousand US dollars. Ghana’s National Health Insurance Scheme does not cover major cardiothoracic surgery, making it imperative that a variety of sponsorship packages are put together to support patients. 10 The irregularity of funding inflows results in insufficient and unreliable financial data, which impedes effective planning and procurement of capital equipment and advanced technology. Currently, the main source of funding for major cardiothoracic surgeries at the Centre comes from philanthropic/charity support, accounting for about 93% of all surgeries done from 2020 to 2024 (Table 5).
Sources of financing for major surgeries at the national cardiothoracic centre from 2020 to 2024.
Source: National Cardiothoracic Centre, Annual Financial and Administrative Report 2020–2024. 21
Technology gaps in the centre
The NCTC faces significant technology gaps that hinder the delivery of contemporary cardiovascular care and limit the institution’s capacity to adopt emerging therapeutic innovations. The gaps in equipment encompass several vital areas, including advanced diagnostic imaging techniques (such as cardiac magnetic resonance imaging and three-dimensional echocardiography), use of virtual and reality, contemporary surgical instruments, cutting-edge cardiac catheterisation laboratory and advanced intensive care monitoring systems.22,23
The technology gap at the NCTC reflects broader systemic challenges endemic to tertiary facilities across sub-Saharan Africa, where cardiothoracic surgery remains costly and underfunded, 19 with many patients unable to afford care due to limited insurance coverage and reliance on out-of-pocket payments. 10 Limited access to modern medical equipment and challenges in maintaining advanced technology perpetuate significant obstacles to providing optimal cardiovascular care. The situation points to the need for increased investment in both technology and human resource development to elevate the standard of cardiovascular care in Ghana.
Notwithstanding, efforts have recently been undertaken to bridge gaps by actively pursuing partnerships within medical device manufacturers, international cardiac surgery organisations and philanthropic foundations to facilitate equipment acquisition and technology transfer. This collaborative strategy corresponds with the Cape Town Declaration on Access to Cardiac Surgery, which underscores the necessity of public-private partnerships and creative procurement methods as vital means for enhancing technological capability in low-resource settings. 24 These relationships encompass equipment donation programmes, discounted pricing agreements and technology-sharing initiatives that facilitate access to modern cardiovascular devices.
Implications and way forward
Following 35 years of existence, the physical infrastructure of the NCTC requires modernisation and strengthening of sub-speciality training programmes and research capabilities. The Centre should assume leadership roles in conducting clinical trials, given that cardiovascular pathologies presenting at the facility exhibit distinct characteristics from those documented in existing literature. The NCTC must establish itself as a sub-regional leader in cardiac biomarker research, genomics, gene sequencing and genetic characterisation of cardiovascular diseases affecting African populations. 25 To this end, the Centre will establish collaborative partnerships with leading research institutions and universities, both domestically and internationally, leveraging their scientific expertise to address unresolved challenges in cardiovascular care specific to Ghana and the African continent. The institutional knowledge and clinical experience accumulated over 35 years provide a robust foundation for strategic expansion to fulfil this mandate for the next 50 years.
Furthermore, artificial intelligence (AI) represents a transformative technology for advancing the subsequent phase of cardiac surgery at NCTC. The Centre’s sustained performance will depend on deploying AI to optimise diagnostic accuracy, enhance surgical safety protocols and accelerate post-operative recovery trajectories. Rheumatic heart valve disease remains the predominant aetiology of acquired heart disease in the region. AI-enhanced screening and early detection systems can improve diagnostic precision and efficiency, facilitating cost-effective interventions that prevent disease progression and associated complications. 23 Appropriately applied AI technologies can improve the precision and safety of cardiothoracic surgeries. 26
Finally, the introduction of AI can enhance training protocols across all cadres of staff and enhance performance and efficiency. Embedding AI algorithms within the electronic medical record systems can help refine the analysis of clinical data and the interpretation of diagnostic data. 27 From AI-driven predictive analysis for supply chain management, patient selection and stratification and diagnostic imaging interpretation to preoperative risk stratification and surgical outcome prediction models, 28 the Centre plans to systematically implement AI across all operational domains, including data storage, retrieval and research analytics. To operationalise this vision, the Centre is investing in staff training with leading institutions in AI technology application for cardiovascular medicine, with the objective of establishing a dedicated research unit in this domain.
Conclusion
The future of the NCTC lies in a National Heart Institute – a multidisciplinary, integrated institution dedicated to advancing cardiovascular health outcomes for Ghanaian and African populations. The Centre’s future viability depends on delivering consistently excellent clinical services to its diverse patient population. Institutional excellence requires executing clinical, academic and administrative functions at global standards. This requires rigorous training protocols, simulation-based education and systematic performance evaluation to attain optimal clinical outcomes and operational excellence.
Ultimately, elevating the standard of cardiovascular care at the NCTC to global standards requires sustained political commitment, innovative financing mechanisms, strategic partnerships that transcend conventional public–private sector boundaries and a comprehensive framework that integrates technological modernisation with workforce development, quality improvement and equitable access expansion.24,29 The implications of this investment extend beyond clinical metrics to encompass fundamental principles of health equity and social justice – whether Ghanaians and West Africans have access to the same global standard of life-saving cardiovascular care.
