Invited Commentary: Local Strength,Global Lessons: Developing Sustainable Pediatric Cardiac Care in Vietnam

Every year, approximately 1.35 million neonates are born with congenital heart defects (CHDs), ¹ and more than 350,000 children worldwide acquire heart disease during childhood. ² Most of these young patients live in regions where cardiac care is either inaccessible or suboptimal. Over the past century, remarkable advances in cardiovascular diagnostics and cardiothoracic surgery have transformed outcomes for children born with CHD. Once uniformly fatal, many forms of congenital heart disease are now treatable with excellent long-term survival in high-resource settings. Yet, despite this progress, between 75% and 90% of children born with CHD worldwide still receive inadequate care or none at all.^1,3–6

The challenge is no longer technological but structural and systemic—how to translate medical knowledge into equitable, sustainable practice across diverse health systems. To address this gap, various models have been implemented: temporary surgical missions, training programs for local staff, patient transfers abroad, and long-term institutional partnerships. While each approach offers benefits, experience has shown that transient or externally driven efforts alone rarely produce lasting change. The persistent underdevelopment of congenital heart surgery (CHS) programs in low- and middle-income countries (LMICs) reflects not a lack of need or compassion but rather enduring barriers—competing health priorities, weak structural organization, insufficient funding, limited human resources, and the absence of stable education and training infrastructure. ⁴

Beyond “Surgical Safaris”: Why Sustainable Systems Must Come From Within

Short-term humanitarian missions—sometimes referred to as “surgical safaris”—have played a visible role in the global cardiac landscape. These missions often provide lifesaving operations for individual patients, yet they can also highlight the limitations of externally driven care. When visiting teams depart, local staff may be left without adequate postoperative support, patients with mechanical valves may lack access to essential anticoagulation monitoring, and no long-term training or system strengthening has taken place. ⁷ In a global survey, 26% of centers did not perform any interventions between missions, and only 29% of programs were initiated locally. ⁸ The majority of sponsoring organizations were based outside the regions they served. ⁸

The lesson is clear: while international assistance remains valuable, true, and lasting improvement must be generated from within. A self-sustaining system for pediatric and congenital cardiac care can only thrive if local ownership, leadership, and accountability are central to its development. This principle echoes the Paris Declaration on Aid Effectiveness ⁹ and the Accra Agenda for Action, ¹⁰ which established five core tenets of effective development assistance: ownership, alignment, harmonization, managing for results, and mutual accountability. ⁹ External partners must resist the impulse to impose their models uncritically and instead foster bilateral learning, cocreation, and respect for local priorities.

As Crisp has eloquently argued, it is crucial to avoid a one-way export of ideas and values from the “rich and powerful world” into low-resource countries. Economic growth and professional independence are the cornerstones of long-term progress. Empowering local institutions to take control of their development ensures that new systems are culturally relevant, financially viable, and ultimately sustainable. ¹¹

The Vietnamese Model: Building Capacity Through Partnership

In this context, the work by Nguyen et al on the Development of a High-Performing Congenital Heart Program in Vietnam offers a compelling study in sustainable collaboration. ¹² Vietnam, classified by the World Bank as a lower-middle-income country, has made remarkable strides in healthcare improvement. The Vietnam National Children's Hospital (VNCH) in Hanoi serves a population of more than 30 million in Northern Vietnam, with over 2,000 inpatients and 4,000 outpatients daily. Within this bustling environment, the VNCH Heart Center has evolved into a hub of excellence, performing an average of 22 open-heart and 12 closed-heart surgeries per week and provides care for 120 to 160 outpatients a day. ¹² Its cardiac intensive care units now encompass 30 specialized beds, including 20 dedicated to postoperative cardiac surgical patients. ¹²

This success did not happen in isolation. Since 2017, VNCH has maintained a strategic partnership with Children's HeartLink (CHL) and the University of California, San Francisco (UCSF). The collaboration was designed with clear objectives: to improve clinical knowledge, enhance technical skills, implement quality initiatives, and benchmark outcomes against international standards. ¹² Rather than relying on intermittent missions, the model emphasized long-term engagement—a consistent senior volunteer team from UCSF conducted twice-yearly on-site training visits, complemented by weekly remote case discussions and virtual conferences. ¹² Over time, these interactions evolved into a continuous learning ecosystem.

The partnership also prioritized capacity building through education. Approximately 10 Vietnamese surgeons and cardiologists have completed extended training placements of two to six months at UCSF or other CHL partner institutions. More than 100 clinicians have participated in virtual courses and case-based conferences, especially since 2021, when the COVID-19 pandemic accelerated the adoption of telemedicine. ¹² These efforts are part of a broader global wave of technological integration that is reshaping international health collaboration. Remote telehealth platforms, real-time videoconferencing, and initiatives such as Curriculum Webinars from the World University for Pediatric and Congenital Heart Surgery ¹³ now make expert-level mentorship accessible across borders and time zones.

The Power of Learning and Quality Management

Sustaining such progress requires more than training—it requires structured learning, reflection, and measurement. As Porter and Teisberg observed, quality improvement in healthcare is driven by experience, scale, and deliberate learning. ¹⁴ Mistakes or inefficiencies are inevitable, but conscious learning—through systematic review and feedback—transforms them into drivers of progress. Establishing quality management tools enables teams to track outcomes, identify areas for growth, and set realistic benchmarks.

The VNCH-UCSF partnership has demonstrated how data can guide this evolution. By comparing outcomes with North American congenital heart centers through the Pediatric Cardiac Critical Care Consortium (PC4), VNCH has been able to evaluate its performance objectively. The center performed slightly fewer neonatal surgeries but a higher proportion of infant surgeries. ¹² Fewer operations involved patients with genetic syndromes or complex anatomical variants, which likely reflects local diagnostic limitations. ¹² Nonetheless, despite these differences in case mix and resource context, VNCH achieved a comparable in-hospital mortality rate to the PC4 aggregate data in 2023—a remarkable accomplishment for a lower-middle-income setting.

These findings highlight that benchmarking should not be an exercise in competition but a tool for learning. Quality assurance and transparency are essential not only for accountability but for the moral imperative that every child deserves high-quality care, regardless of geography. The goal is not merely to provide access to surgery but to ensure that this care is safe, consistent, and continuously improving.

Leadership, Organization, and the Culture of Excellence

Delivering complex healthcare services, particularly in congenital cardiac surgery, requires far more than technical skill. As Porter and Teisberg described, health service delivery encompasses recruitment and retention of skilled staff, adherence to evolving standards, continuous quality improvement, and effective coordination with regulators and funders. ¹⁴ Leadership is, therefore, a pivotal ingredient in success. Drucker identified eight practices that define effective executives—asking what needs to be done, focusing on what is best for the organization, taking responsibility for decisions and communication, and thinking in terms of “we” rather than “me.” ¹⁵ When these principles are applied to healthcare partnerships, they create an environment where shared goals, trust, and accountability flourish.

The VNCH program exemplifies this leadership-driven model. The collaboration's emphasis on joint problem-solving, transparent outcome reporting, and iterative quality cycles has fostered a strong culture of safety and professionalism. By integrating global expertise with local initiative, the partnership has gradually expanded the program's complexity while maintaining high standards of care. The trajectory is clear: from dependency to autonomy, from learning to mastery.

Benchmarking as a Pathway to Equity

Benchmarking, when conducted ethically and thoughtfully, provides a roadmap for development. Mortality rates across LMICs remain variable—13.6% in Indonesia, ¹⁶ 12.4% in Iran, ¹⁷ 8.3% in Guatemala, ¹⁸ 7.9% in India, ¹⁹ and 5.4% in certain regions of China ²⁰ —for example, reflecting differences in case complexity, resource availability, and systemic maturity. Countries with lower levels of development often show greater variability in outcomes. ²¹ By situating their results within this global spectrum, the VNCH team has demonstrated not only technical competence but the feasibility of achieving world-class results through structured partnership and disciplined learning.

“Science tells us what we can do, guidelines what we should do, registries what we are actually doing.” ²² This statement captures the essence of VNCH's transformation: bridging the gap between aspiration and reality through data, transparency, and reflection. The program's risk-adjusted mortality has steadily declined during the collaboration, a testament to both technical improvement and system-level growth.

From Collaboration to Independence

Ultimately, the aim of any international health partnership must be to render itself unnecessary—to cultivate a program that is autonomous, self-governing, and self-financed. For pediatric cardiac care, this means developing local leadership, financial models, and training pipelines that ensure continuity and resilience. The VNCH initiative provides a blueprint for how this can be achieved: sustained mentorship, embedded education, iterative quality improvement, and strategic benchmarking.

Vietnam's broader economic trajectory reinforces this optimism. With steady growth and an ambition to reach upper-middle-income status, the nation is well-positioned to consolidate its healthcare gains. The VNCH heart program's success exemplifies how medical excellence and national development can reinforce one another—each enabling the other's progress.

The journey of VNCH demonstrates that sustainable pediatric cardiac care is not built through charity but through partnership; not through dependency but through empowerment. When international collaboration is grounded in mutual respect, shared learning, and local ownership, it becomes a catalyst for lasting transformation.

This model invites replication elsewhere. It challenges the global health community to move beyond episodic interventions toward systemic strengthening. The ultimate measure of success will not be the number of visiting missions conducted but the number of children who can receive lifesaving care within their own communities from their own doctors.

The Vietnamese experience offers a powerful reminder that progress in global pediatric cardiac care depends not on exporting solutions but on cultivating them locally—supported, not directed, by the international community. True impact lies in helping others to help themselves, so that every child, regardless of birthplace, has the right to a healthy heart and a healthy future.