Unmet need for heart transplantation in Africa

Heart transplantation is a critical treatment option for end-stage heart failure patients, offering a lifeline for those with severe cardiac conditions. However, in Africa, the unmet need for heart transplantation is a significant issue that poses challenges to the healthcare system and patient outcomes. Africa faces multiple barriers to heart transplantation, including limited infrastructure, a shortage of skilled healthcare professionals, a lack of funding, and inadequate organ donation systems. These challenges result in a considerable gap between the demand for heart transplants and the available resources to meet this need. As a result, many patients in Africa do not have access to life-saving heart transplantation procedures, leading to high mortality rates among those awaiting transplants. Addressing the unmet need for heart transplantation in Africa requires a multifaceted approach. The authors recommend that Africa as a continent build up a heart transplantation workforce involving a multidisciplinary team that consists of transplant surgeons, transplant physicians, nurses, anesthetists, pharmacists, etc. Heart transplant education and training programs should be well-constructed to ensure the delivery of safe and effective transplantation services. International collaborations have proven to be effective and should be encouraged between African institutions and transplant centers worldwide to facilitate knowledge transfer. Foreign and local organizations should promote public awareness about organ donation to address the myths about heart transplantation and promote heart donation. With these, African countries can improve access to heart transplantation, enhance patient outcomes, save lives in the region, and ultimately reduce the mortality rate in Africa.


Introduction
Human-to-human heart transplantation, which is the replacement of a failing heart with one from a suitable donor, was first carried out by Dr Christian Barnard at the Groote Schuur Hospital in Cape Town, South Africa [1] .This was a victory for medicine globally and also suggested the potential of Africa as a center for medical innovation.Today, over 6000 heart transplants are conducted annually, and recipients have a one-year survival rate of nearly 90% [2,3] .As specified by guidelines from the American College of Cardiology, American Heart Association, Heart Failure Society of America, and European Society of Cardiology, the procedure is typically conducted for patients with diseases such as cardiomyopathies, coronary heart failure, and congenital heart diseases that are refractory to conventional therapy [4] .Significant progress has also been made in the evolution of heart transplantation, with advances in immunosuppression, noninvasive imaging techniques like transthoracic echocardiography, and screening to prevent acute and chronic rejection of transplants [5] .In this interim, Africa appears to have been left behind in the development of the field of heart transplantation.However, to our knowledge, studies have yet to document the extent of this gap.This review highlights the existing gaps and unmet need for heart transplantation in Africa, exploring the challenges and possible solutions.

Current state of heart transplantation in Africa
The practice of heart transplantation in Africa, with a population of over 1.2 billion and 54 countries, vastly underwhelms the need [6] .According to reports, cardiovascular diseases are responsible for 38% of all non-communicable disease deaths in Africa, contributing to a double burden of infectious and noncommunicable diseases [7] .These are conservative estimates,

HIGHLIGHTS
• In Africa, the practice of heart transplantation is significantly low, compared to the rest of the world.• Only a few countries can support heart transplantation due to a paucity of skilled professionals, a lack of funding, and inadequate organ donation systems.• Suggestions for improving transplantation include increasing investment in infrastructure and personnel development, establishment of organ procurement and transplant systems, and improving public awareness.
however, as most data is from urban centers in a few countries.In some cases, this data is non-existent [8] .According to the Global Observatory of Donation and Transplantation 2017 database, Africa recorded only 14 heart transplants out of 7881 globally, representing 0.2% of the global total in 2016 [9] .Similarly, in 2022, the International Report on Organ Donation and Transplantation Activities recorded heart transplantations in only one country in Africa, Tunisia [10] .The practice of heart transplantation in Africa has historically been limited to a few centers in select countries.Currently, countries such as South Africa, Tunisia, Namibia, and Uganda represent the only territories with heart transplant procedures.The Groote Schuur Hospital in Cape Town, the cradle of heart transplantation, has been one of the most consistent centers for heart transplantation in Africa.Heart transplantation has continued without interruption at this center since the first one in 1967, with heterotopic and orthotopic methods primarily utilized.The team at this center has also engaged in research on cardiac transplantation, advancing concepts such as brain death, organ and tissue donation, and ethical issues [9] .Records at this center show that early graft failure is a key cause of morbidity and mortality [1] .The country has the most advanced transplant program in Africa [11] .Tunisia is another center where heart transplants have been conducted-10 were conducted between 1993 and 2004-although numbers have declined with time, with economic costs and logistics cited as a cause of the low numbers [12,13] .In 2023, the Ministry of Health in Tunisia announced that the Rabta University Hospital in Tunis performed its 21 st heart transplant, a positive development in cardiothoracic surgery in the country [14] .
Countries such as Namibia and Uganda, with one center each, have also been recorded to have performed heart transplants at some point, although scientific reports of the procedure have lately diminished [15] .Egypt has a thriving organ transplantation practice, though reports of heart transplantation are sparse in the scientific record.Nigeria, another country with established organ donation and transplantation centers, has yet to publish a record of heart transplantation.Overall, the records suggest that while heart transplantation is offered in a few countries in Africa, their activity is much lower than that of countries with more economic capacity [16] .In 2020, the Global Report on Organ Transplantation and Donation showed that as of that year, no heart transplant had been carried out in any African country, and there was no heart transplant center in any of the African countries to meet the needs of the population [17] .This is really a serious problem because Africa is home to greater than 1 billion people, and is a major contributor to the global burden of cardiovascular diseases (CVDs) and other heart-related problems [18] .In fact, in 2013, it was estimated that 1 million deaths were attributable to CVD in sub-Saharan Africa alone, which made up about 5.5% of all global CVD-related deaths and 11.3% of all deaths in Africa [19] .Furthermore, CVD-related deaths contributed to about 38% of all non-communicable disease-related deaths in the African region, reflecting the growing threat of both noncommunicable diseases and CVD [19] .As opposed to several highincome countries (HIC), which have recorded reductions in cardiovascular deaths [20] , Africa as a continent has registered about a 50% increase in the CVD burden within the last three decades [21,22] .Some of these cardiovascular conditions would have been averted just with heart transplantation, hence the growing need for heart transplantation in this region.

Barriers to heart transplantation in Africa
Heart transplantation is considered one of the most effective treatments for end-stage heart failure, giving patients another chance for survival and an improved quality of life.However, this practice faces impediments in Africa due to various barriers, including inadequate infrastructure, a lack of personnel for such procedures, a shortage of organ donors, negative beliefs regarding organ donation, and economic constraints.
The infrastructure required to support heart transplantation is often unavailable in many African countries.This includes specialized cardiac centers with dedicated intensive care units, sophisticated diagnostic materials, surgical equipment, tissue typing, cross-matching, and some viral studies [23] , which are essential for pre-and post-transplantation care.This delays the process and affects timely action on tissue rejections and infection.A study conducted by Edwin and colleagues in 2016 on the perceived barriers to and facilitators of physical activity in recipients of solid organ transplantation showed that one of the reasons for poor outcomes in patients with heart transplant surgery was the unavailability of equipment [24] The inadequate availability of transplant surgeons and support staff (pathologists, internal medicine physicians, and surgical nurses) remains a significant setback, limiting the number of transplantations even in centers with adequate facilities.This impedes the growth of transplantation in Africa, given the stark contrast of only 2.3 healthcare workers for every 1000 population in Africa, as opposed to 24.8 healthcare workers for every 1000 population in America [23,25] .In 2015, Ziz and colleagues, in a report on the update of organ transplantation in Tunisia, a study that covered both heart and kidney transplantation, showed that the unavailability and lack of motivation of medical personnel were one of the limitations to carrying out transplant surgeries in the country [26] Insufficient legal and regulatory frameworks, coupled with cultural beliefs and religious views regarding heart transplantation, pose significant obstacles in Africa.Rigid legal frameworks also halt the progression of this practice [25,27] , and the absence of an established organ procurement and allocation system further complicates the process of matching organ donors with recipients and avoiding organ trafficking.Jose-Maria et al. [28] , in their 2023 publication, revealed that cultural and religious beliefs were a major challenge to heart transplantation due to the fact that people believed that heart donation was against their faith and their cultural norms.
The financial costs associated with the procedure, including the preoperative workup, surgery, postoperative care, and immunosuppressive therapy, inflict a great burden on the patient and healthcare facilities.The unavailability of funding also becomes a significant obstacle in implementing this program in most African countries [23] .In fact, in 2021, it was reported in Uganda that one of the major barriers to performing a heart transplant was the financial challenge it poses on the part of the patient and the medical facility due to it being an expensive procedure [29] Heart transplantation holds a promising future for end-stage heart pathologies in Africa.However, there are still major setbacks in its implementation.Resolving the above-mentioned barriers will be crucial for improving access to and increasing the success rate of transplantation.

Changing the landscape: recommendations for improving the penetration of heart transplantation in Africa
Improving the penetration of heart transplantation in Africa will require comprehensive and close collaboration with national and international organizations, non-governmental organizations, and healthcare staff.The following recommendations are vital in enhancing the penetration, accessibility, and success of heart transplantation in Africa.
Public sensitization and education are crucial parts of establishing heart transplant programs, with Africa faced with diverse and conflicting interests (religion, cultural belief, and social norms) regarding the notion of organ transplantation, especially the heart.Therefore, public education campaigns tailored to factors such as age, profession, education level, cultural sensitivity, and religious affiliation, along with community outreach using key community members and partnership programs with churches and community leaders, can help alleviate the dilemmas associated with this practice.This, in turn, can increase the pool of potential donors and improve the acceptability of heart transplantation to recipients.
Training and capacity-building to improve local capacity in African transplant medicine are vital.This will involve expanding existing programs and creating new training programs for medical professionals in cardiac surgery, transplant immunology, and post-transplant care.This will require collaboration with other well-established international transplant centers and societies for mentorship and technical assistance while facilitating knowledge transfer, exchange of expertise, and collaborative research.
Infrastructure development is critical to actualizing the penetration and implementation of heart surgery in Africa due to the huge deficit in infrastructure to support cardiac procedures.Therefore, the building of specialized cardiac centers equipped with standard facilities and equipment for cardiac surgery, intensive care units, and post-transplant care is essential to supporting the growth of heart transplantation programs in Africa.
Health insurance and financing reforms are still underdeveloped in Africa.With the low-income status of the inhabitants, out-of-pocket payments are a huge burden.Thus, health insurance and financial reforms are needed to expand to include the coverage of advanced medical procedures such as heart transplantation.This could be done by developing specific insurance programs or subsidies to promote access to transplant services for eligible patients.The support of NGOs and philanthropists will also be instrumental in the interim.
Organ procurement and allocation centers and systems are key to establishing an efficient transplant system.This will involve developing regulatory frameworks, national registries accessible to all transplant centers, and regulatory boards collaborating with transplant networks to ensure equity and ethical distribution of donor organs.This will equally involve advocating for policy changes and legislation that support and regulate organ donation, transplantation, and post-transplant care.

Conclusion
Heart transplantation in Africa is far below the demand for the procedure, only practiced in a handful of countries.Challenges to the practice range from weak infrastructure to inadequate surgical capacity to a lack of financial capacity on the part of the patients.
We recommend that Africa build up its heart transplantation workforce by involving a multidisciplinary team that consists of heart transplant surgeons, heart transplant physicians, nurses, pharmacists, anesthetists, social workers, dietitians, counselors and clinical coordinators.Heart transplant education and training programs should be well-constructed to ensure the safe and effective delivery of heart transplantation services.International collaborations should be encouraged between African institutions and health transplant centers worldwide to facilitate knowledge transfer.Non-governmental organizations and government agencies in various African countries should promote public awareness about heart donation to address the myths about heart transplantation and promote heart donation.These would help to improve heart transplantation in the African continent.