Madaktari Africa and the Train-Forward model

In 2006, neurosurgeon Dr Dilan Ellegala, MD, founded Madaktari Africa while on a medical sabbatical at Haydom Lutheran Hospital in rural Tanzania. Dr Ellegala observed the shortcomings of medical missions including a failure to establish a local, highly-skilled healthcare workforce. Working closely with Tanzanian colleagues and visiting physicians, Dr Ellegala trained staff members to independently perform neurosurgical procedures. Thus, Madaktari Africa and the Train-Forward model were born, empowering Tanzanian medics to provide neurosurgical services in a sustainable manner.^3,4 While in Tanzania, local staff and Madaktari volunteers cared for an increasing number of patients with CVD related to obesity, uncontrolled hypertension, and diabetes.⁵ These experiences prompted Madaktari to shift its Train-Forward focus to CVD.

Initial training efforts focused on noninvasive diagnosis and management of common cardiovascular conditions. However, many patients with complex CVD were being transferred abroad for interventional or surgical care, incurring significant costs for the country. Thus, it soon became evident that a cardiovascular center of excellence would need to be established to provide tertiary care to Tanzanian citizens and train the next generations of healthcare professionals.

SSA has a limited number of dedicated cardiology training programs and cardiac catheterization laboratories,^6,7 and those that have achieved success have generally developed educational and training partnerships with institutions outside of SSA.^8,9 The unique partnership between Madaktari Africa and the JKCI supported by the Tanzanian Ministry of Health led to the development of the nation’s first tertiary cardiovascular center and cardiac catheterization laboratory and established the foundation for clinical and research programs focused on excellence in teaching and learning, discovery and scholarship, and service and leadership.

President Kikwete’s vision

In early 2008, President Jakaya Kikwete of Tanzania and his cardiologist and personal physician, Dr Mohamed Janabi, MD, called on Madaktari to assist in developing the country’s tertiary cardiovascular services. This included establishing a dedicated cardiac center in Dar es Salaam on the same campus as the Muhimbili National Hospital (MNH). Officials from the Tanzanian Ministry of Health worked with Dr Janabi and Madaktari volunteers to develop a framework for the center’s infrastructure, clinical protocols, and mechanisms for training cardiovascular physicians and technical staff.

For many physicians and healthcare professionals in SSA, training abroad had been necessary to develop local cardiovascular healthcare capacity. However, training abroad presents cultural and financial challenges, and some physicians may not return to their country. Furthermore, the successful completion of complex procedures, such as cardiac catheterization, requires an understanding of the unique circumstances in one’s home country, including social determinants of health, health insurance coverage, patient preferences, and local cultural practices. Such country-specific expertise cannot be obtained abroad. Recognizing these challenges, Madaktari and JKCI led the transition from overseas to local cardiovascular training.

Tanzania’s first public cardiac catheterization laboratory

The cardiovascular center experienced rapid growth, and an increasing number of patients were referred abroad for invasive and surgical cardiovascular care. It became apparent to policy makers and healthcare professionals that establishing advanced cardiovascular capabilities within Tanzania was a priority. Professor Janabi articulated to the Tanzanian government his vision for a self-sufficient, protocol-driven, and cost-effective invasive cardiac and cardiac surgical program to serve Tanzania and other East African countries. Beginning in 2010, Madaktari volunteers, physicians, and nurses and technicians from Medical University of South Carolina and Centra Health worked with and trained their Tanzanian counterparts in Dar es Salaam to establish Tanzania’s first cardiac catheterization laboratory, which was completed in 2012. A formal memorandum of understanding was signed by representatives of Madaktari Africa, MNH, and Muhimbili University Health and Allied Sciences that outlined Madaktari’s role as a provider of in-person training for developing sustainable invasive cardiac services in Tanzania.

In 2015, the department and hospital became independent from MNH, and leadership transitioned to Professor Janabi, and this was paralleled by significant growth in clinical volumes. The cardiac center also began to provide education and clinical training to Muhimbili University of Health and Allied Sciences medical students and residents. Madaktari volunteers established a regular schedule of visits for on-site training and also worked remotely to support other essential program-building initiatives. The teams worked with Muhimbili University of Health and Allied Sciences and MNH healthcare professionals to draft a training timetable to improve procedural competency in diagnostic cardiac catheterization, coronary angiography, percutaneous coronary intervention (PCI), and pacemaker and electrophysiology (EP) programs.

Tanzania’s first cardiac catheterization

Before performing any procedures in the cath lab, Madaktari combined didactic lectures with mock procedures to teach the fundamentals of invasive cardiology, basics of cardiovascular physiology and pharmacology, manifestations of coronary artery disease, vascular access, equipment selection, angiography, equipment troubleshooting, interventional techniques, complication management, closed-loop communication, and radiation safety. Furthermore, the team developed peri-procedural care protocols, including patient handoffs, preprocedural timeouts with medication checklists, laboratory and diagnostic studies, patient consent, vascular access site management, and physician contact protocols in case of postprocedural emergency. All educational content and protocols were collated and documented in the JKCI-specific Madaktari Cardiac Catheterization Manual.

Training efforts culminated in 2014 when the first right heart catheterization was performed in Tanzania by Drs Peter O’Brien, MD, and Peter Kisenge, MD. Later in the same year, the first left heart catheterization and coronary angiogram were performed. Then in 2015, Drs O’Brien, MD, and Kisenge, MD, successfully performed PCI in a patient with unstable angina which marked another milestone – the first PCI in a public Tanzanian hospital.

Cardiovascular care, professional engagement, and partnerships

The cardiac center was formally named the JKCI in 2015 to honor President Kikwete’s vision and commitment to sustainable cardiovascular clinical care. As the JKCI’s program grew and Madaktari successfully helped to train additional interventional cardiologists and staff, the JKCI began to independently perform cardiac catheterization procedures. The growth of the adult cardiology and interventional programs has been substantial in the last decade. For example, 263 adult catheterization procedures were performed in 2015, and over 1,200 catheterization procedures were performed in 2020. The majority of these procedures are coronary angiography (∼60%) and PCI (∼10%) but also include a range of congenital, structural, and EP procedures as described below.

In 2016, several hundred participants from 8 countries attended the second East African Cardiovascular Conference, organized by JKCI. Madaktari volunteers contributed to the conference and provided training to the delegates at JKCI. During this visit, Dr C. Michael Valentine, MD, (Madaktari volunteer and former American College of Cardiology [ACC] President) and Dr Kisenge, MD, implanted the first pediatric pacemaker in Tanzania, highlighting the increasing diversity of the invasive cardiac procedures being performed and inaugurating JKCI’s EP program. The conference and visit also led to the establishment of the first regional chapter of the ACC in SSA and recognition of Dr Janabi as an Fellow of the American College of Cardiology for his contributions to cardiac care in Tanzania.

Sustaining procedural competence at the JKCI

In order to sustain and develop procedural competency, Madaktari training visits have increased steadily since 2010 (2 visits) to an average of 4 to 6 visits per year from 2018 onward. However, the COVID-19 pandemic disrupted the person-to-person international training partnership established between JKCI and Madaktari that had been fundamental to its achievements. As with other medical education initiatives, Madaktari turned to virtual means of training and facilitated the donation of a virtual proctoring system installed in the JKCI cath lab that could enable real-time streaming of the fluoroscopic, hemodynamic, electrocardiographic, and activities of the physicians during a procedure. With Madaktari volunteers based in the United States proctoring the case, JKCI interventional cardiologists performed complex PCI, which represented the first virtually proctored cardiac catheterization in East Africa.

Madaktari volunteers and JKCI physicians have recently focused on training in percutaneous mitral valvuloplasty (PMV) for patients with rheumatic mitral stenosis. Rheumatic heart disease is responsible for significant morbidity and mortality in East Africa, and PMV represents a minimally invasive therapy that may obviate the need for surgical valve replacement. However, the techniques for PMV are complex and require an expensive catheter to perform the procedure. Recently, Madaktari-trained interventional cardiologists at JKCI independently performed the first fluoroscopic-guided PMV in 2 patients in March 2024.

Cardiovascular capacity beyond procedural training

With a maturing cath lab program and an increase in procedural volumes, Madaktari has extended its training programs to other areas including imaging and research. Expertise in advanced imaging techniques, including echocardiography and cross-sectional imaging, such as computed tomography and magnetic resonance imaging, is fundamental to improving cardiovascular care. Visits from MUSC-affiliated Madaktari volunteers helped to establish sustainability and expertise in these vital noninvasive imaging modalities.

Madaktari volunteers worked with JKCI physicians and staff to establish a local cardiac cath lab registry, which was inspired by the ACC National Cardiovascular Data Registry CathPCI registry (which the JKCI later joined formally). Madaktari provided basic training in research methods and quality improvement to medical officers working at JKCI. The early data from these efforts supported the first JKCI abstract to be accepted at the ACC Scientific Sessions in 2019. Initial observations from the registry data highlight that traditional CVD risk factors, ischemic presentations, and angiographic findings among Tanzanian patients with suspected CVD are comparable to those reported in the United States. Importantly, mortality (<1%-2%) rates of patients undergoing cardiac catheterization at JKCI are also comparable to those observed in Western countries.

Impact and sustainability

The partnership between Madaktari and JKCI has led to the establishment of Tanzania’s first public cardiac catheterization laboratory and invasive cardiologists capable of independently performing coronary angiography, PCI, structural heart interventions, and invasive EP procedure (Figure 1). More importantly, the partnership fostered by the Train-Forward model has enabled Madaktari-trained clinicians to train subsequent generations of cardiovascular professionals including Tanzania’s first female interventionalist.

Although a formal cost-benefit analysis has not yet been conducted, the Tanzanian government reduced its spending on the use of Indian healthcare from over 70 billion to 7 billion Tanzanian shillings from 2014 to 2018, a savings equivalent to nearly $30 million US. This was driven in large part by a significant decrease in invasive procedures performed abroad. There were 604 cardiac surgeries performed in Tanzanian from 2008 to 2015, whereas 1,537 cardiac surgeries were performed in Tanzania from 2016 to 2019. Critically, in-hospital mortality at JKCI following cardiac catheterization or cardiac surgery is ∼1% to 2% and ∼5% to 6%, respectively, which is comparable to outcomes in high-income countries.¹⁰

The combination of increased hospital capacity, greater clinical experience, and COVID-related overseas travel lockdowns also led to JKCI caring for an increasing number of patients from neighboring countries, including Malawi, Zambia, Rwanda, Burundi, Democratic Republic of Congo, Comoros, Kenya, and Ethiopia.

Future directions

Due to a combination of the COVID-19 pandemic and increasing procedural autonomy of the JKCI, the scope and nature of the Madaktari-JKCI collaboration has evolved. Virtual educational initiatives have become more common, including clinical case discussions, consultations, and journal clubs. In addition, research programs have continued to grow and focus on areas of unmet needs including a recent collaborative research project characterizing regional practice patterns in the diagnosis and management of acute myocardial infarction which is under review for publication. Other evolving areas of research include rheumatic heart disease and heart failure in partnership with JKCI and MNH.

Conclusions

The partnership forged between Madaktari and JKCI reflects a unique approach that can be leveraged elsewhere. This ongoing partnership has fostered the development of tertiary cardiovascular care and training and established a framework for impactful research and quality improvement. We hope our shared experiences provide a roadmap for the development of CVD training programs, cardiac catheterization services, quality improvement, and research programs elsewhere in SSA and other LMICs.