Between 1990 and 2013, the number of deaths due to cardiovascular disease (CVD) increased by 81 percent in sub-Saharan Africa; it’s estimated that up to 80 percent of these deaths could have been averted with the availability of critical or specialty care. In Kenya, only about a quarter of public health centers have the supplies necessary to effectively treat CVD.
In 2009, this bleak scenario, coupled with a promising funding opportunity from the National Heart, Lung and Blood Institute (NHLBI), inspired Duke faculty and staff to work with their Kenyan partners to develop a sustainable, multi-faceted cardiovascular care program at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya.
Led by the Duke Hubert-Yeargan Center for Global Health (HYC)—one of DGHI’s centers—and the Duke Clinical Research Institute, partners in this endeavor included MTRH, Moi University (a DGHI priority partner in Eldoret), Indiana University, Purdue University and the Icahn School of Medicine at Mount Sinai.
Partnership Addresses Clinical Care, Teaching and Research
Today, this initiative is thriving, thanks to the development and successful execution of a shared vision for improved cardiovascular care in western Kenya and generous funding from the NHLBI, HYC, Hock Family Foundation, Ruth Lilly Foundation, DGHI and industry partners.
The cardiac care unit admits nearly 300 patients per year and the cardiac clinic averages 80 patients per week. Led by the Duke team, the partners produced a clinical cardiology fellowship curriculum that is being submitted for formal adoption by Moi University; this program would be the first cardiology fellowship training program in Kenya.
To date, three Kenyan physicians have been trained as cardiologists, with nearly 100 percent of their training taking place in their home country. Assistant professor of global health and medicine Jerry Bloomfield, one of the project’s primary partners, sees this as the project’s biggest success. “This is a brand new paradigm for Kenya, where physicians typically need to leave the country—and their families and jobs—for several years to complete cardiology training,” he said. “And often, they end up staying in the country where they were trained. These three individuals have strong ties to Eldoret, so we’re hoping they’ll stay at MTRH to deliver high quality cardiovascular care.”
During clinical training, the cardiology fellows also engaged in research training and conducted projects supported by the NHLBI that addressed locally relevant cardiovascular issues, resulting in more than 30 scientific presentations and manuscripts.
Ralph Corey and Cynthia Binanay of the HYC, co-principal investigator Eric Velazquez (Duke cardiologist and DGHI affiliate faculty member), and Bloomfield recently summarized their experiences in an article published in the Journal of the American College of Cardiology.
WHO’s Framework for Action Provided Essential Road Map
The partners recognized early on that building a sustainable program that would effectively meet local needs would require careful strategic planning. They turned to the World Health Organization’s Framework for Action as a guide. This framework was designed to help health policy-makers implement elements of interprofessional education and collaborative practice that will be most beneficial in their particular setting.
The framework addresses leadership and governance, health workforce, health service delivery, health financing, access to essential medicines and supplies, and health information systems. The project partners tapped into each of these components through the development of the cardiovascular clinical and research program, which was one of 11 NHLBI Cardiovascular and Pulmonary Diseases Centers of Excellence across the world.
The collaborators’ recent publication outlines the many facets of the project and how they connect to the Framework for Action, but examples include the following:
- Health workforce: A senior cardiologist and Duke affiliate faculty member, John Lawrence, served as onsite clinical lead in Kenya for the majority of each year. He was joined by Duke’s Bloomfield and Dr. Rajesh Vedanthan from the Icahn School of Medicine at Mount Sinai. Under their leadership and the generous time commitment of other volunteer cardiologists, the outpatient clinic became a robust teaching and consulting service.
- Health financing: The HYC hired an onsite business consultant to develop a new financial model for the hospital that would channel new revenue from improved diagnostic services into the cardiac service operations. This consultant also worked with social workers at the hospital to enroll cardiac clinic patients into Kenya’s National Hospital Insurance Fund to cover future hospitalization costs. In its 22 months of operation, 35 percent of patients admitted to the cardiac care unit were insured. Currently, the unit’s total monthly revenue exceeds its expenses.
- Health service delivery: The HYC also supports a Kenyan cardiac unit administrator, who collaborated with the business consultant to conduct extensive evaluations of patient flow and medical record access and introduce lean inventory principles. As a result of these efforts, wait time was reduced and supply chain management was improved. In addition, short leadership training courses were offered to the cardiology fellows in anticipation of their becoming future leaders at the hospital.
It’s All about Relationships
One of the hallmarks of this project is the “twinning” model, in which both Kenyan and North American partners commit substantial time, personnel and financial resources to the collaboration. The AMPATH (Academic Model Providing Access to Healthcare) Consortium has been implementing this model for more than 25 years. AMPATH, one of DGHI’s priority partners, is a partnership among Moi University, MTRH and 11 North American academic health centers working together with the Kenyan government to address health challenges in Kenya through clinical, training and research initiatives. Several AMPATH member institutions have been involved with this project.
According to Bloomfield, a key to the project’s success has been a mutual commitment to constantly nurture and develop relationships among the partners. “Global health, to have any lasting impact, is about people talking to people,” he reflected. “And the way that has happened most effectively in Kenya is in frequent face-to-face contact and people taking the time to build relationships and have more than just a very directed conversation.”
Opportunities Extend in Both Directions
In addition to the local capacity this project has built in Kenya, its benefits to Duke have been substantial. Cynthia Binanay, director of operations at the HYC noted, “Because of our work and our commitment, Eldoret is one of the top strategic locations for Duke global health trainees, including Fogarty fellows, Doris Duke trainees, graduate and undergraduate global health students, and faculty—resulting in significant academic output.”
Since Duke joined the AMPATH Consortium in 2006, more than 50 Duke undergraduate, graduate and medical students, residents and fellows and more than 25 Kenyan medical students, faculty and staff have participated in bidirectional educational exchange opportunities.
Titus Ngeno, formerly a Kenyan medical officer (similar to a U.S. intern) who was involved in the cardiovascular training program since its inception, is an excellent example of this two-way exchange. Now a Duke internal medicine resident, he’s enrolled in both the Global Health Residency/Fellowship Pathway and the Master of Science in Global Health program at Duke.
Ngeno says his interactions with colleagues from partner institutions such as Duke inspired him to learn more about different health systems and how they’re addressing challenges such as non-communicable diseases. The clinical and research training he’s received here, he says, has enabled him to do just that.
When Ngeno completes his training here at Duke, he plans to return to Kenya to help address the threat of non-communicable diseases and shape the development of adaptive health systems. He believes his collaboration with researchers from partner institutions have helped him lay a solid foundation for this work: “Global partnerships will be indispensable in addressing the needs of patients in the region,” he said.
And the project has been a dream come true for Bloomfield, who came to Duke as a cardiology fellow in 2007 with vast experience as a physician in Kenya, seeking an opportunity to return to Kenya long-term to work as a cardiologist. After a few years of “knocking on a lot of doors at Duke and not getting very far”—global cardiology programs were few and far between at the time—this project came to fruition.
What’s Next for the Partnership?
After six years, the project leadership is in the process of transitioning from Duke to Moi University and MTRH, where one of the fellows trained through this initiative, Felix Barasa, currently heads up the cardiac division.
With both inpatient and outpatient services now in place, the partners are considering the possibility of establishing an open heart surgery unit, but future plans will depend on local needs identified by local leaders.
And looking beyond the partnership, the team hopes that by sharing their experiences through the publication, other researchers and clinicians might be inspired to replicate this model elsewhere.
Because of our work and our commitment, Eldoret is one of the top strategic locations for Duke global health trainees.Cynthia Binany, director of operations at the Hubert-Yeargan Center for Global Health