Sustaining cardiac surgery in low-resource settings: Financial and training lessons from Tenwek Hospital, Kenya

Abstract

Objective

To examine how a mission-based teaching hospital in rural Kenya has evolved into a high-volume regional training hub, evaluate its financing and cost-control mechanisms, and derive lessons for scaling advanced care in sub-Saharan Africa.

Methods

Institutional financial records, clinical volumes, and stakeholder interviews (2008-2025) were reviewed across 3 domains: (1) funding streams, (2) cost-containment mechanisms, and (3) long-term sustainability strategies. Themes were analyzed descriptively for relevance to other low-resource settings.

Results

Tenwek, a 400-bed mission referral hospital serving more than a million residents in Southwest Kenya, inaugurated a new cardiothoracic center in 2024 with capacity for 2000 cases per year—one of the largest in sub-Saharan Africa. This expansion is expected to multiply Kenya's national cardiac surgery volume several-fold, substantially reducing delays in care. Since the program began, the hospital has performed more than 1500 operations, of which 436 (27.7%) were for congenital diseases. Perioperative 30-day mortality was 4.4%, whereas overall all-cause mortality during the study period was 9.6%. The program relies on a mixed funding model—public health insurance, philanthropic funds (eg, Compassionate Cardiac Fund), mission partnerships, and community sponsorships—that collectively support supplies, equipment, and training. Locally, Tenwek's social work department manages patient sponsorships through church networks, charitable foundations, and individual donors to ensure fair access for patients who are indigent. Sustainability has been enhanced through employing more than 300 local staff, bulk-purchasing agreements, and safe reuse protocols. The program's fellowship is gradually localizing expertise by graduating some of the first cardiothoracic surgeons from multiple African countries, equipped with the infrastructure to support their future practice in their respective nations. This effectively shapes the continent's future workforce and reduces dependence on external expertise.

Conclusions

Tenwek's experience demonstrates that sustained cardiac surgery in low-resource settings is achievable through (1) diversified funding, (2) cost control with gradual workforce localization, and (3) social equity mechanisms protecting patients from catastrophic expenditure. These principles offer a pragmatic framework for developing self-sustaining cardiac surgical programs across the Global South.

Sustainable cardiac surgery in a low-resource setting: the Tenwek model.

Central Message.

Diversified financing, cost control, and local workforce training enabled a self-sustaining, high-volume cardiac surgery program in rural Africa.

Perspective.

A locally led cardiac surgery program in rural Kenya achieved sustained growth by combining diversified financing, cost containment, and structured workforce training. Progressive localization reduced reliance on visiting missions while expanding access, complexity, and equity, demonstrating that durable, high-quality cardiac surgical care is feasible in resource-limited settings.

Cardiovascular disease is becoming an increasingly more important cause of illness and death in low- and middle-income countries (LMICs), where access to basic surgical services is still very limited. More than 5 billion people around the world do not have access to safe, timely, and affordable surgical care. Cardiovascular diseases are a major cause of preventable death and disability.¹ Even though there are effective surgical treatments for rheumatic heart disease and untreated congenital heart disease, these diseases continue to be a major cause of death in sub-Saharan Africa.²

Historically, short-term visiting cardiac surgery missions have been the most common approach to attempt to meet these needs. These programs have provided life-saving care for some patients, but they often fall short because services aren't always available, costs are high per case, follow-up after surgery is limited, and they generally are not effective in helping the long-term growth of the workforce.³ The Global Surgery 2030 framework highlighted that long-term improvements in surgical access need systems that are built into the community and include infrastructure, workforce training, and long-term funding, not just short-term service delivery.⁴ In many LMICs, persistent structural barriers like geographic isolation, a lack of workers, and a lack of money continue to make it hard to provide complex surgical care.⁵

The number of health care workers providing cardiac surgery in sub-Saharan Africa is extremely limited. Many African countries have fewer than 1 cardiothoracic surgeon per million of the population, making it difficult for cardiac surgical services to grow.⁶ At the same time, the need for cardiac surgery appears to be growing in this region. For example, global estimates show that there are large differences between the number of people who need cardiac surgery and the number of surgeries that can be performed.^7,8 This gap has a particularly ominous effect on children, given that the unmet need for cardiac surgical services for rheumatic heart disease and congenital heart disease is enormous.

Tenwek Hospital is a faith-based referral center in rural Western Kenya that started offering heart surgery services in 2008 through intermittent visiting teams. Over time, the institution intentionally moved toward a continuous, locally led cardiothoracic surgery program that focused heavily on training and institutional ownership. Tenwek is a good example of how to develop a sustainable cardiac program because it developed in an area with few resources, very limited third-party payers, a mostly rural patient population, and a great deal of unmet need.

This study looks at the long-term growth of the Tenwek cardiothoracic surgery program, its funding and cost-cutting strategies, and the perspectives of stakeholders on its long-term viability. We sought to find transferable principles that can be used to create long-lasting cardiac surgery programs in other low-resource areas by combining quantitative operational data with qualitative insights from members of a multidisciplinary team.

Methods

Study Design

We conducted a retrospective mixed-methods case study of the cardiothoracic surgery program at Tenwek Hospital, Kenya, covering the time frame from January 2008 to December 2025. A mixed-methods approach was selected to obtain both quantifiable programmatic outcomes and the experiential perspectives of stakeholders engaged in program development and implementation.

Study Population and Sampling

Institutional records were examined to obtain annual cardiac surgical volume and case mix, funding sources and expenditures, workforce composition and training outcomes, and milestones in infrastructure development. We used set criteria to group cases by how complicated they were, such as multivalve surgery, redo operations, and major aortic procedures.

For the qualitative aspect, purposive sampling was used to select key informants directly engaged in the cardiac surgery program. There were 2 cardiothoracic surgeons, 1 cardiac anesthesiologist, 3 perfusionists, 2 nurses in the intensive care unit and operating room, 1 hospital administrator, 2 finance officers, and 1 social worker who took part. The goal of this multidisciplinary sampling strategy was to get a wide range of opinions on financing, cost control, workforce development, patient access, institutional sustainability, and how well the model could be used in other settings.

Data Collection

We collected quantitative data from surgical logs, administrative records, and financial reports from institutions. The variables were the number of cases per year, the mix of cases, the complexity of the procedures, the sources of funding, the makeup of the workforce, and the milestones for infrastructure development.

We used a standard interview guide to do semistructured interviews to gather qualitative data. Interviews looked into topics like how the program has changed over time, how it gets funded, how it cuts down costs, what makes it hard to keep going, and what people think will facilitate success. Interviews were done in English, and when possible, they were recorded. Detailed written notes were also taken.

Data Analysis

We looked at quantitative data descriptively, summarizing changes in surgical volume, case complexity, and funding sources over time. We looked at financial data to determine how much each source of income contributed and how cost-control measures changed over time.

Qualitative data were analyzed using thematic analysis. A multistage coding process was used, and any differences reconciled by reaching a consensus. We used both qualitative and quantitative data to make the results more accurate and to put them in a better context.

Ethical Approval

The Tenwek Hospital Institutional Review Board reviewed and approved the study protocol and publication of data (institutional review board approval number: 2026-0005; January 23, 2026). Patients and interviewees provided informed written consent for the publication of the study data. Before analysis, all data were stripped of identifying information to protect privacy.

Results

Program Growth, Clinical Volume, and Outcomes

The number of cardiac surgeries performed each year grew steadily, from 9 in 2008 to 289 in 2025. A total of 1575 heart surgeries were performed, with 1139 being acquired and 436 being congenital (Figure 1). By 2025, the local team was doing more than 95% of the cases, up from 0% in the first few years, reflecting successful workforce localization (Table 1).

Figure 1.

Growth of cardiac surgery volume at Tenwek Hospital (2008-2025).

Table 1.

Growth of the Tenwek cardiac surgery program (2008-2025)

Variable	Value
Study period	2008-2025
Total cardiac operations, n	1575
Acquired cardiac cases, n (%)	1139 (72.3)
Congenital cardiac cases, n (%)	436 (27.7)
Annual case volume, 2008, n	9
Annual case volume, 2025, n	289
Cases performed by local team, 2025, %	>95

Congenital cardiac surgery used to make up almost one half of all cases, but as adult cardiac complexity grew, the percentage of congenital cases went down. However, the total number of congenital cases kept going up. From 2008 to 2012, complex acquired cases constituted only 3.5% to 5% of procedures. By 2022 to 2025, complex cases, including multivalve rheumatic disease, redo operations, and major aortic surgery, comprised 45% to 50% of the total cardiac surgical volume (Table 2). During the same period, minimally invasive valve surgery was introduced, along with the Cox-maze procedure using cryoablation for the treatment of concomitant atrial fibrillation. This shift in handling more congenital and complex acquired cases occurred in parallel with progressive developments in infrastructure, workforce capacity, and training programs.

Table 2.

Evolution of case mix and surgical complexity over time at Tenwek Hospital (2008-2025)

Time period	Program characteristics	Congenital cases (% of total cardiac cases)	Complex acquired cases (% of total cardiac cases)
2008-2012	Early program, visiting teams	∼50	3.5-5
2013-2017	Transitional growth phase	35-40	20-25
2018-2021	Predominantly local workforce	30-35	35-40
2022-2025	High-volume mature program	25-30	45-50

Complex acquired cases included multivalve surgery, redo operations, and major aortic procedures.

Long-term follow-up demonstrated an overall all-cause mortality of 9.6% over the 17-year study period. Perioperative 30-day mortality was 4.4% overall, with a progressive decline despite increasing case volume and procedural complexity, reaching 3.2% in 2025. Perioperative morbidity during the study period was 17%, with low cardiac output syndrome, postoperative arrhythmias, bleeding requiring reoperation, and infections representing the most common complications. Requirement for permanent pacemaker implantation was rare, occurring in only 11 patients (0.7%). Of the patients operated during the study period, a total of 19 patients underwent delayed reoperations, most of them for valve-related complications commonly due to bioprosthetic valve degeneration (n = 8), mechanical valve thrombosis (n = 4), and progressive tricuspid valve disease (n = 4).

Financing Model

In 2025, total annual program funding reached USD 3.23 million. Public health insurance accounted for 59% of revenue, followed by patient contributions (24%), mission partnerships (9%), philanthropic support (6%), and private insurance (2%) (Figure 2). This distribution was generally in line with funding patterns from previous years. However, contributions from missions and charities, which used to make up to 40% of revenue, have gone down over time. This is partly because public health insurance has been paying more for open-heart surgeries in the last few years.

Figure 2.

Sources of program funding at Tenwek Hospital in 2025.

Interviewed stakeholders stressed that having a variety of funding sources is important for resilience. They also said that relying on public insurance is both necessary and risky, pointing to delayed payments and unstable policies as major risks. Donations, especially the Compassionate Cardiac Fund, were very important for helping poor patients get the care they needed.

Cost-Containment Strategies

Reuse protocols, when implemented safely according to established guidelines, contributed to cost savings of up to 20%, while local procurement strategies reduced costs by up to 15% (Table 3). These estimates were derived from program-level financial records comparing procurement and supply costs before and after implementation over the study period, using average case-level consumable expenditures as the reference. These strategies lowered the cost of each case and lessened supply chain problems, which meant that surgical services could continue even during economic downturns and the COVID-19 pandemic. Nurses and perfusionists reported fewer supply interruptions, making operations more consistent. During our early experience with local suppliers of consumables, we found that product quality consistency was a problem. This was addressed by vetting a larger number of suppliers and selecting those with consistently high-quality products.

Table 3.

Cost-containment strategies and impact during the study period

Strategy	Year introduced	Estimated impact
Sourcing donated equipment and supplies	2008	Minimized upfront capital costs and lowered cost per case (especially for needy patients)
Safe equipment reuse protocols	2011	15%-20% cost reduction
Local procurement of consumables	2013	10%-15% cost reduction and improved supply continuity
Bulk purchasing agreements	2016	Lower unit costs
Task-shifting/workforce optimization	2018	Reduced personnel costs

In addition, sourcing donated equipment and supplies significantly reduced program costs. These contributions have included cardiopulmonary bypass machines, oxygenators, perfusion packs, ventilators, surgical instrument sets, cannulas, valves, sutures, synthetic vascular patches, grafts, and other essential consumables. Dependence upon these donations was high initially, but over time donated supplies became a very small percentage of products used.

Equity and Social Support

In 2025, 43% of patients who underwent cardiac surgery got some kind of financial help, with an average of $3500 per patient. Structured evaluations and home visits helped social workers find financially needy patients. Stakeholders stressed that asking patients to make small contributions helped them keep their dignity and sense of responsibility while avoiding dependency.

Workforce Development and Training

The program started in 2008 with only fly-in mission teams, but by 2013, 5 years later, it had grown to include a full-time local workforce doing open-heart surgeries on their own. There were 1 cardiac surgeon, 1 perfusionist, 2 nurse anesthetists, 3 scrub nurses, and 4 critical care nurses in this group. Currently, more than 300 people from the local area work in surgical, anesthesia, perfusion, nursing, and support roles.

Between 2018 and 2025, the cardiothoracic fellowship program graduated 7 surgeons from 3 African countries. Many of them still work in the area. There are currently trainees from 5 different countries, which shows how the program is a continental training center. This training program is fully accredited by the College of Surgeons of East, Central, and Southern Africa and consistently graduates the greatest number of board-certified cardiothoracic surgeons in the region. Administrators stressed how important the fellowship was for localization and reducing reliance on outside sources.

Tenwek also began training in cardiovascular perfusion in 2020. Since then, the program has graduated 5 cardiovascular perfusionists—4 from Kenya and 1 from Rwanda. Currently, there are 6 trainees in the program: 4 from Kenya and 1 from Malawi.

In addition, there is an unaccredited 1-year cardiovascular anesthesia training program for nurse anesthetists, which started in 2022. To date, 6 candidates have completed this training and are now active members of the cardiovascular anesthesia team, which is led by a local consultant cardiovascular anesthesiologist. In 2023, the Tenwek Nursing School launched a 2-year Master's program in Critical Care Nursing. Graduates from this program are now integral members of the cardiac intensive care unit team.

Infrastructure Development

The infrastructure expanded as the number of patients grew. In 2024, a new cardiothoracic center opened with capacity for 2000 operations per year, increasing the number of intensive care unit beds from 6 to 40 and the number of operating rooms available to 25 to 30 tables per week. In 2025, a cardiac catheterization laboratory was added, enabling more comprehensive care.

Challenges and Failures

In the early years, there were funding fluctuations and visiting team inconsistencies, which caused case backlogs. The pandemic in 2020 caused fewer visitors, but the growth of local teams made up for this. There were significant challenges in ensuring fair access for extremely needy patients and patients from remote areas. This led to increased involvement of social workers.

Recent problems have mostly come from inconsistent reimbursement from the public health insurance and many patients having trouble coming up with the extra money they need to pay their share of the costs. To address these problems, the hospital has deliberately worked to improve reimbursement rates while also strengthening fundraising efforts to maximize financial support for patients in need.

Transferable Lessons

Stakeholders identified several operational, financial, and training lessons from the cardiac surgery program at Tenwek Hospital that may be relevant for other resource-limited settings. A recurring theme was the importance of a committed on-site cardiothoracic surgical leader who could provide consistent clinical oversight and long-term program direction. Participants emphasized that relying solely on intermittent foreign visiting teams was insufficient to establish a stable cardiac surgery service or training platform. Instead, visiting surgical teams were most effective when structured as planned teaching campaigns that emphasized mentorship, supervised operative participation, and hands-on skill transfer to local staff. Several stakeholders noted that visiting teams were explicitly encouraged to prioritize capacity building over operative volume, ensuring that each visit contributed to the progressive development of local expertise.

Stakeholders also highlighted the importance of aligning workforce development with financial sustainability. Training programs in cardiothoracic surgery, cardiovascular perfusion, cardiovascular anesthesia, and critical care nursing were viewed as essential to gradually localize expertise while reducing long-term dependence on external personnel. At the same time, diversified financing—including public insurance reimbursement, philanthropic partnerships, and structured patient sponsorship—allowed the program to maintain clinical services while expanding training activities.

Discussion

This study shows that it is possible to create sustainable cardiac surgery programs in resource-constrained settings through strategic planning that emphasizes diversifying funding sources, managing costs, cultivating a local workforce via structured training, and enhancing infrastructure through collaborative efforts. Previous experience performing cardiac surgery in places with few resources has shown that programs that rely mostly on outside missions have problems with continuity, cost-effectiveness, and long-term viability.⁹ The Tenwek experience shows that slowly moving from mission-based service delivery to a locally led model can help get around these problems.

A central finding of this research is the significance of diversified financing. Programs that rely on one source of funding, like donations, government payments, or visiting teams, are still at risk of policy changes and economic instability. Previous global studies of cardiothoracic surgery have shown that a lack of money is a common reason for programs to stop working or fail in LMICs.¹⁰ At Tenwek, the combination of public insurance payments, patient contributions, donations, and partnerships with other organizations made the financial structure stronger. Over time, public insurance became the main source of income, but charitable donations were still important to make sure that financially constrained patients could get care.

Cost containment was equally critical to sustainability. Stakeholders stressed that lowering the cost per case was just as important as raising the number of surgeries. Donated equipment and supplies initially minimized start-up costs and continued to reduce the cost per case. As the program grew, incremental strategies like bulk purchasing, local procurement, safe reuse protocols, and task-shifting were put into place. These strategies helped the program handle more complicated cases without raising operating costs by the same amount, which is what has been seen in cardiac surgery programs in low-resource settings before.^9,10

Localization and training of the workforce were key to long-term success. The gradual replacement of visiting teams with locally trained surgeons, anesthesiologists, perfusionists, and nurses improved the continuity of care and the sense of ownership of the institution. Although workforce shortages remain a major constraint across sub-Saharan Africa, sustained investment in training has been repeatedly associated with durable capacity building and reduced reliance on external partners.^6,7 Tenwek became a regional training center with the establishment of formal training programs in cardiothoracic surgery, cardiovascular perfusion, cardiovascular anesthesia, and critical care nursing. This had an effect that went beyond just providing services.

The program design purposefully included equity issues. Structured social work assessments and targeted sponsorship mechanisms lowered the risk of huge health costs, which are still common in LMICs, where out-of-pocket payments make up a large part of health care funding.¹¹ The program was able to be financially sustainable while still meeting its moral duty to provide care to everyone, regardless of their ability to pay, by combining partial patient contributions with means-tested subsidies.

Several contextual factors contributed to the success of the Tenwek Hospital program but may not be universally replicable. The faith-based institutional mission, long-standing international partnerships, and philanthropic donor networks helped stabilize financing and supported service delivery in ways that may be difficult to reproduce in purely public or private systems. In addition, the hospital's rural southwestern location in Kenya provided access to a large catchment population with a lot of unmet surgical need, limited regional competition, and concentrated referral patterns that facilitated program growth. National political stability, economic growth, and the expansion of public health financing through the National Hospital Insurance Fund further supported procedural demand and improved reimbursement for cardiac surgery. However, these advantages reflect specific institutional, geographic, and policy contexts that may not be present in all low-resource settings.

Overall, the Tenwek experience demonstrates that sustained delivery of advanced cardiac surgical care in resource-limited environments is achievable with acceptable clinical outcomes when programs prioritize local leadership, diversified financing, rigorous cost management, and long-term workforce training. Although the exact organizational structure of this model may not be universally transferable, the core principles of building institutional capacity, promoting equity in patient access, and gradually localizing expertise offer practical guidance for scaling cardiac surgical services across sub-Saharan Africa and other low- and middle-income regions.

Study Limitations

This is a single-center observational study, and findings may not be generalizable to all settings. Financial data before 2016 were incomplete, and qualitative findings may reflect respondent bias. Nonetheless, triangulation of multiple data sources strengthens the conclusions.

Conclusions

Sustained cardiac surgery programs in low-resource settings are feasible when grounded in local team training and leadership, diversified funding, cost containment, workforce localization, and patient equity mechanisms. The Tenwek model offers practical lessons for scaling complex surgical care across sub-Saharan Africa and other LMICs.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.