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

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.