To our knowledge, our study is the first to explore the role of VGHPIs and their perceived benefits and barriers for the resilience of GHPs during the COVID-19 pandemic. Further, our survey is the first to query current LMIC and HIC members of GHPs to document initial preferences for and interest in VGHPIs. Although our data are descriptive only, our findings contribute critical information to advance previous discussions about supporting partners in LMIC during global challenges, such as epidemics or crises [10, 43]. Additionally our findings add a real-world perspective to recent discussions about shifting GHP activities virtually (16, 28, 36, 39), addressing LMIC partner needs thoughtfully (30), addressing virtual education needs within certain specialties (19, 26, 29), and proposing virtual programming relevant only in HIC (40, 41).
Among our 128 respondents from 34 countries, there were a wide range of institutions and clinical specialties represented. Participants shared details of up to three of their GHPs, which allowed for an expanded dataset within a relatively limited participant group. The GHPs described in this study are like those in previous studies (1, 6, 7, 14-16, 20-25), and our data offer insights into VGHPI considerations for similar GHPs. A few GHPs in our dataset represented domestic LMIC/LMIC or HIC/HIC partnerships, “global local” pairings whose unique needs should be considered during implementation of VGHPIs (1, 2, 8). Most partnerships were bidirectional, but the reported exchanges, whether bidirectional or unidirectional, were mainly from the HIC to the LMIC partner. Previously described successful bidirectional and collaborative initiatives during crises (15, 42) may be just as (or more) easily done virtually and favor the needs of the LMIC partner. Such transferable activities include opening access to educational resources; connecting subspecialists from HIC to LMIC sites; assisting LMIC faculty with grant writing and budget preparation; assisting LMIC trainees with residency application or entry examination preparation; offloading administrative tasks from the LMIC partner to HIC partner; and advocating for funds to improve LMIC partners’ administrative, office and technological capacity. VGHPIs provide an opportunity for complementing and coordinating efforts in GHPs, a tenet of ethical GH practices(43), more efficiently than ever before.
Not surprisingly, only a minority of GHPs were engaged in VGHPIs before the pandemic, often with a weekly frequency. Thus, future studies looking at ideal activity frequency and ongoing activity preferences will be helpful in providing best practice recommendations. Interestingly, the respondents reported that VGHPIs would be important to the vast majority (206/219, 94%) of their GHPs moving forward. The significant differences in opinion about how VGHPIs would be important for domestic, transnational, and blended GHPs will be key discussion points for partnerships looking to incorporate or expand VGHPIs. Although we only inquired about four ways in which VGHPIs may be important (enabling continuity of activities vs usefulness in guiding planning vs increasing safety of partnerships vs allowing for career advancement), our findings suggest that partners’ priorities and needs may not be aligned, and shared priorities should not be assumed. Likewise, data showing the significant differences between HIC and LMIC partners regarding preferred types of VGHPIs, most specifically in terms of access to online materials (preferred by LMIC more than HIC respondents) and valuing virtual face-to-face trainings (preferred by HIC more than LMIC respondents), are telling. Because HIC and LMIC partners seem to value different components of VGHPIs, these notable differences should prompt ongoing and intentional discussions to ensure all parties are mutually benefitting from VGHPI implementation and roll out.
Our data show ongoing discrepancies between resource access and allocation that worsened since the pandemic began. For example, most respondents reported pandemic-related disruptions in communication at their GHP sites, but disruptions in funding, partnership activities, and access to professional support and resources were significantly more disruptive for LMIC compared to HIC respondents. This must be taken into consideration for future emergency responses and in how VGHPIs are structured and planned from baseline.
Regarding barriers to VGHPIs, although there were no significant differences between LMIC and HIC respondents on perceived barriers to VGHPIs, the agreement between respondents could counter assumptions that members of GHPs may make about each other. The time needed for training and the lack of training curriculum were among the most frequently reported barriers by GHP sites. This suggests underlying healthcare system challenges in enabling continuous professional education within the GHPs. Regarding technological capacity, our findings agree with previous studies (1, 8, 14, 36, 44-46) that suggest a lack of internet connectivity is a severe concern for GHPs, with important implications for VGHPIs. We found that LMIC partners reported less access to wireless internet, less trainee access to organization-owned hardware, poorer cellular phone service, and less access to physical spaces like meeting and simulation facilities. However, both HIC and LMIC respondents had reliable access to personal smartphones, to organization-owned technology, and video-conferencing services. Considering the technological capacity within GHPs and possibly investing into communication infrastructure will be critical to ensure successful virtual engagement. Funding for in-person activities could be shifted towards resources that improve internet connectivity at LMIC partner-sites to address this challenge.
Between the LMIC and HIC partners, there were several key differences in opinion about VGHPI acceptability. Significantly more respondents in LMIC compared to HIC reported they would need to learn many things to succeed with VGHPIs and require technical support to fully participate in VGHPIs. This need for education and support must be considered moving forward to ensure the needs of LMIC partners are adequately heard and met. Interestingly, more LMIC respondents reported that participating in VGHPIs would be easy, but that virtual applications and technology are complicated. This perhaps reflects the difference between using technology (something many LMIC partners are accustomed to as the hosting partner in a GHP) versus reliable access to technology (reflecting challenges in technological capacity), which indicates that reliable access must be accompanied by reliable training. This could be further examined in future studies.
Our study had several limitations. First, the pandemic likely hindered invited respondents from participating. We actively reached out to our professional networks to mitigate this challenge, but in doing so may have favored respondents from partnerships with greater resources. Second, as an initial exploratory survey, we pursued convenience sampling, which meant it was not possible to document response rate to the survey. Third, we chose not to include participants from the EEA due to lengthy ethical review processes to meet European data protection requirements, an issue we plan to address in future surveys. Fourth, our paper presents only descriptive data given that we received inadequate free-response data for a qualitative analysis. Finally, partial survey response may have affected results, though this was only 10% of the respondents; the pattern was determined to be missingness completely at random and did not disrupt results. Despite the limitations, we believe we gained valuable insight into a wide variety of GHPs at a key moment during the COVID-19 pandemic. Further, we approached this survey as a first step to inform future mixed-method and qualitative work about VGHPIs, helping to direct further study.