To our knowledge, our study is the first examination of access to and interest in VGHAs of GH participants and facilitators during the COVID-19 pandemic. Further, our survey queries respondents from both LMIC and HIC settings to document differences in experiences with VGHAs by country of residence. Our data advance previous discussions about mutual support between GH colleagues during crisis [12, 41] and thoughtfully addressing LMIC partner needs during the pandemic [27] while building upon baseline data initially documenting perceptions of and barriers and facilitators for virtual global health partnership activities [28]. Additionally, our findings add a real-world perspective to recent discussions about shifting GHA activities virtually [11, 24, 28, 42] and complementing and coordinating efforts between GH colleagues, a tenet of ethical GH practices [9].

Comment on respondents

Respondents represented multiple types of institutions active within 45 countries of residence. Four countries (USA, Uganda, India, and Nigeria) represented the majority of respondents, which likely reflect the most common GH partnerships reflected within the authors’ anglophone professional networks. GH participants and facilitators are similar to previously described members of GH partnerships [10, 14,15,16,17, 19, 21, 28], and our results offer insights into VGHA considerations for similar participants.

Of note, a quarter of our respondents represented those engaged in GHAs within resource-constrained areas of HICs, “global local” pairings between LMIC/LMIC or HIC/HIC partners whose unique needs should be considered during implementation of VGHAs [43, 44]. There is a growing body of evidence about these types of partnerships in the literature [23], but papers focusing specifically on “glocal” activities and needs of engaged partners, particularly for virtual engagement, are lacking. Our data and previous papers [23, 28] suggest that future study into these unique partner types would fill a gap in the literature.

Funding and support for GH activities

Our results show an unbalanced trend related to access to GH funding and administrative support within our dataset. HIC respondents reported having significantly more access to GH funding through their own organization; were significantly more likely to have GH funding in addition to their core role funding; and tended to have more access to grants, personal funds, philanthropic donations, health professional tuition, and dedicated GH administrative support through their institution. Other types of funding for GHAs more accessible to those in LMIC settings (such as crowdsourcing and funding from non-governmental organizations) were extremely infrequently reported among our respondents (n = 3/151, 2%). For those reporting GH funding, HIC respondents reported overall more flexibility for using funds for various GH activities and significantly higher use of funds for GH travel compared to LMIC respondents. Perhaps most concerning, LMIC respondents were significantly more likely to report no access to GH funding at all.

These data support that GH funding was not equitably used or available to GH participants, particularly in terms of travel, a known barrier to bidirectionality within GH partnerships [16, 19]. We do not, however, have further details on why these trends emerged, although we speculate that this reflects the norm in GH partnerships for unidirectionality of the HIC partner visiting the LMIC partners. Our findings suggest that support to participants in LMICs is an urgent need within GH partnership and a critical gap in GH equity, particularly during the pandemic which exacerbated the normative model. Further study elucidating partner preferences for allocation of GH funding within partnerships and the use of available GH funds for traditionally expensive in-person activities versus less expensive but infrastructure-heavy activities will be important for improved partnership equity and resource allocation moving forward. Future research on the nuances of funding availability, distribution, and use among various GH participants and facilitators would fill a gap in the literature.

Overall access to VGHAs during the pandemic

While funding was much more accessible to people located in HICs, VGHA accessibility did not vary significantly between the groups; this is an argument for the potential in improving equity of educational resources and bidirectionality through VGHAs. There were important trends to note in our data, however, which serve as cautions for GH partners engaging virtually. First, although not significant, HIC versus LMIC respondents did report overall more access to virtual GHAs, including more access to virtual collaborative GH education sessions, GH experience preparation sessions, and hosting of external GH participants. Second, LMIC partners reported more access to VGHAs related to their training and academic endeavors, such as virtual GH simulation sessions, clinical rounds, case discussions, or research. While we do not know our respondent’s priorities for their VGHAs, this trend may reflect the priorities of the HIC partner, such as a wish to continue training and teaching LMIC partners or continuing joint research beneficial to HIC institutions. These findings together highlight a potential lack of professional support and agency for faculty from LMIC engaged in GHAs which may exacerbate present inequities in capacity building and professional support available to LMIC partners virtually.

Loss of in-person activities during the pandemic at one’s own or another organization

The majority of participants reported loss of in-person GHAs at both their own and another institution during the pandemic. Unsurprisingly, there was a significant difference (HIC > LMIC respondents) in the loss of in-person international experiences, with an overall greater HIC reported loss of in-person activities at one’s own institution and a greater LMIC reported loss of activities at another organization. Further, hosting of external GH partnerships was one of the most frequently lost GHAs for all respondents. These data corroborate trends elsewhere in the literature that although bidirectional GH experiences are preferred, most activities remain unidirectional with HIC to LMIC visits [19]. These findings may also reflect regional and unequal variabilities in quarantine requirements, travel restrictions, and access to more widespread GH networks when the pandemic began. The disparities in access are important considerations when planning how partners might sustain partnerships and GH activities during future periods of restricted travel or global unrest [23, 28, 39, 41].

Gain of virtual access during the pandemic through one’s own or another organization

Although there were no significant differences between HIC and LMIC respondents in terms of overall gain of access to VGHAs during the pandemic through one’s own organization, there were upward trends in our data. Overall, LMIC respondents reported more gain of access to VGHAs at their own organization, but those activities did not include more recognition for their GH work (responses split evenly between HIC and LMIC respondents) nor more reported GH networking opportunities. This may suggest a prioritization for HIC partners to continue GH educational activities virtually for LMIC audiences, while focusing less on virtual GH professional development activities for LMIC colleagues.

Via a gain of access to VGHAs through another organization, LMIC respondents reported significantly more gain of access to GH educational activities and resources and collaborative GHAs. This may reflect a partnership strength among participants, demonstrating either that HIC partners sought to extend virtual experiences to their LMIC partners, or perhaps that LMIC partners requested virtual access from HIC partners. LMIC partners also tended to gain more virtual domestic/local GH experiences through their own organization. Little exists in the literature about in-person or virtual local/domestic GH experiences between LMIC-LMIC partnerships, and our finding suggests that those in LMIC settings pursued a virtual shift of GHAs due to the COVID-19 pandemic’s effect on in-person activities. This is a gap in the literature and an area of future study.

Regarding gain of virtual international GH experiences during the pandemic, HIC respondents tended to report more gain of virtual international GH experiences through their own organization, while LMIC respondents reported more gain of this activity through a partner organization. Further, LMIC respondents reported more virtual hosting of GH participants during the pandemic, both at their own and a partner organization. Although not statistically significant, this trend highlights an important consideration in terms of resource use, equity, and capacity enhancement.

Interest in VGHAs

Our data indicate a widespread interest both during and after the pandemic for most types of VGHAs queried. Interestingly, stratifying our participants by country of GH participation did not reveal any significant difference in interests for VGHAs during or after the pandemic. These findings, in addition to previous studies [23, 28, 39], however, do not delve deeper into the striking lack of equity in terms of access to opportunities and availability of funding support for GHAs in LMICs. Based on our data, we recommend that every GH partnership should frankly evaluate each partner’s interest in VGHAs—both in terms of the specific activities possible within a partnership as well as how power structures at play in the partnership affect the communication of interest and therefore the prioritization of activities. VGHAs, because of their unique ability to bring all voices to the table, should be discussed in every GH partnership and collaboration moving forward to facilitate more equitable activity selection, prioritization, and implementation plans. Further study on how best to facilitate these discussions and agenda setting for VGHAs is merited.

Future considerations

Barriers and enablers to VGHAs must be considered when making recommendations based on our data. A lack of internet connectivity is a severe concern for GHAs [23, 45,46,47], and our previous study [28] 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. The success of virtual engagement will require considering the technological capacity of GH actors and advocating for communication infrastructure investments, access to libraries and resources, and appropriate scheduling of meetings to ensure LMIC partner participation [28, 48]. Further, funding otherwise earmarked for GH travel and in-person activities could feasibly be shifted toward improving connectivity and other professional capacity building targeted to LMIC partner-sites.

Limitations

Our study had several limitations. First, because our survey reached at least two large GH listservs despite targeted sampling among distinct invitee groups, we must estimate our response rate. Second, to focus on augmenting previous baseline data and to not exclude respondents who may not have had access to VGHAs at the time of the survey, we did not query respondents about lessons learned from virtual engagement. Third, the survey length may have contributed to survey respondent fatigue and contributed to missing information. For example, the survey instructed respondents to use the “N/A” column for GHAs that they did not have access to. However, most respondents left activities blank instead of using the “N/A” column in the survey to indicate lack of access. For this reason, we coded responses for access to GHAs as ‘1’ for being checked and ‘0’ for unchecked or missing, “N/A” or “Don’t know.” This limits our ability to distinguish between true lack of access versus missing responses for individual GHAs. Fourth, our study was only available in English, likely contributing to a sampling bias. Fifth, because of the convenience sampling strategy, these results may not be generalizable beyond the study population. Last and most importantly, our categorization of participants into HIC versus LMIC groups for analysis has inherent practical and ethical implications [49, 50] that affect the interpretation of our results.

Despite the limitations, we believe our results deepen our understanding of previous baseline data on VGHAs during the COVID-19 pandemic, and our data create a stronger foundation for future study of the implementation of VGHAs more widely in the wake of the pandemic. This body of data is important to guide future study, to provide a “before” comparison to help other groups with similar goals evaluate the impact of the pandemic on their GHAs, and to foster meaningful discussion within GH partnerships related to resource access, agenda setting, and equity in decision making.