Greater Reciprocity in Global Surgery Partnerships Is Possible

Academic global health partnerships can provide a mutually beneficial exchange of skills, knowledge, and resources between high-income countries (HICs) and low- and middle-income countries (LMICs) to address workforce needs and increase capacity building.

For a procedural specialty such as surgery, an essential aspect of these partnerships is the ability to provide hands-on clinical experiences to trainees. Existing partnerships have demonstrated several benefits to HIC trainee involvement in short-term medical exchanges, including exposure to open techniques and pathologies not routinely seen in their home countries, as well as increased cultural awareness. 

LMIC trainees may benefit from exposure to different techniques, new technologies, and mentorship opportunities.^1,2 It is important to note that while many partnerships claim to be bidirectional, achieving true bidirectional exchange and reciprocity in clinical opportunities remains challenging.

While many global surgery partnerships aim to address the gaps in the surgical workforce, it can be argued that global surgery rotations tend to benefit trainees from HICs more than those from LMICs. In fact, some initiatives have faced criticism for promoting unequal power dynamics between partnering countries.

One method of promoting a more balanced partnership is fostering international reciprocity for surgeons and surgical trainees from LMICs for short-term clinical exchanges. Historically, this approach seems to be largely characterized by a one-way flow where partners from HICs travel to LMIC institutions, but rarely vice versa.³

Fostering reciprocity within academic partnerships between US and LMIC institutions is particularly challenging due to the visa processes, governmental and institutional policies, financial barriers, and cultural differences.

By reviewing the history of global academic surgical partnerships and examining these current challenges, we hope to provide insights for developing a future where achieving true reciprocity is possible, and surgical care can be made safe, accessible, and affordable for all patients around the globe. 

Surgical Missions to Bilateral Partnership

In 2005, the World Health Organization founded the Global Initiative for Emergency and Essential Surgical Care, a multidisciplinary forum that seeks to reduce the burden of surgical disease through international collaboration, development, and policy.⁴

Given the paucity of investment in surgical disease, which continues to account for a significant portion of the burden of treatable diseases worldwide, Paul Farmer, MD, PhD, a pioneer in global health equity, dubbed global surgery the “neglected stepchild of global health.”⁵

The Lancet Commission on Global Surgery highlighted the burden of surgical disease and noted that several of the United Nations Sustainable Development Goals could not be achieved without the provision of surgical care in LMICs.6 Over the last 10 years, there has been a growing effort to forge bilateral partnerships beyond medical mission trips previously grounded in neocolonial and imperialist ideologies toward promoting collaborative efforts rooted in international reciprocity.

Academic global surgery partnerships are relatively new, dating back to about 30 years ago. Many current partnerships use the “twinning model,” in which HIC and LMIC institutions partner to share clinical, education, and research opportunities.⁴ Models have included partnerships between universities, academic, nongovernmental, and governmental organizations.

A particularly effective partnership between HICs and LMICs is the collaboration between the ACS and the College of Surgeons of East, Central, and Southern Africa (COSECSA), which was formalized in 2018.

Since its inauguration in 1999, COSECSA has focused on creating a standardized surgical training pathway for participating countries, while addressing the surgical needs and limited access to qualified surgeons in the sub-Saharan African region.^3,7 The ACS-COSECSA Surgical Training Collaborative has been the largest accomplishment of this partnership, which is focused on surgical education and workforce development.

In 2018, Hawassa University in Ethiopia became the first collaborative site, which serves as a hub for improvements in education, research, quality, and clinical care. Key successes of this partnership include the creation of a trauma registry in Hawassa and “train the trainer” Advanced Trauma Life Support^® (ATLS^®) courses to train local instructors to promulgate ATLS skills, eliminating the need for international travel for local participants. Two additional hubs have since been launched at University Teaching Hospital in Lusaka, Zambia, and the University of Rwanda and Ministry of Health in Kigali, Rwanda.⁷

The COSECSA partnership with the Society of American Gastrointestinal and Endoscopic Surgeons Global Laparoscopic Advancement Program has introduced laparoscopic skills sessions at recent meetings, with the goal of incorporating Fundamentals of Laparoscopic Surgery (FLS) into the COSECSA curriculum.⁸ With the overarching aim of solidifying these training programs, the expectation is that as local capacity expands, there will be an overall reduction in US surgeons traveling to these facilities.

Current State of Short-Term Clinical Exchanges

Despite the progress in bidirectionality made from transitioning from surgical missions to the twinning model, most examples of US-LMIC partnerships may still be perceived as unilateral, especially given the lack of opportunity for LMIC partners to travel to HIC training environments. Short-term clinical exchanges are immersive experiences that provide significant educational benefits. However, most literature on global surgery focuses primarily on the advantages for HIC trainees, who typically travel to LMICs.

Trainees from HICs are frequently exposed to a broader range of cases and receive more opportunities to perform open surgeries than they might in their home countries3, which has contributed to the increasing integration of global surgery rotations in various residency programs across the US. There are several programs where US trainees can earn credit toward Accreditation Council for Graduate Medical Education (ACGME) case requirements by scrubbing into cases and providing direct patient care. Limited infrastructure in LMICs often constrains local trainees, and visiting HIC trainees may take away surgical opportunities from local practitioners.

Conversely, opportunities for LMIC trainees to participate in international rotations are much scarcer, with additional barriers that may limit their role to that of an observer, preventing full participation in patient care. These limitations may vary based on institution and local regulations, but often exclude observers from essential patient care activities, including taking a patient history, performing a physical exam, performing or assisting in procedures, prescribing medications, documenting in the medical record, or obtaining consent for surgery or research.⁹

At the federal level, one of the most significant barriers for LMIC trainees to participate in international rotations is the visa process. While there are several visa pathways available for observerships and medical student exchanges, there is currently no visa category to support hands-on, short-term clinical exchanges for residents and faculty.

Foreign medical graduates may apply for J-1 (exchange visitor) or H-1B (specialty occupation) visas. However, the visa process is lengthy, expensive, and inconsistent. Approvals for J-1 visas are particularly subjective, and applicants may face rejection if they are not deemed to have strong enough ties to their home country.¹⁰

One concern is the potential for “brain drain,” in which highly educated or trained individuals leave their home countries in pursuit of better professional opportunities or compensation if equitable learning opportunities are provided to LMIC trainees. Allowing for short-term clinical experiences may mitigate this concern given limited time training outside an individual’s home country. Additionally, studies have shown that many LMIC trainees seeking training opportunities outside of their home countries often return to their home country or continent of origin after training.¹¹ 

Once LMIC trainees have obtained visas, their involvement is often limited by additional barriers at the state and institutional levels, including state medical board licensure and liability insurance. Foreign medical graduates seeking to participate in US-hosted residency and fellowship programs are usually required to possess Educational Commission for Foreign Medical Graduates (ECFMG) certification. Those seeking to participate in short-term clinical exchanges also may be required to possess ECFMG certification, depending on whether the state offers temporary or special licenses for short-term practice.

This process necessitates significant time and cost investments, as applicants for ECFMG certification must pass both the US Medical Licensing Examination Step 1 and 2 exams, as well as the Occupational English Test, and demonstrate clinical proficiency through an ECFMG pathway. Outside residency and fellowship training, opportunities for hands-on clinical exchanges available to physicians and surgeons are almost nonexistent. There have been few instances documented of surgical trainees from LMICs participating in short-term exchanges in the US, and even fewer where they were allowed to participate in hands-on clinical care or scrub into surgical cases.

Because international trainees rarely participate in US training environments, hospital administrative personnel may have limited experience supporting their integration into clinical and educational activities.

The combined challenges of administrative complexity, potential liability, and lack of institutional support offer little incentive to address these inequities. Access for international trainees to electronic health records is variable; some institutions offer limited read-only access, while others deny access entirely. This restriction limits educational opportunities and may be perceived as blatant mistrust. Stereotypes, preconceptions, and implicit biases also may negatively impact the experiences of visiting trainees, particularly those with accents or unfamiliar social norms, even when they possess comparable knowledge and skills.

Path to Reciprocity

To enhance reciprocity within international surgical training exchanges, efforts have emerged from academic programs and global surgical societies, all aimed at fostering collaboration and enriching mutual learning.

Addressing the unique challenges faced by LMICs trainees and faculty members may collectively enhance surgical training, improve patient outcomes, and lead to the global advancement of surgical care. There remains a continued need to advocate for change at the state and federal levels, as well as with affiliate organizations, to minimize the burden of obtaining visas, state licensure, and malpractice coverage for LMIC trainees.

These changes are particularly important for surgical specialties because they would enable participation in hands-on clinical training, helping visiting trainees develop skills that can strengthen surgical capacity in their home countries.

Advocacy for policy changes at the governmental level can reduce bureaucratic barriers. The Coalition for Building Reciprocal Initiatives for Global Healthcare Training (BRIGHT) was recently founded by the ACS Committee on Global Engagement Advocacy Subcommittee to address the most significant barriers to on-the-ground clinical exchanges, including a proposed amendment to J-1 visas.

This amendment would allow foreign physicians to obtain visas specifically for short-term continuing medical education experiences.¹² Additional streamlining of visa processes through dedicated categories and fast-track processing could be implemented by establishing bilateral agreements between countries.

For licensures and exams, host institutions can work toward mutual recognition of qualifications, offer tailored exam preparation courses, and develop flexible licensing pathways to accommodate the unique needs of international trainees. While some states in the US have created short-term medical licenses for foreign medical graduates, there are still significant barriers associated with obtaining ECFMG certification, which is required by most states and is a disproportionately long and costly process for short-term experiences.

The following recommendations are intended to promote bidirectionality in academic partnerships at individual, institutional, and governmental (state and federal) levels.

Individual

• Become familiar with the systemic, financial, and administrative hurdles—including visa restrictions, credential verification, and expensive licensure processes—faced by international surgeons and surgical trainees.
• Discuss experiences with LMIC partners to generate support from institutional leaders and government representatives.
• Join institutional or national committees that focus on global surgery and health equity.
• Engage with global surgery initiatives that foster relationships with international counterparts.
• Focus on bilateral exchange of ideas in current partnerships, with the goal of reducing practices that primarily benefit HIC participants.

Institutional

• Support Coalition BRIGHT’s J-1 visa amendment proposal.
• Develop institutional policies and best practices that allow LMIC trainees to participate in clinical care at your institution.
• Provide administrative support to assist with the documentation required for hosting visitors at your specific institution.
• Facilitate liability insurance for international visitors analogous to visiting medical students.
• Provide badges that recognize training qualifications of foreign trainees and identify them as physicians (when applicable).
• Create agreements that recognize trainee qualifications from partner institutions.
• Develop pathways for international recognition of surgical training through surgical organizations such as the ACS, Royal College of Surgeons in Ireland, and COSECSA.
• Formalize an orientation program for visiting foreign physicians.

Governmental (state):

• Revise current short-term medical licenses to exempt trainees from ECFMG certification requirements.
• Include language in licensure statutes that addresses and allows direct patient care by foreign trainees under direct or indirect supervision in alignment with ACGME competencies and graduated autonomy.
• Collaborate with state medical boards to propose and adopt a “short-term visitor clinical training license” category for foreign medical graduates.

Governmental (federal):

• Address the lack of an appropriate visa category for short-term clinical exchanges.

Although policy and regulatory reforms will take time, global surgery partnerships should not wait to advance reciprocity. Existing collaborations can promote more equitable engagement through shared educational programs, bilateral research initiatives, and meaningful opportunities for LMIC trainees and faculty to participate in academic and clinical exchanges. By creating pathways for meaningful bidirectional exchange, global surgery partnerships can better fulfill their shared goal of improving surgical education and patient care worldwide.

Acknowledgment

The authors would like to thank Rondi M. Kauffmann, MD, MPH, FACS, and Ray Price, MD, FACS, for their review of this article and ongoing advocacy efforts to support bilateral clinical exchanges in surgery. Dr. Kauffmann is an associate professor of surgery, associate program director, and vice chair of global surgery at Vanderbilt University Medical Center in Nashville, TN. Dr. Price is a professor of surgery and vice chair of global affairs for the Center for Global Surgery at the University of Utah in Salt Lake City.

Disclaimer

The thoughts and opinions expressed in this article are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Cassandra Anderson is a general surgery resident at Vanderbilt University Medical Center in Nashville, TN. She is a current member of the RAS-ACS Global Surgery Committee and former vice president of research for the Global Surgery Student Alliance. Her previous work has focused on pediatric surgical outcomes in the Indiana University-Moi University (AMPATH Kenya) partnership, access to pediatric surgical care, and global surgery.

References

1. Park J, Cheoun ML, Choi S, Heo J, Kim WH. The landscape of academic global surgery: A rapid review. J Public Health Emerg. March 25, 2025. Available at: https://jphe.amegroups.org/article/view/6477/html/. Accessed May 5, 2026.
2. Donnelley CA, Won N, Roberts HJ, et al. Resident rotations in low- and middle-income countries. JB JS Open Access. 2020;5(3):e20.00029.
3. Scheiner A, Rickard JL, Nwomeh B, Jawa RS, et al. Global surgery pro-con debate: A pathway to bilateral academic success or the bold new face of colonialism? J Surg Res. 2020;252:272-280.
4. Bowder AN, Alayande B, Fowler Z. History of Global Surgery. In: Kpodonu J, ed. Global Cardiac Surgery Capacity Development in Low and Middle Income Countries. Springer International Publishing; 2022:3-15.
5. Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J Surg. 2008;32(4):533-536.
6. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569-624.
7. American College of Surgeons. International programs. Available at: https://www.facs.org/for-medical-professionals/membership-community/acs-hope/international-programs/. Accessed May 5, 2026.
8. Society of American Gastrointestinal and Endoscopic Surgeons. GLAP overview. Available at: https://www.sages.org/glap-overview/. Accessed May 5, 2026.   
9. Hudspeth JC, Rabin TL, Dreifuss BA, Schaaf M, et al. Reconfiguring a one-way street: A position paper on why and how to improve equity in global physician training. Acad Med. 2019;94(4):482-489.
10. Al Ashry HS, Kaul V, Richards JB. The implications of the current visa system for foreign medical graduates during and after graduate medical education training. J Gen Intern Med. 2019;34(7):1337-1341.
11. Hutch A, Bekele A, O’Flynn E, Ndonga A, et al. The brain drain myth: Retention of specialist surgical graduates in East, Central and Southern Africa, 1974-2013. World J Surg. 2017;41(12):3046-3053.
12. American College of Surgeons. Coalition BRIGHT. Available at: https://www.facs.org/for-medical-professionals/membership-community/acs-hope/advocacy/coalition-bright/. Accessed May 5, 2026.