Core competencies for global surgery training: a scoping review

Abstract

Background:

Despite calls from various global organizations for increased attention to global surgery, guidance on developing effective curricula is lacking. In this scoping review, we aimed to outline the necessary learning objectives and competencies for establishing sustainable, equitable, and noncolonialist academic global surgery programs.

Methods:

This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews. We used key terms to search 5 electronic databases and conducted a comprehensive grey literature search to identify universities, medical programs, and organizations offering academic global surgery programs. We categorized curricular objectives extracted from these sources into the 11 domains of global health defined by the Consortium of Universities on Global Health. We employed thematic analysis to further categorize these objectives into unique themes within each domain.

Results:

We found a total of 43 studies and 61 programs through database and grey literature searches, respectively. These sources yielded 333 unique curricular objectives, which we analyzed thematically, revealing 41 unique themes spanning various neglected areas in global surgery, such as Indigenous health, environments, chronic diseases, technology, and underserved populations like refugees, urban populations of low socioeconomic status, and racial and ethnic minority groups.

Conclusion:

This review outlines essential skills for effective engagement in modern global surgical care, emphasizing the emergence of nontraditional themes like bidirectional partnerships, sustainability, and self-governance over mission-based approaches. Integrating these forward-looking themes into global surgery curricula is vital for improving global surgical care standards and fostering a skilled, globally aware workforce.

Five billion people lack access to timely, safe, and affordable surgical care.¹ The 2015 Lancet Commission on Global Surgery underscored the importance of surgical diseases, which account for more than one-third of the global disease burden.¹ Global surgery, often referred to as the neglected stepchild of global health,² has long been overlooked despite its vital role in addressing health inequities. However, some key movements have brought global surgery to the forefront, most notably the Lancet Commission on Global Surgery¹ and the World Health Assembly resolution WHA68.15,³ both of which highlighted surgery as an indispensable part of global health and essential to achieving universal health coverage, with the Lancet Commission further proposing several health system metrics to address this global challenge.¹ Since these landmark initiatives, there has been a surge of interest in global surgery, leading to its emergence as a bonafide field of academic study. This growth is evidenced by the increasing number of formal educational programs across all levels of study, ranging from undergraduate and postgraduate courses to graduate education programs and surgical electives.^4,5

There is a critical gap in consensus regarding the specific concepts and learning objectives that should be integrated into global surgery curricula. This hampers the global surgery community’s ability to evaluate and compare educational outcomes effectively across programs, and to develop a common language for global surgery education. As a result, trainees may graduate with varying degrees of preparedness to tackle the unique challenges posed by surgical care in low-resource settings or to engage in advocacy for surgical equity. To address this gap, it is essential to understand the current discourse around global surgery education.

To date, only 1 review has attempted to summarize the literature on learning objectives in global surgery.⁶ This study’s search strategy was limited to published literature and did not incorporate a search of grey literature;⁶ only 18 training programs, primarily from high-income countries (HICs, n = 17), were identified from the published literature searched.⁶ The educational objectives were also categorized using the second edition of the Global Health Education Competencies Toolkit from the Consortium of Universities on Global Health (CUGH). Since this publication, the CUGH has published a third edition, focusing additionally on the domains of decolonization and planetary health, which are vital to global surgical efforts moving forward.⁸

In this synthesis, we sought to identify themes and competencies incorporated in the global surgery literature and global surgery educational programs, to facilitate the development of a consensus framework that can guide future curriculum development and revision. We also sought to provide a comprehensive overview of the current state of global surgical training using the updated CUGH framework. Using this framework, we hope to stimulate dialogue regarding the relevance of existing curricula in addressing the identified objectives and to highlight potential gaps in current educational frameworks and ensure that training is locally relevant and effective for diverse health care settings.

Methods

We conducted the scoping review in accordance with the Arksey and O’Malley framework for scoping reviews,⁹ supplemented by additional methodologic steps to ensure adherence to the Preferred Reporting Items for Systematic Review Extension for Scoping Reviews (PRISMA-SCr). ¹⁰ We registered this review in Open Science Framework (osf.io/b5mhn) and reported it in accordance with the PRISMA-SCr.¹⁰

Data sources and searches

We developed a search strategy in collaboration with a professional research librarian. We conducted comprehensive electronic database searches in MEDLINE, Embase, Global Health, PsycInfo, and Global Index Medicus from their inception until the search date (Sept. 8, 2023) using relevant Medical Subject Headings (MeSH) and non-MeSH terms (Appendix 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.014525/tab-related-content). We included articles published in English and French. We conducted a grey literature search via Google Scholar using a similar search strategy and Boolean logic. For the purpose of this study, we defined grey literature as information not formally published or indexed in commercial academic databases, including reports, websites, theses, conference materials, policy documents, and other non-peer-reviewed sources. We reviewed the first 100 results. We included a grey literature search using Google to identify global surgery programs and courses offered by nongovernmental organizations (NGOs), not-for-profit organizations (NFPs), universities, and other relevant academic institutions involved in global surgery education. We also reviewed reference lists of retrieved articles and conducted consultations with global surgery experts to identify further pertinent studies and curricular documents.

Study and program selection

Two reviewers independently screened titles, abstracts, and full texts using Covidence. Covidence is an online systematic review management platform used to streamline study screening, deduplication, and data extraction throughout the scoping review process. Similarly, 2 reviewers conducted independent screenings of results from Google Scholar and the Google search engine, including program websites and curriculum descriptions. Any discrepancies were resolved through third-party review. We included search results if they pertained to academic global surgery programs from any country or region, or if they specifically addressed learning objectives related to global surgery. We excluded studies and programs if they focused solely on the acquisition of surgical skills, medical missions, or surgical camps without considering the broader context of training within the field of global surgery.

Data extraction and analysis

One reviewer conducted data extraction, and a second reviewer verified the extracted data. The extracted data for identified programs encompassed program name, location, affiliated university or organization, educational level of participants, duration, and defined learning objectives. For institutions or universities with multiple programs, we documented each program independently. We extracted data from grey literature sources and managed these data using Microsoft Excel (version 16.60). The extracted data were synthesized narratively and presented in charts and tables. We categorized identified learning objectives from the retrieved articles and programs thematically according to the domains defined by the CUGH. This study commenced in 2023, with learning objectives initially categorized according to the domains outlined in the second edition of the CUGH Global Health Education Competencies Toolkit.⁷ Following the release of the third edition in early 2024, the objectives were realigned to reflect the updated 14 domains.⁸ We removed duplicate and redundant learning objectives. Redundant objectives were those that encompassed overlapping knowledge frameworks, where content or intended learning outcomes were similar. We consolidated these objectives when they addressed analogous learning objectives or provided comparable educational value within the global surgery curriculum. We conducted a thematic analysis, which involved systematically identifying, organizing, and interpreting patterns within the data to develop a structured understanding of key concepts within each CUGH domain. We catalogued programs identified through the grey literature search by host institution, geographic location, target educational level, and duration. These programs were further classified as either in a HIC or low- and middle-income country (LMIC) per the World Bank, with frequencies reported accordingly.

Results

Study selection and characteristics

A PRISMA-SCr flow diagram outlining the scoping review process is presented in Figure 1. The initial search resulted in a total of 5391 nonduplicate studies, of which 165 were included in full-text review after title and abstract review. After full-text review, expert consultations, and appraisal of text references for additional relevant articles, 45 studies met inclusion criteria for the narrative review (Appendix 2, Table 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.014525/tab-related-content).^6,7,11–54 Included studies were published between 2005 and 2023, with 38 (84%) published within the last decade of the study period (2013 to 2023) (Figure 2). Among the included articles, most were published in education- and surgery-focused journals at 38% (n = 17) and 36% (n = 16), respectively (Figure 3). Global health, medicine, and public health and policy journals contributed to 11% (n = 5), 11% (n = 5), and 4% (n = 2) of the included publications, respectively.

Fig. 1.

Study flow diagram. See Related Content tab for accessible version.

Table 1.

Abridged global surgery learning objectives and competencies

CUGH domain	Learning objectives
Domain 1 Global burden of disease This domain encompasses basic understandings of major causes of morbidity and mortality and their variations between high-, middle-, and low-income regions, and with major public health efforts to reduce health disparities globally.	1. Describe the history and core principles of global surgery, including how surgical care is affordable, saves lives, and promotes economic growth. 2. Describe the global burden of disease, with specific reference to unmet surgical need. 3. Explain how general public health concepts (including the causes and control of epidemics, measures of morbidity and mortality [QALY, DALY], the determinants of health, disease prevention and health promotion, and universal health coverage) relate to global surgical care and vary across time and geography. 4. Describe the major causes of surgical morbidity and mortality around the world, how the epidemiology of surgical diseases varies across regions, the anticipated trends over time, and the major public health efforts to reduce disparities in global surgical care. 5. List and discuss the critical need to support essential surgeries and the most prominent clinical skills necessary in resource-limited environments. 6. Illustrate the concept and development of NSOAPs. 7. Describe how access to safe surgical care is required to meet targets in most global health development goals and analyze how surgery is an indispensable part of health care. 8. Discuss the global crises related to surgical care provision, including workforce shortages and infrastructure issues, identify contributory barriers, and develop context-specific strategies to sustain efficient and effective surgical care systems. 9. Identify and discuss the various characteristics of underserved communities in both HICs and LMICs, in relation to their access and quality of surgical care (i.e., similarities or differences in morbidity and mortality, delivery, and other social determinants of health). 10. Summarize the burden of trauma requiring emergency intervention, defend the urgent need for injury prevention strategies, and outline the spectrum of involvement of surgical activities in preventing and treating disabling impairments.
Domain 2 Globalization of health and health care This domain focuses on understanding how globalization affects health, health systems, and the delivery of health care.	1. Describe the structure, function, and utility of the international organizations that shape global surgery (with specific reference to the WHO), illustrate the complexity of global health governance (including the roles of international organizations like the UN and World Bank, the commercial sector, civil society, charities, and NGOs), and describe the process of surgical care policy-making within the global context. 2. Identify influences that have shaped attitudes toward surgery’s place in global health, including the significance of the WHA declaration on surgery and the WHO accepting essential surgical care as key to primary health. 3. List the international conventions and policy documents of major international organizations with reference to surgical implications in health and disability, including the macroscopic and regional challenges faced in actuating standards set by the Lancet Commission on Global Surgery, the UN Sustainable Development Goals, and the UN Declaration on the Rights of Indigenous Peoples. 4. Analyze international and case-driven public health systems’ disaster preparedness and response strategies and outline recent international initiatives for emergency and essential trauma care, disaster preparedness, and response strategies. 5. Recognize the specific circumstances of performing surgery in LMICs, particularly the greater reliance on open surgical techniques compared with minimal-access procedures in most settings. 6. Describe how globalization and trends in practice contribute to the quality and availability of timely, safe, and affordable local and global health and surgical care. 7. Consider how travel, commerce, armed conflict, culture, multinational agreements, and national plans interplay in the globalization of surgical care and affect perioperative problems.
Domain 3 Social and environmental determinants of health This domain focuses on an understanding that social, economic, and environmental factors are important determinants of health, and that health is more than the absence of disease.	1. Define and compare health disparities and social determinants of health by identifying how nonclinical determinants of health (economic, social, cultural, political, and environmental factors) affect the burden of surgical disease, access to health services, and quality of health services. 2. Describe how determinants of health play into the variations in death and disability observed between regions. 3. Describe various national health system models, components of health systems, and the role of primary care in said models and systems. 4. Describe the complexities of social determinants of health, specifically in the framework of Indigenous health, and relate historical and current circumstances (e.g., Indigenous urbanization) to their relationship with health and well-being. 5. Discuss the application of the principles of disaster readiness to Indigenous communities, explain the concept of “twice burdened” for Indigenous communities that are subject to major disasters, and defend the importance of social resilience in managing disaster readiness, response, and recovery. 6. Describe the effects of violence and war on health, and analyze the challenges in designing and executing military surgical partnerships to achieve global surgical goals.
Domain 4 Capacity strengthening Capacity strengthening is sharing knowledge, skills, and resources for enhancing global public health programs, infrastructure, and workforce to address current and future global public health needs.	1. Outline the basic goals of modern international development and evaluate which elements of international surgery projects contribute to surgical capacity building, infrastructure development, and strategies to assess surgical systems. 2. Reflect on the impact of translating capacity-building programs into high-level public health policy and advocacy initiatives aimed at influencing decision-makers and donors. 3. Identify frameworks for safety, quality improvement, workforce assessment, and advocacy in underserved communities to improve the design, implementation, and scale-up of surgical programs in collaboration with host partners, while considering political and financial factors. 4. Demonstrate a practical understanding of the nuances of meaningful advocacy on national, regional, and local levels of government, and develop a concrete advocacy plan to engage national decision-makers in improving surgical care. 5. Describe the wide array of methods for designing and delivering effective global surgery education (e.g., undergraduate and graduate curricula, pre-departure training, fellowship programs, surgical training). 6. Define and provide examples of contextually relevant task-shifting initiatives and their implementation frameworks. 7. Demonstrate an understanding of the importance of supporting LMIC biomedical equipment markets and advocate for local production to develop more affordable products, improve profit margins, and promote greater benefit to local economies. 8. Reflect on the potential harms of dumping used, outdated, or discontinued devices overseas and the benefits of supporting new low-cost innovations. 9. Describe strategies to develop research capacity and reflect on strategies and systems to improve access to knowledge. 10. Describe how health-related research is conducted and governed globally, including rules and guidelines for research trials set at the international level. 11. Reflect on the benefits of collaboratively producing and disseminating scholarship that advances the field of global surgery and creates value for host sites. 12. Develop skills in project development, IRB proposals approved in home and host institutions, grant proposals, research design, academic writing, and professional academic advancement.
Domain 5 Collaboration, partnering, and communication Collaborating and partnering is the ability to select, recruit, and work with a diverse range of global health partners to advance research, policy, and practice goals, and to foster open dialogue and effective communication with partners and within a team.	1. Understand the benefits of and devise strategies to develop academic, clinical, and philanthropic partnerships that illustrate global surgical work as long-term, collaborative relationships. 2. Develop bidirectional, reciprocal, and equitable exchanges of trainees and exchange programs that strengthen and mature over time to improve health care delivery systems. 3. Describe strategies to catalogue collaborative global surgical efforts and projects to identify areas of overlap and opportunities for collaboration (rather than duplication of efforts) and to design opportunities for sustained exchanges of expertise among partners. 4. Identify characteristics of successful and unsuccessful bi- and multidirectional global surgical partnerships, and describe their function in global operating systems with reference to the concepts of sovereign obligation, transparency, health inequity, global health diplomacy, reciprocity, solidarity, and cultural humility. 5. Outline how effective collaboration between partners (e.g., underserved communities, local ministries of health, NGOs, and health care workers) empowers, informs, and improves surgical practices, reduces barriers to care in low-resource settings, and strengthens the infrastructure necessary for local training. 6. Describe the challenges inherent to being an effective leader in groups with members from multidisciplinary backgrounds and in different contexts (e.g., academic, humanitarian, clinical, research) within global surgery, with an emphasis on developing local, regional, and national leaders in countries where they are most needed. 7. Identify interprofessional values and communication skills that demonstrate respect for and awareness of the unique cultures, values, roles and responsibilities, and expertise represented by other professionals and groups that work in global surgery. 8. Build global health, public health, and surgical system literacy and vocabulary related to global surgery to support effective local and international communication.
Domain 6 Ethics This domain encompasses the application of basic principles of ethics to global health issues and settings.	1. Develop a working understanding of ethical challenges in global surgery related to clinical care, education, research, monitoring and evaluation, and advocacy to avoid creating disparities in surgical care around the world. 2. Demonstrate an understanding of the 4 pillars of ethics and various codes of ethics and use examples to illustrate ethical challenges in surgical care delivery across a variety of settings. 3. Become familiar with the professional evaluation standards, ethical guidelines for evaluation, and general ethical considerations in surgical care planning and evaluation. 4. Describe and acknowledge the “7 sins of humanitarian medicine” and that there is always a risk of unintentional harm in global surgical work. 5. Discuss and critique how the concept of a right to health affects health care delivery. 6. Understand principles of research ethics, appreciate the unique factors in ethics of surgical trials in low-resource settings, and identify challenges to performing collaborative surgical research with mutual benefit to all parties involved. 7. Critically discuss global surgical volunteerism, the effects of expatriates on local health systems, and the ethical challenges of medical donations. 8. Reflect on the resources learners consume in low-resource settings and the unintended consequences of their presence. 9. Define the common ethical variations and challenges unique to the delivery of surgical care in diverse cultural, political, and economic settings, with an emphasis on practising within one’s skill and experience level.
Domain 7 Professional practice This domain refers to activities related to the specific profession or discipline of the global health practitioner.	1. Describe strategies and challenges of upholding universal standards of care, national standards, and interprofessional communication in the contexts of differing resourced settings and an international workforce. 2. Demonstrate collaboration with local health providers to plan and coordinate resources for appropriate follow-up for patients. 3. Outline the spectrum of involvement of surgical activities in preventing and treating disabling impairments, and reflect on the need to adapt clinical or discipline-specific skills and practice in a resource-constrained setting, including conducting clinics and surgeries. 4. Identify the challenges in shifting from practising or providing surgical care in a resource-rich setting to a low-resource setting or to underserved populations.
Domain 8 Health equity and social justice Health equity and social justice is the framework for analyzing strategies to address health disparities across socially, demographically, or geographically defined populations.	1. Describe and demonstrate how to implement strategies to engage marginalized, vulnerable, and underserved populations in making decisions that affect their health and well-being. 2. Explore the unequal distribution of health and surgical access across and within populations, analyze the disparities in health workforce allocation between urban and rural settings, and identify strategies to reduce these inequalities. 3. Discuss gender and culturally sensitive issues and their potential impact on global surgical research, leadership, and inclusion as a health care professional. 4. Outline and discuss some of the factors influencing women’s health and gender equity issues within underserved communities. 5. Describe the concepts of civilian trauma, wartime care, and disaster response, and articulate the various phases of a humanitarian disaster, the unique associated population needs, and the response tools at each stage of disaster response. 6. Define and explore examples of structural and institutional racism and their relationship to health. 7. Apply social justice and human rights principles in addressing challenges in global surgery, with insight into one’s own social positioning and biases.
Domain 9 Program management Program management is the ability to design, implement, and evaluate global health programs to maximize contributions to effective policy, enhanced practice, and improved and sustainable health outcomes.	1. Describe how to plan, implement, and evaluate an evidence-based program, including the purpose, process, strategies, and techniques involved in identifying needs through a comprehensive approach that addresses social, epidemiological, behavioural, and environmental factors. 2. Articulate the role and importance of engaging the community in program planning and evaluation processes, and the relationship between community assessment, planning, and evaluation in a surgical care context. 3. Know and define the basic components of a program logic model and how to critique a logic model and its relationship to planning, outcomes, and evaluation processes. 4. Distinguish between the different types of evaluations, identify potential threats to internal or external validity in an evaluation plan of a surgical care initiative, and list factors that may affect the replicability of programs. 5. Describe how to develop an evaluation plan for a given surgical care program, define its quality indicators, and propose an
Domain 10 Sociocultural and political awareness Sociocultural and political awareness is the conceptual basis with which to work effectively within diverse cultural settings and across local, regional, national, and international political landscapes.	1. Define the terms “culture,” “cultural competency,” and “cultural humility,” and describe how to incorporate these concepts when providing care alongside local colleagues. 2. Define cultural influences and historical contexts that affect perceptions, stigma, and belief systems around surgical care, and explain how these factors may influence the health behaviours of individuals and communities, while acknowledging the dangers of assuming that those from a particular social group will behave in a certain way. 3. Identify the roles of major social, civic, and political entities (i.e., district-level health systems, national health systems, and ministries of health, as well as sociopolitical influences such as capitalism) affecting the development of local and regional surgical practices, policies, and inequities. 4. Explain the unique considerations of working in a faith-based institution or initiative.
Domain 11 Strategic analysis Strategic analysis is the ability to use systems thinking to analyze a diverse range of complex and inter-related factors shaping health trends to formulate programs at the local, national, and international levels.	1. Describe the approach to assess local disease burden, complete a surgical needs assessment, and identify host-country community or hospital needs through a participatory action research model. 2. Develop an approach to conduct a situational analysis across a range of cultural, economic, and surgical contexts to design surgical- and context-specific health interventions based on the situation analysis. 3. Develop a fundamental understanding of analyzing, interpreting, and auditing public health data on surgical and perioperative morbidity and mortality across different settings (e.g., WHO IRTEC, Globocan, local surveillance data), and educate researchers in all settings on hypothesis-driven, impactful research to improve relevance and reduce research waste. 4. Explain how researchers measure the effects of providing or withholding surgical care and describe the methodologic challenges in assessing outcomes of surgical care provision. 5. Compare and contrast different research designs, identify the distinguishing characteristics of each, and reflect on the unique challenges and possible solutions when conducting research in global surgery. 6. Demonstrate literature expertise (i.e., a comprehensive knowledge of publications that address safe surgery, knowledge about the country of interest, country development, and health care capacity measures) and knowledge of research methodology in global surgery research and education. 7. Define core principles of health care economics in surgical services delivery, analyze various models of financing health care and national health plans, and reflect on how they influence global surgery. 8. Assess the economic impact of a surgical condition on the patient’s family among underserved populations.
Domain 12 Institutionalization and sustainable development This domain emphasizes understanding of the interconnectedness of population burden of disease and social development in the context of sustainability and institutionalization of health systems underpinning, for example, sustainable development goals and metrics.	1. Describe the 6 core surgical indicators proposed by the Lancet Commission on Global Surgery to assess surgical systems and how these can be used strategically to achieve the UN Sustainable Development Goals. 2. Define sustainability, and articulate the importance of sustainability and local capacity in partnerships with host nations. 3. Demonstrate the impact of a strong surgical system on the entire health care system of a community and identify the successful components of creating and maintaining the surgical ecosystem (including all care providers, referral systems, and decision-making parties involved in surgical care access locally). 4. Have a working knowledge of the processes of health policy creation, and possess the skills to mitigate associated challenges to effectively assist in the augmentation of health systems. 5. Cultivate a working knowledge of geopolitics, systems of delivery of surgical care, and events likely to affect the delivery of surgical care. 6. Reflect on ways to contribute to local capacity building, and promote sustainability by pursuing projects that focus on local priorities and serve the local system by teaching skills, providing education, and improving access to resources.
Domain 13 Planetary health This domain focuses on developing systems thinking, solution-oriented, and equity-minded competencies to examine the impacts of human activities on Earth’s natural systems and the resulting effects on human health and well-being.	1. Describe how health is influenced by environmental factors such as water and air quality, the impact of climate change on health and health care delivery, and ways to mitigate these effects. 2. Describe the differences in the need for surgical care following a natural disaster or catastrophe. 3. List environmental and occupational hazards and their relationship to the surgical burden of disease, as well as ways to mitigate their effects. 4. Describe how surgical systems strengthening acts as an indicator of preparedness for pandemics and natural disasters.
Domain 14 Decolonizing global health Decolonizing global health acknowledges power imbalances, inequities, and biases present in global health collaborations and works to create and maintain mutually beneficial global partnerships rooted in cultural humility and equity.	1. Appraise and critique how historical factors influenced the identification of health status indicators among Indigenous populations and reflect on how these indicators result in a wider surgical care deficiency for these populations. 2. Provide definitions and examples of surgical colonialism and list strategies to mitigate it. 3. Understand the ethical considerations related to neocolonialism and actionable steps that can be taken to achieve the decolonization of surgical care. 4. Have an understanding of the unique social circumstances that influence health care among Indigenous populations, including the social ramifications of colonialism, and articulate strategies to address the disparities in surgical care between rural and remote Indigenous communities and mainstream urban communities in HICs. 5. Consider how perspectives on decolonizing global health affect surgical care program planning and evaluation.

CUGH = Consortium of Universities on Global Health; DALY = disability-adjusted life year; HIC = high-income country; IRB = institutional review board; IRTEC = International Registry for Trauma and Emergency Care; LMIC = low- and middle-income country; NGO = nongovernmental organization; NSOAP = National Surgical, Obstetric and Anesthesia Plans; QALY = quality-adjusted life year; UN = United Nations; WHA = World Health Assembly; WHO = World Health Organization.

Fig. 2.

Number of included articles by year published (n = 45).

Fig. 3.

Focus of journals in which the included articles were published (n = 45).

We identified a total of 48 unique programs from the grey literature review, 41 of which were programs offered by universities and 7 of which were courses designed and provided by NGOs or NFPs (Appendix 2, Table 2). Most academic programs were offered by institutions in the United States (n = 26, 64%) and Canada (n = 5, 12%) (Figure 4). Other notable host countries included Sweden, England, and Ireland, contributing 5% (n = 2), 7% (n = 3), and 7% (n = 3) of the identified programs, respectively. Rwanda and South Africa each hosted 2% (n = 1) of the programs. Of the 41 institution-associated global surgery programs, 39 (95%) were offered by institutions in HICs. Of the 7 NGO and NFP programs included, 2 (29%) were administered by international organizations (International Student Surgical Network [InciSioN], Global Surgery Student Alliance), while an equivalent proportion (29%) originated from American entities (Figure 5). Switzerland, the Netherlands, and South America each hosted 1 (14%) of the identified NGO and NFP programs. Among the 48 programs, 7 (15%) were at an undergraduate education level, 30 (62%) were at a graduate education level, and 4 (8%) catered to either an undergraduate or graduate level. Additionally, 2 (4%) were specifically intended for postgraduate positions, while 3 (6%) catered more broadly to students in graduate or postgraduate programs. Finally, 2 (4%) programs were structured as research fellowships.

Fig. 4.

Mapped distribution of identified global surgery programs offered by academic institutions (n = 41). N/A = not available.

Fig. 5.

Mapped distribution of identified global surgery programs offered by nongovernmental and not-for-profit organizations (n = 7).

We identified 579 learning objectives in this review. Of these, 246 were determined to be duplicates, leaving a total of 333 unique learning objectives, which we categorized into the 14 CUGH domains (Appendix 3, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.014525/tab-related-content). The most populated domains included Decolonization of Global Health (n = 39, 11.7%); Strategic Analysis (n = 39, 11.7%); Capacity Strengthening (n = 34, 10.2%); and Collaboration, Partnering, and Communication (n = 32, 9.6%). Following thematic analysis and subsequent revision and exclusion of redundant learning objectives, a total of 95 learning objectives were tabulated (Table 1).

The identified objectives focused on the epidemiology of surgical disease across underserved regions. The objectives addressed the novel domains included in the third edition of the CUGH Toolkit, emphasizing sustainable practices within health care systems, examining the interconnections between surgical systems and environmental sustainability, and seeking to address historical inequalities, decolonization, and health challenges of Indigenous populations. They promoted equitable health care through bidirectional clinical and academic partnerships. Additionally, the objectives encouraged students to understand key global surgery partners and the structure of health care governance at international and local levels.

Discussion

This scoping review outlined learning objectives for academic global surgery curricula, identifying 333 unique and broad learning objectives that echo the 14 CUGH domains of the CUGH Global Health Education Competencies Toolkit. Although the Toolkit provides standardized global health education, it lacks content on surgery, perioperative care, and surgical systems.⁶ This review addresses those gaps by specifically engaging in content relevant to surgical care systems and providers.

Our review identified a single 2021 publication that sought to establish consensus on global surgery curriculum objectives using the second edition of the CUGH Global Health Education Competencies as its foundational framework. ⁴² The broad applicability of these data are constrained by the more specific and HIC-focused literature review.⁶ Key differences between our findings and this review include the broadened scope of our literature review (including an extensive grey literature search) and objective mapping as per the updated third edition of the Global Health Education Competencies Toolkit. In so doing, we identified 21 objectives related to health equity and social justice and 39 for decolonizing global surgery, which were previously unaddressed. We also found 18 objectives on social and environmental determinants of health,⁶ compared with just 1 in the earlier study. The increase may reflect recent literature growth and a broader search strategy. Although we acknowledge challenges in direct comparison, our review comprehensively captured a substantial number of learning objectives related to equity, diversity, and inclusion. We therefore advocate for prioritizing cultural humility, anti-colonialism, and the impact of colonialism in the evolution of modern academic global surgery curricula.

Of the 41 institution-hosted academic global surgery programs identified, 95% were offered by institutions in HICs, mirroring similar findings from previous studies.⁶ This creates a disconnect between the location in which academic global surgery programs are housed and the location in which these principles are predominantly implemented (i.e., under-resourced regions). Participants from LMICs in programs in HICs are limited by high expenses, logistical hurdles, travel expenses, lost clinical income, and time away from family and community supports.⁵⁵ Multi-institutional partnerships between LMICs and HICs could help address these disparities.^56,57 These recommendations align not only with principles of global surgical education, but also with broader global surgery priorities, which emphasize training in the settings where skills will be applied and ensuring that local and regional needs, particularly in LMIC and rural or remote contexts, are central to program development.

Few academic global surgery programs are LMIC-led, with notable exceptions including Rwanda’s University of Global Health Equity, InciSioN, and South Africa’s Executive Leadership in Global Surgery program (Appendix 2, Table 2).⁵⁸ Local education programs are crucial in improving retention rates of health care professionals by fostering community ties and addressing region-specific health needs, thereby encouraging professionals to remain and serve in their communities.⁵⁹ Where context allows, efforts should be made to support such programs through reciprocal partnership, mitigation of aforementioned barriers to education, and meaningful collaboration.

Similarly, global surgery research is dominated by authors from HICs, despite most studies focusing on Sub-Saharan Africa and South Asia.⁶⁰ Including authors from LMICs ensures diverse perspectives, equitable knowledge exchange, and contextually relevant solutions.⁶¹ However, efforts should promote true bilateral authorship, ensuring that scholars from LMICs receive first or senior authorship rather than token middle-author roles.

The 10 identified learning objectives in CUGH’s domain of planetary health emphasize the impact of climate change on fragile health systems and surgical disease burden. Incorporating sustainability into National Surgical, Obstetrical, and Anesthetic Plans and global surgical education is critical.⁶² Immediate adaptation and long-term climate-resilient strategies are needed to strengthen surgical infrastructure. The lack of planetary health objectives in global surgery curricula presents an opportunity for growth.

Global surgery is the study and application of strategies to enhance access to timely, high-quality, and affordable surgical care for all. Although this definition encompasses a broad span of under-resourced groups, including Indigenous, rural, remote, and refugee populations, current global surgery education programs primarily focus on interventions in LMICs. However, our review identified 21 learning objectives related to Indigenous and underserved populations in HICs. Rural and remote surgical care is an area that continues to evolve and is an example of an opportunity to learn from expertise of LMIC practices. Such an approach reverses the traditional HIC to LMIC direction of knowledge and skill transfer in academic global surgery.

Decolonization of global health is 1 of 3 novel CUGH domains and involves addressing colonial legacies and power imbalances in global surgery.⁶³ This approach emphasizes the importance of centering the needs and interests of underserved populations ahead of priorities from HICs. The ultimate objective is to foster equitable partnerships that amplify the voices and experiences of those directly affected by disparities in surgical care, thereby promoting a more just and inclusive surgical care landscape.⁶⁴ Actions that align with this framework include directly funding LMIC-based organizations.⁶⁵ It is essential to ensure a bottom–up approach to program design and policy-making in global surgery such that interventions and partnerships are led by local experts within underserved regions, promoting the transfer of health governance to local partners.⁶⁵ Moreover, decolonizing global surgery involves addressing the limitations of short-term medical missions that perpetuate ethnocentrism.⁶⁵

Although some attempt has been made to build consensus around learning objectives for a universal curriculum in academic global surgery,⁴² more work must be done to ensure learning objectives represent academic global surgery’s growth and trajectory. For example, experts from all World Health Organization health regions must be engaged and interdisciplinary colleagues — including anesthesiologists, allied health, obstetrician–gynecologists, and orthopedic surgeons — and must be meaningfully represented as part of a consensus-building panel. Moreover, educational institutions and providers are expected to independently identify learning objectives that satisfy local needs. Given the breadth of the 14 pillars and their numerous learning objectives, programs should clearly delineate which objectives are covered and which are not, thereby enabling prospective trainees to select programs that best align with their educational needs. This scoping review provided a cross-sectional perspective of current learning objectives that programs can utilize as a starting point in conceptualizing training of the next generation of academic global surgeons, locally and globally.

Limitations

Global surgery programs were not directly contacted, relying instead on publicly available grey literature. Most identified sources were from Western countries. Future studies should look at incorporating and identifying objectives and competencies from nonwesternized regions. In addition, nonpublished curricula or publications in languages other than English and French were excluded. Data extraction prioritized learning objectives over surgical skills and technical knowledge, both critical aspects of global surgical care provision. Furthermore, the abridged objectives list may reflect author bias, so the full list of 333 objectives has been provided in Appendix 3. Finally, in using this review to guide the development of global surgery curricula, we acknowledge that there will be regional, cultural, and institution-specific perspectives, which have not been parsed out in this review but may change based on the context of the global surgery course.

Conclusion

This scoping review provides an updated comprehensive synthesis of learning objectives and competencies that can be used as a basis for universal contemporary global surgery curricula. Our findings highlight the diversity and geographic distribution of academic programs, although these are still predominantly situated in HICs. The identified learning objectives align with critical domains such as health equity, decolonization, and planetary health, underscoring the evolving scope of global surgical education beyond traditional clinical skills. We advocate for broader participation and collaboration across diverse settings to foster equitable knowledge exchange and enhance global surgical care delivery. Future efforts should focus on refining universal curricular frameworks, engaging interdisciplinary partners, and amplifying voices from LMICs to ensure global surgical education addresses the complex challenges of the interconnected global health system.