With an estimated 5 billion people lacking access to safe and affordable surgical and anesthetic care, the global burden of unmet surgical needs is staggering.1 In low- and lower-middle-income countries (LICs/LMICs), 143 million additional surgical procedures are required each year to prevent loss of life and disability.1 Augmenting the surgical workforce is one of the priorities outlined in the Lancet Commission on Global Surgery, the World Bank, and the World Health Organization (WHO).1–3 As surgical training programs are lacking in LICs/LMICs, the international community has historically responded to this unmet need by sending surgical providers from high-resourced centers on short-term missions to low-resourced centers.4,5 The often-unintentional harms associated with those missions (lack of follow-up, use of outdated technology, and contextually-inappropriate care) are well described.5–10 Recognizing ethical pitfalls in “surgical tourism,” the global surgery community has undergone a period of introspection.2,8,11 One of the recommendations in the Global Surgery 2030 report is for nongovernmental organizations, professional organizations, and high-income country (HIC) academic institutions to “work in partnership with local institutions to improve surgical capacity through longitudinal educational programs that do not drain human resources away from the public system.”1 Responding to this call to action, global surgery partnerships (GSPs) with a focus on education and training have flourished over the past decade. Short-term missions are being replaced by GSPs that increasingly strive for bidirectionality and sustainability.5,12–17 Despite efforts by associations like the American Surgical Association Working Group on Global Surgery to create guiding principles for ethical engagement in global surgery, there is currently no governing body tasked to oversee the sustainability of these partnerships.15,16

In 1987, the United Nations defined one of the criteria of sustainable development as “an assurance that [the] poor get their fair share of the resources required to sustain […] growth.”18 This principle of reciprocity between high-resource and low-resource settings is crucial to the longevity of global health initiatives. Despite intentions to improve sustainability in GSPs, negative consequences still occur to the detriment of host communities.14 The lack of reciprocity among GSPs is particularly alarming: a recent scoping review identified that 12 of 67 educational global surgery initiatives exclusively involved HIC trainees flying into LMICs to augment their skills.19 These findings reflect the poor governance in modern global surgery education. Since GSPs are one of the cornerstones of surgical capacity-building, it is crucially important that a comprehensive framework for sustainable GSPs, with clearly defined metrics, is available to both high-resourced and low-resourced partners.8,10,13–17

At the University of British Columbia (UBC) Branch for Global Surgical Care, we have explored the definition of sustainability in global surgery (Supplemental Digital Content 1, https://links.lww.com/SLA/E825). Through a systematic review, 6 pillars of sustainability in GSPs were identified: Community Engagement, Multidisciplinary Collaboration, Education and Training, Bilateral Authorship, Multisource Funding, and Outcome Measurement.17

Previously proposed frameworks have not achieved global consensus, nor created a standardized approach or concrete tools for sustainability across the field.15–17 Addressing these gaps, we aimed to establish consensus among an international panel of global surgery experts on a practical framework for GSP sustainability, with concrete evaluation metrics that can be used by partners worldwide to develop, evaluate, and modify GSPs. Our aims were achieved by: (1) identifying essential pillars that characterize sustainable GSPs; (2) establishing a consensus-based definition of the aforementioned pillars; and (3) determining metrics for evaluating GSPs within each pillar.

METHODS

The Delphi method is an iterative process that establishes consensus among groups. Due to its flexibility, emphasis on communication and dialogue, and cost-effectiveness, the method has been widely applied in health care settings.20–22 It is well suited to answer “should” questions. For instance, what should the pillars of sustainable GSPs be? How should these pillars be defined? What metrics should be used to evaluate GSPs to ensure the pillars are upheld? In this study, we used a modified Delphi method to establish consensus among an international panel of global surgery experts around these 3 questions, resulting in a comprehensive framework and associated evaluation metrics for sustainability in GSPs. This study was approved by the UBC Research Ethics Board (Application Number H21-02856). Key terms, including low-resourced, high-resourced, GSPs, surgical care providers, global surgery experts, and consensus were defined to promote clarity and specificity (Supplemental Digital Content 1, https://links.lww.com/SLA/E825).23

Expert Panel Selection

We used purposive sampling to recruit experts. Experts were defined as surgical care providers from any WHO region who had participated in at least 1 GSP within the past 15 years. To maximize inclusivity and diversity of opinions, we opted for a broad definition of surgical care provider, including operating room nurses, surgeons, obstetricians/gynecologists, medical doctors with surgical or anesthesia skills, anesthesiologists, nurse anesthetists, and medical trainees (fellows, residents, students). These experts were identified through a scoping review of the global surgery literature and by nomination from key informants from the UBC Global Surgery Lab and its network of associates. Experts were invited to participate in the study via email. Recruitment continued until at least 3 experts from each of the 6 WHO regions consented to participate.24 At least 80% of Round 1 experts were required to participate in subsequent rounds to achieve our predetermined retention rate. Due to logistical constraints, non-English speakers were excluded.

We collected basic demographic information including experts’ names, contact information, profession, location of primary practice, sex, and years of experience in global surgery. The final survey asked if they wished to be identified and acknowledged for their contributions.

Initial Framework Generation

Deviating from a traditional Delphi method, where experts first generate ideas in response to open-ended questions, this modified Delphi used a previously proposed framework of sustainability based on a systematic review to inform the design of the first round.17 Round 1 asked experts to provide feedback on the previously published pillars, their definitions, and propose evaluation metrics for each pillar.

Delphi Procedure

We administered iterative rounds of the Delphi survey until consensus was achieved on the framework’s pillars, definitions, and evaluation metrics. Throughout the 3 rounds, free-text fields were available to participants when they disagreed with a particular item and at the end of each section for general comments. In Round 1, consensus was defined as >80% of the experts choosing to include a given item from a list (yes or no answer). We used experts’ feedback to adjust the working definitions and evaluation metrics presented in Round 1. In Round 2, experts rated their level of agreement with each pillar’s revised definition and evaluation metrics. A 5-point Likert scale was used to rate the level of agreement. Round 2 items that had not yet achieved consensus were adjusted to incorporate expert feedback and were re-presented in Round 3. In Rounds 2 and 3, consensus was defined as >80% of the round’s experts ranking their agreement as 4±1 on the Likert scale, in keeping with previously published Delphi studies.21,22

Data Analysis

Descriptive statistics summarized experts’ demographic data. Survey responses were deidentified before analysis. A secondary metric used to track the evolution of consensus over time included counting the number of suggestions left by experts, with fewer suggestions indicating increasing consensus.25 Statistical analysis was completed using Microsoft Excel.26 To protect study participants’ privacy, data supporting this study are not publicly available.

RESULTS

Three modified Delphi rounds were conducted between November 2021 and April 2022, at which point consensus on all items in the framework was achieved. Demographic data are summarized in Supplemental Digital Content 2 (https://links.lww.com/SLA/E825). Fifty experts from 34 countries [4/50, 8% LICs; 18/50, 36% LMICs; 7/50, 14% upper-middle-income countries (UMICs); 21/50, 42% HICs] were recruited in Round 1. At least 3 experts from each WHO region participated in each round. In Round 1, 22% (11/50) of experts identified as women. The majority of experts were surgeons (43/50, 86%), followed by medical doctors with anesthesia or surgical skills (4/50, 8%), general medical doctors (1/50, 2%), obstetricians and gynecologists (1/50, 2%), and trainees (1/50, 2%). Experts’ median years of global surgery experience was 9.5 years (range: 1–45 years). The retention rate was 84% (42/50) for both Rounds 2 and 3. A comprehensive map of the consensus results (Supplemental Digital Content 3, https://links.lww.com/SLA/E825) and a printable version of the final framework and evaluation checklists (Supplemental Digital Content 4, https://links.lww.com/SLA/E825) can be found in the Supplemental Materials (Supplemental Digital Content 1, https://links.lww.com/SLA/E825).27,28

Identifying the Pillars

By the end of Round 1, consensus was achieved on the inclusion of the previously proposed 6 pillars of sustainability in GSPs: Stakeholder Engagement (previously called Community Engagement) (41/48, 85%), Multidisciplinary Collaboration (39/45, 87%), Context-Relevant Education and Training (39/43, 91%), Bilateral Authorship (36/40, 90%), Multisource Funding (37/41, 90%), and Outcome Measurement (39/43, 91%). After Round 1, 72% (28/39) of experts stated that the proposed pillars were appropriate, sufficient, and comprehensive (Table 1). Eleven experts suggested we add, edit, or remove 1 or more pillar(s). The majority of suggestions pertained to increasing the pillars’ specificity and attainability. By Round 3, consensus was achieved (35/41, 85%) to rename Community Engagement to Stakeholder Engagement to better reflect local, regional, and international involvement. Complete consensus was achieved on the appropriateness of the 6 pillars with their revised definitions (Round 3: 39/39, 100%) (Table 1).

TABLE 1 - Identifying Pillars of Sustainability Do you think the proposed pillars are appropriate, sufficient, and comprehensive? [n (%)] Yes No Suggestions for improvement [n (%)] Round 1 28 (72) 11 (28) 11 (28) Round 2 38 (97) 1 (3) 0 (0) Round 3 39 (100) 0 (0) 1 (3)

In each round, experts were asked if they agreed that the proposed pillars were appropriate, sufficient, and comprehensive. Consensus grew with 72% of experts agreeing with the statement in round 1, 87% in Round 2, and 100% in round 3.

Defining the Pillars

One of our objectives was to provide a detailed and concrete definition of each pillar (Supplemental Digital Content 5, https://links.lww.com/SLA/E825). For the first pillar, renamed Stakeholder Engagement, consensus was achieved to include patients, health care providers, and local organizations, but not government ministries, as Stakeholders in Round 1. While 5 experts argued that governments have a responsibility to lead health initiatives, provide partnerships with legal frameworks, reduce redundancies, and contribute to project sustainability, 11 suggested that governmental involvement could cause harm by introducing the potential for corruption, bureaucracy, and asymmetric power dynamics. Exemplifying this conflict, 1 LIC participant wrote, “I think government involvement is important in long-term sustainability …. But agree that fraud and coercion by government is a problem.” After thorough dialogue, consensus was achieved to include government ministries in this definition (Round 3: 39/41, 95% agreement). For the second pillar, Multidisciplinary was defined by the inclusion of at least 1 surgical, 1 anesthesia, and 1 allied health provider. The definition of Collaboration evolved from “bilateral collaboration” to encompass “relationship building” and “knowledge translation.” The third pillar was re-named Context-Relevant Education and Training, to capture the importance of local needs. Round 1 consensus suggested that hands-on learning illustrated Education and Training (41/43, 95%). Experts commented that the Round 2 definition lacked reference to important nontechnical skills, like communication, leadership, and decision-making, which were added to the definition by Round 3 (39/40, 98%). Bilateral Authorship, the fourth pillar, was defined as an equal representation of all partners in all GSPs outputs, which was highlighted by one of our HIC experts: “I’ve raised collaborative authorship models before which are an excellent, transparent and equitable method of sharing credit in global surgery work.” The fifth pillar, Multisource Funding, was specifically defined as having at least 2 funding sources, including in-kind (nonmonetary) support. Finally, the definition of Outcome Measurement, the sixth pillar, moved away from prescribing a fixed number of outcomes to be measured, to emphasizing the importance of evaluating quantitative and qualitative outcomes in the domains of “community satisfaction,” “clinical outcomes,” and “education.”

Evaluating the Pillars

By the end of Round 3, consensus was achieved on all 47 metrics (Supplemental Digital Content 6, https://links.lww.com/SLA/E825). We summarize a few of the discussion points that shaped the creation and modification of the evaluation checklist below.

Stakeholder Engagement

In Rounds 1 and 2, 12 experts acknowledged that potential conflicts between the different stakeholders could create barriers to effective engagement and sustainability. In response, consensus was reached in Round 3 to add “Has a conflict resolution strategy been developed to help mitigate and resolve potential conflicts between stakeholders?” to the evaluation checklist (38/41, 93%). Four experts emphasized the need for ongoing consultation with GSP partners to ensure reciprocal and collaborative engagement. Consequently, we added a checklist item: “Has there been documentation of how feedback from community partners and stakeholders has shaped the planning and direction of the project?” (Round 2: 39/39, 100%).

Multidisciplinary Collaboration

To ensure that the local and contextual needs of partnerships were met, one expert suggested “adding an intentional step at the beginning of each project in which the project leaders thoughtfully consider which specialties should be involved.” This was included in the checklist (Round 3: 40/41, 98%).

Context-relevant Education and Training

Experts came to consensus regarding the importance of a “train-the-trainer” model to ensure the sustainability of GSPs’ education (Round 2: 39/39, 100%). Having “formal recognition” of the training received was deemed to be a crucial element of this pillar (Round 2: 39/39, 100%).

Bilateral Authorship

Ten experts raised concerns that necessitating a low-resourced partner for GSP publications could lead to tokenism in authorship. In response, our checklist emphasized international authorship guides (Round 2: 39/39, 100%).28 Shifting focus from authorship order, one expert suggested that “participant satisfaction” be used as a metric to evaluate this pillar. Round 2 queried experts on the following evaluation metric: “On a 5-point Likert scale ranging from “very dissatisfied” to “very satisfied”, at least 80% of the individuals involved in the project state that they are neutral, satisfied, or very satisfied with the author list before the publication of written materials.” While 5 experts suggested that this was impractical, consensus on the inclusion of this item remained stable (Round 3: 34/39, 87%).

Multisource Funding

The checklist item “Multiple funding sources should commit to finance a minimum percentage of the budget” was replaced by the item “If the partnership’s major funding source pulled their financial support from the project, would the partnership still be possible?” (Round 3: 38/40, 95%). In addition, an expert suggested we add a checklist item to acknowledge nonmonetary goods and services that contribute to GSPs (Round 3: 40/40, 100%).

Outcome Measurement

There were important discussions surrounding the adoption of a Competence-by-Design format, such as using Entrustable Professional Activities (EPAs), to evaluate training outcomes. Five experts criticized EPAs as burdensome for low-resourced trainers and trainees. In response, the final checklist item outlined the use of EPAs or a comparable assessment tool (Round 3: 38/39, 97%). To mitigate the potential negative impact of GSPs on low-resourced partners, an expert suggested we measure the number of local staff displaced by the high-resourced partner. This suggestion was deemed too specific and challenging to measure. In Round 3, experts decided that our checklist should include “Was a critical analysis of the potential harms and negative impacts of the partnership conducted?” (Round 3: 38/39, 97%), to better capture the socioeconomic and community impacts of GSPs.

DISCUSSION

We present a comprehensive 6-pillar framework and accompanying 47-item evaluation checklist for the development of sustainable GSPs. To our knowledge, this study is the first of its kind to create a practical tool to build sustainable GSPs based on international expert consensus.

This study had many strengths. We involved participation from a diverse panel of surgical providers with extensive experience in GSPs. When examining the state of GSPs worldwide, Jedrzejko et al17 found that the low-resourced partners most commonly involved in GSPs were from Uganda, Haiti, Kenya, Tanzania, Vietnam, and India. Our study included experts from each of these countries and all WHO regions, honoring calls to amplify non-Western voices in the creation of GSP frameworks.29 In total, 44% of our experts were located in LICs or LMICs, which is closer to a balanced representation than previously published frameworks.9,10 To minimize the potential impact of power differences between panelists, experts completed surveys asynchronously and results were deidentified. The use of the Delphi method also allowed experts from all 6 WHO regions to contribute equally. Overall, all pillars’ definitions and evaluation metrics achieved consensus, with expert agreement ranging between 87.2% and 100%, which is similar to or greater than that found in other global health Delphi studies.21,22 Finally, our pillars and definitions overlap thematically with those proposed in recent research on GSPs, adding generalizability to these recommendations.1,15,17

Although not included as its own pillar, this project elicited discussion about when and how knowledge-sharing and meaningful communication between high-resourced and low-resourced partners should occur. Often referred to as knowledge translation, this concept is most aptly described by the term knowledge exchange (KE). The WHO defines knowledge translation as “the dynamic interface that links health information and research with policy and practice … [and provides] an array of tools to researchers and decision-makers to foster [evidence-informed policy].”30 This definition invokes the sense of a patriarchal and asymmetrical transfer of information from the “leading” individuals to “recipient” individuals. Conversely, KE is defined as “collaborative problem-solving that happens through linkage and exchange [and] results in mutual learning through the process of planning, producing, disseminating, and applying existing or new research in decision-making.”31 We propose that KE should be integrated across all pillars or be honored as its own pillar in future iterations of the framework, ensuring mutual and reciprocal respect, decision-making capacity, and knowledge gain between partners. KE within the global surgery community will strengthen future GSPs, as stakeholders share their “lessons learned” through the literature, conferences, social media, and by word of mouth. While the global surgery community currently lacks a common platform or repository to share these key learnings, this checklist could serve as a guide to contribute to more efficient and universal KE in the field, as participants can compare and connect elements of different GSPs.

Our vision for this tool is that it will be used as a pre-implementation checklist to assess the readiness of prospective GSPs. Funding agencies and sponsors can use it to help create accountability in project development, as the implementation of the evaluation checklist will help ensure salient indicators of sustainability have been addressed. For existing GSPs, we hope that the framework can be used as a reflective tool to guide the partnerships’ next steps and highlight areas in need of attention. The checklist may also be used as an advocacy tool by low-resourced partners to promote equitable education, training, and authorship, thereby giving them more power. As demonstrated by a recent BMJ Global Health editorial by Cancedda et al,32 this redistribution of power is key to sustainability.

Our checklist is not meant to quantify sustainability or define a minimum requirement, but rather function as a self-auditing tool to spark discussion about the key components of GSPs’ sustainability. We acknowledge that not all aspects of the checklist will be relevant across all GSPs. However, as expert consensus identified each item as a key component of sustainability, we strongly believe that all 47 items should be discussed among partners. On a granular level, if GSPs are not able to achieve a given item or deem it to not be relevant to their specific context, they should demonstrate that they have considered the item and explain why it would not optimize sustainability in their case. For example, in a context where the values of government and particular patient populations are not aligned, including government stakeholders would not make the project more sustainable, and could potentially even be detrimental. However, since excluding one or several stakeholders could negatively impact sustainability, we advocate that all potential stakeholders be considered and an explanation provided if one or more group(s) is excluded from a GSP.

Limitations

Using previously proposed pillars as a foundation for Round 1 may have primed our experts, reducing the number of original suggestions captured. This modification to the classical Delphi methods was necessary to accelerate consensus-building and promote expert retention. Furthermore, while we aimed to amplify the voices of diverse individuals, we must acknowledge that this paper was written by high-resourced partners from a Canadian university. In addition, surveys were distributed and completed in English, limiting our ability to engage partners in their native language. We balanced the risk of overburdening our low-resourced experts with survey fatigue with our aim to create a culturally sensitive tool that reflects best practices across contexts. Finally, purposive sampling was used to recruit experts, which has inherent limitations such as lack of representativeness of expert opinions and sampling bias. While all WHO regions were represented, 56% of our experts were from UMIC/HIC. We had more high-resourced than low-resourced partners participating, potentially leading to an ethnocentric view. Further, most experts represented surgeons’ perspectives. In the future, it will be crucial to purposefully integrate the opinions of all surgical disciplines (nonsurgeon providers, nurses, allied health professionals, etc.), in addition to the voices of patients, families, and community leaders into this framework.

CONCLUSIONS

Despite a decade of attempts to reform global surgery from short-term missions to sustainable and reciprocal, capacity-building partnerships, GSPs still lack proper governance. In this study, we used international expert consensus to identify and define 6 pillars—Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, and Outcome Measurement—and their associated 47 evaluation metrics to create a framework for sustainable GSPs. As expertise and sustainability in global surgery continue to evolve, we hope to adapt this framework. As this tool is implemented in the self-auditing of existing partnerships and guides the creation of new GSPs, we welcome engagement and hope to spark further discussions about sustainability in global surgery.

ACKNOWLEDGMENTS

See Supplemental Digital Content 7 (https://links.lww.com/SLA/E825).

REFERENCES 1. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2015;25:75–78. 2. World Bank Group. Good health and wellbeing. In: Atlas of Sustainable Development Goals 2018: From World Development Indicators. World Bank; 2018. pp. 10–13. 3. World Health Organization. Health systems. In: 2018 Global Reference List of 100 Core Health Indicators (Plus Health-related SDGs). World Health Organization; 2018. pp. 115–140. 4. Montgomery LM. Short-term medical missions: enhancing or eroding health? Missiology. 1993;21:333–341. 5. Sama Philipo G, Nagraj S, Bokhary ZM, et al. Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania. BMJ Glob Health. 2020;5:e002118. 6. Isaacson G, Drum ET, Cohen MS. Surgical missions to developing countries: ethical conflicts. Otolaryngol Head Neck Surg. 2010;143:476–479. 7. Ginwalla R, Rickard J. Surgical missions: the view from the other side. JAMA Surg. 2015;150:289–290. 8. Grant CL, Robinson T, Al Hinai A, et al. Ethical considerations in global surgery: a scoping review. BMJ Glob Health. 2020;5:e002319–e002330. 9. Sherif YA, Choudhury T, Makasa E, et al. Ethics of educating American Global Surgeons: an approach to conscientious training on the individual, departmental, and institutional levels. J Am Coll Surg. 2022;234:239–246. 10. Pean CA, Premkumar A, Pean M, et al. Global orthopaedic surgery: an ethical framework to prioritize surgical capacity building in low and middle-income countries. J Bone Joint Surg Am. 2019;101:e64. 11. Logar T, Le P, Harrison JD, et al. Teaching corner: “First do no harm”: teaching global health ethics to medical trainees through experiential learning. J Bioeth Inq. 2015;12:69–78. 12. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533–536. 13. Love TP, Martin BM, Tubasiime R, et al. Emory global surgery program: learning to serve the underserved well. J Surg Educ. 2015;72:e46–e51. 14. Guilfoyle R, Morzycki AD, Saleh A. What makes global healthcare partnerships successful? A systematic review. Global Public Health. 2022;17:662–671. 15. Mock C, Debas H, Balch CM, et al. Global surgery: effective involvement of US academic surgery: report of the American Surgical Association Working Group on Global Surgery. Ann Surg. 2018;268:557–563. 16. Debas H, Alatise OI, Balch CM, et al. Academic partnerships in global surgery: an overview American Surgical Association Working Group on Academic Global Surgery. Ann Surg. 2020;271:460–469. 17. Jedrzejko N, Margolick J, Nguyen JH, et al. A systematic review of global surgery partnerships and a proposed framework for sustainability. Can J Surg. 2021;64:E280–E288. 18. Brundtland GH. Report of the World Commission on Environment and Development. New York; 1987:25. 19. O’Flynn E, Danial A, Gajewski J. Global surgery education and training programs—a scoping review and taxonomy. Indian J Surg. 2021;84(suppl 1):193–206. 20. McKenna HP. The Delphi technique: a worthwhile research approach for nursing? J Adv Nurs. 1994;19:1221–1225. 21. Singh P, Aggarwal R, Zevin B, et al. A global Delphi consensus study on defining and measuring quality in surgical training. J Am Coll Surg. 2014;219:346.e7–353.e7. 22. National Institute for Health Research Global Research Health Unit on Global Surgery. Delphi prioritization and development of global surgery guidelines for the prevention of surgical‐site infection. Br J Surg. 2020;107:970–977. 24. World Health Organization (WHO). Countries; 2022. Accessed July 27, 2022. https://www.who.int/countries. 25. Holey EA, Feeley JL, Dixon J, et al. An exploration of the use of simple statistics to measure consensus and stability in Delphi studies. BMC Med Res Methodol. 2007;7:52–62. 26. Microsoft Corporation. Microsoft Excel [Computer Program] Version 1621. Microsoft Corporation; 2022. 27. International Committee of Medical Journal. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals; 2022. pp. 1–19. 28. McGinnis JM, Malphrus E, Blumenthal D. Vital Signs: Core Metrics for Health and Health Care Progress. National Academies Press; 2015:1–308. 29. Guilfoyle R. External validation of an ethical framework in global surgery. CIRcle: UBC’s dSpace IR. 2020:1–6. 30. World Health Organization Regional Office for Europe. Action plan to strengthen the use of evidence, information and research for policy-making in the WHO European region; 2016:1–20. 31. Canadian Institutes of Health Research. Knowledge translation at CIHR; 2016. Accessed July 27, 2022. https://cihr-irsc.gc.ca/e/29418.html. 32. Cancedda C, Bonds MH, Nkomazana O, et al. Sustainability in global health: a low ceiling, a star in the sky, or the mountaintop? BMJ Glob Health. 2022;7:e011132.