Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

The lead author confirms that this manuscript is an honest, accurate, and transparent account of the study being reported; no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned have been explained.

There is growing international recognition of the need to train a large number of additional healthcare workers in order to meet the health needs of a growing global population. It is projected that by the year 2030 there could be a shortfall of 18 million healthcare workers. ² However, preparing a workforce of 40 million healthcare professionals to meet the demands of 21st-century health systems is a formidable challenge. The most significant shortages, based on need, are concentrated in South-East Asia, with a deficit of 6.9 million health workers, and Africa, with a shortfall of 4.2 million. Relative to population size, the Sub-Saharan African (SSA) region faces the most acute difficulties. ³

In order to address healthcare workforce shortages in low or middle-income (LMIC) settings, structural reforms in education aimed at strengthening the training capacity, relevance and adaptability of the healthcare workforce are critical in order to improve the provision of patient-centred services. Currently, 75% of the capacity to train new healthcare professionals is concentrated in upper-middle- and high-income countries. ² Meanwhile, Sub-Saharan Africa (SSA), which bears 24% of the global disease burden, accounts for only 4% of the world’s health workforce—a disparity that has remained unchanged for over a decade. ⁴ To address these inequities, innovative solutions are needed, particularly in countries with the greatest unmet health needs, such as those in SSA.

E-learning modalities have been acknowledged as a potential solution to address the healthcare workforce in LMIC settings. ⁵ Indeed, the World Health Organization (WHO) has introduced new guidelines to optimize community-based health worker programs and support strategic investments in education and skill development, which include recommendations to harness information and communication technologies. ⁶

There is a need to shift healthcare education systems away from narrow specialisations toward fostering locally relevant competencies that address both health and social priorities. Investment in primary healthcare systems, in particular, has the potential to confer significant benefits in resource poor settings. ⁷ The Declaration of Alma-Ata in 1978 was the first international call for PHC and was followed by the Declaration of Astana in 2018. ⁸ However, PHC is in crisis. It is underdeveloped in many countries, underfunded in others, and facing a severe workforce recruitment and retention challenge, especially in low-income countries such as those in SSA. ^{9– 11} Half the world’s population has no access to essential healthcare services. Nevertheless, 80–90% of people’s health needs across their lifetime can be provided within a primary healthcare framework. ⁸

In an editorial in 2018, WHO Director-General Tedros Adhanom Ghebreyesus and colleagues explained how the original vision of Alma-Ata has gone “largely unfulfilled”. ¹² They highlighted that investing in PHC will support tangible improvements in health and well-being and drive progress towards achieving the health targets of the Sustainable Development Goals. Education and training to support this development are vital. The recent COVID-19 pandemic has highlighted even more the need for a strong multidisciplinary PHC workforce articulated in the Declaration of Alma-Ata and, more recently in Astana. ¹³

The COVID-19 pandemic also highlighted the potential for virtual modalities to be utilised in education. During COVID-19 lockdown, in person education and educational exchanges were not possible, necessitating novel learning approaches. ^{14, 15} Virtual exchange (VE) programs, which connect learners from different parts of the world through technology, offer a way to address this gap. ^{16, 17} Knowledge exchange is a process in which the implicit knowledge is expressed and shared in a manner that is aimed to enhance the knowledge of exchange participants. ¹⁸ Virtual exchanges are knowledge exchanges that are conducted through a combination of physical and virtual platforms. ¹⁹ They consist of “sustained, technology-enabled, people-to-people education programmes” between “individuals or groups who are geographically separated and/or from different cultural backgrounds”. ²⁰

With respect to global health, virtual exchanges have the potential to build capacity and aid in developing life-long learning for the healthcare workforce in LMICs, through partnerships between higher education institutions. ¹⁷ For the purposes of our study, global health virtual exchanges are defined as involving at least one High-Income Country and one Low-or Middle-Income Country.

The potential for increased accessibility to learning materials afforded by using virtual modalities also has the potential to address geographical imbalances in healthcare workforce training and distribution. However it is important to note the importance of introducing online modalities in a structured and responsible manner. ²¹ Promoting socially accountable education has been shown to successfully attract young people from underserved communities into healthcare careers. ²² Expanding rural and community-based education and training programs not only addresses workforce gaps but also generates employment opportunities for youth. ²³

In low- and middle-income countries (LMICs), virtual exchanges for medical education may alleviate the burden of severe health worker shortages and deliver affordable access to high quality medical education. In combination with a e-learning approaches, international knowledge exchange offers the opportunity for healthcare students to glean novel insights within the educational process and to foster personal and professional networks, often resulting in high user satisfaction and greater long term viability of international networks. ^{17, 24}

Despite the potential of global virtual exchanges to bolster healthcare workforce shortages in LMICs, there is a lack of evidence mapping their existence or evaluating their characteristics, efficacy and impact.

This scoping review will summarise the existing literature relating to global health virtual exchanges for healthcare students and professionals. For the purposes of this study, a global health virtual exchange is defined as an exchange that involves at least one LIC and one HMIC.

The primary research question is:

To what extent have virtual exchanges in global health been reported in the literature to date, including their frameworks, impact and sustainability?

The aims of the review: •

To identify and map the pedagogical frameworks underpinning virtual exchanges in global health.

Inclusion criteria

The Participants, Concept and Context (PCC) framework was used to develop the research question and to inform the inclusion and exclusion criteria.

This review will include studies involving participants engaged in virtual exchanges in the context of global health. Participants may include students, educators, healthcare professionals, and researchers from both High-Income Countries (HICs) and Low- and Middle-Income Countries (LMICs). Eligible studies should explicitly describe the involvement of at least one HIC and one LMIC in the virtual exchange initiatives.

Sources relating to healthcare professionals and healthcare students will be included. Healthcare professionals are individuals who “study, diagnose, treat and prevent human illness, injury and other physical and mental impairments in accordance with the needs of the populations they serve”. This includes medical doctors, nursing and midwifery professionals, dentists and pharmacists. We will also include educators or researchers in these fields. We will exclude social care workers and social workers from this list, as they do not fall under the definition of healthcare professionals.

Only studies that involve at least one LIC and one HMIC country will be included.

We will include competencies, curricular frameworks and learning outcomes. We will exclude sources that discuss competencies and learning outcomes without a structure or framework.

The concept focuses on virtual exchanges within the realm of global health education. This includes programs that leverage digital platforms to facilitate intercultural learning, collaborative projects, or shared health education goals between HICs and LMICs.

We will include sources in all healthcare and health professions’ education settings. This includes undergraduate, postgraduate and continuing professional education settings.

We will only include studies if they involve at least one HIC and one LMIC country.

The search strategy, developed by the research team, will include studies addressing virtual exchanges in global health. Eligible works may encompass formal curricula, supplementary courses, or workshops. There will be no restrictions on study design; commentaries and expert opinions will also be included if they provide relevant insights into curriculum components, implementation of virtual exchanges, or recommendations for future development.

Searches will be conducted across MEDLINE OVID, EMBASE, CINAHL and ERIC, supplemented by manual reference list reviews and targeted grey literature searches using Google. Relevant materials will also be sought from national and international organizations, educational institutions, and professional bodies. Only studies published in English will be included, and no date restrictions will be applied. The full search strategy is detailed in Extended data, ²⁷ hosted on the OSF.

The screening process will consist of two stages: (1) title and abstract screening, and (2) full-text review. All citations will be imported into Rayyan ( www.rayyan.ai), a Cochrane-endorsed literature screening tool. Three independent reviewers will pilot the inclusion criteria on 10% of abstracts to ensure clarity and consistency before screening the remaining studies. Disagreements will be resolved through discussion or by consulting a fourth reviewer if necessary. The inclusion criteria are detailed in Table 1. A PRISMA flow diagram will outline the selection process and a PRISMA-ScR checklist is available as supplementary material on the OSF.

Two independent reviewers will extract data using a piloted data extraction tool, with disagreements resolved through discussion or consultation with the research team. Any modifications to the extraction tool during the process will be documented. Authors of included studies may be contacted for missing or additional data. Rayyan will facilitate the extraction process. A draft version of the data extraction tool is available in Extended data. ²⁷

Findings will be summarized narratively and presented in tables. A matrix will organize information on competencies, domains, and learning outcomes under descriptive headings. Framework analysis will guide the thematic coding of pedagogical components, competencies, and challenges/best practices associated with virtual exchanges in global health, in particular in relation to exchange impact and the establishment of sustainable partnerships between HIC and LMIC countries. The lead reviewer will draft the final report, incorporating feedback from the research team. Rigour will be maintained through an audit trail of decisions throughout the review process and through the triangulation of review findings with existing literature and ongoing stakeholder input.

Stakeholder engagement, as proposed by Arksey and O’Malley, will be an integral part of this review. Health professional educators, global health experts, patient representatives, and policymakers will be consulted to ensure comprehensiveness and relevance. Stakeholders will be invited to identify additional sources and provide feedback on preliminary findings. The outcomes of these interactions will be documented and integrated into the final report.

At the time of publication, the review is at the full-text screening stage.

Given that the scoping review methodology consists of the examination and collation of information from publicly accessible resources, ethical approval is deemed unnecessary for this study.