Introduction

Rural health challenges are complex and dynamic, are understood differently by different people, and have multiple root causes1,2. Therefore, these problems require iterative solutions adapted to the local context3 and ongoing stakeholder communication, creativity, and problem-solving. In the US, for example, rural health issues include riskier health behaviors4,5, greater poverty among adults and children6, fewer primary care and specialty healthcare providers6,7, and worse health outcomes, including higher rates of multiple chronic conditions, higher rates of opioid mortality8, higher death rates from the disease9,10,11,12, and worse mental health outcomes7. Globally, those living in rural areas have greater poverty, higher rates of diseases, and worse maternal health13,14. Some factors causing rural health disparities are cultural and geographic barriers, lack of access to broadband, transportation issues, and workforce retention issues15. Evidence shows that the rural health challenges were significantly worsened during the COVID-19 pandemic16,17. The inequities persist despite increased recognition of rural health service delivery and workforce issues18,19 and investment in rural health in recent years20,21,22. Therefore, new approaches are needed to address rural health problems that would acknowledge the interconnectedness of the problems. Moreover, healthcare delivery, workforce, advocacy and policy, and research must be looked at through a rural lens23.

International collaborations provide an opportunity to tackle rural health challenges uniquely. Such collaborations can occur at various levels (e.g. individuals, groups, organizations, associations, and governments), have diverse approaches to obtaining the objective, and provide comprehensive and varied benefits to multiple stakeholders. The key to international collaboration, or any collaboration for that matter, is the ability to create additional value beyond what each entity can achieve individually. International collaborations maximize resource utilization and ensure the impacts are communicated across countries and stakeholders24. Such collaborations offer mutual benefits to partner countries25,26 and propel a two-way learning process for all participants on equal footing25,27. International collaborations provide an opportunity to challenge and critique established frameworks28, probably to create new ones. One tangible benefit of such interactions is changes in pedagogy, as suggested by Nancy et al. while describing the development of qualitative research methods curricula in mental health and conflict28.

International collaborations are imperative and have a long history in rural health. The World Health Organization (WHO) and World Organization of Family Doctors (WONCA) collaboration on rural health14 is one such long-standing collaboration. The Medical and the Nursing Education Partnership Initiatives (MEPI, NEPI) in the sub-Saharan Africa (SSA) region supported by the US President's Emergency Plan for AIDS Relief (PEPFAR)29,30 and a Telemedicine Task Force for SSA by the WHO, the European Commission, the European Space Agency, and organizations within Africa31 to enhance technological infrastructure in rural Africa are another few prime examples. These initiatives have helped educate and train urgently needed physicians and nurses in rural parts of this region and have enhanced technological infrastructure.

The key learnings in rural health from such collaborations are that partnerships need to create context-specific solutions32,33, build trust among partners32,34 and a sense of belongingness34, provide capacity-building opportunities, have clear work agreements and inclusive division of work, and engage local communities34. The potential challenges for such collaborations include agenda setting by only one partner, exclusionary labor practices, lack of accountability, differences in work culture34, inadequate funding support34,35, connecting potential collaborators, sustainability, and lack of evaluation practices35.

In 2021, institutions in Georgia, the US, Scotland, and the UK began a collaboration named CONVERGE—referring to our two homelands, Georgia and Scotland, coming together—following discussions of the leadership of those institutions. The goal of the collaboration is to improve rural health and learn from each other on how to address rural health challenges. A steering committee with representation from all institutions was formed with project management support provided by the host university.

In October 2021, the committee organized a virtual one-day interactive symposium with presenters from all participating institutions. For this first symposium, those directly related to or employed by the partner organizations were invited to have a more collaborative experience and have tangible working groups/partnerships formed from the conference. The committee listed people involved with rural health and health disparities, as well as those educators, researchers, and healthcare providers who were situated in partnering schools and colleges. Approximately 70 people attended the symposium. Immediately following this event, the host university provided small grants of up to $10,000 USD to foster collaborations between the institutions. Four proposals were selected for funding following a peer-review process. In November 2022, a second virtual symposium was conducted over two days with approximately 140 participants, followed by a third virtual symposium in November 2023. The host university has provided two addition rounds of funding for small grants immediately following the symposia. Other activities at the time of writing this paper related to CONVERGE since its origins include multiple visits by the participants to each other’s institutions, the appointment of visiting faculty, and the delivery of seminars on rural health research and practice.

Discussing an international collaboration between Georgia and Scotland is pertinent, given that they share common concerns over non-communicable diseases and mental health issues36,37. Their proportions of rural populations (17%) are also almost identical38,39. However, rural Georgia has relatively weaker socioeconomic indicators than rural Scotland38,39. Cancer-related geographic disparities are less palpable in Scotland than in Georgia40,41,42. Moreover, despite differences in the health systems, they face a shortage of healthcare providers and have incentive programs to attract new medical graduates43,44. Given these (dis)similarities between these two regions, there is a scope for rural health collaborations to exchange workable solutions.

There are several documented rural health collaborations from both regions45,46,47,48, mainly focused on specific health challenges within rural health. However, collaborations encompassing overarching problems in rural health, such as CONVERGE, are missing. Therefore, this study’s objective was to explore the factors that would make the CONVERGE or any similar initiative a sustainable international rural health collaborative. More specifically, we aimed at disentangling the perspectives of educators, researchers, and healthcare providers who were brought together with a desire to address rural health issues through involvement in CONVERGE to understand barriers of, and facilitators to, effective collaboration and to identify ways to improve international collaboration.

Methods

The current study presents results from a larger exploratory case study of the leadership, participant experience, and initiatives stemming from the CONVERGE Rural Health Symposium to understand the facilitators and barriers to effective collaboration and to identify ways to improve international collaboration. An exploratory case study methodology was chosen because it offered an open, in-depth investigation into the single case in order to generate the initial insights used to develop propositions and models relevant for continued research into international collaboration. We followed the US census49 and the Scottish government’s50 definitions for study purposes and theoretical understanding of rurality. The study team comprised two health policy researchers, a qualitatively trained social scientist, a research associate, an undergraduate student, and a medical student. The first author is a founding CONVERGE member who was intimately involved in creating collaborative networks, allocating funds, and organizing the annual symposium. To avoid bias, the first author did not participate in the data collection or early stages of analysis. Interviews were facilitated and coded by two team members who were not directly involved in CONVERGE.

Participant recruitment occurred between August 10 and October 11, 2022. A purposive sample of the 2021 CONVERGE International Symposium attendees were invited by email to participate in an interview and/or focus group with the research team. Enrollment criteria included anyone who participated in the symposium. All participants provided written informed consent before they participated in the study. No incentives were provided to participants for their involvement in the study. The interviews and focus groups were conducted using semi-structured interview guides, including loosely structured questions on experiences with international collaborations, rural health, and experiences with CONVERGE (see Appendix A). CONVERGE leadership was asked about their specific roles, delegation of tasks, motivation for decision-making, what practices did or did not work well, and suggested changes for future symposiums and collaborations. The participants were also asked about their motivations to seek out and engage with CONVERGE and international collaborations in general and their perspective on the initiative's future. Twelve interviews and two focus groups were conducted virtually. Seven members participated in focus groups (4 and 3 in each group). Individuals had the option to participate in both an interview and focus group or just one. Two individuals opted to participate in both the focus group and an interview. Thus, we had 17 unique participants (seven male and ten female) to share their perspectives. Data collection from interviews ceased once data produced no new information to address the research objectives. The number of focus groups was determined by availability or interest in participation. Interviews lasted approximately 30–60 min, and focus groups were approximately 60 min. Besides gender, no other sociodemographic information was collected from the participants. The video and audio files and transcriptions were saved using the host university IRB Secure Storage services.

Data were analyzed using reflexive thematic analysis (RTA)51 using NVivo52. The raw transcripts were organized by participant type (steering committee vs. regular attendee) and format (focus group vs. interview). RTA is an ideal analytical tool for this study because it offers a cohesive framework for nuanced interpretive analysis accessible across disciplines and for non-academic audiences53. Analysis began with familiarization with the data through careful review of transcripts and creating primary-level codes identifying key descriptive and specific ideas present in the data. Next, secondary cycle coding was used to create high-level themes by analytically grouping together similar primary codes that reflected more meaningful relationships and patterns. Themes were reviewed and refined through thematic mapping and were visually outlined to assess their interconnectedness and relation to the primary research objectives. While comparison of responses provided by leadership and symposium participants were noted throughout the final stages of analysis, the codes and themes were developed and refined topically, irrespective of these roles. For further refinement, researchers presented identified themes and thematic maps to seven members of the CONVERGE steering committee and other study participants. The purpose of this last virtual focus group on the initial study results was to allow participants to reflect on the initial findings, including what was missing, what was unclear, and what they found most interesting.

Ethics approval

The Augusta University’s Institutional Review Board (IRB) approved this study (IRBNet ID: 1890530-3). The participants were provided a copy of the informed consent form via email in advance of the interview or focus group meetings. At the beginning of the meeting, interviewers reviewed and prompted the participant to sign and return the form via email. Research had been performed in accordance with the Declaration of Helsinki.

Results

Table 1 summarizes the domains, identified themes, and related examples. Two primary domains were identified through the thematic analysis: motivators to engage in international collaboration (shared struggle to address limited access to care, desire to integrate knowledge and practices, opportunity for growth) and mechanisms for, and barriers to, the continuity needed to create meaningful change (sustained economic support, intentionality in cultivating relationships, structural cohesion)).

Table 1 Summary of themes with supporting examples.
Full size table

Motivators to engage in international collaboration

Before we came to the conversation and as we were talking to each other, knowing you would get to know somebody, you say, “well, what do we have in common? You know, what do we share? How could we learn? How could we benefit from this relationship?” So, health relationships are defined by these sort of mutual bidirectional benefits and that's what we sort of see that in rural health, may be just that thing. (A)

As the above quote indicated, CONVERGE leaders and participants recognized rural health issues in Georgia and Scotland as a source of commonality needed to foster international collaborations, particularly those with “mutual bidirectional benefits” necessary for relationship building. They demonstrated engagement through active participation in the CONVERGE symposium and collaborative research and teaching opportunities and discussed the following pathways for this engagement in international collaboration: shared struggle to address limited access to care (overcoming geographical barriers, navigating political failings), desire to integrate knowledge and practice (innovating healthcare practices and co-creating pedagogies and curriculum), and recognition of the opportunity for growth (professional development and institutional reach).

Shared struggle to address limited access to care

International collaboration generally and CONVERGE specifically was described as a conduits for engagement, particularly when participants shared experiences combatting the impediments to care. Most notably, the need to overcome similar geographic barriers to care, such as difficulty accessing care facilities, technological deficiencies, and personnel shortages, was described as a motivation for engagement. One way this happens is through exposure to the realities of rural poverty,

“I think it allowed me to understand. So you can read all you like about what it looks like for people to have no access to healthcare, but it would be her witnessing the catastrophic failures related to access, that was a moment in time for me of, ‘oh my goodness.’” (C)

As one team leader observed, participants learned from each other about issues related to rural healthcare access. It also served as a means for attendees to “bridge a divide” between disparate systems. An example of this came from a member of the leadership team who noted that the shared experience of limited accessibility to providers, particularly during the pandemic, increased engagement and connection for those attending the CONVERGE symposium:

It seemed like attention to real life right now, issues with which we were facing, technological support for rural health…was entirely relevant and seemed to catch people's attention and really engage in that because they had something to say. Everybody had a piece of that, and it mattered to them. (A)

For this participant, the “relevance” of shared adaptations that participants “had a piece of” provided a framework for engagement because they are conduits for communication. Similarly, connecting through the ideological and political barriers that prevent sustainable improvements in rural healthcare also emerged as a common theme among the participants. As one participant recognized the shared need to.

“build the focus of governments to commit to improving the current status of inequalities … because it’s difficult to do anything sustainably without the political will behind it,” (M).

A team leader echoed this point and added that the underlying political ideologies are creating contexts that make it “very difficult to change” policies to meet the healthcare needs of rural communities, globally:

It is politically such a sensitive issue that it's very difficult to change things in the NHS [National Health Service] because it is absolutely the heart and soul of Britain …So it made me really look at our own health system and those of other countries, and neither one is perfect and neither one is completely flawed either. (C)

For this participant, exposure through involvement provided a platform for discussing “sensitive” topics, such as the potential flaws of the government’s role in addressing rural health needs.

Desire to integrate knowledge and practices

One of the most functional implications of engaging in international approaches to rural health discussed was the innovation prompted by the ability to integrate knowledge and practices. The participants acknowledged the differences in the scope of practice for healthcare providers from Georgia and Scotland. Particularly, the US participants echoed the sentiment of reducing the excessive focus on specialized medicine and embracing a team-based model of care. One symposium participant shared this concern,

“They have a little bit more leeway with prescribing…there's more of a focus on counseling and monitoring and looking at outcomes as opposed to the actual prescription of the medication,” (B).

Another symposium participant echoed this sentiment, adding that the US would benefit from a less individualized approach:

One of the things here on our side we deal with is the term called scope creep. So, you know, you would have physicians thinking that you know, pharmacists are trying to encroach on their activities...I don’t think it really floats over there…I think physicians over there, you know, they welcome more team involvement. (G)

Moreover, participants spoke most enthusiastically about capitalizing on the CONVERGE network to co-construct pedagogies and curriculum in courses supporting experiential learning in rural areas. This was illustrated by a symposium participant who—utilizing funding provided by CONVERGE—was developing a collaboration to integrate curriculums focused on remote rural healthcare that would include,

“didactic case presentations, case studies, simulation, and ultimately, as I was like a service-learning kind of program where they come to us and we go to them in Scotland.” (D).

This same participant shared that the infusion of cultural practices would strengthen the current systems:

I wish I could fuse the some of the cultural aspects and bring back here. Because again, health is so much more than what you know, your insurance coverage and access to clinics and the hospital. (D)

A team leader shared the sentiment of others who see the potential for CONVERGE to encourage engagement in this area by capitalizing on diversity needed to strengthen curriculum in practical ways:

We ought to have a interprofessional learning session where we had multiple professions, students sit down, with cases and talk about how they would approach them from their knowledge base and how they practice and it be really a great learning experience for physicians, nurses and pharmacy students to hear how other folks would approach a problem and we could probably learn from each other. (B)

This participant called for more opportunities for engagement because it could expand the ability to work through knowledge and ideas in the field collectively, in practice, or in the classroom.

Collaboration as pathway to growth

The final theme related to motivators for engagement referred to opportunities for growth personally, and for the institutions and communities they serve. One participant shared that transferring lessons from other systems was personally valuable to her:

I'm learning that perhaps [lessons] can be transferred here, and maybe a different format, but the same intent. That's valuable to me. And I like looking through a different lens. Not just what we have, but what we could have. So that for me is why I stay engaged, is the people and what I'm learning, (E).

This participant shared that her engagement was directly linked to learning from the “different lens” collaboration offers. Similarly, for another participant, the sustained collaboration on something larger was, itself, a personal motivator:

I guess most impactful parts of being a part of CONVERGE and kind of being setting up the first of many I guess in that sense and so being able to be a part of such a big project for a you to collaborate on an international scale with something that was really cool to be a part of (J).

She saw the opportunity for a long-term impact through collaboration to be “a really cool to be a part of.” The final example also alludes to the power of being a part of something larger suggests that growth through exposure applied to institutions as well:

But also I think exposing people on our side to other ways of doing things is a growth initiative that we can use. You know, I like the idea that we all look at problems differently, and sometimes what we need to do is understand other people's perspectives a little differently and that we can create something greater than we could alone, (A).

This participant recognizes that his institution must grow through collaboration in order to combat help combat problems rural healthcare.

Mechanisms for, and barriers to, continuity

In the previous section, we highlighted how rural health experience such as shared struggle to address limited healthcare access and desire for integrated knowledge and practice fostered engagement in international collaboration. However, individual motivation does not guarantee long-term success. As noted in Table 1, we identified three primary themes related to the facilitators and barriers for continued involvement in CONVERGE or international collaboration: sustained economic support for collaborators (compensate organizers, fund research efforts, and support faculty and student exchange), intentionality in cultivating relationships (selecting “right people,” demonstrating of shared commitment, and articulating a shared vision), and structural cohesion (parallel institutional roles, stable infrastructure, and stabilize upper administrative support).

Sustained economic support for collaborators

Sustained economic support emerged as a critical tool for sustained rural health collaborations. Specifically, participants believed compensation for leaders maintaining the relationships, funding for creating rural health research, and financial support for student and faculty exchange was vital. Participants, particularly the collaboration leaders, noted that relationship networking within collaborative entities required adequate support. They admitted that organizing such collaborations should have been at the core of their responsibilities. However, they could neither pay more attention nor were they compensated well to organize such initiatives. One leader said,

“was nobody's main job, really. If you know what I mean, it's vitally important. But, you know... we've all got day jobs that we do,” (M).

Therefore, eventually, such activities became additional responsibilities for them, and funding those “in the trenches” (and not the upper administrative professionals) becomes critical to the longevity of any initiative. Beyond its practical function, economic support also serves as a symbolic indicator of value for those shouldering the workload:

I mean when you want to take this long term, you know, we want to make sure that the people involved in the planning feel valued as well. And I think that message comes from the institution and unfortunately that generally translates into a stipend. (E)

According to these members, economic support compensates and sends a “message” that reflects institutional commitment toward such initiatives.

Funding new research efforts was also identified as a necessity, especially for new faculty members who are yet to secure any grant funding. This is illustrated in a symposium participant’s struggle to travel to establish connections abroad:

[we need] to afford the faculty to travel…the initial investment, the circle, to get to know, connect with each other, have initial consultations and so on. Those are very critical. (R).

Finally, administrators and other participants identified supporting faculty and student exchange as key in creating the infrastructure necessary to facilitate long-term commitment. Participants perceived that such exchanges would create in-person learning opportunities rather than relying on virtual modes of collaboration.

Intentionality in cultivating relationships

As previously mentioned, creating and maintaining lasting relationships is critical for long-term collaborative work. In addition to compensating those tasked with relationship networking, being intentional in cultivating relationships, such as selecting the “right people,” demonstrating evidence of unilateral commitment, articulating a shared vision, and unifying bridges to future involvement are also necessary to motivate continued engagement. According to participants, the most impactful decision made by the CONVERGE steering committee was selecting the “right people” for leadership positions, presenters, and audience members. As one team leader stated,

“I think what we got right was putting the right people on the teams meetings because these are very creative, excited folks who are really interested in pursuing something.” (B)

The participants also reiterated the need for unilateral commitment within and between the collaborating institutions to maintain positive relationships among the collaborators:

We've got the researchers, we've got the educators. We can probably gather people together to do the CONVERGE conference each year, but the overall monitoring and management of that and facilitation of that making it work…our ownership of our lead vision or there is the accountability for our lead vision and I think that's pretty important. (H)

For some, the “monitoring and management” described above should also include articulating a shared vision of the future of collaborations and how this can be actualized. This may begin with leadership in collaborating entities to determine and communicate intent,

“we need…the senior people at all four institutions to get together and say this is what we want,” (M).

Similarly, collaborative efforts would be strengthened by a clear delineation of outcomes,

“when do we call ourselves successful?... Where do we define it? I think having that expectation set up front when we start the project. Is really helpful to the team,” (L).

In sum, the participants leading collaborative efforts shared that they would have benefited from the removal of the uncertainty around a shared vision, goals, and next steps.

Structural cohesion

The above-mentioned factors are contingent upon adequate structural cohesion between partnering institutions. While others were shared, the three primary structural factors include the need for parallel institutional roles, stable collaborative infrastructures, and support from the highest levels of administration within all collaborating institutions. Participants, noted a need to develop complementary roles across the partner institutions, ultimately bringing uniformity in institutional norms, policies, and support. The value of these parallel roles was recognized by university leaders as well:

At least on our side with staffing. Our international fares office. I think we've got great people, there, but it's small probably because traditionally they're scope has not been this broad and so, if you think on the lead on our side…so it might be something where do we need to have a staff person? For each one of our international collaboratives, so a full-time staff person at AU, (K).

In their opinion, it would have a long-lasting impact on existing and future collaborations. They further emphasized that the continued efforts should not depend on a sole person’s initiative so that:

Everyone actually fully understands that and that's not something that as soon as someone leaves it dies, like it has to be sustainable. It has to be something that's not necessarily top down all the time. (R)

Instead, they should be backed up by a stable infrastructure. For this, institutions might need to restructure a few initiatives within their purview and create larger collaboratives, as some discussants suggested. All agreed, however, that cohesive efforts would not be possible without the stabilize upper administrative support of the partnering organizations.

But I think if we really want it to go and come up with some good outcomes hen I think...quite a number of these initiatives come and go and universities and what happens is if there isn't an impetus or leadership to maintain them, (H).

Prioritizing new and existing international collaboration will be crucial regardless of the new initiatives that “come and go.”

Discussion

The CONVERGE showed many aspects of a successful international collaboration. Its comprehensive nature has created a conducive environment for discussing sustainable solutions for rural health challenges. Our study revealed motivators and mechanisms crucial for the continuity of rural health initiatives such as the CONVERGE. Specifically, we found a sense of shared struggle, a desire to integrate knowledge and practices, and a view of collaboration as a growth opportunity were the motivators to participate in the CONVERGE for the study participants. Moreover, they noted institutional factors such as financial support, cultivating relationships by selecting the right people, developing a shared vision, and creating cohesive structures via dedicated roles and infrastructure were critical channels that helped them to collaborate.

Our results are based on the views shared by the participants during the first symposium. Beyond this first meeting, the initiative continued and is now in its fourth year. The opinions expressed in our study also transpired into strategic steps within the initiative, making it more robust and sustainable. The leadership continued financial support to research ideas, removing one of the critical barriers to such collaboration expressed in our study. Individuals from each university were given dedicated responsibility to oversee the coordination of the initiative and the projects undertaken within it. With financial and structural arrangements, the researchers and educators came forward with intriguing research and educational projects, including blended curriculums and others (please see CONVERGE website54).

The other themes identified in our study are also echoed in the literature. In 2019, the National Association of County and City Health Officials (NACCHO) conducted a qualitative study to understand the perceptions of the local health departments about global health48. The study participants acknowledged the cross-country similarities between the communities that could pave the way to effectively transfer global health initiatives to resolve local health challenges in the US, especially those related to immigrant populations48. Like our participants, the NACCHO study respondents reported ideological and political barriers. Hargreaves and Fullan55 suggest that a “strong” collaboration has space for debate where everything is up for discussion. The CONVERGE created such space for its participants where everything, including politics, geography, and cultural barriers, is up for debate to create people-centric rural health solutions.

Moreover, the virtual symposium facilitated discussions to overcome the professional isolation previously faced by rural health practitioners56 and researchers. Our participants viewed CONVERGE as an opportunity to infuse knowledge, pedagogy, and culture to co-create blended curriculums and research ideas. Such infusion can add diversity to academic and research activities in partner universities, further improving intercultural competence and creating global mindsets among the students. Evidence suggests creating such collaborative courses across universities is feasible, especially for online courses57. Further, resonating with our participants, such exposures also create opportunities for professional growth58.

The participants noted the need for sustained funding for international collaborations in rural health. The literature also emphasizes the need to address economic support for sustained international collaborations59,60. Every year, CONVERGE provides seed funding to selected projects and successfully encourages trans-Atlantic alliances among the partnering institutions. Such collaborations can now leverage multiple national and international funding sources. As our participants discussed, stronger international relationships could be cultivated if the “right people” are selected at every level while forming collaborations. A shared vision and defined outcomes should back them. In the same vein, studies suggest practicality (i.e. identifying collaborators with a common interest) and defining common principles61 and clear goals, roles, and commitment62,63 are essential for effective international collaboration. Meißner and Weinmann64 use different phraseology while stating problems and solutions for successful collaborative research from a self-governance point-of-view. However, like our findings, among their 12 possible solutions, they mention that selecting the right participants and creating a sense of shared commitment with a well-articulated vision would overcome challenges faced by the collaborations (focused on research). Choosing the right individuals is also crucial for effectively leading the initiatives. As noted by Aunger et al.65, while reviewing the factors behind (un)successful collaborations in healthcare, the collaborative leadership style (i.e. the ability to integrate different cultures, open to listening and asking questions, and co-creating solutions) is more effective than the combative leadership style in leading the collaborations. Selecting the right individuals could minimize power dynamics and create equitable spaces for cooperation. Santin et al.66 allude to this point while emphasizing the role of teamwork, where international researchers create equitable spaces for each other while conducting cancer-related research.

Much of the cited literature has described the tenets of individual initiatives. On the contrary, our study describes a larger initiative that overarches multiple research projects. Further, it is important to note that none of our identified themes operate in a silo. Instead, they operate in tandem and should be realized in the context of each other. As per the WHO Framework for Action67, collaboration across different governance structures, stakeholders, and residents is imperative for rural health18. Extending this argument, we assert that international collaborations such as CONVERGE should be part of such initiatives. Moreover, the building blocks of health system strengthening (service delivery, health workforce, information, medical products, vaccines and technologies, financing, and leadership and governance (stewardship)) proposed by the WHO framework should be embedded in every international collaboration in health.

Our study has several implications in the context of international collaborations addressing rural health challenges. First, collaborators can learn from the power of utilizing the universal aspects of their respective research areas to encourage engagement in international efforts. Second, co-creating curriculums could be a key area to spark engagement from faculty tasked with innovating student experiential learning. Third, any collaboration would benefit from the findings related to funding, particularly financing the collaboration leaders and not the upper administrative officials. The other funding needs that emerged in our study are also obvious but important. Fourth, the intentionality in cultivating relationships lessons are very important for any collaboration—the right people (rather than open calls) and expressing shared commitment within and between institutions are needed to make sure the “troops” or “worker bees” are filling the void of international rural health research. Fifth, it is also important to link their efforts with robust cross-organizational vision, locating/creating parallel roles, and finding a way to address structural uncertainty.

This research is not without limitations. Due to its cross-sectional nature, the expressed views might have been influenced by the specific events happening in the world at the time of the data collection. Also, our study has a limited sample size and only focuses on two countries. The sample was also limited because CONVERGE participants and leadership was by invitation, which may have inadvertently narrowed the perspectives shared. Another important caveat for our research is that we could focus only on enablers of international collaborations but not on the issues and challenges obstructing it. Further, barring the extra-organizational (e.g. governments, domestic and foreign policies), we could only focus on individual and intra-organizational factors. However, all three factors are critical in understanding international health collaborations68,69. Longitudinal studies discussing collaborative space in rural health across multiple countries with more participants that will address the above-mentioned shortcomings are warranted. Lastly, literature is sparse on how geographical factors, social interactions, service delivery policies, and politics are similar or differ across the countries in the rural context70. Therefore, understanding the themes behind CONVERGE is crucial.

Conclusion

Utilizing the perspectives of participants of CONVERGE—an international collaboration on rural health—we qualitatively derive motivators for engagement in international collaboration and mechanisms encouraging the continuity required to create meaningful change. Geographic commonalities, sharing political and ideological barriers, innovations in health care, opportunities for co-creating pedagogy and curriculums, and growth opportunities emerge as motivators for international collaborations. Further, respondents identify sustained economic support for collaborators; intentionality in cultivating relationships channelized through appropriate collaborators, commitment, and vision; and structural cohesiveness expressed as the creation of complementary institutional roles, stable infrastructure, and support of upper management are essential for the continuity of meaningful collaborations. In a nutshell, individual and institutional factors derive the success of international collaborations like CONVERGE. The international initiatives that target multidimensional rural health issues should be built on robust structures that address these driving forces.