The Mission-to-System Continuum: international partnerships for sustainable paediatric cardiac programme development...

Congenital heart disease (CHD) remains a major contributor to childhood morbidity and mortality worldwide, with the greatest burden borne by low- and middle-income countries (LMICs), where access to specialised cardiac care remains severely limited. International assistance partnerships, including paediatric cardiac surgical volunteer programmes, have historically sought to address this disparity through short-term externally supported interventions. Over time, many of these partnerships have evolved beyond episodic service delivery toward models emphasising capacity building, workforce development, and health system strengthening. This narrative review examines the evolution of paediatric cardiac surgery assistance partnerships in LMICs and proposes a conceptual framework-the Mission-to-System Continuum-to characterise the evolution of partnership models from episodic external intervention toward sustainable, locally led systems of care. Contemporary partnership models are described across a spectrum ranging from short-term service delivery initiatives to training-focused collaborations, hybrid adaptive models, and partnership models supporting increasing local autonomy. Persistent barriers to sustainable programme development include workforce shortages, infrastructure limitations, funding constraints, inequitable access, delayed diagnosis, and restricted availability of specialised consumables and perioperative resources. Emerging strategies increasingly emphasise longitudinal partnerships, distributed training pathways, South-South collaboration, and hybrid engagement models aimed at strengthening multidisciplinary cardiac teams and supporting long-term programme sustainability.

The review argues that traditional measures of success based primarily on procedural volume are insufficient to evaluate sustainable impact. Future progress will require greater emphasis on workforce development, local surgical independence, longitudinal outcomes, and integration of congenital cardiac services within national health systems. Although many paediatric cardiac programmes in LMICs have developed through alternative pathways independent of external partnerships, the Mission-to-System Continuum provides a conceptual framework for understanding the evolution of international partnership models and identifying strategic priorities for sustainable congenital cardiac care.

• Paediatric cardiac programmes in LMICs have historically relied on short-term international surgical partnerships, although contemporary initiatives increasingly emphasise workforce development, multidisciplinary training, and health system strengthening. • Despite this shift toward capacity building and more sustainable models of care, major inequities in access to congenital cardiac care persist worldwide.

• This review introduces the Mission-to-System Continuum, a conceptual framework that integrates existing partnership models and describes how international partnerships may evolve from episodic surgical missions toward sustainable, locally led paediatric cardiac programmes with increasing local ownership, institutional capacity, and health system integration. • The framework highlights that sustainable programme development requires long-term partnerships extending beyond surgical service delivery to encompass leadership development, governance, quality improvement, research, and regional collaboration.