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Increasing equity in global surgery necessitates a drastic and swift increase in surgical access, particularly in low and middle-income countries. While there has been a global push to increase medical education and surgical training in recent decades, smaller states often struggle to establish sustainable domestic training programs to meet local needs. Transnational medical education collaborations have helped to increase the medical workforce in some of these countries, like Solomon Islands. Solomon Islands offers an interesting example of surgical workforce development given the absence of any medical school or general surgery training programs. The country has one of the lowest physician-to-population ratios in the world (0.24 doctors per 1,000 people) and suffers from chronic healthcare infrastructural insufficiency in the face of a high burden of infectious and non-communicable diseases. Most physicians in Solomon Islands are trained in Papua New Guinea, Fiji, Cuba, and China. Upon their return, newly graduated registrars must then undergo training in Solomon Islands to ensure clinical preparedness. Surgical training programs for qualified Solomon Islands physicians are offered primarily by the University of Papua New Guinea (UPNG) and Fiji National University. While the externalization of medical education and surgical training has helped increase the number of surgeons in the country, it has also posed practical and structural challenges to domestic surgery services, namely in terms of surgical practice standardization, trainee retention, and workforce alignment. Additionally, international medical education partnerships have been impacted by changing political circumstances. Efforts to establish domestic training programs may help to expand surgical access and standardize surgical practice nationwide, but such efforts also face barriers to establishment and long-term operation.