Mapping Global Commitments to Neurosurgical Access and Equity: An Analysis of the 2025 Boston Declaration Pledges

The 2025 Boston Declaration advanced the 2016 Bogota Declaration, the first formal initiative to highlight global neurosurgical deficits, by shifting global neurosurgery from formalization to action. It aimed to mobilize multisectoral organizational pledges addressing neurosurgical workforce, infrastructure, financing, research, and systems development. These pledges formed the foundation for collective commitment to improving access to safe, timely, and affordable neurosurgical care worldwide. This study analyzes the 94 pledges submitted as part of the Boston Declaration.

This retrospective, descriptive, convergent mixed-methods analysis examined 94 submitted pledges. Quantitative data included organizational characteristics, geographic focus, collaboration status, subspecialty focus, and adherence to Specific, Measurable, Actionable, Realistic, and Timebound goal criteria. Qualitative content analysis assessed thematic priorities and integration across 7 pledge categories. Final pledges, submitted using Google Forms, were analyzed in Google Sheets and RStudio to assess content. World Health Organization regional groupings and World Bank income classifications were used.

Ninety-four pledges were submitted by 72 distinct organizations, including 7 international organizations and 6 based in low- and middle-income countries. Most pledges (72%) came from single organizations, whereas 25 (26.89%) were collaborative. Geographically, 35.4% addressed global issues, 26.9% were multiregional, and 38.8% focused on a single region or country. Although 92.5% of pledges were specific, only 60.2% included all 1-, 3-, and 5-year benchmarks, although nearly all (92.5%) addressed time-bound goals. The most common focus areas were workforce development (63.4%) and ecosystem expansion (40.9%), whereas technology and financial/philanthropic support were each addressed by only 16.1%. Most (58.1%) did not target a specific subspecialty.

Mixed-methods analysis demonstrates strong global engagement, although most organizations are based in high-income countries, and specificity in pledges, with focus on workforce development and collaboration. Fewer pledges addressed technology and financial support. Future analysis will explore thematic trends across the 7 areas of need.