Analysis of bilateral development assistance for surgery in low- and middle-income countries: trends, challenges and...

Surgical care in low- and middle-income countries (LMICs) remains underfunded despite representing a significant portion of the Global Burden of Disease. Understanding bilateral development assistance for surgery is crucial to address this disparity.

We conducted a narrative review and quantitative analysis of bilateral development assistance for surgery in LMICs from 2014 to 2022 using data from the Institute for Health Metrics and Evaluation and the Organisation for Economic Co-operation and Development Creditor Reporting System. Surgical projects were identified through keyword search. We report funding trends, key actors, project classifications, implementation channels and regional distribution, and examine trends through thematic analysis of key characteristics of bilateral aid.

Between 2014 and 2022, US$2.73 billion was disbursed to surgical projects. Surgical funding decreased as a proportion of total bilateral development assistance for health (DAH), from 2.13% in 2014 to 1.32% in 2022. Key donors were Canada, the USA, Australia, Italy and Korea. Obstetrics and gynaecology received the most funding among surgical subspecialties. Non-governmental organisations were the primary implementation channels (51.4%), which could undermine public sector development by bypassing national health systems, perpetuating fragmentation and limiting governments' capacity to sustain surgical services independently. Sub-Saharan Africa was the principal recipient region, securing 55.17% of disbursements.

Despite increasing commitments, surgical care remains underfunded, with an overall 1.84% share of bilateral DAH. Contributing factors include limited expressed public sector demand and absorption capacity in recipient countries, donor disbursement practices tied to performance indicators and shifting donor priorities. Recipient countries can enhance funding utilisation and donor attraction by strengthening national surgical plans, improving health system capacity, engaging stakeholders collaboratively, advocating for balanced funding across specialties and exploring innovative financing mechanisms. Addressing these challenges is essential to optimising surgical care funding and improving health outcomes in LMICs.