Introduction
Global health has shown remarkable progress over the past two decades. Governments, multilateral organizations, and philanthropists have made strategic investments that have changed responses to infectious diseases; improved health systems to expand access to life-saving medicines and technologies; and transformed programs through targeted financing mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and Gavi, the Vaccine Alliance, to achieve measurable health gains.1 Despite these successes, however, surgical care continues to be severely underfunded, overlooked, and marginalized.2 This funding gap for surgical care is particularly detrimental in Africa, where the high burden of surgical conditions contributes significantly to morbidity and mortality.3,4 Yet, financing mechanisms remain fragmented and insufficient to meet patient needs.5 The continued neglect of surgical care systems, especially amid declining donor funding, is not only inequitable, but also reflects deeper structural weaknesses that will hinder the development of resilient and equitable health systems across the continent.2–5
The Case for Surgery
The Lancet Commission on Global Surgery (2015) estimated that 5 billion people globally lack access to safe, timely, and affordable surgical care.2 The problem is especially serious in sub-Saharan Africa (SSA). Besides the already weak infrastructure, there is a severe shortage of the surgical workforce density, far below the recommended standards, and patients continue to experience catastrophic out-of-pocket expenditures when they seek care.3
Surgeries should not be considered luxury services. They are actually a basic part of universal health coverage and constitute a crucial component of primary health care. Surgical care is needed for trauma, obstetric emergencies, cancers, congenital anomalies, and complications from infectious diseases. Even if there were strong programs for maternal health, without surgical capacity, they would still fail to provide safe cesarean sections. Without surgical capacity, cancer programs would not be able to offer treatments capable of curing the disease, and trauma care would be rendered ineffective. In addition, reducing under-five mortality will be unimaginable without timely surgical treatment of congenital anomalies. In fact, surgery is one of the major areas without which the priorities that are heavily funded by donors could not be fulfilled.
To put it simply, Africa still faces a serious problem with maternal mortality. It is estimated that two-thirds of the mothers dying in the whole world are from the SSA region. Besides being one of the most effective ways of saving mothers’ lives, access to safe cesarean section is also very limited in many parts of Africa due to lack of trained personnel and poor infrastructure.6 It is no different with cancer, whose incidence rate is gradually increasing in almost all parts of Africa. First line treatment for solid tumors is surgery, but the challenges hardly make it possible.7 On the other side, trauma and injuries, especially resulting from road traffic accidents, comprise some of the major causes of death in Africa. Surgical treatments for broken bones, internal bleeding and head injuries are necessary in such cases.8
Just as well, surgical care is sometimes required even in the implementation of infectious disease programs, such as abscess treatment, lymph node biopsies, or surgery in cases of complications. Cumulatively, the burden of surgical diseases is reflected in the observation that 30-day mortalities postoperatively are higher than combined mortalities secondary to the big three most historically prioritized diseases (HIV/AIDS, TB and Malaria). Strikingly, nearly half of these surgical deaths occur in low- and middle-income countries, underscoring the urgent need to elevate surgery as a global health priority.9
Financing Gaps and their impact
Usually, money for global health goes straight into fighting specific diseases through vertical programs. Though these efforts work well, they have created silos that tend to shut out surgery completely. Because of how things are set up, there is no real funding path for surgical care. That setup means something vital just never got covered, which left a critical gap in a surgical system. Embodying the words of the late Paul Farmer, and in view of the surgical funding landscape, surgery has truly been the neglected stepchild of global public health.10 In Africa, surgery relies mostly on scattered projects, temporary donations, or mission-based initiatives, offering occasional help without lasting structure.11 Such patchwork support cannot sustain real growth. Now, shrinking aid from major donors like the United States of America and the United Kingdom reveals deeper cracks. Mainstream global health funds have always left out serious investment in surgery. Without steady backing, surgical services stay fragile and overlooked, leaving African surgical systems vulnerable to neglect. Contrary to popular belief and the view of surgery as a complex and expensive component of health systems, investing in surgery is actually affordable and substantially contributes to human capital.2
Africa faces unique challenges that make surgical investment urgent and the losses insurmountable.
About 93% of SSA continues to lack access to safe, affordable, and timely surgical care, this is in comparison to less than 10% in high-income countries. The WHO Africa region equally incurs up to 47% loss in productivity, equivalent to 1.4 trillion dollars, due to surgical-related conditions. In the same setting, women still face the highest risk of death during childbirth. A safe cesarean section can save lives. Cancer is growing, and surgery is often the first-line treatment, but delays and lack of capacity result in poor outcomes. Road traffic accidents kill many, and surgeries are needed to fix injuries. Without access to surgery, people miss work, stay poor, and slow down economic development.2
Opportunities for Reform
The formalization of global surgery as a public health imperative requires standardized definitions to accurately measure disparities, establish benchmarks, and drive cohesive international policy.7 Global surgery transcends clinical boundaries to encompass the broader sociodemographic, economic, and cultural contexts that govern access to care.7 Disparities in surgical access are deeply influenced by cultural perceptions of care, variable health literacy, and complex health-seeking behaviors that often delay life-saving interventions. Overcoming these multi-layered barriers requires a fundamental paradigm shift: surgical and anesthesia care must be firmly positioned not as luxury interventions, but as foundational, indispensable components of Universal Health Coverage (UHC) and resilient, equitable health systems.6
The World Health Organization (WHO) has established clear guidance for this integration, notably through Resolution WHA68.15, which urgently directs Member States to embed emergency and essential surgical care within primary healthcare networks and first-referral hospitals.12 A primary bottleneck to achieving this mandate is the critical global shortage of the surgical and anesthesia workforce. To mitigate this, task shifting offers a practical, scalable, and evidence-based workforce development strategy. A compelling demonstration of this approach is Médecins Sans Frontières’ (MSF) deployment of task shifting in Somalia.8 In this highly insecure and resource-depleted setting, MSF successfully trained general physicians to perform minor and major emergency operations, including critical obstetric and abdominal surgeries. The initiative proved highly feasible and scalable, achieving safe postoperative outcomes and demonstrating that task shifting can effectively bridge acute service gaps in austere environments.8
To translate discrete interventions into sustainable, system-level reform, governments must prioritize the implementation and scaling of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs).6 NSOAPs provide a structured, evidence-based policy framework to systematically upgrade infrastructure, optimize service delivery, and govern human resources. Within these overarching plans, the operationalization of scalable, high-impact safety interventions—such as the WHO Surgical Safety Checklist and multimodal infection prevention programs—is vital for standardizing surgical quality and significantly reducing perioperative morbidity and mortality.13
Political commitment to NSOAPs must be coupled with robust financial risk protection mechanisms to shield patients from catastrophic and impoverishing out-of-pocket costs.6 Multilateral donors and national policymakers must recognize that financing surgical systems is a highly cost-effective public health strategy with exceptional macroeconomic returns.6,7 While untreated surgically avertable conditions generate catastrophic economic losses due to premature mortality and lifelong disability, strategic investments in surgical capacity restore human capital, stimulate economic productivity, and are ultimately essential to realizing the promise of health equity for all.6
Call to Action
The international health community must recognize surgical care not as a specialty service but as essential health system infrastructure, to address this disparity. In fact, without urgent investments in surgical care, low- and middle-income countries face a projected cumulative economic loss of $12.3 trillion by 2030, equivalent to a 2% reduction in GDP.2
Multilateral organizations should incorporate surgical care into mainstream funding structures, and donors should broaden their portfolios to include strengthening surgical systems. In order to ensure that NSOAPs are implemented with sufficient funding and oversight, African governments must prioritize surgical care within national health policies, allocate adequate domestic resources and leverage innovative financing mechanisms including national health insurance schemes to expand access to surgical services. While declining official development assistance has affected many programs in global health, it is also a wake-up call and presents an opportunity to restructure global health financing toward more sustainable funding models; this is the case for funding in global surgery. The WHO Surgical Safety Checklist and other evidence-based initiatives show how straightforward, scalable actions can dramatically lower complications and mortality. Scaling these interventions throughout African health systems can produce immediate as well as sustained benefits.
Conclusion
The decline in donor support serves as a warning: without funding framework reform, Africa cannot achieve equitable health outcomes without surgery at the core of financing frameworks. For robust, all-encompassing, and equitable health systems, surgery is essential. The international medical community has mobilized billions to combat infectious diseases; now, it needs to do the same for surgical care. For millions of Africans, rebalancing global health finance to include surgery is about justice, resiliency, and survival, not charity. The question is not whether the world can afford to invest in surgical technologies in a time of limited finances. Instead, the question is whether the international health community can afford to keep ignoring a vital aspect of medical care that millions of patients rely on a daily basis.
Ethical Approval
Not applicable
Informed Consent
Not applicable
Data Availability
No datasets are available for this editorial.
Conflict of Interest
The authors declare that they have no competing interests.
Funding
None