Quantifying multilateral contributions to surgical system development in low- and middle-income countries: an analysis of trends and opportunities

INTRODUCTION: Financial limitations have stalled the implementation of national surgical plans in low- and middle-income countries (LMICs), which significantly rely on development assistance for their health expenditures. This paper describes the challenges and opportunities in accessing development assistance from multilateral organisations and quantifies the trends of their financial contributions to surgical systems in LMICs. METHODS: We analysed publicly available data from the Institute for Health Metrics and Evaluation Financing Global Health database and Organisation for Economic Co-operation and Development Creditor Reporting System. We analysed disbursements from multilateral organisations and reported values in the trends from 2014 to 2022, major contributing organisations, geographic variations and implementing partners. RESULTS: Multilateral organisations mobilised $232 billion in development assistance for health from 2014 to 2022, with the highest amount in 2021, during major global crises. Only 0.4% ($901.5 million) of this was disbursed to finance surgical care. Approximately 84% was financed from multilateral development banks, primarily by the World Bank Group and the Inter-American Development Bank. Disbursements went mainly to system-strengthening projects on building infrastructure and blood supply systems. Orthopaedic surgery was the highest, while anaesthesia and critical care were the least funded surgical specialties. Recipient governments were the major implementing partners. CONCLUSION: Despite a noticeable growth following the Lancet Commission on Global Surgery, surgical care remains underfunded at 0.4% of multilateral development assistance, compared with the 50% that goes to communicable diseases. This gap reflects the dominance of disease-specific global health initiatives in the multilateral financing landscape. Multilateral development banks are demonstrating increased capacity to address this shortfall in multilateral finance. They emerge as strategic partners to advance surgical systems strengthening in LMICs by offering flexible financing mechanisms and supporting recipient-led implementation.