Financing surgery in LMICs: building sustainable and equitable systems for universal surgical access – a narrative review

Abstract

INTRODUCTION: Surgical conditions account for nearly a third of the global disease burden yet financing for surgery in Low- and Middle-Income Countries (LMICs) remains fragmented, under-prioritized, and heavily dependent on out-of-pocket (OOP) payments. METHODS: This narrative synthesis focuses on how surgical services are financed in LMICs and what models are emerging to build sustainable, equitable systems. Applying the World Health Organization (WHO)'s health financing framework-revenue generation, pooling, and purchasing -we synthesize quantitative and qualitative evidence from recent literature, with reference to country case studies and economic models. FINDINGS: Most LMIC surgical care is financed predominantly through OOP payments, with minimal earmarked government funds and limited donor contributions. Coverage by insurance is often inadequate and fails to provide true financial protection. Donor support for surgery remains low and uncoordinated. All these structural gaps contribute to inequities in access as well as high-frequency Catastrophic Health Expenditures (CHE). The promising strategic purchasing, performance-based financing (PBF), and National Surgical, Obstetric, and Anesthesia Plan (NSOAP) models have promise when employed with universal health coverage (UHC) goals. The models of Rwanda and Ghana serve to illustrate how pooled financing, political leadership, and national plans can drive access, financial protection, and service quality improvement. The narrative review highlights key enablers of sustainable financing: political commitment, risk pooling, earmarked taxes, public-private partnerships, and integration of surgery into broader UHC frameworks. Improved data systems for monitoring surgical costs, access, and outcomes are essential to inform investment decisions and track progress. CONCLUSION: Surgery financing is not only a public health imperative but also an economically sound investment. We conclude with strategic recommendations for policymakers, global health actors, and donors to design financing models that prioritize equity, resilience, and long-term health system strengthening.