title: Funding flows to global surgery: an analysis of contributions from the USA.
abstract: BACKGROUND
  In recent years, funds for global health have risen substantially, particularly for infectious diseases. Although conditions amenable to surgery account for 28% of the global burden of disease, the external funds directed towards global surgical delivery, capacity building, and research are currently unknown and presumed to be low. We aimed to describe external funds given to these efforts from the USA, the world's largest donor nation.
  
  
  METHODS
  We searched the United States Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center, and registered US charitable organisations databases for financial data on any giving exclusively to surgical care in low-income and middle-income countries (LMICs). All nominal dollars were adjusted for inflation by converting to 2014 US dollars.
  
  
  RESULTS
  After adjustment for inflation, 22 NIH funded projects (totalling US$31·3 million, 1991-2014) were identified; 78·9% for trauma and injury, 12·5% for general surgery, and 8·6% for ophthalmology. Six relevant USAID projects were identified; all related to obstetric fistula care totalling US$438 million (2006-13). US$105 million (2003-13) was given to universities and charitable organisations by US foundations for 14 different surgical specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, burn, general surgery, obstetric emergency procedures, anaesthesia, and unspecified specialty). 95 US charitable organisations representing 14 specialties (ophthalmology, cleft lip/palate, multidisciplinary teams, orthopaedics, cardiac, paediatric, reconstructive, obstetric fistula, neurosurgery, urology, ENT, craniofacial, burn, and general surgery) totalled revenue of US$2·67 billion and expenditure of US$2·5 billion (2007-13).
  
  
  CONCLUSIONS
  A strong surgical system is an indispensable part of any health system and requires financial investment. Tracking funds targeting surgery helps not only to quantify and clarify this investment, but also to ultimately serve as a platform to integrate surgical spending within health system strengthening. Although USAID is a vital foreign aid service and the NIH is a leader in biomedical and health research, their surgical scopes are restricted both financially (less than 1% of respective total budgets over the study years) and in surgical specialty. By contrast, the private charitable sector has contributed more financially and to more specialties. Still, current financial global health databases do not have precise data for surgery. To improve population health in LMICs, more resources should be dedicated to surgical system strengthening. Furthermore, exact classification measures should be implemented to track these important resources.
  
  
  BACKGROUND
  None.
authors: Department of Surgery, Montefiore Medical Center, Bronx, NY, USA; UNC Project Malawi, Lilongwe, Malawi; Center for Surgery and Public Health, Boston, MA, USA. Electronic address: Lily.gutnik@mail.harvard.edu.
authors: Lily A
authors: LA
authors: Gutnik
authors: Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
authors: Joseph
authors: J
authors: Dielman
authors: King's Centre for Global Health, King's Health Partners & King's College London, London, UK.
authors: Anna J
authors: AJ
authors: Dare
authors: Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA.
authors: Margarita S
authors: MS
authors: Ramos
authors: Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Center for Surgery and Public Health, Boston, MA, USA.
authors: Robert
authors: R
authors: Riviello
authors: Harvard Medical School, Boston, MA, USA; Boston Children's Hospital, Boston, MA, USA.
authors: John G
authors: JG
authors: Meara
authors: Evidence to Policy Initiative, Global Health Group, University of California San Francisco, San Francisco, CA, USA.
authors: Gavin
authors: G
authors: Yamey
authors: Harvard University Interfaculty Initiative in Health Policy, Cambridge MA, USA; Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA; Program in Global Surgery and Social Change, Children's Hospital Boston, Boston MA, USA.
authors: Mark G
authors: MG
authors: Shrime