Pediatric surgery in sub-Saharan Africa is disadvantaged by the large number of sick children, disease patterns specific to the region, late presentation, and advanced pathology. In addition, it is practiced in an environment of limited resources and facilities and other health priorities. Obstacles to better pediatric-surgical care (PSC) include a general lack of interest in surgical conditions affecting African children, its poorly defined role, and a lack of political commitment by governments and international agencies to see surgical care of children improve. Pediatric-surgical practice in Africa must be cognizant of the factors that limit delivery of surgical services and work toward developing cost-effective strategies that benefit the largest number of children. Demonstrating that childhood surgical conditions are a significant public health-care problem is the most likely way to change health-care policy and to ensure adequate resources for PSC. Other priorities should be to define a cost-effective package of pediatric surgical services, improve PSC at the community level, and strengthen pediatric surgical-education.