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Innovation in income-poor environments. BACKGROUND: At the core of surgical development in any economic environment lies innovation. Innovation in high-income countries (HICs) often derives from research, whereas innovation in low- and middle-income countries (LMICs) may be spontaneous owing to a desperate drive to meet a local need. The local needs are substantial because of the unequal access to healthcare in LMICs. METHODS: The experience of the author in working in LMICs through Operation Hernia, a medical charity, provides a backdrop for this review. Other published innovative devices and models are discussed. RESULTS: Innovation in income-poor countries has provided cost-effective but efficient solutions to local health needs. Some innovations have been enhanced and adopted worldwide. CONCLUSION: HICs can learn more from innovative strategies adopted in LMICs.