The prevalence of newborns spina bifida and hydrocephalus in low and middle income economies (LMIE) is higher than in high income economies (HIE). In this article, the International Federation for Spina Bifida and Hydrocephalus (IF) reflects on its findings of 20 years of work in East and Southern Africa. Active parent involvement in care and interdisciplinary approach are crucial for a successful long life care program. In LMIE, the IF program tries to overcome the barriers in care. Medical and local materials have to be used creatively and have to be combined with pragmatic choices in surgery and medical imaging. The IF program shows how a cost-saving approach is feasible and does not need to imply a decrease in quality of care.