Globally it is estimated that 1.7 billion children lack access to safe and affordable surgical care1. To put this in context, surgical disease eclipses the burden of HIV, TB, and malaria combined1. While there is increasing recognition of the need to provide adequate surgical services for children, many low- and middle-income countries (LMICs) still lack a specialized children's surgery workforce. This is not only detrimental to the lived experiences of children and their families but also has a significant socio-economic impact. By 2030, it is estimated that LMICs will have lost 12 trillion USD in economic output as a result of surgically amenable disease2. The provision of a robust ‘in-house’ pediatric surgical service in LMICs is therefore imperative. In this paper, we aim to describe our 21 yearlong Tanzania-Oxford Children's Surgery Partnership. A truly reciprocal relationship that has led to the successful provision and ongoing expansion of a comprehensive pediatric surgical service. At the core of this partnership has been the recognition that achieving meaningful impact requires local leadership, long-term commitment, and ‘bottom-up’ change.