ObjectivesThe COVID-19 pandemic significantly affected the provisions of health services to necessary but deprioritised fields, such as transplantation. Many programmes had to ramp-down their activity, which may significantly affect transplant volumes. We aimed to pragmatically analyse measures of transplant activity and compare them by a country’s income level and cumulative COVID-19 incidence (CCI).Design, setting and participantsFrom June to September 2020, we surveyed transplant physicians identified as key informants in their programmes. Of the 1267 eligible physicians, 40.5% from 71 countries participated.OutcomeFour pragmatic measures of transplant activity.ResultsOverall, 46.5% of the programmes from high-income countries anticipate being able to maintain >75% of their transplant volume compared with 31.6% of the programmes from upper-middle-income countries, and with 21.7% from low/lower-middle-income countries (p<0.001). This could be because more programmes in high-income countries reported being able to perform transplantation/s (86.8%%–58.5%–67.9%, p<0.001), maintain prepandemic deceased donor offers (31.0%%–14.2%–26.4%, p<0.01) and avoid a ramp down phase (30.9%%–19.7%–8.3%, p<0.001), respectively. In a multivariable analysis that adjusted for CCI, programmes in upper-middle-income countries (adjusted OR, aOR=0.47, 95% CI 0.27 to 0.81) and low/lower-middle-income countries (aOR 0.33, 95% CI 0.16 to 0.67) had lower odds of being able to maintain >75% of their transplant volume, compared with programmes in high-income countries. Again, this could be attributed to lower-income being associated with 3.3–3.9 higher odds of performing no transplantation/s, 66%–68% lower odds of maintaining prepandemic donor offers and 37%–76% lower odds of avoiding ramp-down of transplantation. Overall, CCI was not associated with these measures.ConclusionsThe impact of the pandemic on transplantation was more in lower-income countries, independent of the COVID-19 burden. Given the lag of 1–2 years in objective data being reported by global registries, our findings may inform practice and policy. Transplant programmes in lower-income countries may need more effort to rebuild disrupted services and recuperate from the pandemic even if their COVID-19 burden was low.