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Objective To assess how preoperative anaemia affects surgical outcomes in elderly patients within a resource-limited setting.Design Prospective cohort study.Setting Two comprehensive specialised hospitals in Ethiopia.Participants Participants consisted of 224 patients aged 65 years and older who underwent surgery between 1 December 2024 and 29 March 2025.Primary and secondary outcome measures Perioperative blood transfusions were the primary outcome. Secondary outcomes included intensive care unit (ICU) admission, risk of postoperative complications, prolonged hospitalisation, poor recovery quality and in-hospital mortality.Results The anaemic group required transfusions of three or more units more frequently than the non-anaemic group (10.5% vs 2.6%; absolute risk difference 8.0%). Their perioperative transfusion rates were significantly higher (42.3% vs 18.4%; p<0.001; absolute risk difference 24.0%). This included intraoperative transfusions (31.5% vs 8.1%; p<0.001; absolute risk difference 23.4%) and postoperative transfusions (17.1% vs 9.9%; p=0.007; absolute risk difference 7.2%). Perioperative transfusion was associated with increased risks of in-hospital mortality (Relative Risk [RR]=3.60; 95% CI 2.40 to 6.80), postoperative complications (RR=2.42; 95% CI 1.25 to 4.70), ICU admission (RR=3.89; 95% CI 1.21 to 12.48), extended hospitalisation (RR=2.14; 95% CI 1.15 to 3.97) and poor recovery (RR=2.87; 95% CI 1.54 to 5.36).Conclusion and recommendation Preoperative anaemia significantly increases the risk of transfusion, poor recovery, ICU admission, prolonged hospitalisation and in-hospital mortality in older patients who underwent surgery. In resource-limited settings, improving perioperative outcomes should prioritise the early detection and treatment of anaemia.