Economic impact of surgery on households and individuals in low income countries: A systematic review

Authors: Platt E, Doe M, Kim NE, Chirengendure B, Musonda P, Kaja S, Grimes CE.

Geographical coverage: Africa, Asia and the Caribbean

Sector: Economic burden

Sub-sector: Surgical costs

Equity focus: Not reported

Study population: Patients with surgical conditions requiring surgery

Review type: Economic review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background: Surgical diseases account for a significant portion of global mortality and disability, disproportionately affecting the poorest communities worldwide. Despite the high demand for surgical care, provision remains inadequate in low-income countries (LICs), where only a small fraction of global surgeries is performed. Many surgical conditions are treatable and, if managed appropriately, can restore individuals to economic productivity. However, the financial burden of surgery on individuals and households is immense, often resulting in catastrophic health expenditure that pushes families into debt and poverty. Although Universal Health Coverage (UHC) emphasises the importance of financial risk protection, substantial gaps remain between policy and real-world outcomes. Moreover, while many studies focus on provider and health system costs, the patient’s perspective on economic hardship is often under-represented and insufficiently explored.

Objective: To consolidate current evidence on the economic burden of surgical disease and treatment on individuals and households, and to foster a meaningful discussion about the relative costs and affordability of surgical care.

Main findings: The review included 31 studies published between 2000 and 2019. Most studies were from single countries, with Uganda being the most represented (11 studies). The only non-African countries studied were Nepal (3 studies) and Haiti (2 studies), and one study performed modelling using worldwide data. The methodological quality of the included studies varied: five were rated strong, two weak, and the rest moderate. Direct medical, direct non-medical, and indirect costs were variably reported but were substantial across all scenarios, often resulting in catastrophic expenditure.

Key findings by surgical context included:

• Caesarean sections (10 studies): Direct medical costs ranged from $22.26 to $143, and direct non-medical costs ranged from $6.90 to $321.60 per case.
• Paediatric surgery (4 studies): Median direct costs ranged from $4 to $45.91, and direct non-medical costs ranged from about $5.46 to $59.23.
• Trauma-related care (3 studies): Direct costs ranged from $29 to $254.14, with long-term income losses of up to 45% of pre-injury annual income.
• Post-abortion care (3 studies): Treatment costs ranged from $19 to $49 for managing spontaneous abortion complications.
• All-surgery categories (4 studies): There was a 78.8–95.1% chance of incurring catastrophic expenditure for surgical care in general.
• Ophthalmic surgery (2 studies): Significant costs were reported (specific values not detailed in the summary).
• Breast cancer surgery (1 study): Transport and food costs for treatment ranged from $243 to $7,223.
• Surgery for peritonitis (1 study): Notable costs were reported (specific values not detailed in the summary).

Despite some patients having health insurance coverage, catastrophic expenditure remained common. This highlights the need for improved financial protection policies to prevent families from falling into poverty due to surgical care costs.

Methodology:

Searches were conducted in Medline and PubMed on 4 June 2019 to identify English-language studies reporting the economic impact of surgery or surgical disease on individuals, families, or local communities. Two reviewers independently screened all titles and abstracts against the eligibility criteria. Full-text screening was performed by a single reviewer, with an experienced reviewer consulted in cases of uncertainty about inclusion. Relevant data were extracted, and findings were synthesised narratively. Two reviewers independently assessed the quality of the included studies using the Joanna Briggs Institute (JBI) tools, and the results of this quality assessment were reported.

Applicability/external validity: The review acknowledged limitations in the external validity of its findings due to significant heterogeneity in methods, cost definitions, and outcome measures across the studies. Cultural factors influencing health-seeking behaviour and informal payments were not consistently captured, potentially affecting generalisability. It also noted possible selection biases; for example, some studies overrepresented higher socioeconomic groups, which may underestimate the true economic burden on the poorest. The authors emphasised the need for standardised data collection tools and universal cost definitions to improve comparability and applicability of future research across different settings.

Geographic focus: No geographical limits were applied in the search strategy. The majority of included studies were conducted in African countries (over 80% of the studies), with a smaller number from Asia and the Caribbean. This distribution suggests that the findings are heavily influenced by African contexts, with limited data from other low-income regions.

Summary of quality assessment: Overall, there is low confidence in the review’s conclusions due to several methodological limitations. On the positive side, the review clearly defined its inclusion and exclusion criteria, performed searches in two major databases, and rigorously assessed study quality using validated JBI tools (with transparent reporting of this assessment). It also provided a detailed narrative synthesis that addressed heterogeneity and presented key characteristics of the included studies. However, several concerns exist: the search was restricted to English-language publications (introducing a potential language bias), and only one reviewer conducted the full-text screening (raising the risk of selection bias). The number of reviewers involved in data extraction was not specified. Additionally, the review did not report checking the reference lists of included studies or contacting authors and experts for any potentially missed data, and it did not provide a list of excluded studies. Although the risk of bias in individual studies was assessed, the review did not stratify or adjust its findings based on the bias level of those studies. These limitations mean that the review’s findings should be interpreted with caution.