Costs of surgeries in low- and middle-income countries: a systematic literature review

Discussion Evidence of costs and resource requirements is important for decision-making and resource allocation. By synthesising cost estimates provided in 74 studies, spanning 29 countries, we present important reference data for 65 surgical procedure groups and 12 surgical specialties. We found large variation in costs across procedures, ranging from I$1.54 for caesarean section in Tanzania to I$618 098 for paediatric cataract surgery in Zambia, and within specialties, ranging from I$4844.76 to I$1.54 for obstetrics and gynaecology. Notably, most studies originated from upper middle-income countries, with limited data from low-income countries. By distinguishing between full and partial costing methodologies, we show that cost estimates tend to be higher for full costing studies compared with partial costing approaches. This emphasises the importance of adopting comprehensive costing approaches to derive more meaningful estimates for integration into local resourcing decisions. Surgeries are often perceived as expensive, especially when compared with traditional public health interventions (eg, tuberculosis treatment, HIV prevention, breastfeeding campaigns, salt iodisation and childhood immunisation) that have received substantial local and international funding over the past decades. Based on our findings, surgeries are indeed expensive. For example, pre-natal micronutrient supplementation costs US$2.60 throughout a woman’s pregnancy19; the production of a new two times per year shots for HIV prophylaxis (lenacapavir) is projected to cost US$40 per treatment under generic production20; and the per person cost of distributing insecticide treated nets ranges from US$0.88 to US$9.54.21 Costs for surgical procedures widely exceed the cost of such interventions. The high cost of surgical procedures is likely a consequence of its complexity and horizontal integration into the whole healthcare system. Cost drivers include the costs associated with well-equipped surgical theatres and wards, trained personnel (surgeons, anaesthetists, nurses and support staff), medical and blood supplies, administration of financing mechanisms and governance structures. As Farmer and Kim succinctly put it, "there is no surgical equivalent to a vaccination campaign or a mosquito net”.22 However, a growing body of evidence has shown that when considering the cost per unit of health gain, low- to moderate-complexity surgical procedures compare favourably to, and in some instances are more cost-effective than conventional public health interventions.16 23 Moreover, the opportunity cost to society at large of not providing surgery is potentially enormous. In 2015, the Lancet Commission on Global Surgery estimated that scaling up surgical services in LMICs would require an investment of US$350 billion to US$420 billion by 2030. Failing to mobilise investments into surgical care, on the other hand, was estimated at a US$12.3 trillion loss in GDP due to lost productivity. More so, using internal instruments techniques to address endogeneity, a recent study has demonstrated a statistically significant positive association between surgical activity and economic development in LMICs, suggesting that surgery may be not just a health intervention but a driver of economic prosperity.24 Despite the growing recognition of surgical care as an essential component of global health, robust evidence on the costs of surgical procedures remains limited.4 We identified only 74 costing studies over 23 years, with only half of those studies providing comprehensive (full) costing estimates. This is particularly inadequate given the vast range of surgical procedures available, each with varying levels of complexity, resource requirements and settings of delivery. Moreover, the existing studies were predominantly from upper-middle-income countries, with virtually no or limited representation from low-income countries and African nations, where the burden of surgical disease is highest. This evidence gap is in line with previous findings in other reviews,16 25 which carries direct implications for policymakers in low-resource settings when determining surgical benefit packages that are tailored to local population needs and inclusive of costing implications. Future research must strive for the provision of detailed, clinically and geographically diverse costing estimates grounded in methodological transparency and consistency in reporting to enhance comparability and usability of such data for policy and planning. Strengths and limitations Our study has several strengths. We adhered to the Cochrane Handbook of Systematic Reviews, CRD Guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), ensuring reliability and replicability. The inclusion of full and partial costing studies enhanced the depth of analysis, allowing for a nuanced interpretation of cost variations. However, there are some limitations. First, the heterogeneity across studies regarding costing methodologies, reporting practices and study populations precluded the use of a meta-analysis to synthesise findings. However, presenting the costs as medians and ranges allowed the aggregation of costs of otherwise disparate interventions across different procedure groups, countries and specialties. Second, the limited breadth of procedures covered in this review limits the extent to which our comparisons especially across countries and specialties represent the real-world variations in surgical costs. For instance, our study finds that in Peru, surgeries cost between I$37 and I$60 whereas in Nigeria they cost I$16 678 to I$29 982. This is more likely an artefact of which surgical procedures were included in the articles included in the review rather than a true difference in the costing of surgery between these two countries. Third, the reliance on retrospective data in most studies introduces potential biases related to data completeness and accuracy. Only a small proportion of costing data were generated using prospective collection methods. Fourth, the concentration of studies in upper-middle-income countries limits generalisability to low-income settings, where cost structures may differ substantially. Fifth, the exclusion of non-medical patient costs (eg, transportation and lost productivity) means that the full societal costs of surgical care are not fully captured in our estimates. Lastly, this study fails to capture the heterogeneities in the ownership (private, public, faith-based, non-governmental organisations), funding mechanisms (government, patient, donors), financial goals (profit vs non-profit) and settings (urban vs rural) of surgical service providers in LMICs as the relevant disaggregated analyses were not included. Addressing these limitations in future research through standardised costing frameworks, inclusion of broader cost components and context-appropriate disaggregated analyses will be essential for strengthening the evidence base for surgical cost analyses in LMICs. Policy implications and conclusion The findings of this review have the potential to serve as reference data, and they hold several policy implications for national surgical planning and health service financing. Robust cost data are essential for priority-setting decisions, ensuring that surgical interventions are appropriately integrated into essential health benefit packages to achieve universal health coverage by 2030. Moreover, national surgical plans must account for the full economic costs of procedures to ensure adequate resource allocation, workforce planning and infrastructural investments. Failure in doing so may be a contributory factor for the lack of implementation of surgical plans observed across LMICs.26 In addition, governments, payers including insurance providers, non-governmental organisations, international organisations and funders may use these cost estimates for calibrating reimbursement schemes and to prevent underfunding of surgical services, which could compromise quality and access to care. Our findings provide insights into cost variations across settings that could help inform regional and national strategies for cost reduction, such as pooled procurement of surgical supplies, task-shifting to optimise human resources and investments in cost-effective surgical innovations. Operative surgical conditions are associated with nearly 18 million deaths and 620 million disability-adjusted life years globally every year.27 Concerted efforts are required to develop strategies that address this growing surgical need, including those that address resource allocation and wider planning decisions. Our study fills an important gap in the global surgery economics literature by providing a comprehensive reference list of costs associated with 65 surgical procedure groups. Yet, there remains, however, overall, a paucity of cost evidence, particularly among low-income countries and countries in sub-Saharan Africa. Future research should prioritise data collection in these settings, adopt standardised costing methodologies and explore innovative strategies to optimise surgical costs while maintaining high-quality care.