Rapidly evolving gangrenous vasculitis in a critically ill patient with ulcerative colitis: a case report.

Ulcerative colitis is a disease characterised by non-granulomatous submucosal inflammation ranging from isolated proctitis to colitis. Extra-intestinal manifestations of the condition occur in multiple organ systems, with dermatological complications occurring commonly. This case report aims to highlight an uncommon dermatological complication of ulcerative colitis with particular focus on patient care and management.

Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist.

INTRODUCTION: Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold. METHODS: The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created. RESULTS: Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed. CONCLUSION: Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.

Cost-Effectiveness of Two Government District Hospitals in Sub-Saharan Africa.

BACKGROUND: District hospitals in sub-Saharan Africa are in need of investment if countries are going to progress towards universal health coverage, and meet the sustainable development goals and the Lancet Commission on Global Surgery time-bound targets for 2030. Previous studies have suggested that government hospitals are likely to be highly cost-effective and therefore worthy of investment. METHODS: A retrospective analysis of the inpatient logbooks for two government district hospitals in two sub-Saharan African hospitals was performed. Data were extracted and DALYs were calculated based on the diagnosis and procedures undertaken. Estimated costs were obtained based on the patient receiving ideal treatment for their condition rather than actual treatment received. RESULTS: Total cost per DALY averted was 26 (range 17-66) for Thyolo District Hospital in Malawi and 363 (range 187-881) for Bo District Hospital in Sierra Leone. CONCLUSION: This is the first published paper to support the hypothesis that government district hospitals are very cost-effective. The results are within the same range of the US$32.78-223 per DALY averted published for non-governmental hospitals.

Demographics of patients affected by surgical disease in rural hospitals in two sub-Saharan African countries: a retrospective analysis.

BACKGROUND: Awareness is growing of both the importance of surgical disease as a major cause of death and disability in low-income and middle-income countries (LMICs) and the cost-effectiveness of fairly simple surgical interventions. We hypothesised that surgical disease predominantly affects young adults and is therefore significant in both the macroeconomic effect of untreated disease and the microeconomic effects on patients and families in low-resource settings. METHODS: We retrospectively reviewed all admission data from two rural government district hospitals, Bo District Hospital in Sierra Leone and Thyolo District Hospital in Malawi. Both hospitals serve a rural population of roughly 600 000. We analysed data from 3 months in the wet season and 3 months in the dry season for each hospital by careful analysis of all hospital logbook data. For the purposes of this study, a surgical diagnosis was defined as a diagnosis in which the patient should be managed by a surgically trained provider. We analysed all surgical admissions with respect to patient demographics (age and sex), diagnoses, and the procedures undertaken. FINDINGS: In Thyolo, 835 (12·9%) of 6481 hospital admissions were surgical admissions. In Bo, 427 (19·8%) of 2152 hospital admissions were surgical admissions. In Thyolo, if all patients who had undergone a procedure in theatre were admitted overnight, the total number of admissions would have been 6931, with 1344 (19·4%) hospital admissions being surgical and 1282 (18·5%) hospital patients requiring a surgical procedure. In Bo, 133 patients underwent a surgical procedure. This corresponded to 6·18% of all hospital admissions; although notably many of the obstetric admissions were referred to a nearby Médecins Sans Frontières (MSF) hospital for treatment. Analysis of the admission data showed that younger than 16-year-olds accounted for 10·5% of surgical admissions in Bo, and 17·9% of surgical admissions in Thyolo. 16-35-year-olds accounted for 57·3% of all surgical admissions in Bo and 53·5% of all surgical admissions in Thyolo. Men accounted for 53·7% of surgical admissions in Bo and 46·0% of surgical admissions in Thyolo. Analysis of the procedure data showed that younger than 16-year-olds accounted for 7·0% of procedures in Bo and 4·5% of procedures in Thyolo, with 16-35-year-olds accounting for 65·6% of all procedures in Bo and 84·4% of all procedures in Thyolo. Men underwent 63% of all surgical procedures in Bo, but only 7·7% of surgical procedures in Thyolo. This discrepancy is explained by the high rate of maternal surgery in Thyolo, which was not present in Bo because this service was provided at the nearby MSF hospital. INTERPRETATION: Most people affected by disease requiring surgery are young adults. It would be expected that failure to provide surgical care could have long-term adverse effects on both individual and national wealth. FUNDING: The Sir Ratanji Dalal Scholarship from the Royal College of Surgeons of England.

Surgery and Obstetric Care are Highly Cost-Effective Interventions in a Sub-Saharan African District Hospital: A Three-Month Single-Institution Study of Surgical Costs and Outcomes.

BACKGROUND: The Lancet recently sponsored a commission examining the role of surgery in global health. There is a paucity of published information on the cost-effectiveness of surgery in low- and middle-income countries, a key metric in the prioritisation of limited resources. METHODS: All patients undergoing emergency laparotomy, elective and emergency inguinal hernia repair, elective and emergency caesarean section, amputation, fracture manipulation, or fracture fixation over a 3 months period in a single district African hospital were assessed. World Health Organisation global burden of disease (GBD) methodology was used to calculate the disability-adjusted life years (DALYs) saved for each patient (using global and local life expectancy). Fully loaded costs were calculated for each patient's care and providing the overall surgical service. Cost-effectiveness was calculated in year 2012 US$ per DALY saved for each procedure and overall. RESULTS: A total of 428 patients were included, with an overall cost-effectiveness of $10.70 per DALY averted. The cost-effectiveness of individual procedures (global life expectancy) was: Amputation­$17.66; Emergency caesarean section­$7.42; Elective caesarean section­$20.50; Emergency laparotomy­$8.62; Elective hernia repair­$15.26; Emergency hernia repair­$4.36; Fracture/dislocation reduction­$69.03; Fracture/dislocation fixation­$225.89. CONCLUSIONS: Surgery is a highly cost-effective healthcare measure in the setting of an African district hospital. The presented outcomes demonstrate that surgery is on a par with better-recognised and funded interventions such as HIV anti-retrovirals, malaria prevention and diarrhoea treatment. There are recognised limitations with the GBD methodology used here; however, this remains the best way to investigate the cost-effectiveness of health interventions. This study provides useful information on an, at present, under-studied field.

Essential surgery: the way forward.

INTRODUCTION: Very little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need. METHODS: Consensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability. RESULTS: Essential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care. CONCLUSION: A basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing "Essential Surgery" is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Cost-effectiveness of surgery in low- and middle-income countries: a systematic review.

BACKGROUND: There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions. METHODS: PubMed and EMBASE were searched using single and combinations of the search terms "disability adjusted life year" (DALY), "quality adjusted life year," "cost-effectiveness," and "surgery." Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies. RESULTS: Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06-$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88-$78.18), male circumcision (cost/DALY averted range US$7.38-$319.29), emergency cesarean section (cost/DALY averted range US$18-$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44-$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78-$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00-$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00). CONCLUSIONS: Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.

The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures.

OBJECTIVES: The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia. DESIGN: A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups. RESULTS: A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia. CONCLUSION: The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.

Guidelines for surgeons on establishing projects in low-income countries.

BACKGROUND: There is increasing interest by surgeons in high-income countries to support colleagues in low-income countries to improve the provision of surgical care, particularly in rural areas. Such interest may be demonstrated by single individuals, short-term surgical missions, or establishment of partnerships. Such altruistic efforts may cause problems unless properly planned and carried out. METHODS: We reviewed the available literature and consulted widely to establish consensus guidelines for any surgeon considering participating in an initiative to improve surgical care in low-income countries. RESULTS: A series of recommendations is presented. These include ensuring that projects are appropriate, that there is an emphasis on training local healthcare providers in all aspects of perioperative care, that outcomes are monitored, and that initiatives work with local and regional training programs. CONCLUSIONS: With adherence to these recommendations, we hope that future partnerships and missions can maximize their effectiveness and minimize the risks of potential harm done.

Snapshot of surgical activity in rural Ethiopia: is enough being done?

BACKGROUND: Surgical conditions are responsible for a significant burden of the disease prevalence in sub-Saharan Africa. However, there is a paucity of data surrounding the amount and availability of surgical care. Few surveys exist that document current rates of surgical activity in the low-income setting, and most figures rely on the country estimates. We aim to document accurately the rates of surgery at the district level. METHODS: We performed a retrospective survey of surgical activity in 10 hospitals in the Southern Nation and Nationalities Peoples' Region of Ethiopia using a standardized data collection form. We also performed structured interviews with hospital directors. RESULTS: Surgical output varied across the hospitals from 56 to 421 operations per year per 100,000 catchment population. The most commonly performed operation was cesarean section (29% of major procedures). Emergency surgery accounted for 55% of operations, with the most frequent emergency operation being cesarean section. The overall cesarean section rate was alarmingly low at 0.6%. There are only 76 health workers that are providing a surgical service to this sample population of 12.9 million people. CONCLUSIONS: The rates of surgery found here were very low, consistent with the huge shortage of health workers providing a surgical service. The low cesarean section rate indicates that there is a large unmet surgical disease burden at the population level, and more comprehensive surveys are required to investigate this further. The most important steps to tackle the problem of deficiencies in global surgery are to increase access to surgical care and the surgical workforce capacity.

Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa.

BACKGROUND: Little is known about the burden of surgical disease in rural sub-Saharan Africa, where district and rural hospitals are the main providers of care. The present study sought to analyze what is known about the met and unmet need of surgical disease. METHODS: The PubMed and EMBASE databases were searched for studies of surveys in rural areas, information on surgical admissions, and operations performed within rural and district hospitals. Data were extrapolated to calculate the amount of surgical disease per 100,000 population and the number of operations performed per 100,000 population. These extrapolations were used to estimate the total, the met, and the unmet need of surgical disease. RESULTS: The estimated overall incidence of nonfatal injury is at least 1,690/100,000 population per year. Morbidity as a result of injury is up to 190/100,000 population per year, and the annual mortality from injury is 53-92/100,000. District hospitals perform 6 fracture reductions (95% CI: 0.1-12)/100,000 population per year and 14 laparotomies (95% CI: 7-21)/100,000 per year. The incidence of peritonitis and bowel obstruction is unknown, although it may be as high as 1,364/100,000 population for the acute abdomen. The annual total need for inguinal hernia repair is estimated to be a minimum of 205/100,000 population. The average district hospital performs 30 hernia repairs (95% CI: 18-41)/100,000 population per year, leaving an unmet need of 175/100,000 population annually. CONCLUSIONS: District hospitals are not meeting the surgical needs of the populations they serve. Urgent intervention is required to build up their capacity, to train healthcare personnel in safe surgery and anesthesia, and to overcome obstacles to timely emergency care.

High quality care following orthopaedic injury in Zambia: A qualitative, patient-centred study.

BACKGROUND: Injuries are a significant cause of mortality and morbidity, particular in low- and middle-income countries (LMICs). While there is a focus on increasing injury care capacity, less attention is given to assessing, improving, and understanding the quality of care provided, especially from a patient perspective. This study therefore aims to understand what patients from a Zambian orthopaedic ward believe good quality care to be, to identify its key components, and contribute to better understanding what patients believe local healthcare priorities could be. METHODS: Patients admitted to the orthopaedic ward of a Zambian tertiary care hospital were invited to take part in-depth face-to-face interviews. Interviews were continued until thematic saturation was achieved. Interviews were recorded and transcribed. Analysis was done using an inductive grounded theory approach. RESULTS: Of 13 patients approached, 12 consented to take part. Analysis of the themes from the transcripts led to the emergence of four core categories of quality care which are important to the patient: i) restoring the patient to normality (category: 'restoring normality'), ii) establishing trust between patients and providers ('trusting the provider'), iii) respecting the patient and allowing them to maintain autonomy ('autonomy and respect') iv) finding ways for patients to enjoy their time in the hospital ('enjoying life'). From these results, a patient perspective theory of quality care emerged. This theory posits the idea that high-quality care in this context needs to fulfil these four core categories. Additionally, these core categories were ranked on significance and priority. CONCLUSION: The hierarchy of core categories could help to identify areas to improve care quality in this setting. Not only has this study helped to determine local priorities for achieving high-quality care but can encourage others to test injured patient perceptions of care quality in comparable settings.

Systematic review of barriers to surgical care in low-income and middle-income countries.

BACKGROUND: There is increasing evidence that lack of facilities, equipment, and expertise in district hospitals across many low- and middle-income countries constitutes a major barrier to accessing surgical care. However, what is less clear, is the extent to which people perceive barriers when trying to access surgical care. METHODS: PubMed and EMBASE were searched using key words ("access" and "surgery," "barrier" and "surgery," "barrier" and "access"), MeSH headings ("health services availability," "developing countries," "rural population"), and the subject heading "health care access." Articles were included if they were qualitative and applied to illnesses where the treatment is primarily surgical. RESULTS: Key barriers included difficulty accessing surgical services due to distance, poor roads, and lack of suitable transport; lack of local resources and expertise; direct and indirect costs related to surgical care; and fear of undergoing surgery and anesthesia. CONCLUSIONS: The significance of cultural, financial, and structural barriers pertinent to surgery and their role in wider health care issues are discussed. Immediate action to improve financial and geographic accessibility along with investment in district hospitals is likely to make a significant impact on overcoming access and barrier issues. Further research is needed to identify issues that need to be addressed to close the gap between the care needed and that provided.

Current Use of EEN in Pre-Operative Optimisation in Crohn's Disease.

Despite the increasing array of medications available for the treatment of Crohn's disease and a focus on mucosal healing, approximately 35% of patients with Crohn's disease undergo bowel surgery at some stage. The importance of nutritional optimisation before Crohn's surgery is well-highlighted by surgical, nutritional, and gastroenterological societies with the aim of reducing complications and enhancing recovery. Surgical procedures are frequently undertaken when other treatment options have been unsuccessful, and, thus, patients may have lost weight and/or required steroids, and are therefore at higher risk of post-operative complications. EEN is used extensively in the paediatric population to induce remission, but is not routinely used in the induction of remission of adult Crohn's disease or in pre-operative optimisation. Large prospective studies regarding the role of pre-operative EEN are lacking. In this review, we evaluate the current literature on the use of EEN in pre-operative settings and its impact on patient outcomes.

Living with a hernia: A qualitative study of patient experience of abdominal wall hernias in Ndola, Zambia.

Despite hernias being one of the most common surgical problems in low and middle income countries, very little is known about the impact that having a hernia has on the quality of life of patients in these settings. We performed a pilot study to understand how living with a hernia impacts on the quality of life. Twelve semistructured interviews were performed. A number of themes were identified. These demonstrated the significant impact on physical health, ability to work, psychological health and social relationships. Further work is required to better understand the patient perspective and ensure that hernia operations improve quality of life in these settings.

The role of exclusive enteral nutrition in the pre-operative optimisation of adult patients with Crohn's disease. A systematic review.

AIM: To conduct a systematic review in order to bring together the current knowledge about the use of exclusive enteral nutrition (EEN) in the pre-operative optimisation of adult patients with Crohn's disease undergoing intestinal resection. METHODS: We searched Pubmed, Cochrane Library, ClinicalTrials.gov and the EU clinical trial register to identify experimental and observational studies on the effect of pre-operative EEN on nutritional and clinical outcomes of patients undergoing surgery. Methodological quality was assessed using the Downs and Black checklist. RESULTS: Seven studies were included in the final analysis. Of these 5 were retrospective cohort studies and 2 were retrospective case-control studies. There were 4 ongoing RCTs, however they have not reported data to analyse. Overall the 7 retrospective studies, support that with EEN; body mass index (BMI) does not increase, C-reactive protein decreases (CRP), albumin usually increases and haemoglobin does not significantly change. There were fewer infectious complications in patients who had taken EEN. There was a trend towards fewer stomas but only one of the studies was powered enough to demonstrate significance. There was no significant difference in recurrence rates of Crohn's disease at 12 months in any of the studies. Quality of the studies were either medium or poor. CONCLUSION: The current data on the use of EEN in pre-operative optimisation is of poor quality and underpowered to demonstrate significance. Randomised controlled trials are needed to demonstrate whether or not EEN can improve outcomes and reduce stoma formation in adult patients undergoing intestinal resection.

Does exclusive enteral nutrition reduce the rate of stoma formation in patients requiring ileocolic resection for Crohn's disease? A single center experience.

BACKGROUND AND AIM: Nutrition has a role in achieving and maintaining remission in Crohn's disease. The aim of this study was to determine the impact of a strategy of steroid-avoidance and Exclusive Enteral Nutrition (EEN) for 6 weeks (with a minimum of 4 weeks) in adult patients presenting with acute small bowel Crohn's disease followed by an interval ileocolic resection 4-6 weeks later. METHODS: Retrospective review of prospectively collected data. Patients were administered exclusive enteral nutrition (EEN) for at least 4 weeks prior to surgery. RESULTS: 24 EEN patients included. Median age of 45 (range 23-73). 17/24 patients tolerated Modulen for at least 4 weeks, 5 were switched to Ensures and 2 a liquid diet. 6 patients underwent surgery earlier than planned. Prior to surgery, there was no change in the mean BMI, albumin increased from a mean of 36 g/L (range 25-43) to 40 g/L (range 30-48). CRP levels decreased by a mean of 35.8 mg/L overall. 19 (79%) of operations were performed laparoscopically. 6 of the cases were re-do operations. All but 3 patients avoided a stoma at the time of the original operation. There were 5 post-operative complications: 1 anastomotic leak in a patient with a BMI of 42, 3 cases of paralytic ileus and 2 wound infections. Median length of stay was 7 days (range 3-76 days). Only 2 patients were readmitted within the 30-day post-operative period. CONCLUSION: The pre-operative use of EEN appears to avoid unnecessary stoma formation with acceptable clinical outcomes.

What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure.

OBJECTIVES: To measure the financial burden associated with accessing surgical care in Sierra Leone. DESIGN: A cross-sectional survey conducted with patients at the time of discharge from tertiary-level care. This captured demographics, yearly household expenditure, direct medical, direct non-medical and indirect costs for surgical care, and summary household assets. Missing data were imputed. SETTING: The main tertiary-level hospital in Freetown, Sierra Leone. PARTICIPANTS: 335 surgical patients under the care of the hospital surgical team receiving operative or non-operative surgical care on the surgical wards. OUTCOME MEASURES: Rates of catastrophic expenditure (a cost >10% of annual expenditure), impoverishment (being pushed into, or further into, poverty as a result of surgical care costs), amount of out-of-pocket (OOP) costs and means used to meet these costs were derived. RESULTS: Of 335 patients interviewed, 39% were female and 80% were urban dwellers. Median yearly household expenditure was US$3569. Mean OOP costs were US$243, of which a mean of US$24 (10%) was spent prehospital. Of costs incurred during the hospital admission, direct medical costs were US$138 (63%) and US$34 (16%) were direct non-medical costs. US$46 (21%) were indirect costs. Catastrophic expenditure affected 18% of those interviewed. Concerning impoverishment, 45% of patients were already below the national poverty line prior to admission, and 9% of those who were not were pushed below the poverty line following payment for surgical care. 84% of patients used household savings to meet OOP costs. Only 2% (six patients) had health insurance. CONCLUSION: Obtaining surgical care has substantial economic impacts on households that pushes them into poverty or further into poverty. The much-needed scaling up of surgical care needs to be accompanied by financial risk protection.

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

BACKGROUND: Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com). METHODS: We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. RESULTS: 31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs. CONCLUSION: Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.