Neurosurgical bills in Nigeria push vulnerable households deeper into poverty

In Nigeria, a single neurosurgical admission can cost a household more than a year of income — and almost every family in a new study was already poor before the first bill arrived. Researchers tracking 99 neurosurgical patients at the University College Hospital (UCH) in Ibadan found that the median out-of-pocket cost of care reached ₦1,410,787, roughly $922, in a country where more than half of the households studied reported total monthly expenditures below ₦250,000, about $163. The median household income in the cohort was just ₦100,000 per month, meaning a typical admission cost the equivalent of more than 14 months of earnings. The study, published in Frontiers in Neurology, is the first comprehensive analysis of the full patient-borne cost of neurosurgical hospitalization in Nigeria, capturing everything from surgical fees and intensive care to bus fares, lost wages, and caregiver burdens. Its central finding is stark: neurosurgical care in Nigeria’s public hospitals is financed almost entirely by households, and the financial shock does not merely push families into poverty — it deepens poverty that already exists.

To quantify this burden, the team — led by researchers from the University of Ibadan, University College Hospital, and Duke Global Neurosurgery and Neurology — conducted a prospective mixed-methods cohort study between January and August 2024. Trained research assistants administered structured questionnaires hosted on the Qualtrics platform at three time points: within 24 hours of admission, within 48 hours of discharge, and two to four weeks after discharge through in-person home visits or phone calls. Because many neurosurgical patients were children, comatose, or physically unable to respond, caregivers served as proxy respondents for 82.8 percent of the surveys. The questionnaires captured three cost categories in detail. Direct medical costs included imaging, laboratory tests, medications, consumables, procedures, surgery, anesthesia, intensive care, rehabilitation, and medical devices. Direct non-medical costs covered patient and caregiver transportation, food, and lodging during hospitalization and transit. Indirect costs were estimated from lost income: the number of workdays missed by patients and caregivers was multiplied by reported daily earnings. All expenditures were recorded in Nigerian Naira and converted to US dollars at an exchange rate of roughly ₦1,531 per dollar.

The cohort reflected the clinical spectrum of a busy West African neurosurgical unit. Traumatic brain injury was the most common diagnosis, accounting for 48 percent of admissions, followed by brain tumors at 20 percent and hydrocephalus at 8.2 percent. Patients were overwhelmingly male — 74.7 percent — with a median age of 33 years and a median household size of five. The median hospital stay was 14 days, though the duration varied sharply by diagnosis: traumatic brain injury patients stayed a median of 10 days, brain tumor patients 20 days, and hydrocephalus patients 13.5 days, with longer stays typically linked to intensive care needs or rehabilitation. Geographically, 73.7 percent of patients resided in Oyo State, where UCH is located, but 26.3 percent traveled more than 50 kilometers for care, often across multiple transport legs. Although 78.8 percent of respondents arrived by referral, the distances involved foreshadowed one of the study’s secondary findings: substantial indirect costs that accumulate even before a patient reaches the operating theater.

The financial anatomy of a neurosurgical admission reveals where the money goes. Direct medical costs dominated, with a median of ₦969,000 ($633) per patient. Among patients undergoing surgery, procedure fees carried a median price tag of ₦280,000 ($183), while medications added ₦150,000 ($98) and hospital consumables ₦60,000 ($39). These figures reflect systemic gaps in neurosurgical infrastructure, equipment, and critical care capacity previously documented in Nigeria and Uganda, gaps that force patients to procure items that better-financed systems would supply. Direct non-medical costs were also substantial, with a median of ₦202,000 ($132) for transportation, meals, and in-hospital necessities such as toiletries. Indirect costs from lost income added a median of ₦141,639 ($93). Taken together, the median total out-of-pocket expenditure per patient was ₦1,410,787 ($922), with an interquartile range stretching from ₦815,951 to ₦2,442,176 — roughly $533 to $1,596. Patients who required intensive care or advanced devices tended to report the highest bills, and the study notes that these costs far exceed what most other in-hospital healthcare costs are, even in advanced health systems.

How households raised this money tells its own story of financial distress. Ninety-two percent of participants drew on personal or household savings, and 51.5 percent borrowed money, with a median loan of ₦700,000 ($457). Among borrowers, 74.5 percent incurred interest, adding a median of ₦100,000 ($65) in charges. Nine percent sold assets such as land or equipment to fund care. Financial support flowed from extended networks: 86.9 percent received help from others, mostly family members, followed by religious organizations and friends, though only 4 percent received charitable assistance. Households needed a median of five days to raise the necessary funds — five days in which treatment could stall. The human toll extended beyond money. Patients missed a median of 19 household or childcare days, while caregivers missed a median of 20 workdays, and 86 percent of those missed days went uncompensated. Nearly 90 percent of patients relied on relatives to handle childcare and household chores during hospitalization. These coping mechanisms — borrowing, debt, asset sales, and uncompensated labor — mirror patterns documented elsewhere in low- and middle-income countries, including a Ugandan study in which 53 percent of households borrowed money, 21 percent sold possessions, and 17 percent lost employment due to hospitalization.

To measure financial catastrophe, the researchers applied two established thresholds. Catastrophic health expenditure was defined as out-of-pocket spending exceeding 10 percent of total household income, consistent with the Sustainable Development Goal 3.8.2 framework, or at least 40 percent of household capacity to pay, following the World Health Organization approach; a household facing either threshold was classified as experiencing catastrophic spending. Impoverishment was assessed against the World Bank’s international poverty line of $3 per person per day for low- and middle-income countries, equivalent to ₦4,593. Among the 67 households with sufficient baseline economic data, 97 percent were already below the poverty threshold before any healthcare payment. Both households initially above the threshold crossed below it after out-of-pocket expenditure, corresponding to incident impoverishment in 3 percent of the analyzable cohort. The more striking result was the deepening of pre-existing poverty: the mean daily per-capita poverty gap — the shortfall below the poverty line — surged from ₦3,296 before payment to ₦30,350 afterward, a nearly tenfold widening of deprivation.

The findings land in a health financing context that leaves households dangerously exposed. Although Nigeria operates a National Health Insurance Scheme, it covers fewer than 5 percent of the population, primarily formal public-sector workers who represent less than 10 percent of the national population. In this cohort, only 12.1 percent of patients had any insurance — all through the national scheme — and among those, the median proportion of costs covered was just 30 percent. Nationally, out-of-pocket payments account for approximately 74 percent of health spending, and projections from the Institute for Health Metrics and Evaluation suggest the share will still be 71.2 percent in 2025. The financial toll of neurosurgical care also appears disproportionate compared with other conditions: comparable Nigerian studies of patients with non-communicable diseases reported catastrophic expenditure rates between 21.7 and 46.8 percent and impoverishment rates between 24.3 and 30.9 percent. The authors caution that the apparent gap between the cohort’s median monthly income (₦100,000) and median routine expenditures (₦155,000) reflects independently calculated medians rather than a uniform household deficit, and that underreporting of income — the denominator for the 10 percent threshold — could overestimate catastrophic spending on that measure.

From a policy standpoint, the study documents how severely constrained Nigeria’s public financing has become. In 2022, 76.1 percent of all healthcare expenditure was paid out-of-pocket by households, while domestic general government health expenditure accounted for only 0.62 percent of gross domestic product and 14.5 percent of total health expenditure. Government health spending per capita stood at just $13 — far below the $86 per capita minimum the World Health Organization suggests for delivering essential health services in low-income countries, and well under the sub-Saharan African average of approximately $34 in the same period. The authors argue that advancing universal health coverage requires strengthening prepaid, pooled financing mechanisms and government commitment to protecting vulnerable populations. For Nigeria, they propose scaling up national insurance enrollment beyond the formal sector and explicitly including expensive surgical services; targeted subsidies for high-cost neurosurgical interventions, including coverage of direct non-medical and indirect expenses such as patient transportation; and decentralizing neurosurgical services while improving referral pathways and coordination to reduce travel costs and care delays that worsen outcomes and extend hospital stays.

The study carries limitations the authors acknowledge. It was conducted at a single high-volume national referral center, so costs might differ in smaller hospitals or private clinics across Nigeria’s diverse geopolitical regions. The observational design cannot prove causality or capture unmeasured factors, and the most critically ill patients were likely under-sampled despite caregiver proxies, possibly underestimating costs for that subgroup. Recall bias is possible, though mitigated by the multiple survey points, and self-reported household income and expenditure may be subject to reporting error, particularly in households with variable or informal income sources. Future research, the team suggests, should follow households longitudinally to assess long-term financial recovery. Even so, the baseline data are unambiguous. Almost every household in the cohort faced catastrophic health spending, and out-of-pocket expenditure substantially deepened pre-existing poverty among already vulnerable families. As Nigeria strives toward universal health coverage, the authors conclude, ensuring equitable access to life-saving neurosurgical interventions must become a priority — because without reform, vulnerable households will continue to bear the hidden cost of neurosurgical care.

Subject of Research: Health economics of neurosurgical care in Nigeria

Article Title: Socioeconomic analysis of the in-hospital neurosurgical continuum of care for patients in Nigeria

Article References: Adeleye, A. O., Bakesiga, A., Agboola, O. O., Fernandez Perez, C., Antwi, P., Mukumbya, B., Agwu, C., Ozobu, I., Monawar, M.-Y., Beck, C. M., Evans, M., Salami, K. K., Orimadegun, A. E., Ogbuoji, O., Haglund, M. M., & Ukachukwu, A.-E. K. (2026). Socioeconomic analysis of the in-hospital neurosurgical continuum of care for patients in Nigeria. Frontiers in Neurology, 17, Article 1897423. https://doi.org/10.3389/fneur.2026.1897423

Image Credits: AI Generated

DOI: 10.3389/fneur.2026.1897423

Keywords: neurosurgery, Nigeria, out-of-pocket expenditure, catastrophic health expenditure, health financing, universal health coverage, traumatic brain injury, poverty, Socioeconomic, analysis, in-hospital, neurosurgical