Cost-Effectiveness of Epilepsy Surgery in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

This review aim to analyse the cost-effectiveness of epilepsy surgery for drug-resistant epilepsy in low- and middle-income countries (LMICs). Medline, PubMed, Scopus, and Cochrane Library were searched without restrictions. Studies from World Bank-classified LMICs reporting original cost and/o cost-effectiveness data for epilepsy surgery were included. Two reviewers independently screened records, extracted data, and assessed risk of bias. Pooled seizure freedom (Engel Class I ≥ 12 months) and cost differences were analysed using random-effects Hartung-Knapp models in RevMan app. PRISMA 2020 guidelines were followed. From 20,948 records, 11 studies (2,684 patients) from seven LMICs were included. Direct surgical costs ranged from US$500 to US$14,894 (2025 USD). The pooled mean cost difference (surgery vs. medical management) was US$1,290 (p = 0.07; I²=100%). Surgery showed markedly superior efficacy, with pooled odds ratio for Engel Class I seizure freedom (≥ 12 months) of 22.51 (p < 0.00001; I²=9%), corresponding to 52–79.4% freedom rates in surgical groups versus 7.7–16% in medical groups. Two studies reported ICERs of approximately US$1,236 and US$26,564 per QALY gained. Epilepsy surgery in LMICs offers over 20-fold higher odds of seizure freedom at modest costs and cost-effective, supporting expansion of accessible surgical programs to reduce the treatment gap in resource-limited settings.