Clinical efficacy and cost‐effectiveness of epilepsy surgery in low‐ and middle‐income countries: A systematic review and meta‐analysis
Muhamad Thohar Arifin, Firman Pribadi, Nurettin ÖnerAbstract
Objective
To synthesize evidence on clinical outcomes, direct surgical costs, and cost‐effectiveness of resective epilepsy surgery for drug‐resistant epilepsy in low‐ and middle‐income countries (LMICs).
Methods
MEDLINE, PubMed, Scopus, and the Cochrane Library were searched through May 17, 2026. Original studies from World Bank‐classified LMICs reporting clinical outcomes and/or direct costs of resective surgery were included. Engel Class I favorable seizure outcomes at ≥ 12 months were pooled using a random‐effects model with the Hartung‐Knapp‐Sidik‐Jonkman variance estimator, while cost data were synthesized narratively because of heterogeneity.
Results
Ten studies involving 2587 patients from seven LMICs were included from 20 948 identified records. Direct surgical costs ranged from US$500 in Iran to US$14894 in Colombia in 2025‐adjusted dollars, equivalent to 9.4%–271% of national GDP per capita. Across four comparative observational studies, surgery was associated with higher odds of achieving Engel Class I favorable seizure outcomes than continued medical management (pooled OR 22.51; 95% CI 11.17–45.38; p < 0.00001; I 2 = 9%). Favorable outcomes occurred in 52%–79.4% of surgical patients versus 7.7%–16% of medically managed patients. Two Thai studies reported conflicting cost‐effectiveness results relative to the national willingness‐to‐pay threshold.
Significance
Resective epilepsy surgery was associated with substantially better seizure outcomes in appropriately selected patients in LMICs. However, the observational clinical evidence and heterogeneous, limited economic data preclude causal interpretation and broad conclusions on cost‐effectiveness across settings.
Plain Language Summary
Epilepsy surgery can help people whose seizures remain uncontrolled despite medication, but access to surgery is limited in low‐ and middle‐income countries. This review examined 10 studies involving 2587 patients from seven countries. Patients who underwent surgery were more likely to experience favorable seizure outcomes than those receiving medication alone. Surgical costs varied widely between countries, and evidence about whether surgery provides good value for money remains limited and inconsistent. These findings suggest that expanding access to epilepsy surgery may benefit appropriately selected patients, while further research is needed to understand its affordability and long‐term economic value.