Estimating the economic burden of cholera: evidence from Nepal and Mozambique

Cholera remains a major public health concern in resource-limited settings, causing an estimated 4 million cases and approximately 143,000 deaths each year. While its clinical and epidemiological impact is well recognized, data remain limited on the economic burden of cholera. This study estimated the economic burden of cholera from patient and provider perspectives in Nepal and Mozambique. This prospective cost-of-illness (COI) study was embedded within the Enhanced Cholera Control projects in Nepal (ECHO-N) and Mozambique (ECHO-M). In Nepal, data were collected from 38 health facilities in the Kathmandu Valley and Kailali District between 2021 and 2024. In Mozambique, data were collected from cholera treatment centers in five provinces during the epidemic period and Nampula province during the endemic period (2023–2025). All eligible cholera cases meeting country-specific case definitions were consecutively enrolled. Patient interviews captured direct medical, direct non-medical and indirect costs. Healthcare provider costs were estimated using facility records in both countries with hospital-specific revenue-to-cost ratio (RCC) adjustment applied in Nepal. Costs are reported in 2023 US$ with 95% bootstrapped confidence intervals. This study analyzed 273 cases in Nepal and 252 in Mozambique. Cost patterns differed between the two study settings, reflecting differences in healthcare utilization, financing mechanisms, and service delivery models. During epidemic periods, the mean cost per episode was higher in Nepal (US$113.5; 95% CI: 93.3–133.7) than in Mozambique (US$54.1; 95% CI: 50.8–57.0). In contrast, during the endemic periods, the mean cost per episode was higher in Mozambique (US$72.5; 95% CI: 65.0–80.5) than in Nepal (US$63.6; 95% CI: 48.4–78.7). After adjustment for purchasing power parity (PPP), the mean cost per episode was I$346.9 in Nepal and I$155.3 in Mozambique. In Mozambique, all patients received government subsidies for cholera treatment. In Nepal, 89.5% of enrolled participants reported making out-of-pocket payments for cholera treatment during endemic period, while out-of-pocket payments accounted for 92.6–96.6% of total direct medical costs (Figs. 2 and 4B). The proportion of household income represented by cholera-related costs was higher in Mozambique than in Nepal and varied across income groups. Cholera imposes significant economic costs. In Nepal, substantial out-of-pocket expenditures placed a considerable financial burden on households, whereas in Mozambique, government subsidies covered most direct medical costs. Cost patterns differed between settings, highlighting the influence of healthcare utilization, financing mechanisms, and service delivery. These findings support context-specific financing strategies and consideration of preventive investments to reduce the economic burden of cholera.