Out-of-pocket expenditure for neurosurgical care in Uganda: quantifying financial catastrophe and identifying policy pathways to universal health coverage

Background Out-of-pocket payments remain the primary source of healthcare financing in many low- and middle-income countries, frequently resulting in catastrophic and impoverishing expenditures. Neurosurgical care is particularly costly due to substantial direct and indirect expenses borne by patients and caregivers, typically with little or no financial protection. This study quantifies these OOP costs, estimates the prevalence of catastrophic and impoverishing health expenditures, and examines their socioeconomic impact to inform equitable surgical financing policies. Methods We conducted a cross-sectional study at the two main Ugandan public neurosurgical centers - Mulago National Referral Hospital, Kampala, and Mbarara Regional Referral Hospital, Mbarara. Consecutive patients with confirmed neurosurgical diagnoses were enrolled at discharge or within two weeks post-discharge. Structured surveys captured sociodemographic, clinical and cost data. OOP health payments were direct medical plus direct non-medical payments; total economic burden added indirect costs. Catastrophic health expenditure (CHE) was OOP payments exceeding 10% of annual household consumption expenditure (World Bank) or 40% of it after food costs (WHO). Impoverishment was the change in poverty headcount against the $3.00/person/day line (2021 purchasing power parity). Data was analyzed using R 4.4.2. Ethical approval was obtained from Ugandan and Duke University institutional review boards. Results Seventy-six respondents (mean age 39 years; 65% male) were enrolled, mostly at discharge (67%). Traumatic brain injury was the leading diagnosis (65.8%). No participant had health insurance. Median OOP health payments were UGX1.23 million [$351] (direct medical UGX880,000 [$251]; direct non-medical UGX359,000 [$103]); adding indirect costs of UGX125,000 [$36] gave a median total economic burden of UGX1.38 million [$394]. OOP payments exceeded 10% of annual household expenditure in 76.0% of households (95% CI 65.2 to 84.2) and 40% of capacity to pay in 41.2% (30.3 to 53.0). The poverty headcount rose from 50.7 to 62.7% (net impoverishment 12.0%). Conclusion Neurosurgical care in Uganda imposes a substantial economic burden on households: three quarters incurred catastrophic expenditure, and one in eight of those not already poor was pushed below the poverty line. These findings highlight the urgent need for financial risk protection, targeted subsidies, and health system reforms to ensure equitable and sustainable access to neurosurgical services.