Assessing the Economic Impact of Implementing Enhanced Recovery After Surgery Practices in Ethiopia: A Cost-Effectiveness Analysis

BACKGROUND: The global demand for surgical care continues to rise, yet access and affordability remain disproportionately limited in low- and middle-income countries (LMICs). Postoperative complications significantly drive surgical costs, with even minor complications doubling expenditures. While Enhanced Recovery After Surgery (ERAS) protocols have reduced costs and improved outcomes in high-income countries, their economic impact in LMICs remains underexplored. This study evaluates the cost implications of implementing selected postoperative ERAS components in Ethiopia. METHODS: We conducted cost-effectiveness analyses alongside a cluster-randomized trial evaluating postoperative ERAS protocol implementation across 10 hospitals in Ethiopia among patients undergoing major abdominal surgery, including cesarean delivery and emergency laparotomy. Cost data were extracted from hospital financial records, procurement logs, and the National Perioperative Quality Improvement Network (NaPQIN) clinical registry. Capital and recurrent costs were estimated, and complication-related expenses were stratified using the Clavien–Dindo classification. Inpatient costs were calculated by multiplying the mean length of stay by the unit bed cost. RESULTS: Implementation of the ERAS intervention was associated with reduced complication-related costs and shorter postoperative hospital stay. Training costs totaled $5651.60 across five hospitals (intervention arm). Additional per-patient implementation costs during routine ERAS delivery were minimal, averaging $3.21 per patient for ERAS-related consumables, while educational materials required a one-time institutional printing cost, equivalent to $2.80 per patient when amortized across participants. ERAS reduced the cost of managing severe complications by $325.60 per patient ( P = .04) and shortened postoperative stay from 8.10 to 5.64 days. The intervention improved clinical outcomes while reducing costs compared with routine care. The incremental cost-effectiveness analysis indicated savings of $3516 per complication prevented and $35.50 per hospital day avoided. CONCLUSION: These findings suggest that simplified ERAS interventions can deliver meaningful cost savings and improved outcomes in Ethiopian surgical facilities and may be feasible in comparable low-resource settings. The results support integration of ERAS into national surgical strategies, emphasizing its feasibility, affordability, and potential to enhance surgical care efficiency without major capital investment.