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CC BY 4.0 · Indian J Med Paediatr Oncol
DOI: 10.1055/s-0045-1815734
Review Article

Economic Burden of Pediatric Oncology Care in Developing Countries: A Systematic Review

Authors

  • Sri Mulatsih 

    1   Division of Hemato-Oncology, Department of Child Health, Dr. Sardjito General Hospital, Yogyakarta, Indonesia

  • Clements Nicodhemus Garuda Nagara

    2   PDHI Yogyakarta Islamic Hospital, Yogyakarta, Indonesia

  • Barlaam Bagus Purwaka

    3   Faculty of Medicine, Universitas Kristen Duta Wacana, Yogyakarta, Indonesia

  • Devanya Tiara Kirani

    3   Faculty of Medicine, Universitas Kristen Duta Wacana, Yogyakarta, Indonesia

  • Felicia Dara Puspitaning Pandita

    3   Faculty of Medicine, Universitas Kristen Duta Wacana, Yogyakarta, Indonesia

  • Devie Kristiani

    4   Division of Hemato-Oncology, Department of Child Health, Bethesda Hospital, Yogyakarta, Indonesia

Funding None.
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Abstract

Introduction

Pediatric oncology care in developing countries poses considerable economic challenges due to high direct medical, direct nonmedical, and indirect costs related to childhood cancer treatment. Families often face catastrophic financial burdens, which impact treatment adherence and outcomes.

Objectives

This article summarizes and analyzes the economic burden of pediatric oncology care on families and health systems in developing countries.

Materials and Methods

A systematic review of studies from low- and middle-income countries was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, utilizing six major databases (PubMed, ScienceDirect, Cochrane Library, Lippincott Home, Sage Journals, and Google Scholar) to identify relevant studies published from 2015 until 2025. The Population, Intervention, Comparison, and Outcomes (PICO) framework was applied alongside specific keywords to select studies relevant to the research topic.

Results

Findings show that families bear substantial out-of-pocket expenses, including treatment, transportation, accommodation, and lost income, often exceeding their financial capacity. Health financing systems are often inadequate, leading to high treatment abandonment rates. Access to insurance and financial support programs reduces economic hardship and improved treatment continuity. Cost-effectiveness analyses demonstrate that investing in pediatric oncology care yields substantial health and economic benefits, with the cost per disability-adjusted life year averted typically falling below one times the country's gross domestic product per capita.

Conclusion

The economic burden of pediatric oncology care in developing countries is profound and multidimensional, necessitating strengthened health financing, expanded insurance coverage, and social support programs to improve access and reduce financial toxicity for affected families.


Keywords

economic burden - pediatric oncology care - developing countries - children - health systems

Introduction

Cancer remains one of the leading causes of morbidity and mortality among children worldwide. In developing countries, where approximately 90% of the global pediatric population resides, the epidemiology of childhood cancer reveals a notable burden with distinct patterns in incidence and cancer types. Common pediatric malignancies in these regions include leukemias (particularly acute lymphoblastic leukemia [ALL]), lymphomas (such as Burkitt lymphoma), nephroblastoma (Wilms tumor), retinoblastoma, and various central nervous system tumors.[1] Despite notable advances in pediatric oncology in high-income countries (HICs) leading to survival rates exceeding 80%, survival in low- and middle-income countries (LMICs) remains markedly low, ranging from 10 to 60%. This disparity stems from multiple factors, including lack of resources, late-stage diagnosis, treatment abandonment, and insufficient health care infrastructure.[2] [3]

The delivery of pediatric oncology care in developing countries is fraught with intricate difficulties, including resource limitations in health care infrastructure, shortage of trained personnel, restricted availability of essential medicines, and insufficient health financing mechanisms.[4] [5] Effective pediatric oncology care is crucial not only for saving young lives but also for reducing long-term disability and improving quality of life. However, pediatric oncology care in developing countries imposes substantial economic challenges on affected families and health systems.[6]

This economic burden comprises several cost categories. Direct medical costs include expenditures for diagnostics, chemotherapy, surgery, hospitalization, supportive therapies, and personnel.[7] Direct nonmedical costs encompass transportation, accommodation, and food expenses for patients and caregivers during treatment periods.[8] [9] Indirect costs involve productivity losses due to caregiver absenteeism from work, psychosocial stress, and broader social implications affecting household income and economic stability.[10] In many developing countries, these costs contribute to catastrophic health expenditures and are a major reason for treatment abandonment and delay.[11] Families confront catastrophic out-of- pocket (OOP) expenses encompassing direct medical costs, such as diagnostics, chemotherapy, hospital stays, and supportive care, alongside direct nonmedical costs like transportation, accommodation, and meals. Additionally, indirect costs including lost parental income, productivity losses, and psychosocial impacts significantly exacerbate the financial strain. These economic burdens often lead to treatment discontinuation and adversely influence clinical outcomes.[12]

Compared with HICs, where comprehensive health insurance systems and government subsidies often mitigate the financial impact on families, developing countries exhibit substantial disparities in health care financing for pediatric oncology. Limited insurance coverage, OOP expenses, and inadequate social support result in inequitable access to care and poorer health outcomes.[13] [14] These disparities underscore the pressing need for health policy reforms that incorporate sustainable financing models to enhance access and reduce the economic barriers that impede effective childhood cancer treatment. The current systematic review aims to synthesize available evidence on the economic burden associated with pediatric oncology care in developing countries. By assessing diverse studies of direct and indirect costs, financing mechanisms, and policy implications, this review seeks to highlight research gaps, inform resource allocation, and support the development of equitable health systems capable of delivering cost-effective pediatric oncology care. Moreover, the findings aim to assist policymakers, health care providers, and international stakeholders in formulating strategies that reduce financial toxicity for families, improve treatment adherence, and ultimately enhance survival rates for children suffering from cancer in resource-limited settings.


Materials and Methods

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, as established by Cochrane Reviews. An extensive search was performed across six medical-scientific databases (PubMed, ScienceDirect, Cochrane Library, Lippincott Home, Sage Journals, and Google Scholar) for studies published between January 1, 2015 and December 31, 2025. The Population, Intervention, Comparison, and Outcomes (PICO) framework ([Table 1]) guided the search strategy, which utilized Medical Subject Heading terms and keywords: (“pediatric oncology”) AND (“cost analysis OR “cost-effectiveness analysis” OR “economic evaluation” OR “economic burden” OR “financial toxicity”) AND (“low- and middle-income countries” OR “developing countries” OR “LMICs”). Inclusion criteria were quantitative, qualitative, or mixed-methods studies reporting on the economic burden of childhood cancer care in children diagnosed with cancer in developing countries, available in full text and open access. Exclusion criteria were studies not reporting on economic burden, case reports, expert opinions, review articles, and studies conducted in HICs.

Table 1

Population, Intervention, Comparison, and Outcomes (PICO) search strategy

Population (P)

Children diagnosed with cancer in developing countries, particularly LMICs

Intervention (I)

Assessment of economic burden (direct and indirect medical costs)

Comparison (C)

Economic burden/impact, geographic location, type of childhood cancer

Outcomes (O)

Quantification of financial costs and economic impact at the household, national, or health system level

Abbreviation: LMICs, low- and middle-income countries.


The study selection process involved two independent reviewers (S.M. and C.N.G.N.) who screened titles and abstracts. Discrepancies were resolved through discussion with a third reviewer (B.B.P.). Full texts of potentially eligible studies were then assessed independently by the same two reviewers. The final set of included studies underwent a qualitative assessment using the Joanna Briggs Institute (JBI) appraisal checklist for economic evaluations to evaluate methodological rigor ([Table 2]).

Table 2

Overview of study characteristics for the final 17 records

Authors

Study characteristics

Type of costs

Saxton et al[1]

(2022)

Country: Tanzania

Type of cancer: lymphomas, leukemia, renal tumors, retinoblastoma, and hepatic tumor

Direct medical costs: laboratory tests, medications, imaging, hospital stays, clinic visits, surgeries, and surgical consumables

Direct nonmedical costs: travel costs for the patient and a caregiver to and from the hospital

Indirect costs: not explained

Agulnik et al[28] (2019)

Country: Guatemala

Type of cancer: all cancer types

Direct medical costs: medications (chemotherapy and supportive care drugs), medical and surgical materials, oxygen and respiratory therapy, laboratory tests, radiographic imaging, blood bank use, pathology requisitions, radiotherapy use, diet and nutritional supplementation (enteral and parenteral), personnel costs (nurses, doctors, etc.)

Direct nonmedical costs: transportation to and from the hospital, accommodation for family members, food and daily living expenses during hospitalization

Indirect costs: not explained

Srinivasan et al[7] (2024)

Country: India

Type of cancer: childhood acute myeloid leukemia

Direct medical costs: personnel costs (medical and nonmedical staff), inpatient and ICU stays, outpatient visits (cost for clinic visits, ambulatory chemotherapy, bone marrow aspirations/biopsies), diagnostic and laboratory tests, pharmacy, surgical procedures (portacath insertion), blood bank, central administration

Direct nonmedical costs: local housing (hostel nights for patients and families during treatment)

Indirect costs: not explained

Bolous et al[4]

(2024)

Country: Zimbabwe, Zambia, Uganda

Type of cancer: all cancer types

Direct medical costs: medical personnel (salaries and time dedicated to childhood cancer care), pharmacy (chemotherapy and supportive medications), pathology (diagnostic laboratory services), radiation therapy, imaging (diagnostic scan), surgery, blood services, outpatient clinic visits (consultations, follow-ups), administration (hospital overhead related to cancer care)

Direct nonmedical costs: nonmedical personnel (salaries for support staff such as social workers, data entry, housekeeping), housing (costs for patient and family accommodation during treatment), local transportation

Indirect costs: not explained

Denburg et al[8] (2019)

Country: Uganda

Type of cancer: Burkitt lymphoma

Direct medical costs: chemotherapy, supportive care agents, laboratory, blood bank, pathology test, radiology (chest X-ray and ultrasound), overhead and personnel costs

Direct nonmedical costs: family transportation cost

Indirect costs: not explained

Owusu et al[13]

(2025)

Country: Ghana

Type of cancer: Burkitt lymphoma

Direct medical costs: chemotherapy medications, diagnostic tests such as full blood count, uric acid, hepatitis C, HIV), imaging (chest X-ray, abdominal ultrasound, CT scan), bone marrow aspiration, fine-needle aspiration cytology, inpatient care, physician consultations, and follow-up visits.

Direct nonmedical costs: transportation costs for families, food during travel

Indirect costs: productivity loss for caregivers

Chen et al[5]

(2022)

Country: China

Type of cancer: acute lymphoblastic leukemia, non- Hodgkin lymphoma, Hodgkin lymphoma, medulloblastoma, and nephroblastoma

Direct medical costs: prices of anticancer medicine (generic and originator brands)

Direct nonmedical costs: not included

Indirect costs: not included

Soliman et al[29] (2023)

Country: Egypt

Type of cancer: All type of cancer

Direct medical costs: High treatment costs and limited ability to afford novel cost-effective therapies; no specific patient-level cost data reported

Direct nonmedical costs: not included

Indirect costs: physicians experience limited time and resources to achieve cost-effectiveness

Soliman et al[9] (2022)

Country: Egypt

Type of cancer: Leukemias, lymphomas, brain tumors, other tumors

Direct medical costs: Personnel costs; laboratory and imaging tests; medications/drugs, surgery, radiotherapy, supplies; and overhead costs from central administrative departments and operations of inpatient/ outpatient units

Direct nonmedical costs: Travel expenses, accommodation, meals, and daily living expenses

Indirect costs: Loss of caregivers' income, opportunity costs, psychosocial stress, and reduced productivity

Fuentes-Alabi[6] (2024)

Country: El Salvador

Type of cancer: Leukemias, lymphomas, central nervous system tumors, and various extracranial solid tumors

Direct medical costs: Personnel cost (medical and nonmedical), pathologic diagnosis, pharmacy (chemotherapy), radiation, imaging, surgery, blood bank, supportive care medication, outpatient clinic

Direct nonmedical costs: nutrition, hoteling (ICU, general ward)

Indirect costs: hoteling (for families)

Islam et al[14]

(2015)

Country: Bangladesh

Type of cancer: acute lymphoblastic leukemia

Direct medical costs: Laboratory test, imaging, procedures, blood products, drugs (essential and cytotoxic drugs)

Direct nonmedical costs: Transportation, food, and parental accommodation charge

Indirect costs: Not explained

Joseph et al[30]

(2021)

Country: Nigeria

Type of cancer: Leukemia, lymphoma, rhabdomyosarcoma, Wilms tumor, retinoblastoma, osteosarcoma, central nervous system tumors, neuroblastoma

Direct medical costs: Diagnostic investigation (CT scan and MRI, blood investigations, molecular testing, urine investigation), drugs, surgery, chemotherapy, radiation therapy, rehabilitation

Direct nonmedical costs: Ward admissions

Indirect costs: Not included

Dawson et al[10] (2021)

Country: Ghana

Type of cancer: Lymphoma

Direct medical costs: Consultation, diagnosis, medication, other medical intervention

Direct nonmedical costs: transportation, personal care, food and drinks

Indirect costs: travel time, productivity day lost by patient and caregiver

Arega et al[31]

(2024)

Country: Ethiopia

Type of cancer: Hematolymphoid cancers, soft tissue sarcoma, renal tumors, central nervous system tumors, retinoblastoma, bone tumors, neuroblastoma, Wilms tumors, another tumor

Direct medical costs: Monthly treatment

Direct nonmedical costs: Not explained

Indirect costs: Forgone 19–24 hours every day for caring the children, psychologically difficult and stressful

Sneha et al[11]

(2017)

Country: India

Type of cancer: Acute lymphoblastic leukemia, acute myeloid leukemia

Direct medical costs: All treatment costs were subsidized

Direct nonmedical costs: Food, travel, accommodation

Indirect costs: Loss of pay, overtime jobs

Mardakis et al[32] (2018)

Country: India

Type of cancer: All cancer types, but mostly acute lymphoblastic leukemia (ALL)

Direct medical costs: Hospitalization (admissions for treatment, unexpected admissions due to treatment side effects, admission during diagnosis period); treatment, medications, and diagnostics (diagnostic tests, chemotherapy medications, medications to treat side effects)

Direct nonmedical costs: Travel and accommodation (renting rooms, trains from out of town, increased cost of living in big city, telephone charges due to being away from home); food (increased cost of preparing food at home, buying more nutritious foods); additional support (hiring tutor for the siblings; hiring a nurse to deliver home treatments)

Indirect costs: Costs for providing care to the patients, managing financial burden, forgone paid and unpaid work, forgone social and leisure time, forgone sleep (quality and duration), and psychosocial costs (facing uncertainty, feeling low, watching their children suffer, experiencing personal changes, and neglecting their other children)

Ahmad et al[33] (2021)

Country: Pakistan

Type of cancer: Hematological malignancies and solid tumors

Direct medical costs: The treatments was provided by the hospital

Direct nonmedical costs: Transportation cost and additional expenses during lengthy treatment in hospital

Indirect costs: 80% of families had more than three children, with the youngest child being less than five years in 75%. Patient's siblings had to stay without parents in 85% of cases during the prolonged treatment phase, causing multiple psychological problems over time

Abbreviations: CT, computed tomography; HIV, human immunodeficiency virus; ICU, intensive care unit; MRI, magnetic resonance imaging.



Results

Study Selection and Characteristics

A total of 299 records were identified through database searches. [Fig. 1] tracks the number of records as well as details the screening stages and reasons for excluding studies, to show the final selection of studies. After removing duplicates and screening titles and abstracts, 70 unique records were assessed for eligibility. Of these, 39 were excluded, and 31 full-text articles were retrieved for detailed evaluation. Following the application of inclusion and exclusion criteria, 13 studies were excluded, resulting in 17 studies being included in the qualitative synthesis ([Fig. 1]). The methodological quality of all 17 studies was assessed using the JBI checklist for economic evaluations ([Table 2]).[15]

Zoom
Fig. 1 Flow diagram of the systematic review process, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

The included studies were predominantly cross-sectional (n = 12) and retrospective cohort studies (n = 5). Geographically, the studies originated from Africa (Tanzania, Uganda, Ghana, Zimbabwe, Ethiopia, Nigeria; n = 8), Asia (India, China, Bangladesh, Pakistan; n = 6), and Latin America (Guatemala, El Salvador; n = 2). One study provided a multicountry analysis across sub-Saharan Africa. The most frequently studied cancers were ALL, Burkitt lymphoma, and Wilms tumor. Detailed characteristics of each study are presented in [Table 2].


Economic Burden on Families

  • Direct medical costs: Direct medical costs varied widely but constituted a substantial portion of the total expenditure. A study in Tanzania found direct medical costs averaged approximately US$840 per child for various cancers. In Bangladesh, the mean treatment cost for ALL was US$4,443, increasing to US$7,672 with complications. For pediatric acute myeloid leukemia in India, the average cost per newly diagnosed patient was US$4,454, with personnel and pharmacy costs being the largest components (35% and 28%, respectively).

  • Direct nonmedical costs: These costs, primarily transportation, accommodation, and food, were a critical financial strain. In Uganda, family travel expenses for Burkitt lymphoma care averaged US$149 per patient. In India, nonmedical expenses accounted for approximately 46% of monthly household income for rural families and 22% for urban families. Studies consistently reported that these costs were a significant factor contributing to treatment abandonment.

  • Indirect costs: Indirect costs due to caregiver productivity loss were profound. In Nigeria, 10.9% of caregivers lost their jobs after their child's diagnosis. In Ethiopia, caregivers spent an average of 19 to 24 hours per day caring for their child. In India, many parents had to take on overtime or odd jobs, and some families reported having to withdraw siblings from school to support the affected child financially or provide care.


Economic Impact on Patients’ Families and Society

The economic burden of pediatric cancer treatment on patients' families in developing countries is consistently shown to be very high. Families often face direct medical costs, such as treatment fees, hospital stays, medications, and health care services, as well as direct non medical costs like transportation, accommodation, and food. Additionally, they suffer indirect costs, including loss of income and productivity due to caregiving responsibilities. These OOP expenses frequently exceed families' financial capacity, causing severe economic hardship, debt, and discontinuation of treatment. Nonmedical costs alone represent a significant portion of the total financial burden, adding to the stress experienced by caregivers. At a broader societal level, government funding for pediatric cancer care in many developing countries remains limited, meaning families bear most of the costs. Nonetheless, pediatric cancer treatment is generally cost-effective, with costs per disability-adjusted life year (DALY) averted being much lower than the countries' gross domestic product (GDP) per capita, demonstrating substantial long-term economic and health benefits through increased survival and future productivity. Some studies emphasize that including pediatric cancer care within national health insurance systems can improve funding sustainability and ease the financial strain on families ([Table 3]).

Table 3

Overview of study outcomes for the final 17 records

Authors

Economic impact on patients' families and society

Policy recommendations

Saxton et al[1]

(2022)

Families: direct medical costs (tests, medicines, hospital stays) ∼$840 per child, travel expenses ∼$170 per child, and total burden over $1,000 per child (a significant expense in a country where many live on less than $2/day.

Society: the cost for the health care system (hospital infrastructure, staff, equipment) is ∼$4,240 per child.

Meanwhile, the return on investment for society are human capital Method: treating 161 children generated $1.7 million in economic value (survivors' future earnings); value of statistical life (VSL): up to

$3.6 million in societal benefits by preventing premature deaths; cost- effectiveness: every $1 invested in treatment yielded $2–$4 in long-term economic benefits

Strengthen health system infrastructure and capacity, workforce development and training, improve early diagnosis and referral pathways, enhance financial and social support for families, address treatment abandonment and improve adherence, invest in data systems and quality improvement, foster multisectoral partnership and sustainable financing

Agulnik et al[28] (2019)

Families: In LMICs, families of children with cancer often face severe financial hardship due to out- of-pocket (OOP) expenses for diagnosis, treatment, medications, and supportive care. The mean OOP cost per PICU admission can be over

$350, with costs doubling for children requiring ventilation. The implementation of pediatric early warning systems (PEWS) can indirectly benefit families by reducing the risk of costly and catastrophic health events (such as unplanned PICU transfers), thus lowering unexpected expenses and the emotional and financial burden associated with critical illness episodes

Society: The cost to implement PEWS at the National Pediatric Oncology Unit (UNOP) was

$13,644 (about $7 per admission). In the year after implementation, the hospital saved $354,514 in variable costs due to 457 fewer unplanned PICU transfer days, equating to a net saving of $173 per admission. These savings allow hospitals to reallocate limited resources and improve the overall quality of pediatric oncology services

Adopt and expand pediatric early warning systems (PEWS) as standard practice in pediatric oncology units within LMICs countries, invest in training and dedicated personnel (such as nurse educators), integrate PEWS into broader national childhood cancer care, encourage health system planets and hospital administration in LMICs

Srinivasan et al[7] (2024)

Families: The study primarily captures direct medical costs incurred by the hospital and not out- of-pocket or indirect costs borne by families

Society: The total annual cost of treating approximately 20 children with AML was $89,089, with an average cost of $4,454 per newly diagnosed patient. The largest cost components were medical personnel (35% of total) and pharmacy (28%). Investing in pediatric AML treatment yields substantial health benefits relative to the resource spent, even in a resource-limited setting

Strengthen supportive care and infection control, reduce treatment abandonment, ensure uniform access to therapy, capacity building and workforce training, establish multidisciplinary and social support teams, promote data collection and multicenter collaboration, sustain and expand financial assistance programs, optimize cost- effectiveness

Bolous et al[4]

(2024)

Families: Total health expenditure on cancer remains low (often less than 5% of GDP), and government spending per cancer patient is frequently under %10, meaning families frequently shoulder the costs for diagnostics, treatment, medications, and supportive care Society: The cost per disability-adjusted life year (DALY) averted for childhood cancer treatment ranged from $316 to $2,789 (0.3–0.6 times GDP per capita, indicating that childhood cancer treatment is generally cost-effective). The study also notes that investing in childhood cancer care can generate an approximate net return of $3 for every dollar spent, due to the number of productive life-years gained

Integrate childhood cancer into National Cancer Control Plans (NCCPs), adopt context-specific budgeting tools, strategic multiyear budgeting, strengthen data collection and economic analysis (CC-BRIDGE tool), promote equity and universal health coverage, customize policy to local contexts, advocate for political commitment and diversified funding

Denburg et al[8] (2019)

Families: Family costs refer to out of pocket incurred by families as a result of care. Family costs averaged US$149 (Int$462) per patient. Other indirect patient costs, such as food and accommodation, are difficult to capture in the Ugandan setting. The burden of travel and its associated costs have been implicated as a significant factor in treatment abandonment in LMICs. Lost economic productivity is likewise difficult to estimate

Society: The mean total cost of treating pediatric BL in Uganda was US$1352 (Int$4195) per child. Fixed costs averaged US$705 in personnel and US$148 (Int$459) in overhead per patient. The average variable cost per patient was US$350 (Int$1087), of which laboratory analyses comprised nearly half, followed by the costs of pathologic diagnoses (including pathologist fees) and chemotherapy. The corresponding cost per DALY averted in the base case was US$97 (Int$301)

Data from this journal can be the basis for policy makers' decision- making, especially in allocating health resources. Investment in children with cancer can strengthen the health system as a whole, especially in LMIC because it has been proven to save costs

Owusu et al[13]

(2025)

Families: Family transportation costs and food during the trip are important components in collecting data, but are not written in detail such as the average cost per trip and total transportation expenses per patient

Society: From the societal perspective, estimated cost for current practice is $9,558, compared to $8,302 for the NHIS-reimbursed treatment. Total NHIS burden: $951,750–$1,620,000 over 5 years (depending on tariff scenario).

Percentage of national NHIS budget: only 0.5–0.9% of total NHIS claims in 2022. ICER from a societal perspective: –$219 per DALY averted. ICER from a health system perspective (NHIS): $113 per DALY averted. NHIS

It is recommended that childhood cancer treatment, particularly for Burkitt lymphoma, be incorporated into Ghana's National Health Insurance Scheme (NHIS) as part of the essential benefits package.

The study advocates for sustainable financing mechanisms to support pediatric oncology care, alongside broader efforts to improve early diagnosis, treatment retention, and awareness at the community level. These policy actions were adopted following the presentation of study findings to the Ministry of Health's HTA Technical Working Group

Chen et al[5]

(2022)

Families: Before insurance: 8 of 38

generics (21.1%) and 6 of 16 originator brands (37.5%) were considered very unaffordable (costs

> 25% of monthly income). Some drugs such as pegaspargase and imatinib had monthly costs of 106–576% of household income. After insurance, affordability improved but there were still drugs that cost

> 25% of income

Society: The availability of essential medicines is very low in public hospitals (generic: 18.5%, originator: 2.6%), indicating that the distribution system and access to public services are not evenly distributed in all cities. This causes inequality in access to health services

Improve the availability of affordable generics in public hospitals, strengthen medical insurance coverage, provide higher government subsidies for essential medicines to avoid catastrophic health expenditure, and enhance drug supply chain management to reduce shortages of key anticancer drugs

Soliman et al[29] (2023)

Families: The study did not report direct financial burden on families, as treatment was largely provided free of charge through hospital donations (covering 40–50% of pediatric cancer cases). However, limited access to expensive novel therapies (e.g., targeted and immunotherapies) remains a challenge due to unaffordability

Society: Structural and economic burdens include lack of cost- effectiveness data from the local context, absence of policies for evaluating treatment costs, and inability to fund newer cost-effective therapies. Specific examples included unaffordable surgical expandable prostheses for bone cancer patients and absence of economic evaluation for salvage chemotherapy in relapsed AML

Develop hospital-wide mechanisms to evaluate cost-effectiveness; increase clinicians' access to local cost and effectiveness data; integrate cost-effectiveness into clinical protocols; build capacity in health economic evaluation among clinicians; adopt evidence-based, cost-effective treatment protocols; provide standard guidelines for relapsed patients; and introduce policies for discontinuing nonbeneficial salvage therapies and initiating palliative care when appropriate

Soliman et al[9] (2022)

Families: Children's Cancer Hospital Egypt (CCHE) provided free-of-charge treatments. However, families still face substantial economic burdens of nonmedical costs (travel, accommodation, and meals), especially for those from rural or distant regions. They also experienced income loss due to caregiving responsibilities. The median 3-year treatment cost per patient was $19,799, which is over six times Egypt's GDP per capita in 2019, and would be unaffordable for most families without financial assistance. While CCHE helps cover some nonmedical expenses for families with limited resources, these costs remain a major concern and can lead to financial distress or treatment abandonment in settings without such support

Society: The economic impact of childhood cancer on society includes increased health care system costs, reduced productivity due to caregiver work loss, and long-term financial strain on public and philanthropic resources.

Additionally, premature deaths and long-term disabilities in children contribute to a significant loss of potential human capital, widening economic disparities and placing a burden on national development, particularly in low- and middle- income countries

Recommendations: Policymakers should prioritize funding for cost-effective childhood cancers, expand bone marrow transplant capacity, and subsidize nonmedical costs to improve access. Integrating real-world cost-effectiveness data into national cancer plans, supporting locally adapted treatment protocols, ensuring financial coverage, and strengthening health data systems and partnerships are key to improving pediatric cancer care in resource-limited settings

Fuentes-Alabi[6] (2024)

Families: This study examine cost and sources of financing of a pediatric cancer unit and did not include the cost incurred by the family

Society: The primary funding for oncology expenses originated from the government (52.5%), charitable foundations (44.2%), and a social security contribution scheme (3.4%). Considering 181 new patients annually and a 5-year survival rate of 48.5%, the cost per disability adjusted life year (DALY) averted was $1,624, which falls below the threshold and being classified as very cost-effective

Successful cancer treatment in LMICs occurs through strong and sustainable programs for pediatric oncology funding required through both charitable foundation support and other support such as core and ancillary cost financing, educational campaigns, family support groups, and advocacy targeting governments and other stakeholders. To reduce local neglect rates future cost studies in LMIC pediatric cancer are needed including costs associated with psychosocial and family support, as these are integral determinants of survival outcomes

Islam et al[14]

(2015)

Families: The mean treatment cost for children with ALL in Bangladesh treated on this protocol was 4,443 USD (BDT 311,028) with

a range of 3234 USD (BDT 226,400) to 7672 USD (BDT

537,040). However, with an average of three episodes of febrile neutropenia or sepsis, the mean overall cost increased to 4,443 USD. In cases where refractory fever necessitated changes in the antibiotic regimen, an additional average cost of 1,740 USD was incurred. For these patients, the total expenses rose to 7,672 USD

Society: Not explained

Although the average total cost of treating pediatric patients in LMICs is lower than in high-income countries, it is necessary to consider the family's ability to pay for treatment. Collaboration is needed from medical professionals, the pharmaceutical industry, international agencies, and individual governments to determine solutions so that the costs charged to families can be reduced

Joseph et al[30]

(2021)

Families: The average cost related directly to cancer care from diagnosis to remission or death was

₦5,064,700 ($13,876), in juxtaposition to the average monthly family income of ₦115,228 ($316). None of the caregivers had health insurance

Society: 10.9% of caregivers reported losing their jobs as a result of their child's diagnosis.

Additionally, 78.2% of caregivers sold property and personal belongings to afford the treatment. Due to the high cost of pediatric cancer care and limited access to health insurance, many families are likely to opt-out of treatment

Policies are necessary to enhance the affordability of health care services for childhood cancer. This includes ensuring sufficient health insurance coverage and implementing public health policies that provide financial support specifically aimed at health care delivery for childhood cancer, ultimately to improve patient outcomes

Dawson et al[10] (2021)

Families: The average cost of treating lymphoma in children was estimated at US$440.32, with 97% of this amount attributed to direct expenses and the remaining 3% representing indirect cost (US$13.27). The major cost driver was medical cost (89.9%)

Society: Caregivers spent an average of 52.3 hours per month providing care. Approximately 94% of caregivers reported experiencing a high burden, with a greater proportion of males indicating high levels of burden. Overall, the average quality of life among caregivers was 2.20 on a scale of 1 to 5. About 85% of respondents reported a low quality of life, with females experiencing lower quality of life than males

There is a clear need for the National Health Insurance to cover the costs of childhood cancer treatment. Government policies should also focus on reducing the caregiving burden. To achieve this, a national program should be established to lower the cost of cancer medications and treatments while enhancing the quality of life for both caregivers and patients.

This approach would help ease the financial and social strain on affected families and benefit the nation as a whole

Arega et al[31]

(2024)

Families: More than a third-fourth of caregivers had insufficient income for the monthly treatment. Parents were having a difficult and stressful situation and making them experience a lot of care burden.

Multiple factors which cause a burden for the caregivers of children with cancer, includes the challenges associated with cancer treatment, financial problems, lack of information about the course of the disease, feelings of inadequacy, worries about the future of the child, and disorganized family life. The burdens was decreased by 46.7% among children above 10 years (compared to < 5 years old)

Society: Not explained

Recommendations: This study highlights the importance of holistic interventions to reduce the care burden on parents of children with cancer and to improve care quality. Suggested efforts include expanding equitable access through satellite clinics, strengthening pediatric oncology systems and workforce, ensuring adequate insurance coverage to reduce financial stress, and developing comprehensive supportive care for both children and caregivers.

Additionally, fostering national and international collaborations is emphasized, along with the need for future research to better understand the underlying causes of caregiver burden

Sneha et al[11]

(2017)

Families: Out-of-pocket expenses for food and travel and accommodation have emerged as a major contributing factor for severe economic effect on the family as it accounts for two-thirds of the total expenses incurred during each hospital admissions. Loss of pay is seen more often with working mothers than with fathers. Most of the parents had to restrict the needs for other siblings. They had to borrow money from their relatives and money lenders (which pushes them to a state of debt for the next few years). Majority of them had to do overtime and other odd jobs, or sell their properties to overcome the financial crisis. One family had to abandon the treatment due to the financial constraints

Society: Not explained

Recommendations: Successful pediatric cancer treatment depends on sufficient financial assistance for families lacking adequate resources or private health insurance. Those who need to travel beyond their local area for medical care should receive subsidies for transportation, meals, and lodging expenses.

Policymakers are encouraged to start providing coverage for certain types of cancer, prioritizing based on their prevalence and the availability of funding

Mardakis et al[32] (2018)

Families: Families were overwhelmed by the direct and indirect costs related to their children's treatment. Several families had to deal with unexpected costs due to changes in their child's condition. At times, they negotiated for a lesser charge or a different treatment approach. They also had to leave work which aggravated their financial condition. In several cases, the patient's siblings had to leave school to enter the labor market and/or care for the child with cancer Society: Not explained

Recommendations: The health care professionals and institutions are expected to develop interventions aimed at reducing the costs associated with cancer treatment.

Further research into the relationship between various costs and treatment abandonment is needed

Ahmad et al[33]

(2021)

Families: 95% of families relied on public transport, with 65% of them traveling 100–500 km with 2–10 hours' duration to reach the primary treatment center. 68% had to borrow money from relatives and 58% got bank loans to afford additional expenses during lengthy treatment.

Society: Not explained

Recommendations: Not explained

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; BDT, Bangladeshi taka; BL, Burkitt lymphoma; CC-BRIDGE, Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity; GDP, gross domestic product; ICER: Institute for Clinical and Economic Review; LMICs, low- and middle-income countries; NHIS, National Health Insurance Scheme; PICU, pediatric intensive care unit; USD: United States dollar.



Out-of-Pocket Expenditure and Health Coverage

OOP payments were the predominant mode of financing. In Nigeria, the average OOP costs for pediatric cancer care was ₦5,064,700 (US$13,876), starkly contrasting with an average monthly family income of ₦115,228 (US$316). None of the caregivers in this study had health insurance. In Bangladesh, 78.2% of families sold personal belongings to afford treatment. While Egypt's Children's Cancer Hospital (CCHE) provides free medical treatment, families still face substantial OOP costs for nonmedical expenses. Limited national health insurance coverage for pediatric cancer remains a widespread issue, exacerbating financial hardship.


Cost-Effectiveness of Pediatric Oncology Care

Despite the high individual burden, pediatric cancer treatment is highly cost-effective from a societal perspective. The cost per DALY averted ranged from US$97 in Uganda for Burkitt lymphoma to US$1,624 in El Salvador, all well below the threshold of one to three times the country's GDP per capita, classifying them as very cost-effective interventions according to the World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) criteria. For instance, treating childhood cancer in Tanzania yielded a return of $2 to $4 in long-term economic benefits for every $1 invested. Similarly, integrating pediatric cancer care into Ghana's National Health Insurance Scheme (NHIS) was found to be cost-saving from a societal perspective (incremental cost-effectiveness ratio of –$219 per DALY averted).


Key Policy Recommendations

To address these challenges, key policy recommendations include strengthening health care systems and infrastructure to provide affordable, quality pediatric oncology services. Expanding national health insurance coverage is critical to reducing OOP payments and improving access. Governments should increase budget allocations and subsidies, especially for costly cancer drugs and essential supportive care, while promoting early diagnosis and continued treatment adherence to optimize outcomes and resources. Ensuring the availability of affordable generic cancer medicines through effective supply chain management, as well as integrating pediatric cancer care into national cancer control strategies, are also important. Furthermore, social and financial support programs are needed to help families cover nonmedical costs and alleviate psychosocial burdens on caregivers. Collecting comprehensive economic data will support informed policy making, and fostering collaboration between governments, nongovernmental organizations, health care providers, and the private sector is essential to secure sustainable funding and improve care quality. Overall, although pediatric cancer treatment imposes a heavy financial burden on families in developing countries, it is a worthwhile investment with significant benefits, and policy efforts must prioritize reducing financial hardship, enhancing access, and strengthening health systems ([Table 3]).

Most studies emphasize that health financing systems play a crucial role in determining access, sustainability, and treatment outcomes for pediatric cancer care in developing countries. Currently, national health insurance coverage for pediatric cancer is often very limited or even absent, causing families to bear high OOP costs. This situation increases the risk of financial hardship and treatment abandonment. Several financing models have been implemented in developing countries, including government funding programs, public–private partnerships, expanded national insurance schemes, as well as fundraising from charities and international donors. For example, programs like CAP (Cancer Access Partnership) and the Cancer Health Fund in Nigeria provide subsidies for cancer drugs and care, although challenges remain regarding limited coverage and unequal access. Studies also show that integrating pediatric cancer care into existing national insurance schemes and health financing programs can improve access and financial sustainability ([Table 4]).

Table 4

Overview of study endpoints for the final 17 records

Authors

The role of health financing systems

Endpoints

Saxton et al[1] (2022)

Understanding and addressing the economic barriers to pediatric cancer care in Tanzania, a low-income country transitioning to lower-middle income status, evaluates the total costs of cancer diagnosis and treatment from a societal perspective, including expenses incurred by the health care system, hospital, and patients' families

Five-year overall survival rates of pediatric

cancer patients treated at Bugando Medical

Centre (BMC), Tanzania

Cost of care per patient from a societal perspective, including fixed and variable provider costs, direct medical costs, and nonmedical costs

Health impact measured by averted disability-adjusted life years (DALYs), quantifying the clinical benefit of treatment. Economic impact assessed using two models: value of statistical life (VSL) and human capital approach, estimating the societal economic benefits of pediatric cancer treatment.

Treatment abandonment and loss to follow-up rates, which affect survival and outcomes

Agulnik et al[28]

(2019)

Determining access to, quality of, and outcomes from pediatric cancer care in LMICs. The health financing system at the National Pediatric Oncology Unit is a mixed model supported by both government and private philanthropic funding, allowing children to receive care regardless of their ability to pay

Reduction in unplanned PICU transfer days: The decrease in the number of unplanned transfers to the PICU, can reflect fewer clinical deterioration events

Cost savings: The economic endpoint was the calculation of net cost savings for the hospital, specifically the reduction in variable costs.

Implementation cost: The study reported the total cost of implementing PEWS, including training, materials, and administrative expenses, and calculated the incremental cost per hospitalization

Srinivasan et al[7] (2024)

Enabling access to and continuation of childhood AML treatment through government-funded health schemes and support from NGOs. These financial mechanisms help cover the high costs of therapy, reduce treatment abandonment, and make care more affordable for families

The cost-effectiveness analysis found that AML treatment was cost-effective in the Indian context, with a cost per disability-adjusted life year (DALY) averted of $530, which is 24% of India's GDP per capita, well within accepted thresholds for cost-effectiveness. The total cost per newly diagnosed patient treated with curative intent was $4,454

Bolous et al[4]

(2024)

Determining whether countries can realistically plan, budget, and sustain childhood cancer services within their national cancer control plans (NCCPs). The CC-

BRIDGE tool developed in this study helps countries quickly estimate the cost and cost-effectiveness of childhood cancer services, supporting better financial planning, advocacy, and resource allocation

Development and validation of the CC-BRIDGE Tool: creating and piloting a rapid, context-specific budgeting and cost-effectiveness tool (CC-BRIDGE) for childhood cancer programs in low- and middle-income countries (LMICs)

Budget estimation: accurately estimating the 5-year national budget needed to fund childhood cancer services within National Cancer Control Plans (NCCPs) for Zimbabwe, Zambia, and Uganda

Cost-effectiveness analysis: calculating the cost per disability-adjusted life year (DALY) averted for childhood cancer treatment under different survival and morbidity scenarios, and comparing these costs to each country's GDP per capita

Budget breakdown: identifying and reporting the main cost categories (e.g., personnel, housing, pharmacy) for childhood cancer care in each country

Feasibility and adaptability: demonstrating that the tool can be rapidly adapted to local data, provide actionable results for policymakers, and support the inclusion of childhood cancer in NCCPs

Denburg et al[8] (2019)

To assess the cost-effectiveness of treating Burkitt lymphoma in Uganda and provide evidence to inform health financing and priority setting in low-income countries

This outcome served as a proxy for cure in the local context. The intervention was shown to be highly cost-effective, with a cost per disability-adjusted life year (DALY) averted of US$97 (international dollars: $301). At the national level, it was estimated that treatment could avert a cumulative total of 8,607 DALYs annually. These findings indicate that the treatment program not only improves survival outcomes but also represents a highly efficient use of limited health system resources in a low-income country setting

Owusu et al[13]

(2025)

To evaluate the cost-effectiveness and budget impact of including Burkitt lymphoma treatment for children under Ghana's National Health Insurance Scheme (NHIS), and to provide evidence for informed health financing policy in LMICs

The study found that NHIS-covered treatment was more effective and less costly than out-of-pocket care, with an ICER of −$219 per DALY averted from the societal perspective and $113 from the NHIS perspective. The intervention significantly reduced treatment abandonment and was adopted into national insurance policy

Chen et al[5]

(2022)

Assess the accessibility of essential anticancer medicines for children in public hospitals in Sichuan province, China, a middle-income region

Availability: Generics: 18.5%; originator brands: 2.6%. Only 3 generics had high availability (≥ 80%)

Price: 41.9% of generics and 87.5% of originator brands had MPR > 1.5 (too expensive)

The study focuses on the availability, price, and affordability of 34 anticancer and 3 supportive medicines

Affordability (before insurance): 21.1% of generics and 37.5% of originator brands were unaffordable (> 25% of monthly household income)

After insurance: affordability improved, but 2 generics and 8 brands remained unaffordable

Soliman et al[29] (2023)

Determine the clinicians' perceptions of barriers and facilitators to implementing cost-effective evidence-based treatment for children with cancer in a resource-limited pediatric oncology setting in Egypt

Identification of four major themes (awareness, skills, systems, clinical practice) influencing implementation; qualitative insights into systemic barriers (e.g., lack of policies, unaffordability of novel therapies); and practical clinician-led suggestions for integrating health economics into routine care

Soliman et al[9] (2022)

Determine the cost-effectiveness of childhood cancer treatment in a large pediatric oncology center in Egypt between 2013 and 2017.

Determine the association between costs and survival, and identify the childhood cancer types/groups associated with high costs and poor survival.

Provide evidence-based recommendations to promote high value care and increase cost-effectiveness of treatment

For all cancers combined, cost/DALY averted was $1384 (0.5 × GDP/capita), which is very cost-effective according to WHO–CHOICE thresholds. Ratio of cost/DALY averted to GDP/capita varied by cancer type/subtype and disease severity (range: 0.1–1.6), where it was lowest for Hodgkin lymphoma and retinoblastoma, and highest for high-risk acute leukemia and high-risk neuroblastoma. Treatment was cost-effective (ratio < 3 × GDP/capita) for all cancer types/subtypes and risk/stage groups, except for relapsed/refractory acute leukemia and relapsed/progressive patients with brain tumors, hepatoblastoma, Ewing sarcoma, and neuroblastoma. Treatment cost-effectiveness was affected by the high costs and inferior survival of advanced-stage/high-risk and relapsed/progressive cancers

Fuentes-Alabi[6] (2024)

Measuring the total cost and cost-effectiveness of maintaining a pediatric cancer treatment program in El Salvador. Cost-effectiveness was estimated based on the number of newly diagnosed patients and their survival rates

Cost-effectiveness analysis: Based on an annual incidence of 181 new patients and a 5-year survival rate of 48.5%, the cost per disability-adjusted life year (DALY) averted was calculated at $1,624. When compared to El Salvador's 2015 per capita GDP of $4,219, this figure indicates a highly cost-effective intervention according to WHO-CHOICE criteria

Budget breakdown: Based on identification, most costs are attributed to personnel, pathological diagnosis, pharmaceuticals, and blood products

Financing sources: For the source of financing, the government is responsible for most of the funding, amounting to 52.5% of the total funding requirement. Other funds were obtained from a private foundation assistance program that provided 44.2% funding and a social security contribution scheme (3.4%). The funding requirements financed by these sources do not include hospital administration costs

Islam et al[14]

(2015)

Identifying the financial burden for treating children with ALL in Bangladesh as a low-middle income country, identifying total average cost incurred by family

The cost for treating ALL in LMICs is lower than high-income countries but remain prohibitively high for most parents in LMICs. Most families have a modest monthly income that makes it difficult to afford to pay the full cost of treatment and results in increased treatment abandonment

Joseph et al[30]

(2021)

Investigate the outlining direct cost needed for diagnosing and treating child with cancer in Lagos, Nigeria, identifying the sources of funding for treatment in childhood cancer patient

The average total cost of pediatric cancer is significantly lower than the monthly income of most families, creating a barrier to successful treatment and leading to higher rates of therapy abandonment. Additionally, 93.5% of families reported that medical expenses were covered by friends, relatives, nongovernmental organizations, and charitable groups. None of the caregivers had health insurance

Dawson et al[10] (2021)

Assess the costs, burden, and quality of life related to caregiving for children with lymphoma in Ghana

The costs were analyzed from the perspective of primary caregivers and reflect expenses incurred by them. Direct costs included consultation, diagnosis, medication, and other medical interventions, while indirect costs covered transportation, personal care, food, and drinks. About 42% of the monthly direct caregiving expenses were covered by alternative sources, with relatives contributing approximately 16% and borrowed funds accounting for 14%. Donations or gifts made up 10% of the costs, and the remaining 2% primarily came from remittances and the sale or transfer of assets.

Quality of life was assessed using the EUROHIS-QoL scale. Caregiving for children with lymphoma was linked to a higher caregiver burden and lower quality of life. Female caregivers reported significantly lower quality of life compared to male primary caregivers

Arega et al[31]

(2024)

Determining the extent of the care burden in the caregivers of children with cancer and the relevant influential factors in Ethiopia

Most of the caregivers (87.5%) had insufficient income for the cancer treatment cost. The average caring time was 19 to 24 hours for 76.4% of caregivers, and more than one-fourth of caregivers intended to abandon treatment if they could not get support to continue the care. About 53.4 and 35.1% of caregivers had moderate and severe care burdens. The burden factors associated with an increased care burden were the caregiver's occupational status, lack of support from NGOs, and insufficient monthly income for the treatment

Sneha et al[11]

(2017)

Find out the details of out-of-pocket expenses incurred by the families during their treatment of cancer children in India and its implications on their quality of life

Nonmedical expenses account for about 46% of the families' monthly household income from rural areas and 22% of their household income from urban areas. A family from a rural area spends four times the normal amount spent on home for their daily food expenditure. Thirty-eight percent of families have borrowed money from money lenders with an average interest rate of about 12.5%, which pushes them to a state of debt for the next few years. These out-of-pocket expenses contribute a significant proportion to the financial burden of the families with childhood malignancies and these invisible expenses should be recognized and provide adequate support to lessen the burden of this economic impact

Mardakis et al[32] (2018)

Exploring the direct, indirect, and psychosocial costs experienced by caregivers of children being treated for cancer in New Delhi, India

The primary sources of direct costs were hospital admissions, medications, food, and travel expenses. Indirect costs involved managing their child's treatment, affecting caregivers' sleep, work hours, and time spent with other family members. Psychosocial costs included coping with the uncertainty caused by a cancer diagnosis, feelings of guilt, and sadness as well as having to watch their children suffer. Caregivers accessed a network of support to cope with their child's treatment

Ahmad et al[33] (2021)

Evaluate the extent of psychosocial challenges faced by these families in an LMIC like Pakistan in a public sector hospital with resource-limited settings

The considerable socioeconomic challenges faced by these families and caregivers included large family size with low incomes increasing their financial difficulties, logistic burden like traveling long distances to access health care, and parental employment and family dynamics disruptions

Abbreviations: AML, acute myeloid leukemia; CC-BRIDGE, Childhood Cancers Budgeting Rapidly to Incorporate Disadvantage Groups for Equity; EUROHIS-QoL, EUROpean Health Interview Survey-Quality of Life; GDP, gross domestic product; ICER, Institute for Clinical and Economic Review; LMICs, low- and middle-income countries; MPR, median price ratio; NGOs, nongovernmental organizations; PEWS, pediatric early warning score; PICU, pediatric intensive care unit; WHO-CHOICE: World Health Organization Choosing Interventions that are Cost-Effective.


The treatment outcomes (endpoints) influenced by these financing systems include treatment continuation rates, access to adequate therapy and essential medicines, as well as long-term clinical and economic results such as reduced mortality and improved survival. Good financing interventions, including eliminating direct costs for families and subsidizing generic medicines, have been shown to reduce financial barriers and increase treatment adherence. Overall, the studies highlight the importance of strengthening inclusive and sustainable health financing systems that combine domestic resources and international support. This is essential to alleviate the financial burden on families and ensure affordable and quality pediatric oncology services in developing countries ([Table 4]).

Specific references from studies in Nigeria demonstrate that combining existing financing programs, expanding insurance coverage, and involving the private sector can optimize fund use and improve treatment access. Additionally, support from global platforms and donors plays a key role in promoting innovation and policy reforms in health financing in resource-limited countries (Chukwu, 2024).[25] Effective health financing systems are vital for improving access, affordability, and outcomes of pediatric cancer treatment in developing countries, as shown by evidence from multiple studies ([Table 4]).



Discussion

The economic burden of pediatric cancer care in developing countries is profound and multifaceted, imposing catastrophic financial hardship on families while simultaneously representing a highly cost-effective investment for health systems and society. The studies reviewed show that families face a heavy combination of three main types of costs: direct medical costs (such as treatment, hospitalization, laboratory tests, chemotherapy, surgery), direct nonmedical costs (transportation, accommodation, food), and indirect costs (loss of income and productivity of caregivers). Our systematic review synthesizes evidence demonstrating that the combined weight of direct medical, direct nonmedical, and indirect costs often exceeds a family's financial capacity, leading to debt, asset liquidation, and treatment abandonment.[16]

Our findings align with and build upon previous systematic reviews in the field. For instance, Fung et al concluded that childhood cancer treatment in LMICs is generally cost-effective, a finding robustly supported by our analysis showing cost per DALY averted consistently below WHO-CHOICE thresholds. Russell et al highlighted the scarcity of economic evaluations in pediatric oncology, a gap that is slowly being filled, as evidenced by the 17 studies we analyzed though methodological heterogeneity remains a challenge. Quantification of financial costs and the economic impact at the household level is a critical dimension of understanding the true burden of pediatric cancer care in developing countries. Studies consistently show that these costs are substantial and often catastrophic for families. A systematic review in sub-Saharan Africa found the median total cost of childhood cancer per patient to be approximately US$909.50, but costs varied widely depending on cancer type, from as low as around $163.80 for lymphoma to as high as $88,803 for neuroblastoma treatment. Importantly, for many families these costs far exceed their income, with treatment costs reaching over 80% and up to 345% of GDP per capita in purchasing power parity in some countries. This disproportionate financial burden leads to severe economic hardship, forcing families to borrow money often with high interest rates, incur debt, and in some cases abandon treatment for their children.[17] [18]

From the perspective of health systems and society, although treatment costs are high, pediatric cancer care in developing countries generally proves to be very cost-effective, with the cost per DALY averted much lower than the country's GDP per capita. This confirms that investing in pediatric care not only saves lives but also provides long-term economic benefits by increasing life expectancy and productivity of the future workforce. For example, a systematic review in Africa showed pediatric cancer treatment costs can reach over 80% up to 345% of GDP per capita in international dollars (purchasing power parity), meaning without adequate financing interventions, families face truly catastrophic financial burdens.[19]

A key finding is the crucial role of health financing systems in determining access, sustainability, and treatment outcomes. In most developing countries, national health insurance coverage for pediatric cancer is very limited or absent, pushing families to pay very high OOP costs. Financing models adopted include government funding, public–private partnerships, integration into broader national insurance schemes, and fundraising from donors and philanthropy. Studies from countries such as Nigeria show these integrations can improve financial sustainability and access to services significantly. Eliminating direct costs to families and subsidizing generic medicines reduce financial barriers and improve treatment adherence, which strongly correlates with better long-term health outcomes.[20] [21]

Other global literature supports these points; for example, a study in Tanzania emphasizes that investment in pediatric oncology programs not only reduces mortality but also has positive economic effects regionally and nationally, despite the country's classification as low-to-middle income.[17] Research in the Eastern Mediterranean region highlights disparities in access and the need for sustainable financial support to expand inclusive pediatric cancer services. These findings underline the importance of strengthening financing systems that combine domestic resources with international aid.[19] [20]

In contrast, in HICs, the absolute cost of pediatric cancer treatment is much higher, reaching tens to hundreds of thousands of dollars per patient. However, universal health insurance and social welfare systems substantially reduce families' direct financial burden. Nevertheless, indirect costs and psychosocial burdens remain significant challenges universally, indicating that comprehensive solutions must also address social and psychological aspects.[21]

Indonesia, as a developing country with a large population and a developing health system, faces a growing cancer burden, including childhood cancer. Data from the Ministry of Health and various studies show that cancer treatment costs are a heavy economic burden for patients, families, and the national health system. Pediatric cancer treatment in Indonesia faces significant challenges but also shows promising developments. Indonesia, as a lower- middle-income country with a high pediatric cancer prevalence (43.5% in 2020 among Southeast Asian countries), struggles with relatively low survival rates; for instance, the 5-year survival rate for high-risk pediatric ALL was reported at only 48.8% in the national cancer referral center (Dharmais Cancer Hospital). Several factors contribute to these challenges, including limited access to effective therapies, especially for high-risk, relapsed, or refractory patients. Advanced treatments like CAR T cell therapy, which are widely used in HICs, remain uncommon in Indonesia but hold promise for improving survival outcomes.[22] Similar to what the systematic review found, many families in Indonesia face direct treatment costs as well as nonmedical expenses like transportation and accommodation, especially for patients coming from remote areas who require services at referral hospitals. Indirect costs such as the loss of income from caregivers are also real problems. Indonesia's national health insurance system (BPJS Health) has improved access to cancer treatment, but insurance coverage for pediatric cancer still has limitations, such as issues related to distribution of facilities, availability of specialist doctors, and nonmedical costs that are not yet fully covered.[23] [24] [25] [26] [27]

Overall, this discussion underscores that addressing the economic burden of pediatric cancer care in developing countries requires systemic approaches integrating inclusive and sustainable health financing strengthening, insurance coverage expansion, medicine subsidies, and social-economic support for patient families. More detailed economic data collection and contextual policy adaptations are also essential for optimal interventions. Comparisons with developed countries reveal how financing systems and social support are key determinants in alleviating family economic burdens, offering lessons for developing countries on strengthening pediatric oncology financing and health system infrastructure for better health and economic outcomes.[16] [17] [19]

The stark contrast between the high cost-effectiveness of treatment and the severe financial toxicity experienced by families underscores a critical policy failure: the lack of adequate risk-pooling mechanisms. As demonstrated by the success of Ghana's NHIS integration, expanding health insurance coverage to include pediatric cancer can dramatically reduce OOP expenditures and improves treatment continuity. Other successful models, such as the government-foundation partnership in Guatemala and the fully subsidized care at CCHE in Egypt, provide valuable blueprints for sustainable financing. To effectively shape policies and close financial gaps, future efforts must prioritize the development of inclusive and sustainable health financing systems. This includes not only expanding insurance but also implementing targeted social support programs to cover nonmedical costs, which are a major driver of hardship. The newly developed CC-BRIDGE (Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity) tool offers a practical solution for countries to estimate budgets and advocate for political commitment within their National Cancer Control Plans. Regarding standardization, the considerable heterogeneity in cost definitions, data collection methods, and study design among the included studies precluded a quantitative meta-analysis, as noted in our limitations. To enable stronger statistical syntheses in the future, the global community should adopt standardized costing methodologies and reporting frameworks, such as those proposed by the International Society for Pharmacoeconomics and Outcomes Research or the WHO's guide on conducting economic evaluations. Harmonizing metrics for indirect costs and incorporating broader measures of financial toxicity would greatly enhance comparability.

This review did not identity sufficient data within the included studies to determine if there was a discrepancy in health care access or treatment continuation based on the sex of the child. Most studies reported aggregate data without gender-based subgroup analyses for economic outcomes. This represents an important area for future research, as gender dynamics could influence caregiving responsibilities and financial decision-making within households. While this review focused on economic aspects, it is imperative to recognize that financial toxicity is intertwined with psychosocial stress, which affects the entire family unit. Future studies should adopt multidimensional analyses to capture the full scope of the burden. In conclusion, reducing the economic burden requires systemic approaches that combined sustainable financing, expanded insurance, strategic subsidies, and robust social support. By implementing the remedial interventions outlined in [Table 5], policymakers can transform pediatric oncology care from a source of financial catastrophe into a sustainable and equitable investment in human capital.

Table 5

Remedial financial interventions to reduce economic toxicity

Intervention strategy

Examples from included studies

Impact/Outcome

Expansion of national health insurance

Incorporation of Burkitt lymphoma treatment into Ghana's NHIS

Reduced out-of-pocket spending, decreased treatment abandonment, cost-saving intervention

Government and philanthropic funding

Mixed funding model at Guatemala's National Pediatric Oncology Unit (government and private foundations)

Enabled access to care regardless of ability to pay

Subsidies and free treatment programs

Children's Cancer Hospital Egypt (CCHE) provides free-of-charge treatment

Eliminated direct medical costs, though nonmedical costs remain a burden

Financial assistance for nonmedical costs

Recommendations for subsidies on transportation, meals, and lodging (based on Indian and Pakistani studies)

Proposed to alleviate indirect costs and reduce financial distress

Strategic budgeting tools

Implementation of the CC-BRIDGE tool in Zimbabwe, Zambia, and Uganda

Provided rapid, context-specific budget estimates to support national cancer control planning

Abbreviations: CC-BRIDGE, Childhood Cancers Budgeting Rapidly to Incorporate Disadvantage Groups for Equity; NHIS, National Health Insurance Scheme.



Conclusion

Strong and inclusive health financing systems, such as expanded insurance coverage, subsidy programs, and social support for nonmedical costs, are essential to reduce OOP expenses and improve treatment access and outcomes. Combining sustainable financing, better data, and tailored policies is key to easing the economic burden and improving care for children with cancer in developing countries.



Conflict of Interest

None declared.

Data Availability Statement

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.


Authors' Contributions

S.M. contributed in conceptualization, methodology review, offered critical revisions, supervised the manuscript, secured funding, contributed to discussion and result interpretation, provided project oversight, and also provided final approval of the manuscript. C.N. contributed in methodology review, offered critical revisions, supervised the manuscript, secured funding, provided project oversight, contributed to discussion, and result interpretation. B.B. contributed in conceptualization, study design, collected and analyzed data, created tables, drafted the manuscript, and contributed to discussion and result interpretation. D.T. and F.D. contributed in study design, reviewed methodology, analyzed data, and contributed to discussion and result interpretation. D.K. contributed in methodology review, discussion, and data organization.


Patient Consent

Patient consent is not applicable as this study is a systematic review of published literature and does not involve primary patient data.



Address for correspondence

Sri Mulatsih, MD
Division of Hemato-Oncology, Department of Child Health, Dr. Sardjito General Hospital
Perumahan Unisia II/11, Prumpung Baru, Sleman, Yogyakarta
Indonesia   

Publication History

Article published online:
20 January 2026

© 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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Fig. 1 Flow diagram of the systematic review process, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.