Economic burden and cost drivers of traumatic brain injury

Abstract

Background:

Traumatic brain injury (TBI) is a significant public health concern in low-income countries. This study assesses the economic burden of TBI in Togo, estimating both direct and indirect costs and identifying key cost drivers.

Methods:

We conducted a cross-sectional study at CHU Sylvanus Olympio in Lomé from January to December 2022, including patients with complete medical and financial records. Direct medical costs included expenditures directly related to hospital-based medical care from admission to discharge, consultation fees, laboratory investigations, radiological examinations, medications, surgical procedures, intensive care charges, and hospitalization fees. Indirect costs included nonmedical and productivity-related expenses incurred during hospitalization: transportation, food, communication expenses, and loss of income for both patients and caregivers due to missed workdays.

Results:

A total of 219 patients were analyzed (mean age 37.3 ± 14.1 years; 81.7% male). Road traffic accidents accounted for 86.7% of TBIs, with motorcycles involved in the vast majority. The median total cost of care was USD 512 (IQR: 380–890), and the mean cost was USD 648 ± 478 — approximately 7.1 times the national monthly minimum wage. Direct medical costs constituted the largest share of expenditures, particularly treatment-related items. Intensive care unit admission, surgical intervention, and longer hospital stay were all significantly associated with higher total costs (p < 0.005).

Conclusion:

TBI management imposes a substantial financial burden in this tertiary hospital setting in Togo. Resource-intensive care, particularly surgery, intensive care admission, and longer hospital stay, significantly increases costs. Broader studies are needed to assess the full national and long-term economic burden of TBI. The financial burden of TBI management in our setting is considerable, particularly given limited health insurance coverage. TBI management imposes a substantial economic burden in this tertiary hospital setting, with costs significantly driven by intensive care admission, surgical intervention, and prolonged hospitalization.

INTRODUCTION

Traumatic brain injury (TBI) is a significant cause of mortality and long-term disability worldwide and represents a substantial public health challenge. According to global estimates from the World Health Organization and the Global Burden of Disease Study, millions of individuals sustain a TBI each year, with a disproportionate burden borne by low- and middle-income countries due to rapid urbanization, weak road safety enforcement, and limited trauma care systems. In sub-Saharan Africa, road traffic injuries – particularly those involving motorcycles – are the leading cause of TBI and continue to increase in incidence.[8,10,17]

In high-income countries, the initial cost of managing a single TBI patient can range from $64,800 to $162,000.[8,16,24] While these regions benefit from strong insurance systems, low-income countries like Togo struggle with inadequate health financing mechanisms. As a result, the economic burden primarily falls on out-of-pocket expenses, which contribute to poverty and limit access to essential care. Previous studies in Benin have reported average treatment costs ranging from about $309 to $817 per patient.[10] However, to our knowledge, no study has specifically assessed the economic impact of TBI management in Togo. This study aims to evaluate the overall cost of TBI and identify factors that influence the total cost of care.

MATERIALS AND METHODS

Togo information

Togo is a low-income West African country with an estimated population of approximately 9.5 million in 2024.[27] According to the World Bank, the country’s gross domestic product (GDP) amounted to about United States dollar (USD) 9.9 billion, corresponding to a GDP per capita of roughly USD 1,040.[27] The national currency is the West African CFA franc (XOF), which is pegged to the euro, with the exchange rate fluctuating around 600 XOF per US dollar. Life expectancy at birth reached approximately 63 years in 2023, reflecting gradual improvements in health outcomes.[26] The demographic structure is characterized by a relatively young population, with individuals aged 15–64 accounting for just over 55% of the total population. Urban residents represent approximately 40–45% of the population, indicating ongoing but incomplete urbanization. Despite sustained economic growth in recent years, poverty remains pervasive, with an estimated 34% of the population living below the international poverty line of USD 3.00/day (2021 PPP). The statutory minimum monthly wage, estimated at approximately USD 33, underscores low labor incomes and constrained purchasing power. The national health system in Togo is structured into three tiers, comprising primary care delivered through peripheral health centers, secondary care provided by regional hospitals, and tertiary care offered by university teaching hospitals, notably the Centre Hospitalier Universitaire Sylvanus Olympio (CHU-SO) in Lomé, the country’s central referral facility. Since 2021, the Togolese government has progressively implemented a Universal Health Insurance scheme, known as Assurance Maladie Universelle (AMU), to reduce financial barriers to healthcare access. [25] Nevertheless, as of 2024, insurance coverage remains partial, and outof-pocket payments continue to constitute the primary mode of healthcare financing for most patients, including consultations, diagnostic procedures, medications, and surgical interventions. Hospitalization costs are estimated at approximately USD 10–12/day, while the price of a cranial computed tomography (CT) scan ranges from USD 42.50 to USD 150, depending on the healthcare facility.

Lomé, the country’s economic and administrative capital, relies heavily on informal motorcycle taxis, locally known as zémidjans, as a dominant mode of urban transportation. Although helmet use is legally mandated, enforcement remains inconsistent, contributing to elevated rates of road traffic injuries.[13,21,28] These risks are exacerbated by rapid urbanization, inadequate transport infrastructure, and the limited development of prehospital emergency medical services, placing additional strain on an already resource-constrained health system.[28]

Study design and setting

Our study was conducted at CHU-SO, the largest tertiary referral center in Togo, located in the capital city of Lomé. The study employed a descriptive-analytical design with a cross-sectional approach, spanning 12 months from January 1, 2022, to December 31, 2022.

Study population

We included all patients admitted to the Neurosurgery Department with a diagnosis of TBI, regardless of age or gender. Patients were included if they had complete medical and financial records available. We excluded cases with incomplete files and those with non-TBIs. However, it is essential to note that our study was conducted in a single hospital, which may limit the generalizability of our findings to the entire Togolese population.

Data collection

Data were prospectively collected from medical records and financial registries using a preestablished questionnaire. The collected variables included demographics and clinical information, direct costs (such as consultations, diagnostic tests, medications, surgery, and hospitalization), indirect costs (including loss of income for the patient and caregiver, as well as transportation, food, and phone expenses), length of hospital stay, and patient outcomes.

Cost estimation

• Direct medical costs were operationally defined as all expenditures directly related to medical care during hospitalization, including consultation fees, diagnostic investigations (laboratory tests and imaging), medications, surgical procedures, and hospital bed charges. Direct medical costs were collected from hospital billing records and financial documents. Nonmedical expenses and productivity losses were obtained through structured interviews with patients or caregivers using a standardized questionnaire.

• Indirect costs were operationally defined as productivity losses attributable to TBI, including loss of income for patients and caregivers resulting from missed workdays during hospitalization and recovery, as well as nonmedical expenses such as transportation, food, and communication costs. Loss of income was calculated by multiplying the number of workdays lost by the patient and caregiver by the national minimum daily salary or reported income. For pediatric patients, students, and unemployed patients, no personal income loss was assigned. Productivity loss was calculated only for accompanying caregivers. For adult workers, income loss was estimated using reported income when available or the national minimum wage when income was not reliably documented. For patients or caregivers without documented or stable income, the national minimum wage was used as a standardized proxy estimate.

Because some medications, laboratory tests, imaging studies, and surgical consumables were not always available within the hospital, families sometimes purchased them outside the hospital. These costs were recorded using receipts when available and caregiver-reported expenses when receipts were unavailable.

For the purposes of this study, costs were calculated from the time of injury until hospital discharge only. Costs incurred outside the study hospital or after discharge were not included.

The total cost of care per patient was obtained by summing all documented cost components using the following formula:

Total cost = Direct medical cost + Indirect costs

All costs were converted from CFA francs to US dollars using the average exchange rate applicable during the study period.

Protocol of management

In our context, there is no system for prehospital care or any prefinancing mechanism for paraclinical examinations and treatment. During our study period, we administered the following protocol to all patients:

• In cases where the Glasgow Coma Scale (GCS) score was eight or lower, or in the presence of repeated seizures, hemodynamic and/or respiratory instability, the traumatized patient was managed in the general intensive care unit.

• Diazepam or phenobarbital was administered in cases of seizures.

• Emergency surgical intervention was indicated in the following circumstances:

• Symptomatic and/or compressive epidural hematoma (EDH)

• Subdural hematoma >5 mm, with a midline shift of at least 5 mm

• Depressed skull fracture resulting in compression

• Cranio-cerebral wound.

• The clinical parameters that were monitored daily included:

• Level of awareness

• Seizures

• General, respiratory, and hemodynamic indicators

• Pupil size

• Search for limb motor deficits.

• In the event of any clinical deterioration, a follow-up CT scan is requested.

Outcome definition

Outcome was assessed at hospital discharge. Because standardized functional outcome scales such as the Glasgow outcome scale extended were not consistently documented in medical records, the outcome was reported as:

• Discharged alive with clinical improvement

• In-hospital death

• Clinical deterioration.

Ethical considerations

This study was conducted in accordance with the ethical standards of the Comité de Bioéthique pour la Recherche en Santé (CBRS) of the Togolese Ministry of Health. The CBRS operates under an approval framework initially established in 2016 (Ref No: 0101/2016/MS/CAB/DGS/DPLET/CBRS), which remains valid for hospital-based observational studies. Authorization to conduct the present study was obtained in 2022, before data collection. All data were anonymized to ensure confidentiality.

Statistical analysis

Data were analyzed using Epi Info 7.2. Descriptive statistics presented frequencies and means ± standard deviations. Only bivariate analyses were performed to examine factors associated with total care costs. Multivariate analysis was not performed due to the relatively small sample size, missing values for some cost-related variables, and collinearity among key predictors, including TBI severity, ICU admission, surgery, and length of stay. Therefore, the reported associations should be interpreted as exploratory rather than causal.

Cost comparisons were performed according to the most reliably recorded clinical and therapeutic variables, including TBI severity, ICU admission, surgical intervention, and length of hospital stay. Other variables, such as loss of consciousness, seizures, CSF leak, open versus closed head injury, and associated extracranial injuries, were not systematically documented and were therefore not included in the subgroup cost analysis.

RESULTS

Demographic characteristics

During the study period, 2,926 patients were admitted to the surgical emergency department of Sylvanus Olympio Teaching Hospital. Among them, TBI accounted for 538 cases (18.38%). Based on the inclusion criteria, 219 patients with complete clinical and financial data were retained for analysis. The study population included 179 males (81.74%) and 40 females (18.26%), yielding a male-to-female ratio of 4.46. The mean age was 37.32 ± 14.14 years. Regarding occupation, most patients worked in the informal sector (74.89%), followed by civil servants (12.78%), students (7.31%), and unemployed individuals (5.02%). Only 6% of patients had health insurance coverage.

Clinical data

Traffic-related road accidents were the primary cause of brain trauma among 190 patients (86.76%), followed by falls (7.3%) and assaults (5.94%). Among the 190 victims of traffic-related road accidents, motorcycles were involved in 94.74% of cases. Specifically, 48.42% of these cases involved a motorcycle-to-motorcycle collision, while 22.11% involved a motorcycle-to-automobile collision [Table 1].

Table 1:

Mechanisms of road traffic accidents leading to traumatic brain injury (n=190).

Firefighters transported patients in 74.43% of cases, taxi drivers in 18.26%, private vehicles in 4.57%, and ambulance services in 2.74%.

TBI severity was classified according to the GCS at admission: severe TBI (GCS ≤8), moderate TBI (GCS 9–12), and mild TBI (GCS 13–15). Upon admission, 21 patients (9.59%) presented with severe TBI, 45.66% had moderate TBI, and 44.75% had benign TBI. A cerebral CT scan was conducted in 124 cases (55.62%). Patients with severe TBI were admitted to and treated in the intensive care unit.

Among the patients, 70 (56.45%) had a surgical lesion and underwent surgery for EDH (31.43%) and depressed skull vault fracture (24.29%) [Table 2].

Table 2:

Types of surgical lesions among operated traumatic brain injury patients (n=70).

Length of hospital stay and outcomes

Given the skewed distribution of hospital length of stay, the median length of stay was 4 days, with an interquartile range of 2–9 days. The mean length of stay was 7 ± 8.5 days.

Lower admission GCS was significantly associated with longer hospital stay in bivariate analysis (p < 0.0001). However, no adjusted effect estimate was calculated because multivariate regression was not performed.

Regarding in-hospital outcome: in-hospital mortality rate was 1.36%, and 85.84% patients were discharged alive and with clinical improvement.

Total costs

The total cost distribution was right-skewed. The mean total cost per patient was USD 648 ± 478. The median total cost was USD 512 (interquartile: USD 380–890). This represented approximately 7.1 times the national monthly minimum wage in Togo. The distribution of total cost was right-skewed.

The largest expenditure items with the highest costs were treatment (60.51%) and paraclinical tests (12.24%) [Table 3].

Table 3:

Breakdown of TBI cost components.

Direct medical costs (in USD)

Because a detailed itemized ranking of individual services (CT scan, ICU daily charges, laboratory subcategories, specific medications) was not performed, only grouped cost categories are presented.

The mean direct cost of managing TBI was $589.83 ± $463.88, ranging from $183.80 to $1,957.69.

Treatment-related expenditures represented the largest component of direct costs (60.51%), followed by paraclinical investigations (12.24%) and hospitalization charges. Higher total costs were significantly associated with surgical intervention ($918.04 on average; p = 0.0026), intensive care unit admission ($1,103.72 on average; p = 0.003), cranial CT imaging, and prolonged hospitalization ($43.93 on average; p = 0.003).

Indirect medical costs (in USD)

The mean indirect cost was $113.44 ± 63.69, ranging from $17.27 to $418.92. The income loss per patient ranged from $1 to $179.62, with an average of $31.37.

Patient productivity loss averaged $31.37, while caregiver productivity loss averaged $27.36.

The indirect cost of TBI management accounted for 17.51% of the total expenses. These indirect costs ranged from $17.27 to $418.92, with an average of $113.44 ± 63.69.

DISCUSSION

This study assessed the hospital-based economic burden of TBI management at the principal tertiary neurosurgical referral hospital in Togo.

This study has several limitations. First, it was conducted at a single tertiary referral center and therefore reflects hospital-based costs rather than the full national economic burden of TBI in Togo. Second, costs incurred before referral, at peripheral facilities, or after hospital discharge were not included, likely leading to an underestimation of the total burden. Third, indirect cost estimation relied partly on reported income or proxy wage assumptions in a population dominated by informal-sector employment, introducing potential measurement bias. Finally, multivariate analysis was not performed, thereby limiting the ability to adjust for confounding among interrelated clinical variables. Despite these limitations, this study provides useful baseline data on the economic burden of TBI in a resource-constrained West African neurosurgical setting. These findings may help inform health financing strategies, trauma system strengthening, and prevention policies.

Our findings show that TBI imposes a substantial financial burden in this setting, with a median total cost of $512 and a mean cost of $648 per patient, representing approximately seven times the national monthly minimum wage. Higher expenditures were significantly associated with intensive care admission, surgical intervention, and prolonged hospitalization.

TBI in our cohort predominantly affected young adult males, with a mean age of 37 years and a male predominance exceeding 80%. This demographic pattern is consistent with reports from other African settings, where TBI disproportionately affects economically active young men exposed to motorcycle-related road traffic injuries.[6,10,11,20,21]

Studies conducted in sub-Saharan Africa – including Nigeria, Benin, and Ghana – also report a predominance of young male patients, who often engage in economic activities and face higher risks due to motorcycle-related road traffic accidents.[1,10,13,20] In contrast, high-income countries exhibit a demographic profile that includes a greater proportion of elderly patients, with falls being a more frequent cause of TBI.[8,29]

Road traffic accidents, particularly motorcycle-related injuries, accounted for the overwhelming majority of cases in this study (86.7%). This reflects the transport realities of urban Togo, where informal motorcycle transport (“zémidjans”) plays a central role in daily mobility. Similar findings have been reported in Benin, Ghana, and Tanzania, where motorcycle-related injuries account for over 60% of TBIs.[10,11,21] The absence of a formal prehospital care system and delays in reaching hospitals exacerbate both clinical and financial outcomes.

Clinically, the high prevalence of moderate to mild TBI (GCS >8) in our cohort is comparable to findings from Tanzania and South Africa, where most cases presented with moderate injury severity.[12,21] Only 55.6% of patients underwent cranial CT imaging, reflecting the financial and logistical constraints of emergency neurotrauma care in our setting. In high-income environments, CT scanning is generally considered standard practice in suspected moderate or severe TBI.[16,29] In our context, diagnostic and therapeutic decisions are frequently influenced by affordability, which may affect both clinical outcomes and cost estimation.

Regarding management, our data indicate that 32% of patients underwent surgical intervention, primarily for EDHs and depressed skull fractures. These figures align with surgical rates reported in Benin and Côte d’Ivoire for similar injury patterns.[7,14] The lack of a structured prehospital care system and dependence on informal transportation methods remain significant barriers to timely management, as previously emphasized in regional trauma system analyses.[3,4,9]

The average cost per patient ($648 ± $478.13) is nearly 7 times the national minimum monthly wage, presenting an unsustainable financial challenge for most families, especially given that 94% of patients were uninsured. These findings align with previous data from Benin, where Hode et al. reported treatment costs ranging from approximately $309 to $817 per patient.[10]

While indirect costs accounted for 17.5% of the total burden in this study and were primarily linked to income losses and caregiver time, these figures are likely underestimated. Long-term impacts such as disability, job loss, and dependence on family members for daily activities were not evaluated. In high-income settings, these long-term indirect costs can account for up to 70% of the total TBI burden.[2,23] Income-loss estimates did not account for age-specific productivity differences or informal economic variability, which may have led to underestimation or overestimation of indirect costs, particularly among younger or informally employed patients. In our studies, most patients worked in the informal sector (74.89%), followed by civil servants (12.78%), students (7.31%), and unemployed individuals (5.02%). Reliable monthly income was not consistently documented, particularly among informal workers; therefore, income loss was estimated using reported income when available and the national minimum wage when income was not reliably reported. Because many participants worked in the informal sector, indirect cost estimation required pragmatic assumptions, which may have introduced measurement bias.

Direct costs, chiefly treatment expenses and imaging tests, align with trends observed in other sub-Saharan African countries.[1,21,29] For example, in Nigeria, Ojo et al.[20] estimated the costs of TBI management to range from $300 to $1,000, depending on injury severity and treatment method. In contrast, high-income countries report much higher costs, often exceeding around $108,000 per patient for severe TBI cases.[8,16,19] However, these expenses are primarily covered by health insurance systems, which lessen out-of-pocket spending. In the United States, for instance, hospitalization costs for severe TBI can exceed $150,000 due to intensive care, prolonged hospital stays, and long-term rehabilitation.[15,29]

The association between increased costs and intensive care admission, surgical intervention, and more extended hospital stay observed in this study is consistent with findings from other studies conducted in sub-Saharan Africa and high-income countries, where injury severity and resource-intensive care have been identified as the principal cost drivers in TBI management.[3,9,12] Dewan et al. also noted that ICU stays are among the primary cost drivers in TBI management globally.[5] Similarly, the necessity for surgical intervention significantly elevates a patient’s average expenditure. Surgical and TBI cases often require more extended hospital stays, intensive monitoring, and expensive consumables, contributing to increased healthcare costs.[18] The length of a hospital stay is another key determinant, as longer stays correlate with increased costs due to prolonged use of hospital resources and medications.[18] Furthermore, injury severity, particularly in patients with low GCS scores, is significantly associated with higher treatment costs, aligning with findings from Tanzania and South Africa.[12,22] Associations identified in this study should be interpreted cautiously, as confounding between severity, ICU admission, surgery, and hospital stay could not be adjusted for.

The recent implementation of the Universal Health Insurance AMU in Togo shows promise in alleviating the financial burden of healthcare. However, as of 2024, its coverage remains limited, highlighting the urgent need for investment in health financing, road safety enforcement, emergency medical systems, and public awareness initiatives.[25]

CONCLUSION

This study offers critical insights into the financial impact of managing TBIs in low-resource settings like Togo. The findings highlight the direct and indirect costs that patients and their families incur, particularly in the absence of adequate insurance coverage. The key cost drivers identified – intensive care unit admission, surgical intervention, extended hospital stays, and injury severity – should be prioritized in health policy reforms and clinical guidelines. As road traffic accidents continue to be the leading cause of TBI, especially among the economically productive population, preventive strategies need to be strengthened. Expanding the coverage and effectiveness of national health insurance schemes, enhancing trauma care systems, and implementing public health interventions could significantly reduce the burden of TBI. Further studies are necessary to evaluate the long-term socioeconomic consequences and to inform the development of cost-effective care models tailored to low-income countries.

Submission declaration

This manuscript has not been published or submitted elsewhere.

Authors’ contributions:

Conceptualization: Doléagbénou AK; Data Collection: Assogba P, Quenum K; Analysis: Djoubairou BO, Doléagbénou AK; Drafting: Doléagbénou AK, Kpélao E; Critical Revision: All authors.

Ethical approval:

The research/study was approved by the Institutional Review Board at Comité de Bioéthique pour la Recherche en Santé, number No: 0101/2016/MS/CAB/DGS/ DPLET/CBRS, dated March 01, 2023.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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