Valuing Invisible Labor: A Feminist Political Economy Analysis of the Cost and Burden of Critical Care Nursing in Low- and Lower-Middle-Income Countries.

Critical care nursing is central to intensive care delivery, yet its costs and burdens remain largely invisible in low- and lower-middle-income countries. As critical care services expand in response to epidemiological transitions and global health emergencies, economic evaluations increasingly guide policy and resource allocation. However, prevailing health economic frameworks privilege infrastructure, technology, and physician-led interventions while treating nursing labor as a fixed or residual input. Using a feminist political economy and social reproduction lens, this discursive paper argues that the key research gap lies not only in limited data but also in systematic undervaluation of critical care nursing as gendered, socially necessary labor. Drawing on feminist economics, labor theory, and health workforce research, this paper examines how dominant costing and cost-effectiveness approaches obscure the variable and value-generating nature of nursing work. Nursing labor misclassification can distort incremental cost-effectiveness ratios, creating a false appearance of efficiency by excluding key labor inputs. These omissions shift costs onto nurses through work intensification, burnout, moral distress, migration, and onto households through unpaid caregiving and out-of-pocket spending. The paper proposes a feminist health economics research agenda prioritizing labor-sensitive costing, workforce well-being, gender-responsive analysis, household cost accounting, and nurse-led research supporting equitable and sustainable critical care systems.