PURPOSE OF REVIEW: Cost-effectiveness of cochlear implants is a major concern for expanding these services to low-income and middle-income developing countries. RECENT FINDINGS: Recent studies have applied appropriate methodology to make determination of cost-effectiveness for cochlear implants in developing countries. In addition, important parameters that effect cost-effectiveness have been reviewed in a systematic way. The combination of these new studies along with existing reports of cochlear implant programmes in developing countries allows for a discussion of cost and outcomes determinants that drive cost-effectiveness in these environments. SUMMARY: Cochlear implants are a very cost-effective treatment for profound hearing loss in all high-resource countries and in many low-income and middle-income developing countries. A number of cost considerations affect cost-effectiveness of cochlear implants in developing countries including device cost and device-related expenses such as power consumption and reliability, but also including rehabilitation and access-related expenses. Large-scale programmes confer an advantage for cost-effectiveness, primarily through device-related savings.