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Background: Proper treatment of hospital wastewater (HWW) is crucial to minimize the long-term effects on human health and aquatic ecosystems. However, the majority of HWW generated in low and middle-income countries (LMICs), is discharged without adequate treatment. This systematic review aims to fill the knowledge gap in LMICs by examining the efficacy of HWW treatment and the types of technologies used., Methods: Studies included in the review offered valuable insights into the current state of HWW management in LMICs. Between 2000 and 2022, only 36 research studies focused on hospital-based wastewater treatment within LMICs. Data were extracted on wastewater treatment technologies in hospitals or healthcare settings in LMICs. Data on sampling techniques, effectiveness, microorganisms and risk of bias of included studies were recorded., Results: A total of 36 articles met the eligibility criteria: mentioned about 1) hospitals 2) wastewater treatment 3) LMICs and 4) treatment efficacy. Twenty-two studies were conducted in Asia (22/36), 17 were conducted in countries with high Human Development Index. Constructed wetland, and activated sludge process were the most common technologies used in LMICs. A few studies utilized membrane bioreactors and ozone/UV treatment. Fourteen studies reported the concentration reduction to assess the microbial efficacy of the treatment process, 29/36 studies did not meet the national standards for effluent discharge. Reporting on sampling methods, wastewater treatment processes and efficacy of HWW treatment were at high risk of bias. Extreme heterogeneity in study methods and outcomes reporting precluded meta-analysis., Conclusions: The existing evidence indicates inadequate microbial treatment in low- and middle-income country hospitals, with this systematic review emphasizing the need for improvement in healthcare waste management. It underscores the importance of long-term studies using innovative treatment methods to better understand waste removal in LMIC hospitals and calls for further research to develop context-specific healthcare waste treatment approaches in these regions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)