Background: The Lancet Commission on Global Health recommends that by 2030 no household should be impoverished while accessing needed surgical operation. Meeting this target in Nigeria is challenging. This study aims to evaluate the payment coping strategies adopted by households in southeast Nigeria in gaining access to needed major surgeries electively. The findings will aid in designing policies towards improving access to needed surgical care. Methods: A hospital-exit cross-sectional survey of households that accessed major surgeries electively from the study health institution from July to December 2017. Payment coping strategies were compared across household wealth quintiles and household characteristics. SPSS® version 20 was used for analysis. Results: Household characteristics associated with deployment of extreme payment coping strategies were: household size >6 persons (p=0.001), female-headed households (p=0.001) and lower formal education of household heads (p=0.004), but not household socioeconomic status (p=0.16). Whereas 98.7% of uninsured households and 88.5% of insured households drew from household savings, 61.4% of uninsured households and 26.9% of insured households deployed further payment coping strategies beyond drawing from savings (p=0.05). Conclusion: Extreme hardship financing is evidently prevalent among uninsured households accessing major surgical operation electively, irrespective of household socioeconomic status.