Economic and clinical implications of metabolic dysfunction-associated steatotic liver disease management: Regional challenges and opportunities in Middle East and North Africa

Abstract

“We must accept finite disappointment, but never lose infinite hope” said Martin Luther King Jr., the American civil rights activist. He stressed that people, by all means, must keep moving forward toward collective action even in the face of adversity, with the ultimate goal of achieving equity for all. In a different world, King’s political philosophy has parallels in the struggle of the medical community against disparities of unequal representation and advocacy; nowhere is the focus of healthcare planning so deficient, as it is with metabolic dysfunction-associated steatotic liver disease (MASLD). It is an underappreciated liver condition, which, despite being an urgent public health concern, is underlined by the reality that no nation across the globe is well prepared to address it.[1] The wealth of a nation is determined by the health of its citizens, and a healthy population is more productive, contributes more to the economy, and is better equipped for innovation and overall prosperity. A nation’s wealth is measured not solely by its financial assets but also by the wellbeing and productivity of its people. MASLD is increasingly recognized as a public health emergency due to its rising prevalence and potential for serious complications like cirrhosis and liver cancer.[2,3] It is an imposing condition that also significantly increases the risk of multiple life-threatening diseases and places a considerable burden on individuals and healthcare systems.[4] It follows then that investing in MASLD is an investment in public health and is not just a social good; it is also an economic imperative for long-term prosperity. The prevalence of MASLD is notably high in the Middle East and North Africa (MENA), with recent epidemiological data revealing rates as high as 45% in countries such as Egypt and Kuwait, figures substantially surpassing the global average.[5] The MENA region consistently demonstrates higher prevalence, mortality, and disability-adjusted life year (DALY) rates compared to global averages [Figure 1].[6] In Saudi Arabia, modeling analysis of the disease over 13 years estimated noncirrhotic cases doubling to 2.5 million, compensated and decompensated cirrhosis and liver cancer trebling to 212,000, and liver-related death accelerating from <10,000 to >200,000.[7] Similar trends in cascading disease burden were also predicted in United Arab Emirates (UAE) and Kuwait.[7] This heightened prevalence is closely intertwined with the increasing incidence of obesity, type 2 diabetes mellitus (T2DM), and metabolic syndrome, conditions exacerbated by distinct regional dietary patterns, sedentary lifestyles, urbanization, rapid economic transitions, and unique genetic predispositions.[8]Figure 1: Global vs. Middle East and North Africa (MENA) trends in metabolic dysfunction-associated steatotic liver disease (MASLD), 1990–2021. (a) Age-standardized prevalence per 100,000 population. (b) Age-standardized mortality rate (ASMR) per 100,000 population. (c) Age-standardized disability-adjusted life years (ASDR) per 100,000 population. Data are shown for the global population (dashed lines) and for the MENA region (solid lines). Source: Data extracted from the Global Burden of Disease Study 2021, as reported in Huang M et al.[ 6 ] Global burden and risk factors of MASLD: trends from 1990 to 2021 and predictions to 2030. Internal and Emergency Medicine. 2025;20:1013-1024Economic evaluations of MASLD management strategies, typically modeled using data from high-income countries, frequently overlook critical regional disparities in healthcare infrastructure, availability of advanced diagnostics, and access to pharmacological therapies.[9,10] Modeling analysis from the region estimated discounted lifetime costs of MASLD increased substantially, totaling US$ 40.4 bn, 1.6 bn, and 6.4 bn in Saudi Arabia, UAE (Emiratis only), and Kuwait, respectively. MASLD-related costs estimated in 2019 comprised, respectively, 5.8%, 5.8%, and 7.7% of national healthcare spending.[7] However, such evaluations must be cautiously interpreted when extrapolating to the MENA region in general, where healthcare systems vary dramatically in terms of resource availability, specialist care, and diagnostic capabilities.[8,11] Crucially, cost-effectiveness thresholds established in wealthier regions rarely align with economic realities in lower- and middle-income MENA nations, necessitating tailored regional analyses that utilize locally relevant healthcare costs, utilities, and willingness-to-pay thresholds. The limited availability and accessibility of validated diagnostic tools, such as transient elastography (FibroScan®), pose further challenges.[11] The accuracy of such tools in populations with distinct body compositions prevalent in MENA region requires validation and potentially adapted diagnostic algorithms to ensure accurate risk stratification and monitoring. Moreover, reliance on these diagnostic tools without appropriate regional validation could lead to inaccurate disease staging, inappropriate resource allocation, and ineffective intervention strategies. Compounding these clinical and economic challenges is the persistent underrepresentation of MENA populations in pivotal MASLD pharmacotherapy clinical trials.[12,13] This underrepresentation poses a critical barrier to translating global clinical trial outcomes into regionally applicable treatment guidelines and economic evaluations. The subsequent lack of region-specific evidence impairs effective health policy formulation and resource allocation, exacerbating disparities in access to novel therapies and targeted management strategies.[11] Additionally, existing healthcare delivery systems within the region are often fragmented, characterized by limited integration between primary care providers, specialists, and public health sectors. This fragmentation hinders effective management, surveillance, and continuity of care for MASLD patients, ultimately leading to suboptimal patient outcomes and increased healthcare costs. Public and professional awareness of MASLD remains inadequate across the region, resulting in significant delays in diagnosis and intervention.[14] Strategic implementation of targeted screening programs for high-risk populations, such as those with obesity and T2DM, could significantly mitigate the disease burden. However, successful deployment of these programs necessitates substantial political will, adequate resource allocation, effective public health communication strategies, and the establishment of multidisciplinary clinical care pathways. Given these complex regional dynamics, it is imperative to advocate for coordinated regional efforts. Future economic modeling, clinical guidelines, and health policy frameworks must explicitly incorporate region-specific epidemiological data, infrastructure limitations, and socioeconomic contexts. Comprehensive regional studies are essential to support informed policy-making and efficient resource allocation, ultimately addressing the growing MASLD epidemic effectively in the MENA region. To effectively address the escalating MASLD crisis, regional stakeholders, including policymakers, healthcare providers, researchers, and advocacy groups, must collaborate to prioritize and fund region-specific epidemiological research and validation studies for diagnostic tools and therapeutic interventions. Advocacy for greater representation of MENA populations in global clinical trials to ensure regional applicability of outcomes must be undertaken. Steps must be taken to develop and implement targeted screening and early intervention programs tailored to high-risk populations; foster public–private partnerships to improve healthcare infrastructure, access to diagnostic tools, and availability of effective pharmacotherapies; and strengthen healthcare system integration through enhanced training and resource allocation, promoting effective multidisciplinary care. Only through coordinated, regionally sensitive, and evidence-based approaches can the significant MASLD burden in MENA be effectively managed, ultimately improving clinical outcomes and economic sustainability across the region.

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