The State of Chronic Care Management in the Kingdom of Saudi Arabia

Executive Summary

• Chronic conditions account for ~75% of deaths in KSA, amid an increasingly obese population and rising disease burden that are accelerating the crisis. The current healthcare infrastructure is struggling to keep pace, leading to delays in diagnosis, treatment gaps, and fragmented patient journeys
• Despite nearly one-third of the Kingdom’s $57 billion healthcare budget being directed toward chronic-disease management, persistent EMR silos, referral bottlenecks, and inventory gaps continue to drive bottlenecks in Chronic Care Management

Market Context

Chronic diseases are a growing global crisis, responsible for 43M deaths¹ (2021) representing 75%¹ of all deaths worldwide. KSA has one of the highest rates of chronic diseases globally and highest in the GCC region due to cultural and lifestyle factors, where one in six people have at least one chronic condition. Among them, 15% have 3+ chronic diseases — and for those over 65 years of age, that number jumps to 50%. This leads to 74% of all deaths in KSA with 38% occurring prematurely. 

Notably, four leading diseases, Cardio-vascular disease (CVDs), Cancer, Diabetes, and Respiratory diseases, contribute to 35% of all deaths. The economic impact is substantial—annual healthcare spending on chronic care is estimated at ~$16B.

With an aging population, rising patient demand, and challenges in digitizing healthcare, chronic care in KSA demands serious innovation, with startups playing a critical role. As the burden rises, so does the need for more efficient, data-driven solutions. This presents a unique opportunity to integrate AI-driven innovations that can enhance care delivery and  improve patient outcomes.

Challenges in Chronic Care Management

Chronic care in KSA faces critical challenges, from limited access and delayed diagnoses to fragmented management and overburdened facilities. As chronic diseases rise, the following systemic challenges are becoming unsustainable, making urgent intervention essential.

1. Low Screening and Preventive Care: Routine check-ups and preventive screenings are highly underutilized, leading to delayed detection and late stage disease presentation. Without early screening, 75%² of high-risk CVD individuals remain unaware of their status, increasing the risk of  hospitalization rates. Additionally, 28%³ of chronic kidney disease patients have undetected hypertension, leading to End State Renal Dialysis.
2. Fragmented Referral Pathways: The lack of an enforced, structured patient flow forces patients to bypass primary and secondary care levels, resulting in overcrowded tertiary hospitals. This inefficiency is evident in delayed appointments, where newly diagnosed patients often wait 60–90 days for tertiary care consultations. Further, only 14% of patients⁴ with multiple chronic diseases receive follow-up consultations longer than 15 minutes, significantly below the OECD average of 47%.
3. Disconnected EMR Systems: With public, private, military, and university hospitals operating independent EMR systems, there is significant redundancy in testing and a loss of continuity in care. Only 27% of patients ⁴  with chronic diseases are managed in practices that can exchange medical records electronically, compared to an OECD average of 57%. The absence of interoperability exacerbates inefficiencies and impacts the overall quality of chronic care. 
4. Medication and Inventory Management Gaps: Poor inventory control leads to situations where essential drugs face frequent stockouts, while more expensive medications are overstocked and eventually wasted. This imbalance not only increases costs but also limits patient access to necessary treatments.
5. Post-Treatment and Rehabilitation Deficiencies: Fragmented rehabilitation services and underdeveloped telemedicine platforms contribute to a lack of standardized long-term monitoring and post-discharge support, particularly for patients residing outside major urban centers. These gaps result in delays in follow-up consultations and reduce the effectiveness of ongoing care.

In addition to these broad systemic challenges, each chronic disease comes with its own set of specific pain points, making effective care management even more complex.

Conclusion

Saudi Arabia’s chronic-care infrastructure faces many  operational bottlenecks and disease-specific gaps that warrant focused interventions. The room for innovation is immense.

In our next installment, we will dive into potential  solutions —exploring how AI-driven and digital innovations can enhance care coordination, support proactive patient management, and align with Vision 2030’s chronic-care objectives.

References

1. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-disease
2. https://www.sciencedirect.com/science/article/pii/S1876034119301893?via%3Dihub
3. https://www.scirp.org/journal/paperinformation?paperid=138898
4. https://www.oecd.org/conte nt/dam/oecd/en/publications/reports/2025/02/does-healthcare-deliver-results-from-the-patient-reported-indicator-surveys-paris-country-notes_40213115/saudi-arabia_003350e6/28b4bbde-en.pdf
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC7502961/
6. https://saudigazette.com.sa/article/96278
7. https://hail.mydiabetes.com/media/5441/saudi-health-council-diabetes-screening-1.pdf

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