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Abstract Background and Objectives Pesticide-attributable neurological disease — intellectual disability (ID) from gestational organophosphate exposure and Parkinson's disease (PD) from occupational exposure — imposes a substantial but unquantified economic burden across the Middle East and North Africa (MENA). We estimated the total economic cost across 18 MENA countries (2010–2023) and evaluated the return on investment of four pesticide-reduction interventions. Methods A societal costing framework was applied across 252 country-year observations, integrating GBD-consistent epidemiological estimates with World Bank, ILOStat, and cost-of-illness data. Direct healthcare costs, indirect productivity losses, and intangible quality-of-life costs were quantified. Four interventions were evaluated using benefit-cost ratios, cost-effectiveness ratios, and net present value. Results Total regional burden reached USD 83.4 billion (mean USD 5.96 billion annually): direct costs 52.9%, indirect 26.5%, intangible 20.6%. ID drove 87.6% of direct expenditures. Three interventions were cost-beneficial: Surveillance System (BCR 11.0; USD 651/DALY), PPE Programme (BCR 3.25; USD 2,796/DALY), and Buffer Zones (BCR 2.23; USD 3,138/DALY). Conclusions Pesticide-attributable neurological disease represents a major preventable burden across MENA. The surveillance system offers exceptional return on investment as a first-line policy action.
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