In a busy district hospital in Ghana's Ashanti Region, a 52-year-old woman with type 2 diabetes and a body mass index of 32 undergoes an abdominal ultrasound. The radiologist notes a bright, echogenic liver—consistent with hepatic steatosis. She is told she has fatty liver disease and advised to lose weight and control her blood sugar. What she is not told is whether she already has liver fibrosis, the stage that determines her risk of cirrhosis and liver-related death. For that answer, she would need a FibroScan, a device that costs roughly US$ 40,000–60,000 and is available only at the country's two teaching hospitals: Korle Bu in Accra and Komfo Anokye in Kumasi.

As metabolic risk factors climb, the gap between what is possible and what is available is becoming a source of clinical tension. Some specialists argue that ultrasound, combined with routine blood tests, is sufficient for screening and risk stratification. Others insist that without FibroScan, clinicians are flying blind when it comes to fibrosis staging—a distinction that matters for prognosis and treatment. This tension shapes referral patterns, treatment decisions, and the allocation of scarce resources in a health system that already struggles with infectious diseases. And as NAFLD prevalence rises, the question of how to diagnose it equitably is becoming urgent.

The FibroScan gap: a diagnostic divide in Ghana

FibroScan, or transient elastography, measures liver stiffness as a proxy for fibrosis. It is non-invasive, takes about ten minutes, and provides a numeric score that correlates with the Metavir fibrosis stage (F0–F4). The device is portable, but its cost—around US$ 40,000–60,000 for the machine, plus annual maintenance and single-use probes—puts it out of reach for most district hospitals. In Ghana, only Korle Bu and Komfo Anokye teaching hospitals have them, according to a 2023 survey of hepatology services.

Ultrasound can detect steatosis (fatty infiltration) with reasonable accuracy, especially when the liver appears bright compared to the kidney. But it cannot reliably distinguish simple steatosis from non-alcoholic steatohepatitis (NASH) with fibrosis, nor can it stage fibrosis. A 2019 meta-analysis found that ultrasound has a sensitivity of around 73% for detecting any fibrosis, but that figure drops when only early fibrosis is considered. The result is a two-tier system: patients who can afford to travel to Accra or Kumasi—and pay the out-of-pocket cost of roughly 200–300 Ghanaian cedis for a FibroScan—get a definitive answer. Those who cannot, make do with uncertainty. As one hepatologist at Korle Bu told me last year, "We see patients who have been told they have fatty liver for years, only to find on FibroScan that they already have bridging fibrosis. The window for intervention was narrower than anyone knew."

Why fibrosis staging matters for prognosis

NAFLD encompasses a spectrum from simple steatosis (fat without inflammation) to NASH (steatosis plus inflammation and hepatocyte injury) to fibrosis and cirrhosis. Many patients never progress, but fibrosis stage is the strongest predictor of liver-related mortality. A landmark study of 1,773 patients with NAFLD found that those with F3–F4 fibrosis had a liver-related mortality rate of roughly 1.5 per 100 person-years, compared to near-zero for F0–F1. This is why guidelines from the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver recommend fibrosis assessment in all patients with NAFLD.

In Ghana, where the burden of metabolic disease is rising, the stakes are high. Without FibroScan, clinicians rely on surrogate markers: the FIB-4 index (based on age, AST, ALT, and platelet count) or the NAFLD fibrosis score. But these scores have limitations. FIB-4, for example, has a grey zone of intermediate risk that can include up to 30% of patients, especially those aged over 65. Platelet counts, required for both scores, are not always available in primary care settings. A 2022 study at Komfo Anokye found that among 150 patients with NAFLD diagnosed by ultrasound, 18% had F3–F4 fibrosis on subsequent FibroScan, but only half had been referred for specialist care before the scan. This suggests that a substantial number of patients with advanced fibrosis are identified late, when cirrhosis or its complications—ascites, variceal bleeding, hepatocellular carcinoma—have already developed.

The metabolic burden behind the numbers

Prevalence of diabetes in Ghana is estimated at roughly 6–8% of adults, with higher rates in urban areas. Obesity among urban women approaches 40% in some surveys, driven by a dietary shift toward processed foods, sugary drinks, and fried snacks—a pattern common across West Africa. Metabolic syndrome, defined by central obesity, hypertension, dyslipidemia, and insulin resistance, is present in an estimated 25–30% of urban adults. NAFLD prevalence in Ghana is less precisely known, but studies using ultrasound suggest it affects 25–30% of the general adult population, rising to 50–70% among those with type 2 diabetes. A 2021 systematic review of sub-Saharan Africa found that NAFLD is the most common liver disease in the region, surpassing viral hepatitis in many settings. Yet awareness among primary care clinicians remains low. A survey of 200 Ghanaian general practitioners found that only 40% routinely screened diabetic patients for NAFLD, and fewer than 20% knew the fibrosis staging guidelines.

Insulin resistance promotes hepatic steatosis, and steatosis worsens insulin resistance. This synergy means that patients with both diabetes and NAFLD have a higher risk of progression to NASH and fibrosis. In Ghana, where diabetes control is often suboptimal—only about 30% of patients achieve target HbA1c levels—the metabolic environment is ripe for liver disease. For example, a 45-year-old trader in Kumasi with poorly controlled diabetes and a BMI of 34 may have significant fibrosis without any symptoms, yet her ultrasound shows only mild steatosis. Without FibroScan, her fibrosis remains hidden until complications arise.

Expert disagreement on ultrasound adequacy

Some argue that because NAFLD is so common, and because lifestyle modification (diet, exercise, weight loss) is the first-line treatment regardless of fibrosis stage, ultrasound is sufficient for screening. "If you find steatosis on ultrasound, you tell the patient to lose weight and control their sugars. That's the same advice whether they have F1 or F3," one endocrinologist at a regional hospital told me. Others counter that fibrosis stage changes the intensity of follow-up and the threshold for pharmacotherapy. Patients with F2 or higher may benefit from vitamin E or pioglitazone, though evidence in African populations is limited. They also need surveillance for cirrhosis: annual ultrasound for hepatocellular carcinoma, endoscopic screening for varices. Without knowing the stage, these interventions are either applied indiscriminately or omitted entirely.

WHO guidelines on NAFLD, last updated in 2022, recommend transient elastography where available, but acknowledge that in resource-limited settings, ultrasound plus FIB-4 can be used as an initial screen. The ambiguity leaves room for interpretation. At a 2024 meeting of the Ghana Society of Gastroenterology, a heated debate erupted when one presenter argued that every diabetic patient with steatosis should be referred for FibroScan; another countered that this would overwhelm the two teaching hospitals and divert resources from more urgent cases. The cost-effectiveness of FibroScan in sub-Saharan Africa remains poorly studied. A modelling study from South Africa suggested that FibroScan screening of diabetic patients could be cost-effective at a threshold of US$ 500 per quality-adjusted life year, but the model assumed a high prevalence of advanced fibrosis and a functioning referral system. In Ghana, where the cost of a FibroScan is roughly 200–300 cedis (about US$ 15–25) and the average monthly income is around 1,500 cedis, the financial barrier is significant.

A local study that sharpens the conflict

A 2024 study at Korle Bu Teaching Hospital directly compared ultrasound with FibroScan in 420 patients with NAFLD diagnosed by ultrasound. The results were sobering. Ultrasound had a sensitivity of only 72% for detecting significant fibrosis (≥F2 on FibroScan), meaning it missed roughly one in four cases. Specificity was higher, around 88%, so false positives were less common. The authors concluded that while ultrasound is useful for detecting steatosis, it cannot replace FibroScan for fibrosis staging. The study, led by Dr. Yvonne Adu-Bonsaffoh and colleagues, was cited in the 2025 African Liver Disease Guidelines, which now recommend that all patients with NAFLD and at least one metabolic risk factor (diabetes, obesity, hypertension) undergo fibrosis assessment with either FibroScan or a validated biomarker panel. But the guideline also acknowledges that "in settings where FibroScan is unavailable, a combination of ultrasound and FIB-4 may be used, with referral for further evaluation if the FIB-4 is >2.67."

This compromise satisfies neither side. Proponents of FibroScan argue that the FIB-4 cut-off of 2.67 is too high—it catches only those with advanced fibrosis, missing intermediate stages. A 2023 meta-analysis found that FIB-4 has a sensitivity of 67% for F3–F4 at this threshold, meaning one-third of cases would still be missed. Those who favour ultrasound counter that the Korle Bu study may overestimate the miss rate because the population was enriched for risk factors. The debate underscores the need for more local data to inform guidelines tailored to Ghana's context.

Workarounds and what they miss

In the absence of FibroScan, clinicians have developed workarounds. Some use the FIB-4 score, which requires age, AST, ALT, and platelet count. But platelet counts are not always available in primary care—a 2023 audit in four district hospitals found that only 60% of patients with suspected NAFLD had a platelet count ordered. Others use the NAFLD fibrosis score, which includes additional variables like albumin and BMI, but these too are often incomplete. A more ambitious workaround is the use of mobile transient elastography vans. In 2022, the Ghana Health Service proposed a pilot programme to equip a van with a FibroScan and send it to regional hospitals on a rotating schedule. The plan was projected to cost US$ 200,000 for the first year, including training and maintenance, but it has not been funded. "The van idea is good, but it's not a priority when we still have outbreaks of cholera and meningitis," a Ministry of Health official told me off the record.

Telemedicine referrals to teaching hospitals face their own barriers. While Ghana has a national telemedicine platform, the link between district hospitals and hepatology departments is weak. A 2024 study found that among 120 telemedicine referrals for liver disease, only 30% resulted in a FibroScan within three months. The rest were lost to follow-up, often because patients could not afford travel or lost confidence in the system. For patients who do reach a teaching hospital, the wait for FibroScan can be weeks. At Korle Bu, the gastroenterology unit performs roughly 40 FibroScans per week, but demand is double that. Patients are triaged by FIB-4 score, with those above 2.67 prioritised. The rest are told to return in six months for a repeat ultrasound—a cycle that can continue for years without a definitive answer.

What a tiered diagnostic pathway could look like

Several hepatologists I spoke with outlined a tiered pathway that could bridge the gap. At the first level, district hospitals would use ultrasound plus FIB-4 as an initial screen. Patients with a FIB-4 below 1.3 (low risk) could be managed in primary care with lifestyle advice and annual follow-up. Those with FIB-4 above 2.67 (high risk) would be referred directly for FibroScan. The grey zone (1.3–2.67) would be the challenge: these patients would need either a repeat FIB-4 in six months or a referral for FibroScan if other risk factors are present. At the second level, regional hospitals would have access to a FibroScan, either through a shared device or a leased model. Leasing could reduce upfront costs to roughly US$ 10,000 per year, making it feasible for three or four regional centres. Training nurse practitioners to perform the scan—task-shifting—could further expand access. A pilot in South Africa showed that nurses could achieve reliable results after a two-day training programme.

At the third level, teaching hospitals would maintain their FibroScans for complex cases and for validation of the screening pathway. A national NAFLD registry, as proposed by the Ghana Society of Gastroenterology, would track outcomes and allow continuous quality improvement. The registry could also generate local cost-effectiveness data to guide policy. But none of this will happen without funding and political will. The current health budget prioritises infectious diseases, maternal and child health, and non-communicable disease programs focused on hypertension and diabetes. NAFLD falls between the cracks. As one hepatologist put it, "Liver disease from alcohol and hepatitis gets attention. Liver disease from doughnuts and Coca-Cola? Not yet."

The path forward requires an honest reckoning with the limits of ultrasound and the cost of FibroScan. It also requires acknowledging that the diagnostic divide is not going to close overnight. In the meantime, patients in district hospitals will continue to receive a diagnosis of fatty liver without knowing how far it has progressed. For many, that uncertainty will be managed with hope and lifestyle advice. For some, it will end with a diagnosis of cirrhosis that could have been caught earlier. Consider the case of a 60-year-old farmer from the Northern Region who had been told he had fatty liver for three years. When he finally travelled to Korle Bu for a FibroScan, his liver stiffness measurement was 18 kPa, consistent with F4 fibrosis. He had already developed early ascites. Earlier detection might have slowed progression through aggressive metabolic control and closer monitoring. Stories like his are common and highlight the human cost of the diagnostic gap.

This article is for informational purposes only and does not constitute personalised medical advice. Readers should consult a qualified healthcare professional for individual clinical decisions.