The Middle East and North Africa (MENA) region is an arid and hyper arid region with nineteen countries/states with annual renewable freshwater per capita below water scarcity threshold (1000 m3/year). Groundwater is a key resource in the MENA region for improving water supply and agriculture uses. Due to the scarcity of renewable freshwater, increasing demand, and stress on surface water, nearly twelve states primarily depend on groundwater as a primary source of freshwater. Groundwater resources account for more than 80% of freshwater withdrawals in six states. There are 43 transboundary aquifer systems within the region. About 50% of the MENA region’s aquifer systems are non-renewable with over-abstraction which lead to sever drop in water table and deterioration in groundwater quality. In eight states, about 85% of agriculture irrigation water comes from groundwater compared to a global average of about 35% which also affects the food security. This is exacerbated by low water use productivity within the region with an average of about $0.25/m3 compared to $0.68/m3 globally. Groundwater valuation studies indicating that the economic value of groundwater is some states ranges between $0.52 and 0.85/m3. Economic valuation of groundwater supports planners and decision-makers in allocating and prioritizing available limited water resources in different developing sectors. Also, it will help in comparing between investing in groundwater protection with other environmental matters, and in balancing groundwater withdraw with conservation it for future generations. This chapter will assess how groundwater declining and deterioration due to increased demands, inefficient use and impacts of climate change should prompt MENA states to explore innovative and integrated governance frameworks to improve the management and ensure equitable access to strategic resources for both current and future generations. The groundwater importance for water security in the region should enhance the use of innovative technologies and dedicated funding towards integrated water resources management and heightened regional cooperation. Many countries in the region started to regulate groundwater resources with emphasis on allocation, well drilling, licensing, metering and sometimes pricing. However, the enforcement of these regulations is still weak. The depletion and quality deterioration of many aquifers are increasing the abstraction costs which affecting the social differentiation, as smaller farmers are pumped out and foreshadows a gradual collapse of the groundwater economy within the region. Few countries in the region still subside the groundwater abstraction which also affects the sustainability of this limited resource.