The investment case for folic acid fortification in developing countries

Abstract

There is compelling evidence that neural tube defects can be prevented through mandatory folic acid fortification. Why, then, is an investment case needed? At the core of the answer to this question is the notion that governments and individuals have limited resources for which there are many competing claims. An investment case compares the costs and benefits of folic acid fortification relative to alternative life‐saving investments and informs estimates of the financing required for implementation. Our best estimate is that the cost per death averted through mandatory folic acid fortification is $957 and the cost per disability‐adjusted life year is $14.90. Both compare favorably to recommended life‐saving interventions, such as the rotavirus vaccine and insecticide‐treated bed nets. Thus, there is a strong economic argument for mandatory folic acid fortification. Further improvements to these estimates will require better data on the costs of implementing fortification and on the costs of improving compliance where regulations are already in place.

A 2017 global update on folic acid‐preventable spina bifida and anencephaly

“…These defects are associated with an increased risk of stillbirths and child mortality (Blencowe, Kancherla, Moorthie, Darlison, & Modell, ; Kancherla, Druschel, & Oakley Jr., ; Oakeshott, Hunt, Poulton, & Reid, ; Sutton, Daly, & Kirke, ; Wang, Hu, Druschel, & Kirby, ). Babies born with anencephaly die soon after birth, and those with spina bifida have major social and economic impact, commonly associated with caregiver stress, loss of human potential, and high medical care costs (Grosse, Berry, Tilford, Kucik, & Waitzman, ; Grosse, Waitzman, Romano, & Mulinare, ; Hoddinott, ; Ouyang, Grosse, Armour, & Waitzman, ).…”

Improving maternal folate status to prevent infant neural tube defects: working group conclusions and a framework for action

“…Food fortification with folic acid is a cost‐effective intervention with the potential to cover the majority of the population in many countries . However, much work is needed to build new programs and improve industry compliance and effective coverage of existing programs.…”

“…Overall, the study concludes that folic acid fortification compares favorably with other well‐recognized life‐saving interventions, like insecticide‐treated bed nets and rotavirus vaccine. The report recognizes that more precise estimates will require better data on the costs of implementing fortification and on the costs of improving compliance where regulations are already in place …”

“…One of the key drivers for adopting and scaling up folic acid fortification is demonstrating the investment case for fortification to drive the political will to invest in it among a myriad of other competing priorities. Our review highlights that investment in folic acid fortification makes sound fiscal sense, with demonstrated health impact economic estimates on cost per death averted through mandatory fortification and cost per DALY …”

“…Food fortification with folic acid is a cost-effective intervention with the potential to cover the majority of the population in many countries. 20,21 However, much work is needed to build new programs and improve industry compliance and effective coverage of existing programs. Information is needed on the reach and effectiveness of folic acid fortification, and novel approaches should be considered to reach WRA, either through new fortification vehicles or other technologies where high coverage is not achievable through current programs.…”