Elsevier

Health Policy

Volume 83, Issues 2–3, October 2007, Pages 295-303
Health Policy

Cost-effectiveness of a folic acid fortification program in Chile

https://doi.org/10.1016/j.healthpol.2007.01.011Get rights and content

Abstract

Objective

Periconceptional intake of folic acid reduces the risk of neural tube defects (NTDs), a frequent birth defect that can cause significant infant mortality and disability. In Chile, fortification of wheat flour with folic acid has resulted in significant reduction in the risk of anencephaly and spina bifida. We investigated the cost-effectiveness implications of this policy.

Methods

We conducted an ex-post economic analysis of this intervention. Estimates of the effect of fortification in decreasing NTDs and deaths were derived from a prospective evaluation. The costs of fortification and provision of medical care to children with spina bifida in Chile were based on primary data collection.

Findings

The intervention costs per NTD case and infant death averted were I$ 1200 and 11,000, respectively. The cost per DALY averted was I$ 89, 0.8% of Chile's GDP per capita. Taking into account averted costs of care, fortification resulted in net cost savings of I$ 2.3 million.

Conclusion

Fortification of wheat flour with folic acid is a cost-effective intervention in Chile, a middle income country in the post-epidemiological transition. This result supports the continuation of the Chile fortification program and constitutes valuable information for policy makers in other countries to consider.

Introduction

Periconceptional intake of folic acid (FA) has been demonstrated to reduce the risk of having a fetus affected with anencephaly or spina bifida by 50–70% [1], [2]. Anencephaly and spina bifida are among the most common birth defects contributing to infant mortality and disability. In Chile, they together represent the second most frequent isolated type of birth defect after congenital heart disease [3].

In response to the evidence of a beneficial effect of periconceptional intake of FA, statements from USA, Europe [4], [5] and FAO/WHO recommended that all women of fertile age should consume 400 μg of FA daily to reduce the risk of NTDs. Several evaluations identified grain fortification as the most cost-effective way to increase consumption of folic acid [6], [7]. Studies show that fortification of cereals with FA significantly increases blood folate levels and is associated with reductions in NTDs [8], [9], [10], [11], [12].

In Chile, a wheat flour folic acid fortification program showed an increase in blood folate levels [13] and a decrease in the risk of NTDs [14], [15]. An ex-post economic evaluation of the program should provide useful information for policy makers in other countries where congenital malformations are an important cause of infant mortality.

Section snippets

Methods

We compared the strategy of fortification with the baseline alternative of no fortification. Other alternatives directed to increase FA intake such as promoting consumption of supplements were excluded from consideration because they were not in place during the period of evaluation. Consequently, improvements in folate intake and blood folate status and subsequent reductions in the risk of NTDs can best be explained by the implementation of the fortification program.

Birth defects surveillance

Results

Estimates of the numbers of cases, fetal and infant deaths prevented, and cost-effectiveness ratios for the different health outcomes are presented in Table 3, along with upper and lower bounds for the estimates. These numbers apply the incidence rates from the study sample of hospitals to all births in Chile during 2001. Fortification is calculated to have resulted in 175 averted NTD births per year, including 107 births with spina bifida and 68 with anencephaly. The estimated reduction in the

Discussion

A CEA evaluation provides information that allows the health sector to allocate resources to those programs in which the ratio of health benefits of the intervention to costs exceeds alternatives. In this analysis, we utilized data derived from prospectively designed evaluations on NTDs risks, morbidity, and mortality from our NTD registry in combination with cost data from program implementation to estimate cost-effectiveness ratios for health outcomes.

We have conducted a CEA of a wheat flour

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