From Dietary Adequacy for Vitamin A in Children and Folate in Women to Children's Lives Saved in Cameroon: A Bioeconomic Model to Inform Cost‐Effective Policy Choices
Authors: Vosti Stephen A , Engle‐Stone Reina , Luo Hanqi , Kagin Justin , Clermont Adrienne , Walker Neff 
Published: November 2023

Background

While national vitamin A (VA) programs targeted to young children and folic acid (FA) programs targeted to women of reproductive age (WRA) are both expected to reduce child mortality, they are commonly designed and managed separately, and implemented uniformly nationally. Jointly managed, region‐specific vitamin A and folic acid programs could be more efficient, especially if mortality rates, cause‐specific mortality, and program costs differ spatially.

Methods

We predicted effective coverage (EC; proportion of individuals achieving adequate intake) of programs delivering VA to children and FA to WRA by modeling national dietary data and then “translated” the EC of separate and joint VA and FA programs into estimates of lives saved using the Lives Saved Tool. Program costs were estimated and a bioeconomic optimization model identified the most cost‐effective combinations of national and subnational programs over 10 y for achieving a set objective (the same benefits as existing national programs), using different outcomes: EC for VA, EC for FA, or child mortality.

Results

In the absence of interventions, the prevalence of inadequate intake varied by macro‐region (VA among children: 71.2% North, 32.8% South, 47.6% Urban; folate among women: 37% North, 65% South, 79% Urban). Mortality rates were greater in the North (119.8 deaths/1000 live births for children <5 y) compared to the South (87.5) and Cities (85.3), and within each region the total number of deaths preventable by VA (e.g., diarrhea) was predicted to be greater than that attributable to neural tube defects (preventable by FA). The results of the economic optimization model focusing only on EC of VA for children suggested shifting resources from a collection of national programs (fortified oil, VA supplements (VAS), and deworming delivered via Child Health Days) to a strategy that adds VA‐fortified bouillon cubes nationally, and focuses VAS distribution in the North macro‐region. The model for EC of FA programs for WRA suggested a national program of fortified wheat flour (rather than fortified bouillon cubes, which have greater reach but deliver less FA). The model for lives saved suggested further concentration of subnational VA programs in the North, and national VA fortification of oil and bouillon cube. FA fortification contributed little to mortality reduction compared to VA, so only inexpensive programs would be continued. Compared to continuing the current program portfolio for 10 y, the economically optimal strategy would save a similar number of lives nationally over a 10‐y period (by design) and do so at significantly lower cost (>50% reduction).

Conclusions

Economically optimal strategies for VA programs for children and for FA programs for WRA that independently focus on EC were similar to that for a joint VA and FA program that aims to save lives. Greater child mortality in the North macro‐region suggests that VA programs be concentrated in the North. Under these assumptions, FA was less cost‐effective than VA in saving lives. If the marginal cost of including FA in wheat flour is low, then the program could be continued; if not, then shifting to FA delivery via doubly‐fortified bouillon cubes may increase program efficiency.

Support or Funding Information

This analysis was supported by the Bill & Melinda Gates Foundation, the Michael and Susan Dell Foundation, and Sight and Life.