A Strategic Approach to the Unfinished Fortification Agenda: Feasibility, Costs, and Cost-Effectiveness Analysis of Fortification Programs in 48 Countries

Abstract

IntroductionOne-third of the world's population suffers from micronutrient deficiencies, due primarily to inadequate dietary intake. The World Health Organization (WHO) and the United Nations Food and Agriculture Organization (FAO) have identified food fortification, supplementation, nutrition education, and disease control measures as the four main strategies for improving dietary intakes [1]. Fortification-the addition of micronutrients to a processed food to improve the food's nutritional quality-is often regarded as the "easiest" of these four strategies to implement, for several reasons. First, by virtue of the fact that it piggybacks on an existing product market, fortification, to be successful, does not require changing food behaviors before it can have an impact. Second, it can have an impact in the short run. Third, once it is established, fortification affects people's micronutrient status without their having to make a conscious decision to "participate" in the program. Fourth, it is generally regarded as costeffective relative to the other three strategies [2]. Fifth, fortification is generally thought to be more sustainable Despite these appealing characteristics and the fact that there is considerable experience in implementation, progress in fortification, with the exception of salt iodization, has been slow. This has particularly been the case in middle-and lower-income countries,* due to a number of factors, including the following:** » Inadequate understanding and inadequate information about the significance of micronutrient deficiencies; » Private sector concerns about the public's acceptance of altered (i.e., fortified) food; » Inadequate understanding about what fortification will cost and who will pay (i.e., the incidence of the costs of fortification); » Uncertainty about the competitive impact of fortification-both within the same product market and on substitute products due to fortification-induced higher relative costs and prices; » The distinct and largely nontraditional types of activities that are required by governments to initiate, implement, monitor, and maintain a mass fortification program; » Little understanding of the potential coverage of such a program; » Lack of understanding of the impact of micronutrient deficiencies (hidden hunger) and the potential benefits-i.e., the public health impact-that a fortification program could be expected to produce. This study attempts to address several of these factors and thereby help to accelerate the rate of progress of introducing fortification and reducing micronutrient deficiencies. The paper presents an analysis of the feasibility, cost, and cost-effectiveness of fortifying four food vehicles-wheat flour, maize flour, vegetable oil, and sugar-in 48 high-priority countries and discusses how these results and other criteria might be used to devise a strategy for addressing the unfinished fortification agenda. Selection of countriesTo identify priority countries, a series of countryranking analyses was undertaken using six "need" c...

Health economics and nutrition: a review of published evidence

“…To date, the most comprehensive study pertaining to the economics of micronutrient food interventions identified the feasibility and cost‐effectiveness of 122 food fortification strategies in 48 countries 24 . To address the criticism that the cost estimates of previous studies are out of date, not sufficiently detailed, and lacking in rigor, the authors estimated the cost‐effectiveness analysis of micronutrient‐fortified foods in those countries by building upon an existing model 25 .…”

Improving nutrition through biofortification.

“…Ex post results on the cost-effectiveness of biofortification are currently limited to OSP in Uganda. These results show biofortification to cost US$15-20 per DALY saved (HarvestPlus, 2010), while for the same country the cost of vitamin A sugar fortification is US$56 per DALY saved (Fiedler and Macdonald, 2009) and the cost of vitamin A supplementation is US$52 per DALY saved (WHO, 2018).…”

Fortification of condiments with micronutrients in public health: from proof of concept to scaling up

“…Taxes and duties on fortificants will significantly affect costs, unless increased demand leads to higher volume and economies of scale, and government subsidies may mitigate the costs to protect consumers. In order to ensure sustainability of a fortification program, the structure, funding, and subsidy mechanism must be defined early when planning the program …”

“…In order to ensure sustainability of a fortification program, the structure, funding, and subsidy mechanism must be defined early when planning the program. 32 There are multiple, potentially complementary, approaches to combat micronutrient deficiencies. Any nutritional intervention should focus on working on the structural causes of malnutrition.…”