Ann. N.Y. Acad. Sci. ISSN 0077-8923
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES
Special Issue: Folate Status in Women and Neural Tube Defect Risk Reduction
The investment case for folic acid fortiﬁcation in
Division of Nutritional Sciences and Charles H. Dyson School of Applied Economics and Management, Cornell University,
Ithaca, New York
Address for correspondence: John Hoddinott, Division of Nutritional Sciences, Cornell University, Savage Hall, Room 305,
Ithaca, NY 14853. Hoddinott@cornell.edu
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.
Keywords: folic acid fortiﬁcation; neural tube defect prevention; economics; disability-adjusted life years; cost per
Neural tube defects (NTDs) are a signiﬁcant cause
of early-life (neonatal, infant, and under-ﬁve)
The two most common forms of NTDs,
spina biﬁda and anencephaly, can be prevented by
the consumption of folic acid during preconcep-
tion and early pregnancy.
Folic acid fortiﬁcation
has proved to be effective in reducing mortality and
morbidity associated with NTDs.
acid fortiﬁcation is common in many developed
and there exists guidelines and recom-
mendations for doing so.
Why then do developing
countries need an investment case for an interven-
tion that saves lives? 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. Consider a govern-
ment that can invest resources (money and time)
in supporting folic acid fortiﬁcation or purchasing
insecticide-treated bed nets that reduce child mor-
tality due to malaria. Both can save lives, but, given
a limited budget, will more lives be saved by invest-
ments in folic acid fortiﬁcation or by buying and
distributing bed nets? An investment case attempts
to shed light on questions such as these. If folic
acid fortiﬁcation compares well against alternatives,
there is a strong investment case for expanding folic
acid fortiﬁcation in developing countries.
Materials and methods
The investment case for folic acid fortiﬁcation
requires information on the beneﬁts of folic acid
fortiﬁcation, the costs associated with implement-
ing fortiﬁcation, and a means of bringing the two
together in such a way that it is possible to compare
these against alternative interventions.
Beneﬁts of folic acid fortiﬁcation
There is an extensive literature documenting the
impact of folic acid fortiﬁcation on NTDs; however,
there is considerable variation in the magnitude
of these impacts across and within countries.
Furthermore, the vast majority of these come from
Ann. N.Y. Acad. Sci. 1414 (2018) 72–81
2018 The Authors. Annals of the New York Academy of Sciences.
The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in
any medium, provided the original work is properly cited.