Folic Acid Fortifications in Rice and Wheat Reduce Neural Tube Defects-Associated Mortality and Disability in India: A Cost-Effectiveness and Cost-Benefit Analysis.

BACKGROUND: Mandatory folic acid fortification of staple foods has been shown to substantially reduce the prevalence of neural tube defects (NTDs). No economic evaluation has examined the potential impact of implementing universal folic acid fortification in India, where NTD prevalence remains relatively high and current fortification policies provide insufficient levels of folic acid for NTD prevention. OBJECTIVE: This study evaluated the cost-effectiveness and cost-benefit of mandatory folic acid fortification of wheat flour and rice in India to prevent NTDs. METHODS: We developed a decision-analytic model to estimate the cost-effectiveness and cost-benefit of mandatory fortification of wheat flour and rice with folic acid, compared with no fortification, for an annual birth cohort in India. The model incorporated the costs of premix, healthcare for treating spina bifida, and lost productivity from NTD-associated mortality and disability. Model inputs were derived from published literature and stakeholder consultations. Outcomes included NTD cases and deaths averted. RESULTS: Mandatory folic acid fortification was cost-saving, reducing per capita costs from USD 26.89 (INR 2,340) to USD 3.41 (INR 297). Fortification prevented an estimated 4.5 NTD cases and 3.3 deaths per 1,000 births. Savings from avoided healthcare expenditures and productivity losses resulted in a cost-benefit ratio of approximately 1:78. Results were robust across extensive sensitivity analyses including inadequate fortification compliance. CONCLUSIONS: Increasing folic acid levels in staple foods could substantially reduce NTD-associated mortality and disability while generating significant economic returns. These findings support strengthening India's national food fortification policies to achieve effective primary prevention of folic acid-preventable NTDs.