Vitamin A Fortification in Uganda: Comparing the Feasibility, Coverage, Costs, and Cost-Effectiveness of Fortifying Vegetable Oil and Sugar

Abstract

Twenty-eight percent of Ugandan preschool children suffer from vitamin A deficiency. With vitamin A supplementation covering only a third of children under 5 years of age, fortification is essential to reduce their vitamin A deficiency-related disease burden. At present, the only widely consumed food in Uganda that is fortified with vitamin A is vegetable oil. To compare the feasibility, coverage, costs, and cost-effectiveness of fortifying vegetable oil and sugar with vitamin A in order to assess, from a public health policy perspective, whether sugar should also be fortified. The 2005/6 Uganda Household Budget Survey was used to analyze households' apparent consumption levels of sugar and vegetable oil and to model the additional intake of vitamin A, assuming the sugar and oil fortification levels are those set by the Uganda Bureau of Standards. The annual incremental private sector cost of vitamin fortification is US $555,668 for oil and US $2,644,765 for sugar. Assuming that oil and sugar fortification are both effective in reducing vitamin A deficiency by 30% among those who consume these foods, the estimated cost per disability-adjusted life year (DALY) averted is US $82 for sugar and US $18 for oil. Vitamin Afortification of vegetable oil is 4.6 times more cost-effective than vitamin A fortification of sugar. If sugar were to be fortified, the 17% of Ugandans who purchase sugar but do not purchase oil would become new beneficiaries of vitamin A fortification. This would increase the coverage of vitamin A-fortified foods by 31% and reduce the percentage of Ugandans without any coverage to 25%. Those most at risk for vitamin A deficiency-members of rural, poor households-would benefit disproportionately from the introduction of sugar fortification. Although the lack of information on the vitamin A deficiency status of consumers of oil and sugar precludes making definitive conclusions, the increased coverage and cost per DALY averted due to sugar fortification suggests-based on World Health Organization guidelines-that the Government of Uganda should pursue sugar fortification.