HSRAANZ 2019 Awards – Best Paper by an Early Career Researcher – Winner, Sopany Saing


Mandatory fortification of bread flour with folic acid is found to be a highly effective public health intervention that also improves equity of outcomes among Australian children.

Since the mid 1990's pregnant women have been recommended to take folic acid supplements to prevent neural tube defects such as spina bifida. In 2009 mandatory folic acid fortification of bread-making flour was introduced in Australia and was predicted to reduce the prevalence of neural tube defects by 14–49 cases per year.

Sopany Saing and researchers from the Centre for Health Economics Research and Evaluation at the University of Technology Sydney used real-world data to provide the first ex-post evaluation study of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. Equity in outcomes were demonstrated by larger reductions in the neural tube defect rate in babies of teenage mothers and Aboriginal and Torres Strait Islander mothers, both sub-groups who had the highest rates of neural tube defects prior to the introduction of the mandatory policy.

Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. A decision tree model was developed to compare different fortification strategies and used registry data to quantify the change in neural tube defect rates due to the policy. A societal perspective was adopted that included costs to industry and government as well as healthcare and broader societal costs. Mandatory folic acid fortification improved health outcomes and we found 32 fewer neural tube defects per year in the post-mandatory folic acid fortification period. Despite the high up-front cost to flour millers and bakers, the total cost of the policy was low per capita. Overall, mandatory folic acid fortification was highly cost effective. The study proves it is extremely likely mandatory fortification has improved health and reduced healthcare costs for the Australian population. This policy showcases the benefits of the healthcare system working with government and industry in delivering a public health approach. Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia. 2019

Applied health economics and health policy.

Authors: Saing S1, Haywood P1, van der Linden N2, Manipis K1, Meshcheriakova E1 & Goodall S1

1Centre for Health Economics Research and Evaluation, University of Technology Sydney

2Erasmus School of Health Policy and Management, Erasmus University Rotterdam