Oral iron supplementation as a public health intervention in children aged 6 to 23 months for preventing iron deficiency and anaemia: Economic evaluation for the South African health system

Background: Anaemia prevalence among Southern African children aged 6–23 months was estimated at 65% in 2019. The World Health Organization recommends that children aged 6–23 months living in countries with an anaemia prevalence above 40% should receive preventive oral iron supplements. Aim: This study aimed to conduct a context-specific economic evaluation of oral iron supplementation in children aged 6 months – 23 months for preventing iron deficiency and anaemia in South Africa (SA). Method: We undertook a cost-effectiveness analysis (CEA), comparing preventive iron supplementation with no supplementation. Using a 1-year time horizon, we took a provider perspective and used circulating haemoglobin as the effectiveness outcome. The incremental cost-effectiveness ratio (ICER) was calculated as the cost per disability-adjusted life year (DALY) because of anaemia averted. A budget impact analysis (BIA) was carried out to estimate start-up and total annual costs of intervention implementation in SA. Results: The ICER (cost per DALY averted) was R1077.00 ($58.40); below a conservative context-relevant threshold (R62 916.00 [$3410.00]) (2024). Budget impact analysis estimated total costs over 2 years (2024–2025), excluding start-up costs, of R16.94 ($0.92) per child aged 2 years in SA, based on the CEA dosing regimen. Intervention costs (including start-up costs) represent 0.007% of the total health budget (2024). Conclusion: Preventive oral iron supplementation resulted in increased effectiveness for averting DALYs because of anaemia. Comparisons of the ICER with context-relevant thresholds suggested the intervention could be considered cost-effective in SA. Contribution: Our findings of potential cost-effectiveness and budget impact could be used to inform decision-making for primary healthcare resource allocation in SA’s health system.