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Review Article
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
Submitted: 10 June 2025 | Published: 16 April 2026
About the author(s)
Pamela Vorster, Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and National Institute for Theoretical and Computational Sciences (NITheCS), Stellenbosch University, Cape Town, South AfricaAmanda S. Brand, Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
Celeste Naude, Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
Funeka Bango, Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
Gerald Manthalu, Department of Planning and Policy Development, Ministry of Health, Lilongwe, Malawi
Dachi Arikpo, Cochrane Nigeria, University of Calabar Teaching Hospital, Calabar, Nigeria
Tamara Kredo, Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
Lungiswa Nkonki, Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and Department of Public Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa
Abstract
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.
Keywords
Sustainable Development Goal
Metrics
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