Optimizing vitamin A supplementation: A comparative cost-effectiveness analysis of routine distribution strategies in northern Côte d'Ivoire.

The total program cost for routine VAS delivery across two health districts in northern Côte d'Ivoire for July–December 2023 was 25.5 million FCFA, with personnel costs comprising over 70% of expenditures.

• The study covered two health districts: Ferkessédougou and Niakaramandougou in northern Côte d'Ivoire.
• The six cost categories assessed were: planning, procurement, training, social mobilization, distribution, and supervision.
• Personnel costs were the dominant cost driver, representing more than 70% of total program expenditures.
• The study period spanned July to December 2023.

In Ferkessédougou, the routine advanced community-based strategy was the most cost-effective approach in rural areas at 458 FCFA per child supplemented.

• The routine-fixed facility-based approach in the same rural areas of Ferkessédougou cost 596 FCFA per child supplemented.
• The advanced community-based strategy was approximately 23% less costly per child than the routine-fixed approach in rural Ferkessédougou.
• The advanced community-based strategy also achieved better geographic reach in rural settings.

In Niakaramandougou, the December catch-up strategy was more cost-effective in rural areas (606 FCFA per child) than the routine-fixed approach (714 FCFA per child).

• The catch-up strategy in rural Niakaramandougou cost 606 FCFA per child supplemented.
• The routine-fixed approach in rural Niakaramandougou cost 714 FCFA per child supplemented.
• The catch-up strategy was approximately 15% less costly per child than the routine-fixed approach in that district's rural areas.

Across both districts combined, the routine-fixed strategy averaged approximately 651 FCFA per child supplemented.

• This combined average of 651 FCFA per child for the routine-fixed strategy represents a pooled figure across both Ferkessédougou and Niakaramandougou districts.
• This figure reflects the overall cost efficiency of the fixed facility-based approach as a baseline comparison for the other strategies.

The cost per DALY averted ranged from 30,093 FCFA for the advanced strategy in Ferkessédougou to 89,550 FCFA for the catch-up strategy in Niakaramandougou (July 2023), with all values below Côte d'Ivoire's cost-effectiveness threshold.

• Côte d'Ivoire's cost-effectiveness threshold is defined as 0.5 × GDP per capita, approximately USD 1,265.
• The lowest cost per DALY averted (30,093 FCFA) was associated with the advanced community-based strategy in Ferkessédougou.
• The highest cost per DALY averted (89,550 FCFA) was associated with the catch-up strategy in July 2023 in Niakaramandougou.
• All three strategies — routine-fixed, advanced community-based, and catch-up — were found to be cost-effective by this threshold.
• A sensitivity analysis was conducted to test the robustness of findings under different cost scenarios.

VAS coverage was assessed using a post-event coverage survey (PECS) employing a two-stage cluster sampling methodology.

• The PECS methodology was used to measure VAS coverage across the two health districts.
• Two-stage cluster sampling was the sampling design for the coverage survey.
• Coverage data were collected alongside cost data to enable the cost-effectiveness analysis.

Côte d'Ivoire transitioned from mass campaigns to routine VAS delivery integrated into health services beginning in 2016, amid limited evidence on the cost-effectiveness of routine distribution approaches.

• The 2004 Côte d'Ivoire Nutrition and Mortality Survey reported that 26.7% of children aged 6–59 months were affected by vitamin A deficiency (VAD).
• Approximately 60% of children aged 6–59 months were at risk of VAD according to the same 2004 survey.
• The transition to routine delivery began in 2016, but evidence on cost-effectiveness of these routine approaches remained limited prior to this study.