This is the summary of the report. Click the button above to read the pdf of the full report (29 pages).

Summary

Iron deficiency is the most common cause of anaemia, which impacts over 1.2 billion people worldwide. Anaemia often induces a sense of fatigue, tiredness or lethargy, which many consider a risk factor for depression. One way to address iron deficiency is through ‘fortification’, where vitamins or micronutrients are added to food to improve their nutritional content. Fortification is standard practice in high-income countries, but not universal in low-income countries.

In this shallow report, we spent around 90 hours examining the cost-effectiveness of an NGO, Fortify Health. Their model is to approach millers, persuade them to fortify their wheat, and then supply them the equipment and the micronutrient mixes required for free. They support fortification in the open market as well as with NGOs and the government – but we only focus on their open market programme here for simplicity. Fortification is, in general, very cheap, and only slightly increases the cost of flour. This means there’s a plausible case for iron fortification to be a very cost-effective way to improve wellbeing at scale, which is why we investigate it here.

This is part of our research to try and find the most cost-effective ways to increase wellbeing globally. We believe this report, alongside our analysis of Taimaka, is the first wellbeing cost-effectiveness analysis of a nutrition charity.

Why wellbeing? We evaluate charities with wellbeing-adjusted life years (WELLBYs). The metric is simple: one WELLBY equals a 1-point increase on a 0-10 life satisfaction scale for one year. WELLBYs allow us to impartially compare the impact of very different charities addressing very different problems. While not without limitations, we think it is the best way (yet) of measuring wellbeing.

We found sufficient evidence to estimate the benefit of providing a year’s worth of fortified wheat to two distinct groups.

First, people who are anaemic (40% of the population in India). We estimate providing a  year of fortified wheat flour has a 0.01 WELLBY effect for those in this group. This is based on 6 studies (4 correlational, 2 causal) of the link between anaemia and depression and 5 RCTs of the effect of wheat fortification on rates of anaemia.

Second, for children in utero, we estimate this provides a larger 0.4 WELLBY effect per person affected. This is based on one RCT of the 12-year effects of taking iron during pregnancy.

Ultimately, we estimate Fortify Health’s cost-effectiveness over the next three years to be 22 WELLBYs per $1,000 donated (WBp1k) or $46 per WELLBY. By comparison, we estimate this to be about three times as good as cash transfers (i.e., $132 per WELLBY; McGuire et al., 2022a). GiveDirectly is an NGO which provides cash transfers to impoverished households. We take cash transfers as a useful benchmark because they are a straightforward, plausibly cost-effective intervention with a solid evidence base. For more detailed and updated charity comparisons, see our charity evaluations page.

However, this estimate indicates that Fortify Health is about half as cost-effective as treating depression at scale (40 to 49 WBp1k, McGuire et al., 2024b). This leads us to conclude Fortify Health is a ‘good buy’ for improving wellbeing globally, but not among the ‘best buys’ we’ve found so far.

We compare Fortify Health to other charities and discuss our final verdict regarding whether we recommend it for funding on our website. At the time of writing this, Fortify Health could absorb $6.5 million over the next three years (mid-2025 to mid-2027).

Because Fortify Health seems likely and capable of realising further economies of scale, decreasing the cost of fortification, we expect the cost-effectiveness to improve over time. But given our effect estimates, we don’t foresee this rising above 37 to 68 WBp1k.

We rate our depth of analysis as low and the quality of the available evidence also as low (i.e., weak). Our main uncertainty is about the causal relationship between anaemia and mental wellbeing. We think it’s quite possible that any research (there currently is none we know of) on the causal relationship between iron fortification and wellbeing could change our minds about the cost-effectiveness of fortifying iron.