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

Summary

Problem

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.

Solution

Iron deficiency and anaemia can be efficiently addressed by fortifying wheat with flour, which just means adding small amounts of iron to the flour as part of the milling process. 

Organisation

Fortify Health is an NGO operating in India that persuades millers to fortify their wheat, and then supports them with the equipment and the micronutrients mixes containing iron for free. They support fortification in the open market as well as with NGOs and the government.

Evaluation

Methods

We estimate the benefits of iron fortification by combining results for two groups. 

First, the short run effects on people who are anaemic. 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 of mothers who receive iron supplementation. This is based on one RCT of the 12 year effects of taking iron during pregnancy. 

Impact

We estimate the short run effects of iron fortification on people who are anaemic is 0.01 WELLBYs per person affected, affects 2,508,649 people with anaemia, and produces 33,853 WELLBYs. The effect on children in utero is 0.38 WELLBYs, affects 67,907 persons, and produces 40,620 WELLBYs. 

Cost

We estimate the average cost of Fortify Health providing a person with a year of fortified wheat flour is $0.54. The average expenditure is $3,185,243. Our cost calculations are averaged over forecasts for the next three years because Fortify Health is currently investing heavily in scaling.

Cost-effectiveness

The cost-effectiveness of Fortify Health is $46 per WELLBY. This means for every $1,000 donated, the organisation creates 22 WELLBYs.

Because Fortify Health seems likely and capable of realising further economies of scale, decreasing the unit cost of fortification, we expect the cost-effectiveness to improve over time. But, because of our given effect estimates, we don’t foresee this rising above 37 to 68 WELLBYs created per $1,000 donated.. 

Quality of evidence

Our quality of evidence assessment is stringent. We assess quality of evidence according to an adapted version of the ‘GRADE’ criteria, a widely-used and rigorous tool for assessing evidence quality across healthcare and research fields. The GRADE criteria for evidence quality are very stringent, so we expect very few interventions that we evaluate for wellbeing in LMICs (which tend to be less well-studied) will score more than ‘moderate’ on the quality of their evidence. Considering most decisions about charities are made with little-to-no evidence, this is a substantial improvement.

We characterise the evidence quality as low, and thus the analysis that’s based on it as speculative. This is particularly because the evidence is not very relevant to the intervention Fortify Health delivers. We have no direct evidence of iron fortification on wellbeing. Instead of relying on direct causal evidence, we have to extrapolate from other sources of evidence.

Depth of our analysis

We also rate the depth of work gone into creating this estimate as low. By this we mean that we believe we have only reviewed some of the relevant available evidence on the topic, and we have completed only some (20-60%) of the analyses we think are useful.  We’ve spent about 80 hours on this analysis.

Funding need

At the time of writing this, we believe Fortify Health could absorb $6.5 million for the next three years (mid 2025 to mid 2027). 

Conclusion

Based on the cost-effectiveness, we conclude Fortify Health is a ‘good buy’ for improving wellbeing globally, but not among the ‘best buys’ we’ve found so far.

Our conclusion relies on some thin evidence (1 RCT of the long-term wellbeing effects of in-utero exposure) and some speculative assumptions about several key parameters. 

On the organisational side we hold a positive view of Fortify Health. We are reasonably convinced by their theory of change. Generally, they seem to be a well functioning organisation that’s already scaled a complex technical enterprise while maintaining the quality of their operation. 

Given our uncertainty, we think it would be valuable to collect further causal evidence on the wellbeing effects of iron fortification.

Our reports so far

We have one shallow report on Fortify Health so far.