Fortify Health — General Support

Published: June 2018

Note: This page summarizes the rationale behind a GiveWell Incubation Grant to Fortify Health. Fortify Health staff reviewed this page prior to publication.

We have had the following conversations about updates on this grant:

• Brendan Eappen and Nikita Patel on September 18, 2018
• Brendan Eappen and Nikita Patel on December 14, 2018
• Brendan Eappen, Nikita Patel, and Dr. Urmi Bhattacharya on March 13, 2019
• Brendan Eappen, Nikita Patel, and Dr. Urmi Bhattacharya on April 19 and 25, 2019
• Brendan Eappen, Nikita Patel, and Dr. Urmi Bhattacharya on April 13, 2020
• Brendan Eappen, Nikita Patel, and Dr. Urmi Bhattacharya on July 20, 2020

The intervention

Mass fortification of wheat flour with iron involves adding iron to industrially produced flour in mills in order to decrease the prevalence of iron deficiency in the population. The World Health Organization (WHO) reports that iron deficiency is thought to be the most common cause of anemia,1 which can inhibit physical and cognitive development in children.2 The Global Burden of Disease estimates that in India, about 56% of children under five and 38% of the population in general have some degree of iron-deficiency.3

The organization

Fortify Health is a relatively new organization founded by members of the effective altruism community with the goal of creating a potential future GiveWell top charity. Fortify Health chose to prioritize micronutrient (iron, folic acid, vitamin B12) fortification work in India based on research by Charity Science and others suggesting this as a potentially highly cost-effective intervention with existing gaps that are unlikely to be filled by other actors.

Planned activities

Fortify Health plans to spend about a month identifying which Indian state it will initially work in, after which it will approach medium- to large-scale mills and offer to install fortification equipment and provide iron, folic acid and vitamin B12 premix. It also plans to hire a consultant to support government progress towards a mandate for iron, folic acid and B12 fortification of wheat flour in whichever state it ends up working in.

Key questions of our grant investigation

1. How cost-effective is iron fortification of wheat flour? Iron fortification of wheat flour in India appears to be a potentially highly cost-effective intervention; at scale, we estimate iron fortification could be 15x as cost-effective as cash transfers to people living in extreme poverty.4 We have not yet included the potential benefits of folic acid or vitamin B12 in our analysis. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally, due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible. We have spent less time working on this cost-effectiveness analysis than we have for our top charities. In our experience, modelled cost-effectiveness tends to decrease as we refine our estimates.
2. What is the value of adding a new organization to this space? There appears to be a large, unfilled gap for immediate iron fortification of wheat flour in India, and we are not aware of any other group planning to fill this gap. Other micronutrient groups we are aware of in India focus on different approaches to increase iron intake, such as supplementation, rice fortification, pursuing fortification in limited market channels, or working with government partners. We are uncertain whether there are good reasons to prioritize these different approaches. Given the high prevalence of anemia, we think it is plausible that multiple approaches could beneficially be used simultaneously, although we remain uncertain about the extent to which implementing both in the same population would reduce the effectiveness of each.
3. Do the founders of Fortify Health seem well-suited for this project? Fortify Health's founders appear highly aligned with GiveWell's reasoning style and values. They view this project as an experiment, and would be willing to wind down Fortify Health if it falls substantially short of their goals.
4. How will Fortify Health measure its success at the end of one year? We will evaluate the success of the grant after 1 year based on (i) our best estimate of how many people were reached by Fortify Health’s iron fortification efforts, and (ii) whether we feel confident in Fortify Health’s monitoring. At this stage, we are uncertain about the best ways to do this monitoring, but would want to see evidence that fortification equipment is being used, and flour is being fortified with the correct dosage.

Budget

Fortify Health expects its total first-year budget of $295,217 to break down as follows:5

• Contractor to assist states with introducing mandatory iron fortification standards: $40,000
• Other staff: $187,167 (full-time salaries for the two co-founders for a full year, plus four part-time contractors for roughly half a year)
• Equipment (premix and dosing equipment): $34,000
• Travel: $17,000
• Services and subscriptions (e.g. website, office space): $8,250
• Registration as a charity in India and legal fees: $4,000
• Contingency: $4,800

Risks and reservations

• Neither of Fortify Health's founders has previous experience with this program. We believe there is a significant chance (~50%) that Fortify Health will not end up partnering with any mills in its first year.
• While implementation success can be measured in terms of the (output-adjusted) number of mills that are successfully fortifying flour after a year, it is less clear how to measure a link between mass flour fortification and positive health outcomes. In particular, we are uncertain whether it would be necessary to run a randomized controlled trial (RCT) evaluating the health outcomes of Fortify Health's program before recommending it as a top charity, or if the existing evidence base for iron fortification is sufficiently generalizable to apply to Fortify Health’s program.
• Although Fortify Health plans to evaluate the output of fortified wheat flour, we are uncertain whether consumers will purchase and consume the flour in the quantities needed to ensure optimal dosing.
• The plans that Fortify Health has shared with us are somewhat less detailed than usual for Incubation Grant recipients. However, we think this is reasonable given the relatively early stage at which Fortify Health has approached us.
• We have not comprehensively reviewed other groups working on iron supplementation and/or fortification in India (although Fortify Health has provided us with some information). Given the low proportion of flour in India which is currently fortified (<10%, according to Food Fortification Initiative),6 it seems likely that there is room for more funding in this space, and we think it is unlikely that a deeper review of other groups would change this view.
• A new Cochrane review on iron fortification, scheduled to be released in 2018, may substantially affect our cost-effectiveness estimates.7

Internal forecasts

For this grant, we are recording the following forecasts:

Confidence	Prediction	By Time
35%	GiveWell makes another grant to Fortify Health to work on iron fortification in India	May 1, 2019
50%	Fortify Health completes installation of fortification equipment in at least one mill	May 1, 2019
20%	Fortify Health completes installation of fortification equipment in at least five mills	May 1, 2019
10%	Fortify Health becomes a GiveWell top charity	May 1, 2022
60%	GiveWell models Fortify Health as more than 10x as cost-effective8 as cash after updating our CEA based on the Cochrane review of iron fortification that is scheduled to be released in 2018	May 1, 2019

Plans for follow-up

We plan to check in with Fortify Health roughly every three months to discuss monitoring and evaluation and its progress relative to its plans.

Our process

Fortify Health approached GiveWell with its project proposal. Our investigation for this grant focused on the four key questions above.

Sources

Document	Source
FFI website, Regional Activity, India	Source (archive)
Fortify Health, Year 1 budget	Source
GiveWell, Iron fortification CEA	Source
IHME Global Burden of Disease tool, Dietary iron deficiency prevalence, 2016	Source
Peña-Rosas et al. 2014	Source (archive)
WHO, Health topics, anaemia	Source
WHO, The global prevalence of anaemia in 2011	Source

• 1

  “Iron deficiency is thought to be the most common cause of anaemia globally, although other conditions, such as folate, vitamin B12 and vitamin A deficiencies, chronic inflammation, parasitic infections, and inherited disorders can all cause anaemia.” WHO, Health topics, anaemia

• 2

  “Anaemia resulting from iron deficiency adversely affects cognitive and motor development, causes fatigue and low productivity and, when it occurs in pregnancy, may be associated with low birth weight and increased risk of maternal and perinatal mortality. In developing regions, maternal and neonatal mortality were responsible for 3.0 million deaths in 2013 and are important contributors to overall global mortality. It has been further estimated that 90 000 deaths in both sexes and all age groups are due to iron deficiency anaemia alone.” WHO, The global prevalence of anaemia in 2011, pg. 1

• 3

  IHME Global Burden of Disease tool, Dietary iron deficiency prevalence, 2016
  

• 4

  GiveWell, Iron fortification CEA, sheet "Consolidated model", cell H120

• 5

  See Fortify Health, Year 1 budget for a more detailed breakdown. (Note that this is an earlier version of the budget which does not include the $40,000 for a contractor to assist states with introducing mandatory iron fortification standards.)

• 6

  "In 2000, the Darjeeling district of West Bengal became the first place in India to fortify wheat flour. Now we estimate that 7.6% of the industrially milled wheat flour in India is fortified." FFI website, Regional Activity, India

• 7

  For the protocol for this upcoming review, see Peña-Rosas et al. 2014.

• 8

  Note: This prediction concerns only our cost-effectiveness estimate of the direct intervention at a scale of >20 mills or their equivalent output (roughly 233,600 metric tons of flour per year), not taking into account e.g. implementation risk or the benefits of supporting state efforts.