Fortify Health – Support for Expansion (December 2021)

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

Published: April 2022

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.1 The World Health Organization (WHO) reports that iron deficiency is thought to be the most common cause of anemia,2 and that this can negatively affect physical and cognitive development in children, productivity, and birth weight.3

In our current cost-effectiveness model for this program (further discussion below), we model three key benefits of iron fortification:4

1. Benefits from averting anemia-related morbidity (50% of the value of the program in our current model)
2. Cognitive benefits for children (6% of the value of the program)
3. Cognitive benefits for adults (44% of the value of the program)

More information on the evidence for iron fortification is in our intervention report.

The organization

Fortify Health pays for and installs the equipment needed to fortify flour and pays for premix (which contains the iron compound that is used as a fortificant) so that its partner mills can fortify flour at no additional cost.5 It partners with privately owned mills that produce flour that is sold at market prices to consumers.6

Fortify Health was founded in September 2017.7 As of November 2021, Fortify Health had signed contracts with 15 mills in three states (Maharashtra, West Bengal, and Madhya Pradesh).8 Of these 15, it had installed equipment in 12 and launched fortified products in 3.9

Fortify Health also intends to provide premix and equipment at no cost to mills producing atta for government programs, such as providing meals to children in residential schools for tribal children in the state of Maharashtra.10 While Fortify Health has been in conversation with the Tribal Development Department about fortifying atta for schools in the Amravati division, it has not yet partnered with mills who can potentially produce for schools or government programs.11

Planned activities and budget

During the 5-year period of the grant, Fortify Health plans to:

• Increase the number of open market mills it partners with over 3 years. Fortify Health projects that it will reach 29 open market chakki atta12 mills in Year 1 and expand to 83 mills by Year 3.13 The cost of this component is $6.3 million, which includes $5.9 million over 3 years with an exit grant of $0.4 million.14

  If Fortify Health has made sufficient progress over Years 1-3, we may consider Fortify Health for a further grant to continue expanding in years 4 and 5. Fortify Health estimates it could reach 154 mills by Year 5.15 However, given uncertainties about Fortify Health’s ability to scale, we are not recommending providing the full 5 years of funding up front.

• Begin partnering with mills producing for schools in Maharashtra and explore partnerships with mills producing for the public distribution system (PDS) over 5 years. Fortify Health plans to provide premix and equipment to millers serving atta in the Amravati division of Maharashtra.16 Fortify Health has told us that having 5 years of funding is necessary for cultivating partnerships with the government,17 so we have recommended committing 5 years of funding, rather than 3 years, for this government partnerships work. We have not vetted this claim from Fortify Health, and it’s possible we should instead provide funding over 3 years to start and provide the additional 2 years of funding once Fortify Health meets milestones for the number of partnerships with mills producing for schools. The cost of this component is $1.9 million over 5 years.18

  Specifically, Fortify Health projects that it will serve 1 mill supplying atta for one school year in Amravati division in Maharashtra in Year 1, 14 mills providing atta for all four divisions in Maharashtra by Year 3 and 16 mills in Year 4 and Year 5.19 Fortify Health anticipates that its work with millers producing for schools will allow it to deepen relationships with government officials, and it will try to leverage those relationships to partner with mills producing atta for the public distribution system (PDS)20 Fortify Health will have a floating partnership team that scopes these opportunities in Years 1-3.21

We have told Fortify Health that if they find additional mill partnerships that exceed their budget we would consider funding those opportunities as well.

Under this grant, Fortify Health may also scope at a shallow level opportunities to expand through providing open market fortification of maida (a white flour typically used in biscuits and western breads) and considering expansion into other countries as well.22 However, these opportunities will be prioritized below expanding its footprint in open market commercial chakki atta, ashram schools, and PDS. The budget covers scoping of these opportunities but does not cover any partnerships in these other areas.23 We expect to consider funding for these opportunities if they develop.

Fortify Health’s budget for expanding partnerships with millers producing open market chakki atta over 3 years breaks down as follows:24

• Staff salary: $3.5 million
• Equipment and premix: $1.6 million
• Mill operations: $215,000
• Travel and accommodation: $250,000
• Business and publications: $211,000
• Legal and sponsorship fees: $247,000
• Exit grant: $378,00025

The budget includes rolling over leftover funds from the previous incubation grant to Fortify Health.26

In general, we believe it is a good practice to offer exit grants to organizations we support, in order to:

• Enable the organization to remain operational long enough to seek out other sources of funding.
• Reduce potential harms to the staff, partners, and program beneficiaries of the organization which might result from a sudden shut down.
• Maintain a reputation as a responsible funder.

We’ve chosen to provide funding now which could function as an exit grant if we choose not to renew (rather than making an additional exit grant later) for a number of reasons:

• It allows us to account for the full expected costs of the grant up front, since we expect that we would either make an exit grant or renew funding after 3 years.
• It provides the charity with better visibility into its future funding situation.
• It reduces the potential for cash flow difficulties for the organization that might have arisen from the timing of exit or renewal grant disbursement.

Fortify Health’s budget for partnerships with schools and PDS over 5 years breaks down as follows:27

• Staff salary: $1.1 million
• Equipment and premix: $187,000
• Mill operations: $50,000
• Travel and accommodation: $180,000
• Business and publications: $279,000
• Legal and sponsorship fees: $91,000

Case for the grant

In short:

• Our best guess is that if Fortify Health is able to meet its targets for adding mills over the next 3 years, its cost-effectiveness will be within the range of programs we plan to recommend funding. (more)
• While cost-effectiveness is likely to be lower during the grant period, we think that by providing Fortify Health an opportunity to scale, this grant potentially opens up room for more funding at cost-effective levels in the future. (more)
• We think it will be straightforward to assess the success of this grant by monitoring how many mills Fortify Health is able to partner with over the grant period. (more)
• We believe Fortify Health has a reasonable chance at continuing to scale. (more)
• Fortify Health has shown progress in onboarding mills, including larger mills that affect more individuals and can absorb more funding, especially in the past several months. (more)
• We have a positive qualitative impression of the organization. (more)
• There do not seem to be other funders of this program. (more)

Cost-effectiveness

We quantify the value of this grant to Fortify Health based on both (1) cost-effectiveness during the incubation grant period and (2) the possibility that funding Fortify Health during this incubation grant period will enable it to continue to scale and, therefore, absorb additional room for more funding at cost-effective levels in the future.

How we use cost-effectiveness estimates in our grantmaking

After assessing a potential grantee's room for more funding, we may then choose to investigate potential grants to support the spending opportunities that we do not expect to be funded with the grantee's available and expected funding, which we refer to as "funding gaps." The principles we follow in deciding whether or not to fill a funding gap are described on this page.

The first of those principles is to put significant weight on our cost-effectiveness estimates. We use GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding gaps, which we describe in multiples of "cash." Thus, if we estimate that a funding gap is "10x cash," this means we estimate it to be ten times as cost-effective as unconditional cash transfers. As of this writing, we have typically funded opportunities that meet or exceed a relatively high bar: 8x cash, or eight (or more) times as cost-effective as GiveDirectly's unconditional cash transfers. We also consider funding opportunities that are between 5 and 8x cash.

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. 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 to other grants we have made or considered making, and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible. Our process for estimating cost-effectiveness focuses on determining whether a program is cost-effective enough that it is above our bar to consider funding; it isn't primarily intended to differentiate between values that are above that threshold.

Cost-effectiveness of Fortify Health’s program

We estimate that providing iron-fortified atta to adults and children leads to modest reductions in morbidity from anemia and iron deficiency and improvements in cognitive function at a very low cost per person. (See our intervention report on iron fortification and previous grant page on Fortify Health for more information.)

During the first 3 years of the grant to support Fortify Health’s open market partnerships, we estimate Fortify Health’s program will be roughly 5x as cost-effective as cash transfers to GiveDirectly.

If Fortify Health is able to meet its targets for the number of additional mills onboarded over the next 3 years, our best guess is that it will be roughly 8x as cost-effective as cash transfers to GiveDirectly.28 (We have not modeled cost-effectiveness of Fortify Health’s government partnerships work.)

Cost-effectiveness is lower during the initial years of the grant because (a) Fortify Health’s cost per person receiving fortified atta is higher than at scale, since its fixed costs are spread over fewer millers and, ultimately, consumers of atta, and (b) we assume there’s a reasonable chance Fortify Health is not able hit its targets for growth and, as a result, has a higher cost per person reached than estimated. (We assume there’s a 40% chance it takes twice as long as anticipated for Fortify Health to reach its targeted number of open market mills over 3 years.)29

Value of unlocked room for more funding for Fortify Health

We think that by providing Fortify Health an opportunity to scale, this grant adds further value by potentially opening up room for more funding at cost-effective levels in the future.

If Fortify Health is successful at scaling during the grant period, we may direct additional funding to them and away from less cost-effective programs we would fund counterfactually. We think there’s a 60% chance we decide to make an additional grant to Fortify Health following this incubation grant. We estimate that this possibility of providing additional grants in the future implies that this grant is cost-effective compared to others we will fund this year, excluding benefits of fortification during the incubation grant period. That analysis is based on a shallow value of information back-of-the-envelope cost-effectiveness estimate.

Key uncertainties

We have several uncertainties about our cost-effective estimate for Fortify Health:

• Our estimate of the cost-effectiveness of Fortify Health’s program in steady-state and during the grant period are based on a superficial update of our previous cost-effectiveness model of Fortify Health, and we have not addressed the uncertainties we had previously about this model or incorporated any additional evidence on fortification published since that report.
• We account for declines in cost-effectiveness if Fortify Health is unable to meet its targets for onboarding mills using a rough downward adjustment, based on rough guesses of likelihood it takes them twice as long to hit targets and percentage of costs that can be delayed.30 We have not yet tried to carefully model this adjustment.
• Consistent with our previous cost-effectiveness model of Fortify Health, the current model does not include some of the adjustments we typically include in more advanced CEAs, such as incorporating additional benefits and negative effects, downside adjustments, and funging (including the risk that some millers would fortify their flour even without this program).31 We are implicitly assuming these roughly cancel out.
• The cost-effectiveness model does not include the costs or benefits of Fortify Health’s plans to provide premix and equipment to mills producing atta for schools in Amravati or its plans to work with mills providing atta for the public distribution system. We have not yet tried to model this.
• This value of information cost-effectiveness analysis is especially rough and is based on parameters that we have a great deal of uncertainty about. We view this as a rough check on the value of the grant and a way to make sure we've considered key drivers of value. We do not put a lot of stock in the specific cost-effectiveness estimate provided.

Potential to scale

Fortify Health currently operates at a small scale, but we believe it has the potential to grow.

Fortify Health’s proposal is to grow Fortify Health to have an organizational budget of roughly $3 million per year by Year 3 and $4.5 million in 5 years.32 Fortify Health estimates it could reach 50%-60% of the total addressable market for open market commercial chakki atta over the next 10 years, which they estimate corresponds to $35 million annually in room for more funding, provided several “pre-conditions for success” are in place.33

These pre-conditions include Fortify Health being able to recruit a leadership team to help lead expansion, Fortify Health being able to reducing onboarding time for mills, sales of atta not changing because it is fortified (vs. unfortified), Fortify Health being able to continue finding millers interested in partnering, and government maintaining its current stance on wheat flour fortification.34

While we think it’s unlikely Fortify Health will reach $30 million per year within 10 years, we believe there is enough chance it continues to expand to justify the grant (see above).

This does not include the potential for partnerships beyond the open market with schools or the PDS, which Fortify Health will continue to explore during the grant period. These additional partnerships would increase room for more funding.

Track record

During the most recent incubation grant, Fortify Health was able to substantially increase its number of mill partnerships, though at a slower pace than initially predicted. The mills Fortify Health partners with also appear to be meeting intended targets for fortified iron per kg of atta, though we have some uncertainty about these estimates.

Mill partnerships

During the most recent incubation grant period, Fortify Health increased the number of mills it had established partnerships with from 4 mills (and signed contracts in 2 mills) in April 201935 to having signed contracts with 15 mills in three states (Maharashtra, West Bengal, and Madhya Pradesh).36 This includes signing agreements with 7 new mills since June 2021, 4 of which have large capacity (compared to 8 mills before June, 1 of which had large capacity), following the end of COVID-19 restrictions.37

However, Fortify Health’s expansion during the most recent incubation grant was slower than expected. Its current number of partnerships is between the upper and lower bound for Fortify Health’s plans (12 total partner mills, 20 partner mills). It had planned to hit these goals by July 2020. Fortify Health has indicated that this slower pace was driven in large part by the COVID-19 pandemic and other unforeseen issues.38

We view this reason for delay as plausible. We have also been particularly impressed by Fortify Health’s onboarding of larger mills over recent months39 and think there may be “network effects” that could allow the organization to expand more easily as it signs more agreements with mills, especially larger ones.

Fortification targets

Data shared by Fortify Health show that the 6 partner mills for which Fortify Health has reported information on iron per milligram of atta are meeting recommended targets on average.40 Fortify Health has indicated that these data are consistent with separate checks they do on the amount of premix added by millers. However, we have not explored these data in depth and have some uncertainties about scope for bias (since data are collected by monitoring and evaluation staff from Fortify Health)41 and the selection of samples used for testing.42

Ability to learn during the grant period

A primary reason for this grant is to learn about Fortify Health’s ability to continue scaling. We guess this will be straightforward to assess, based on the number of new mill partnerships from Fortify Health during the period (see below).

We may also request additional monitoring data to audit the quality of iron fortification process at partner mills, such as third-party audits of iron levels in fortified atta (see below).

Qualitative impressions

We have been impressed with Fortify Health’s value alignment and strong on-the-ground capabilities and knowledge. They have also been transparent with us about potential limitations of their program and factors that could worsen cost-effectiveness.

Lack of other funders

While we have not thoroughly explored other funding sources, our impression is that few other funders are interested in supporting the type of program Fortify Health provides. Our impression is also that it’s very unlikely millers would choose to adopt fortified flour on their own.43

Risks and reservations

• There’s a good chance Fortify Health will not be able to reach a large scale. GiveWell is currently prioritizing opportunities with high room for more funding (roughly $30 million or more annually). While Fortify Health has projected it could reach that mark in the next 10 years, this requires overcoming several barriers to scale identified by Fortify Health44 and we think it’s more likely than not that Fortify Health will end up operating at a smaller scale than the goal. We think the possibility that they could grow justifies the risk here and that, even at small scale, it could be cost-effective (see above).
• The organization is still relatively new and has not operated at a large scale. Fortify Health was founded in 2017 and its current leadership does not have experience running a large organization. As a result, Fortify Health has proposed expanding its executive team earlier than it had initially planned to include two experienced individuals in leadership roles.45 We guess it may also be beneficial to provide additional support to Fortify Health through consultants or others who can help advise on growth. This is not currently included in this grant, but we may consider adding funding for consultants on top of the current grant.
• There is a risk that the program becomes less effective as the organization scales. Fortify Health itself noted this concern.46 We guess this can be mitigated through the monitoring and evaluation data Fortify Health intends to collect on iron values in fortified atta and other data points, and we plan to assess this during the grant period.47
• Other efforts to address iron deficiency and anemia in India may reduce the need for Fortify Health’s program more than we’ve estimated. Our cost-effectiveness analysis incorporates downward adjustments to account for declines in iron deficiency and anemia over time, due to activities by the government or others to expand availability of iron-fortified foods, iron supplementation or other activities. This decline is based on extrapolating changes from 2013-2017.48 It is not based on modeling specific policy changes or other activities over the next several years. For example, Prime Minister Narendra Modi recently announced plans to provide fortified rice through the public distribution system (PDS) and the mid-day meal scheme (MMS) by 2024.49 If this leads to larger reductions in iron deficiency and anemia than we’ve forecasted, cost-effectiveness will be overestimated. Given our impression that wheat fortification is likely to be neglected and that wheat constitutes a significant source of consumption, we guess there will still be continued need for the program, but we haven’t tried to model this explicitly.50
• Atta produced by Fortify Health’s partner mills may be reaching individuals with lower rates of iron deficiency and anemia than we’ve estimated. Our cost-effectiveness analysis assumes that atta produced by Fortify Health’s mills reaches individuals who are in the top 60% of the wealth distribution and, in turn, have lower than average rates of iron deficiency and anemia.51 It’s possible that these individuals are even higher in the wealth distribution or have even lower iron deficiency and anemia, in which case cost-effectiveness would be overestimated. While we’ve tried to account for this with our best guess, this is an important area of uncertainty, and we may decide to commission an external survey of the demographics of those consuming atta produced by mills partnering with Fortify Health and what other sources of iron they have in their diets (see previous grant page on Fortify Health notes several uncertainties about the impact of iron fortification and the cost-effectiveness of Fortify Health’s program. We have not explored these uncertainties further for this grant, and it’s possible further investigation would lead to substantial changes in our assessment of the evidence and cost-effectiveness of Fortify Health’s program.
• Fortify Health may crowd out more sustainable approaches to wheat flour fortification. Some of the experts we spoke to about this grant noted that Fortify Health’s model of providing premix and equipment to mills is likely to require philanthropic funding indefinitely, rather than being able to “pay for itself” or be funded by the government longer term. We do not view this as a major concern, since our best guess is that Fortify Health’s program is a cost-effective way to reduce morbidity and improve cognitive outcomes and, as a result, is a good use of philanthropic funding, especially if other sources of financing are likely to support it and especially as we look for large funding gaps that need to be filled long term. However, it’s possible that Fortify Health is crowding out more sustainable approaches. We guess this is unlikely, since our impression is that millers are unlikely to adopt fortified flour on their own without strong incentives and we have not heard about government programs to fortify atta at a large scale, but we have not explored this issue in depth.
• It’s possible that policy-oriented approaches are a more cost-effective way to increase fortification. Our understanding is that the prevailing opinion among other organizations working in this space is that policy approaches, such as mandating iron fortification, or improving compliance with existing regulations are likely to have the biggest impact. We have not explored or tried to model these approaches in order to make an assessment about whether they are likely to be more or less effective than a program like Fortify Health. Fortify Health has told us it agrees that policy work is important, yet found that has shown itself to be insufficient for change in other fortification contexts; for this reason, they are focusing initially on implementation, which they believe may help with policy work later on.52 As a result, we’re uncertain about whether grants to Fortify Health would be better spent on more policy-oriented approaches.
• It’s possible we should only recommend funding for Fortify Health’s open market work, not its partnerships with mills producing for schools and government. We’re especially uncertain about Fortify Health’s work with mills producing outside of the open market, since Fortify Health has yet to partner with mills producing for schools or other government programs and since we have not yet modeled cost-effectiveness for this work specifically. We think funding for these government partnerships is worth the risk because it provides an additional avenue for Fortify Health to scale and because Fortify Health has told us they have been meeting with officials at the Tribal Development Department to plan for fortification of atta for schools.53 However, we think it’s plausible that we should only recommend funding for its open market work.
• Discontinuation of funding is likely to be more disruptive if Fortify Health scales more aggressively. We plan to provide an exit grant with a grant to Fortify Health that would enable it to wind down its operations if GiveWell were to discontinue funding. In addition, because one of the main criteria we’ll be looking at in deciding to provide additional funding is how successful Fortify Health has been at scaling, this risk of major disruptions due to discontinuation of funding is lower the more Fortify Health scales.

Plans for follow-up

We plan to assess the success of the grant based on how well Fortify Health is able to:

• Form new partnerships with the number of mills it intends to:
  • Open market: 29 total partner mills in Year 1, 53 in Year 2, and 83 in Year 354
  • Government programs: 1 partner mills in Year 1, 8 in Year 2, 14 in Year 3, 16 in Year 4, and 16 in Year 555
• Maintain its partnerships with current mills.
• Demonstrate that its partner mills consistently meet their targets for iron quantity in their fortified flour.
• Keep its cost per person reached with fortified atta sufficiently low that Fortify Health’s program is within the range of cost-effectiveness of programs for which we would recommend funding.

We also plan to monitor other iron fortification activities in India to assess whether there is a continued need for Fortify Health’s program.

Monitoring and evaluation

To enable us to track Fortify Health’s progress in increasing mill partnerships and ensuring fortification is occurring properly, Fortify Health plans to collect the following data for its partner mills:56

• Fortified atta production
• Sales of fortified and unfortified atta
• Quantitative values of added iron in atta samples
• The amount of premix used, relative to production
• Surveys of partner mills57

Fortify Health plans to collect data from consumers of open market fortified atta as well.58 Fortify Health plans to do qualitative interviews with consumers of fortified atta from mills which began fortifying 1 year previously to understand:

• How regularly they consume fortified atta
• Whether they are aware that they are consuming fortified atta
• How much atta they consume per day on average

In addition, Fortify Health will collect data from schools that it partners with. It will collect the following information monthly in a randomly selected 20% of schools in each division:

• Added iron in atta consumed at school
• Number of children consuming atta on day of visit
• How much atta is consumed on day of visit
• How much plate wastage occurs on day of visit
• Amount of fortified atta used in the school monthly for consumption vis-a-vis any leakages
• The school’s experience with fortified atta consumption and supply, storage quality of fortified atta59

We anticipate being able to combine information on quarterly organizational expenditure and fortified atta production to assess cost per person reached.

Additional data we may want to collect

We may also ask for a more intense level of monitoring, either from Fortify Health or in partnership with an outside evaluator. This might include:

• A representative consumer survey to help us understand, for example, demographic characteristics of those consuming atta produced by Fortify Health’s partner mills, other sources of iron in these individuals’ diet, consumption quantities, plate wastage, the consumption of inhibitors in beneficiaries' diets, and changes in the bioavailability of iron in flour stored in the household. Fortify Health has included in its proposal school-level surveys to address some of these questions. We have not yet explored similar surveys for consumers of open market fortified atta.
• Additional audits of the quality of iron fortification process at partner mills, such as third-party audits of iron levels in fortified atta.
• The collection of biomarkers (to directly monitor iron status in the blood), potentially as part of a randomized controlled trial.
• Information on the number of mills in the states that Fortify Health works in, and more detailed information about those mills' characteristics and activities (e.g. the proportion that are already fortifying flour).

Internal forecasts

Confidence	Prediction	By time
50%	Fortify Health has successfully signed agreements with at least 29 open market mills total by Year 1	July 2023
50%	Fortify Health has successfully signed agreements with at least 53 open market mills total by Year 2	July 2024
50%	Fortify Health has successfully signed agreements with at least 83 open market mills total by Year 3	July 2025
70%	Fortify Health has successfully signed agreements with at least 1 mill producing for schools total by Year 1	July 2023
60%	Fortify Health has successfully signed agreements with at least 8 mill producing for schools total by Year 1	July 2024
50%	Fortify Health has successfully signed agreements with at least 14 mill producing for schools total by Year 1	July 2025
20%	Fortify Health has successfully signed agreements to partner with at least one mill producing for the public distribution system total by Year 4	July 2026
20%	Fortify Health has successfully signed agreements to partner with at least one mill producing for the public distribution system total by Year 5	July 2027
85%	Laboratory tests from random samples of atta produced by Fortify Health’s partner mills do not fall more than 1 mg below the target (21.25 mg of iron per kg of wheat flour) in more than 25% of cases	July 2025

See our forecasts of annual average room for more funding for Fortify Health, 2025-2035 in this spreadsheet.

Our process

• GiveWell made an initial incubation grant to Fortify Health in June 2018.
• GiveWell made a subsequent incubation grant to Fortify Health in August 2019.
• GiveWell has had several check-in calls and received written updates from Fortify Health to discuss updates on progress since the August 2019 grant.
• As Fortify Health got close to spending down the August 2019 grant, GiveWell and Fortify Health discussed appropriate evaluation timelines and GiveWell’s increased focus on giving opportunities that can absorb a substantial amount of room for more funding.
• In November 2021, Fortify Health shared several options for an additional incubation grant that would permit learning about its ability to scale.
• In December 2021, GiveWell asked for additional information from Fortify Health on the additional incubation grant and conducted an expedited review of the grant.
• We also spoke to several experts with knowledge of wheat flour fortification with iron in India and elsewhere.

Sources

Document	Source
Fortify Health, "Introducing Fortify Health," 2017	Source (archive)
Fortify Health, “About Us,” 2020	Source (archive)
Fortify Health, Branched activities of Fortify Health	Source
Fortify Health, Email, December 4, 2021	Unpublished
Fortify Health, Menu of scale-up options, 2021	Source
Fortify Health, OPTION 1 MILL SIZES ABOVE 20 MT/DAY_ Open Market Miller Scale up Plan from 2022-2026	Source
Fortify Health, OPTION 5 MILL SIZES ABOVE 20 MT/DAY_ Open Market Miller Scale up Plan from 2022-2027	Source
Fortify Health, Pre-read for GiveWell, Dec 1. 2021	Source
Fortify Health, Quarterly operations document for GiveWell, 2021	Source
Fortify Health, Scale-up Plan (2022-2025), Nov. 9, 2021	Source
Fortify Health, Snapshot of government strategy options, 2021	Source
Fortify Health, Total Addressable Market [atta, maida, PDS], 2021	Source
GiveWell, Fortify Health – General Support (2019)	Source
GiveWell, Fortify Health Budget Summary, 2021	Source
GiveWell, Fortify Health iron fortification cost-effectiveness analysis, 2021	Source
GiveWell, Fortify Health value of information BOTEC, 2021	Source
GiveWell's non-verbatim summary of a conversation with Fortify Health, December 1, 2021	Source
GiveWell's non-verbatim summary of a conversation with Fortify Health, November 9, 2021	Source
India Today, "Why mandatory fortification of rice is ineffective against malnutrition," 2021	Source (archive)
WHO, "Health topics," anaemia	Source (archive)
WHO, The global prevalence of anaemia in 2011	Source (archive)

• 1

  “Fortification is the addition of vital micronutrients to food, usually staple foods such as flour or rice. Boosting consumption of these micronutrients, to ensure adequate intake is attained through the existing food supply, ensures long-term health benefits. Our focus is on reducing anaemia and neural tube defects, as well as the downstream consequences of these conditions.” Fortify Health, “About Us,” 2020

• 2

  "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

• 3

  "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

• 4

  Fortify Health, Iron fortification cost-effectiveness analysis, 2021

• 5

  "Fortify Health is funding the premix and equipment provided to millers for cost-neutral fortification." Fortify Health, Branched activities of Fortify Health, pg. 3. Fortify Health also indicated to us that it is funding a market awareness fund to absorb the cost of changing packaging labels because of fortification. Fortify Health, comments on a draft of this page, March 9, 2022 (unpublished).

• 6

  "[Fortify Health is] working directly with millers to fortify wheat flour (atta) that will be sold on the open market." Fortify Health, Branched activities of Fortify Health, pg. 2

• 7

  See Fortify Health, "Introducing Fortify Health," 2017 from October 2017.

• 8
  • “To date, we have active partnerships with fifteen mills.” Fortify Health, Quarterly operations document for GiveWell, 2021, p. 4.
  • “Eight of the fifteen partner mills are in Maharashtra, two are in West Bengal, and five are in Madhya Pradesh.” Fortify Health, Quarterly operations document for GiveWell, 2021, p. 5.

• 9

  Fortify Health, Quarterly operations document for GiveWell, 2021, Table 1, p. 3.

• 10

  “Year 1: Provide premix and equipment to fortify atta for one school year in Amaravti division of tribal development dept of Maharashtra. It also includes a cost of a floating partnership team to pursue fortification opportunities in PDS (state unknown).” Fortify Health, Snapshot of government strategy options, 2021

• 11

  “We plan to work with millers serving 4 divisions for ashram schools in Maharashtra. We anticipate that in year 1 (July 2022-June 2023) the government will extend chakki atta fortification in 1 division (amravati) and in years 2-5 to the whole division, given delays etc. We made the budget accordingly. We are working with the Tribal Development department and the ATC Amravati to secure a letter of support (which takes less time) or MoU (which takes a longer time), but we understand that even without these, the government will partner with us as they are currently doing (i.e. including Fortify Health in meeting with millers, working with the Tribal Development Department on drafting tendering guidelines of millers, working with Fortify Health to coordinate with various sub-departments for implementation of the project). Currently, the ATC Amravati is awaiting a letter from the department to start the tendering process of millers. We are coordinating with various sub departments within the Tribal Development Department to get that.” Fortify Health, Email, December 4, 2021 (unpublished)

• 12

  Chakki atta is another term for high-extraction wheat flour made in stone chakkis, a type of mill.

• 13

  Fortify Health, Menu of scale-up options, 2021, Total Number of Mills, “Option 1”

• 14

  Fortify Health, Menu of scale up options, 2021, Budget USD millions, “Option 1”

• 15

  Fortify Health, Menu of scale up options, 2021, “Option 5”

• 16

  “Provide premix and equipment to fortify atta for one school year in Amaravti division of tribal development dept of Maharashtra.” Fortify Health, Snapshot of government strategy options, 2021

• 17

  “Fortify Health would prefer a five-year timeline, because it believes this would allow it to cultivate government partnerships” GiveWell's non-verbatim summary of a conversation with Fortify Health, December 1, 2021

• 18

  Fortify Health, Snapshot of government strategy options, 2021, “TOTAL OPTION 1 BUDGET (USD MILLIONS)”

• 19 Fortify Health, Snapshot of government strategy options, 2021, “TOTAL NUMBER OF MILLS SUPPLYING IN GOVT PROGRAMS”
• 20

  Atta fortification in a public distribution system: “Fortify Health has also considered and is quite interested in the option of entering the world’s largest food safety net program - India’s Public Distribution System (PDS) - with its current model. Our current government partnership with the Tribal Development Department of Maharashtra will allow us to make inroads within government and demonstrate the acceptability of our program.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021 in Year 4 and Year 5.

  Fortify Health, Snapshot of government strategy options, 2021 Year 4 and Year 5

• 21

  “It also includes the cost of a floating partnership team to pursue fortification opportunities in PDS (state unknown). Fortify Health, Snapshot of government strategy options, 2021

• 22
  • Open market maida fortification: “One area of expansion Fortify Health has considered is to extend our mill partnership program to maida producers pan-India. In the medium-term, this would mean Fortify Health would include roller flour mills in our program, and cover the cost of fortification of maida across Indian states. Maida is low extraction, roller-milled refined white flour, with germ and bran completely removed, most typically used in biscuits and western breads. Local foods made with maida include naan, and fried snacks such as samosas.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021
  • Expansion to a new country: “Beyond India, we could also anticipate working in other countries at scale within the next 10 years, of which there are several promising opportunities initially considered in 2017.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 23

  “If Fortify Health were to receive this grant, expansion to maida or other countries would be prioritized below its work on atta fortification in the open market, schools, and PDS. The current budget covers scoping of these opportunities but does not cover any partnerships in these other areas.” GiveWell's non-verbatim summary of a conversation with Fortify Health, December 1, 2021.

• 24

  See this spreadsheet, “Open market” tab.

• 25

  The exit grant includes premix cost for new mills added in last year of funding and one personnel cost to manage premix delivery. “Exit Grant in Year 4 (July 2025-June 2026) (premix cost for new mills added in year 3 and one personel cost to manage premix delivery).” See this cell.

• 26

  “Do the budgets you’ve provided include rolling over current funds from GiveWell?
  “Ans: Yes, they include rolling over current funds from GiveWell.” Fortify Health, Email, December 4, 2021 (unpublished)

• 27

  See this spreadsheet, “Government” tab

• 28

  As of the writing of this page, we are primarily looking to recommend grants for funding opportunities that we estimate are 8 or more times as cost-effective as GiveDirectly's unconditional cash transfer program, and are willing to consider recommending a limited amount of funding to grants that are between 5 and 8 times as cost-effective as GiveDirectly. For examples of the cost-effectiveness of our recommendations, see here.

• 29

  This is incorporated in the cost-effectiveness analysis here.

• 30

  See this cell.

• 31

  Both Fortify Health and external experts we talked to noted that, due to low margins, millers are unlikely to fortify atta on their own and that governments would also be reluctant to pay the additional costs to fortify atta for schools or other government programs. As a result, we guess this risk is low, but we haven’t tried to quantify it yet.

  • “Historically, when the government has provided subsidies for fortification, millers have fortified, but due to low consumer awareness and demand, fortification has not continued after subsidies have stopped. Therefore, it is unlikely that millers will decide to fortify their own products without incentives from either the government or a group like Fortify Health.” GiveWell's non-verbatim summary of a conversation with Fortify Health, November 9, 2021, p. 5.

• 32

  Key projections and budget, Option 5, p. 12. Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 33

  “Assuming certain pre-conditions for success and if funding is not a constraint, we anticipate we would be able to reach 50-60% of the total addressable market of open market commercial chakki atta over the next 10 years. We anticipate that we would be able to reach 75% within 15 years.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021
  $35 million annually is from chart “Room for funding to saturate India’s commercial chakki atta market,” 50% saturation rate, Average of all sources. Fortify Health, Total Addressable Market [atta, maida, PDS], 2021

• 34

  See section “What pre-conditions need to be met for a) feasibility of option 1, and b) feasibility of reaching 75% saturation of open market commercial chakki atta pan-India?” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 35

  “As of March 2019, Fortify Health had verbally agreed to partnerships with four mills; in April 2019, Fortify Health confirmed that it had signed formal agreements with two of the mills and had installed fortification equipment in one mill.” GiveWell, Fortify Health – General Support (2019)

• 36

  “To date, we have active partnerships with fifteen mills.” Fortify Health, Quarterly operations document for GiveWell, 2021, p. 4.
  “Eight of the fifteen partner mills are in Maharashtra, two are in West Bengal, and five are in Madhya Pradesh.” Fortify Health, Quarterly operations document for GiveWell, 2021, p. 5.
  Table 1, p. 3. Fortify Health, Quarterly operations document for GiveWell, 2021,

• 37

  "In June 2021 Fortify Health opened up travel after India’s second COVID-19 wave, and completed the training of four new mill technologists on the program team. This meant we had a total of six in-house mill technologists who could conduct mill partner outreach and support. Since June 2021, we have been able to sign partnerships with seven new mills, four of which have a production capacity of above 100 metric tonnes per day and are based in Madhya Pradesh. Previously, we only had one mill of this production capacity." Fortify Health, Scale-up Plan (2022-2025), Nov. 9, 2021, pg 1.

• 38

  “Some mills with installed equipment have been unable to complete calibration because to fortify atta, they need at least two metric tons of flour, so they are waiting for large orders. The COVID-19 pandemic has also caused delays.” GiveWell's non-verbatim summary of a conversation with Fortify Health, December 1, 2021, p. 4.

• 39

  “New partnerships: Since our last update, we have signed a partnership with four new mills: Mill 15 (West Bengal), Mill 12 in Vidisha (Madhya Pradesh), Mill 14 in Indore (Madhya Pradesh), and Mill 13, Mandsaur (Madhya Pradesh).” Fortify Health, Quarterly operations document for GiveWell, 2021, pg 4

• 40

  Average added iron per kg of fortified atta (mg) in each mill is available here: Fortify Health, Quarterly operations document for GiveWell, 2021. Table 4, Table 6, Table 9, Table 7, Table 11, and Table 12.
  Average added iron per kg of fortified atta (mg) was 18.2 for Mill 1, 24.32 for Mill 3, 23.11 for Mill 5, 22.15 for Mill 4, 21.86 for Mill 9, and 19.94 for Mill 11, for an overall average of 21.60 mg of iron per kg of fortified atta.
  The target is 21.25 added iron per kg of fortified atta. "Demonstrate that its partner mills consistently meet their targets for iron quantity in their fortified flour (i.e. 21.25 mg of iron per kilogram)" GiveWell, Fortify Health – General Support (2019)

• 41

  “Currently, Fortify Health collects multiple sources of data from the mills it works with, such as daily data from mills on how much premix they have used per metric ton of atta and how much atta they have fortified. Consistency between rates of premix used and iron levels reported give Fortify Health confidence in the data. Fortify Health’s monitoring and evaluation staff also conduct checks of the data.” GiveWell's non-verbatim summary of a conversation with Fortify Health, December 1, 2021, pp. 4-5.

• 42

  “According to samples, iron added in operational mills is close to the target of 21.25 milligrams of iron per kilogram of fortified atta. GiveWell wonders if it is possible that this data is too well-aligned with the target to be accurate, but Fortify Health believes it to be accurate.” GiveWell's non-verbatim summary of a conversation with Fortify Health, December 1, 2021, p. 4.

• 43

  “Historically, when the government has provided subsidies for fortification, millers have fortified, but due to low consumer awareness and demand, fortification has not continued after subsidies have stopped. Therefore, it is unlikely that millers will decide to fortify their own products without incentives from either the government or a group like Fortify Health.” GiveWell's non-verbatim summary of a conversation with Fortify Health, November 9, 2021, p. 5.

• 44

  Barriers to scale include: “What pre-conditions need to be met for a) feasibility of option 1, and b) feasibility of reaching 75% saturation of open market commercial chakki atta pan-India?
  Team capacity pre-conditions

  1. Leadership team can recruit and manage x program teams
  2. Leadership team can grow to manage growth
     • Installation of a CSO and COO can boost leadership capacity

  Logistical pre-conditions

  1. Program team can successfully reduce onboarding time for mills from ten months to four - five months. (Fortify Health is addressing existing bottlenecks in onboarding already, and continuously innovating quickly around this.)

  Market response to intervention pre-conditions

  1. Sale of atta does not reduce because it is fortified (i.e. because consumers don’t like fortified atta, or because of organoleptic changes, etc.)
  2. There are enough big or influential players starting fortification, and creating network effects
  3. Fortification becomes more visible as more millers adopt fortification and are successfully selling atta with packets having +F logo at consumer and industry level
  4. The government maintains its current stance on wheat flour fortification with only minor changes to policy” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 45

  “To this end, we could expand our executive team earlier than otherwise planned to include two very experienced individuals as chief operating officer and chief strategy officer (with a scaling focus), who will remain qualified to lead the organisation at scale years later.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 46

  “On the one hand, we want to have maximal impact as soon as possible. On the other hand, we do not want to compromise too much on the quality and cost effectiveness of our program delivery (maintaining quality of hiring and internal processes, not disproportionately focusing on onboarding new mills over maintaining partnership with existing mills, allowing enough time for network effects to come into play, etc.).” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 47

  “Monitoring and evaluation under open market and government scale-up options.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 48

  See this cell.

• 49

  “Prime Minister Narendra Modi’s announcement in his Independence Day address that fortified rice would be distributed under the various government schemes--including the public distribution system (PDS) and the mid-day meal scheme (MMS)--by 2024 addresses a vital concern.” India Today, "Why mandatory fortification of rice is ineffective against malnutrition," 2021

• 50

  Both Fortify Health and external experts said the fragmentation of the wheat production makes government-led fortification challenging.

• 51

  See this cell.

• 52

  Fortify Health, comments on a draft of this page, March 9, 2022 (unpublished).

• 53

  “We plan to work with millers serving 4 divisions for ashram schools in Maharashtra. We anticipate that in year 1 (July 2022-June 2023) the government will extend chakki atta fortification in 1 division (amravati) and in years 2-5 to the whole division, given delays etc. We made the budget accordingly. We are working with the Tribal Development department and the ATC Amravati to secure a letter of support (which takes less time) or MoU (which takes a longer time), but we understand that even without these, the government will partner with us as they are currently doing (i.e. including Fortify Health in meeting with millers, working with FH on drafting tendering guidelines of millers, working with Fortify Health to coordinate with various sub-departments for implementation of the project). Currently, the ATC Amravati is awaiting a letter from the department to start the tendering process of millers. We are coordinating with various sub departments within the Tribal Development Department to get that.” Fortify Health, Email, December 4, 2021 (unpublished)

• 54

  Fortify Health, Menu of scale-up options, 2021, “Option 1”

• 55

  Fortify Health, Snapshot of government strategy options, 2021

• 56

  “Monitoring and evaluation under open market and government scale-up options.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 57
  • Production and fortification data collection: We will continue to collect data from each mill on:
    1. Monthly production for fortified atta
    2. Monthly sale of fortified and unfortified atta
    3. monthly premix reconciliation rates
    4. quantitative values of added iron by testing composite samples of fortified atta (using icheck). Fortify Health, Pre-read for GiveWell, Dec 1. 2021
  • Partner mill surveys: We plan to conduct a semi-structured survey with partner mills (and with millers who haven’t partnered yet) after one year, two years, and three years of rollout (or first contact) to better understand how millers perceive Fortify Health’s program, what elements of it work, what elements do not, and why. This data would ideally support us to improve intervention delivery. Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 58

  “Monitoring and evaluation under open market and government scale-up options.” Fortify Health, Pre-read for GiveWell, Dec 1. 2021

• 59

  “Random monthly observations: We will conduct monthly observations in a randomly selected 20% of schools in each division to understand:

  1. added iron in atta consumed at school
  2. number of children consuming atta on day of visit
  3. how much atta is consumed on day of visit
  4. how much plate wastage occurs on day of visit
  5. amount of fortified atta used in the school monthly for consumption vis-a-vis any leakages
  6. what has theen [sic] the schools experience with fortified atta consumption and supply, storage quality of fortified atta” Fortify Health, Pre-read for GiveWell, Dec 1. 2021