Benefit-Cost Analysis of Introducing Double Fortified Salt for Control of Iron Deficiency Anemia in India

Abstract

Background: The alleviation of iron deficiency through iron supplementation has not effectively reduced anemia in India, mainly due to low compliance. Food fortification with iron is now considered a viable alternative, and the provision of double fortified salt (DFS, with iron and iodine) has been mandated in public health programs. Still, there is limited evidence on its benefit-cost ratio. Methods: The economic benefit, in terms of wages earned, of introducing DFS in India was derived using a series of mathematical, statistical and econometric models using data from national surveys capturing earnings and dietary iron intake of the population. Anemia status was predicted from data on dietary intake, sanitation and for women, menstrual losses. The association of iron deficiency anemia (IDA) and wages was estimated using a Heckman Selection model, followed by estimation of the benefit of DFS through increased wages attributed to anemia reduction compared to its cost. Findings: Men and women with IDA had lower wages (by 25·9%, 95%CI: [11·3,38·1] and by 3·9%, 95%CI: [0·0,7·7] respectively) compared to those without IDA. Additional iron intake through DFS was predicted to reduce the prevalence of IDA (from 10·6% to 0·7% in men; 23·8% to 20·9% in women). The economic benefit-to-cost ratio of introducing DFS at a national level was estimated at 4·2:1.InterpretationIron fortification delivered through DFS under a universal program, can improve wages and be sufficiently cost-effective for its implementation at scale in India. Funding: International Development Research Centre [grant number-108123]. Declaration of Interest: We declare no competing interests. Ethical Approval: For the primary study from Jharkhand, institutional ethics approval was obtained from both St. John’s Medical College, Bangalore, Karnataka, India and Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India. Informed consent was obtained from all the participants.