Iron Fortification through Universal Distribution of Double-Fortified Salt Can Increase Wages and Be Cost-Effective: An Ex-Ante Modeling Study in India

Abstract

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 considered a viable alternative, and the provision of double-fortified salt (DFS; with iron and iodine) has been mandated in public health programs. Limited evidence exists on its benefit–cost ratio. Objective In this study we sought to estimate the economic benefit in terms of increased wages in relation to introduction of DFS in reduction of anemia and the cost of doing so. Methods The economic benefit 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 impact of iron deficiency anemia (IDA) on wages was estimated using a Heckman Selection model and 2-stage least squares procedure. Benefit of DFS was estimated through increased wages attributed to anemia reduction compared with its cost. Results 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) than those without IDA. Additional iron intake through DFS was predicted to reduce prevalence of IDA (from 10.6% to 0.7% in men and 23.8% to 20.9% in women). The economic benefit–cost ratio of introducing DFS at a national level was estimated to be 4.2:1. Conclusions Iron fortification delivered through DFS under a universal program can improve wages and be sufficiently cost-effective for its implementation at scale in India.