Evidence Action — Bridge Grant for Iron and Folic Acid Supplementation Program (August 2024)

Note: This page summarizes the rationale behind a GiveWell grant to Evidence Action. Evidence Action staff reviewed this page prior to publication.

Published: April 2025

The intervention

IFA supplementation is done by providing oral supplements, in either syrup or tablet form.1 Evidence Action supports IFA supplementation programs that aim to reach school going children ages 5-19 years and children ages 6-59 months twice per week.2

We expect most of the benefits of this intervention to come from iron, rather than folic acid, supplementation.3 We think there is strong evidence that iron supplementation reduces cases of anemia and that there is weak to moderate quality evidence that iron supplementation, with or without folic acid, increases cognitive ability. We discuss the evidence for IFA supplementation in greater detail in our intervention report on iron supplementation.

We have several uncertainties about the evidence for iron fortification/supplementation programs, which we are currently working on addressing.4

The organization

Evidence Action provides technical assistance to the government to implement IFA programs. Since March 2018, we've directed approximately $13.7 million to support Evidence Action's technical assistance program for IFA supplementation in five Indian states: Haryana, Jharkhand, Madhya Pradesh, Rajasthan, and Uttarakhand.5

In January 2024, we made an additional ~$100,000 grant to support baseline surveys in two additional states, Karnataka and Tripura. The goal was for the survey findings to inform future decisions about supporting Evidence Action to expand its IFA program into those two states.

The grant

The baseline surveys we supported in Karnataka indicated that IFA coverage there is low, and there is room for improvement.6 As a result, Karnataka seems like a promising candidate for future Evidence Action support.

However, before we decide whether to provide further funding for IFA in Karnataka, we'd like to see results from endline surveys we funded in the five states we currently support.7 We expect endline surveys to provide a significant update to our understanding of the impact of the program. We expect to receive the results in March 2025.8

Evidence Action has been running another program, Deworm the World, in Karnataka and Tripura. When IFA and Deworm the World are implemented in the same state, they often share staff, due to similarities in how the programs are delivered and implemented.9 However, Evidence Action plans to exit Deworm the World in Karnataka in March 2025.10

This grant is a bridge grant to cover Evidence Action's costs in Karnataka for eight months. It will cover (i) the period between Deworm the World shutting down and when we expect to make a decision on whether to fund IFA and (ii) notice for staff, should we decide not to make a grant.

Budget for grant activities

The grant budget is for eight months:

• Two months of funding for the gap between Deworm the World winding down and GiveWell making a decision on funding IFA in Karnataka. Evidence Action told us they have funding for Deworm the World until March 2025.11 This is also when we expect to receive endline results from its program in Rajasthan, Madhya Pradesh, Jharkhand, Haryana, and Uttarakhand.12 We think we'll be able to use these results to inform a grant decision by the end of June 2025.
• Six months of funding to cover notice for Deworm the World staff, should we decide not to recommend additional funding for IFA in Karnataka.

The budget breakdown is:13

Budget
Karnataka: personnel costs	$41,827
Karnataka: other Costs	$2,713
Shared Direct Costs14 (14%)	$6,236
Fee15 (10%)	$5,078
Indirect costs (20%)	$11,171
Total	$67,024

The case for the grant

We are recommending this grant because:

• We think Evidence Action's program in Karnataka is highly promising. Although we're waiting for results from Evidence Action's before-and-after surveys, we think there's a good chance that we will want to fund the program in Karnataka. Baseline surveys we supported in Karnataka indicated that IFA coverage there is currently low, and there is room for improvement.16 Our current best guess is that it is at least as cost-effective as the program we funded in Rajasthan, Madhya Pradesh, Jharkhand, Haryana, and Uttarakhand in 2022, which we modeled as roughly 12 times as cost-effective as unconditional cash transfers.17 This is above our current funding bar of 10x cash as of March 2025.
• We believe that there is significant room for more funding for IFA in Karnataka. We think that a Karnataka IFA program might be able to use $3.6 million over 5 years.18
• We think this bridge grant will increase the likelihood that Evidence Action retains staff from their Deworm the World program, and therefore increase the effectiveness of future IFA programs if we decide to fund additional support. We think this is valuable because:
  • We expect setup costs to be lower, since Evidence Action would not need to recruit staff again.
  • We expect staff quality to be higher, since current Deworm the World staff have expertise and networks that would be relevant to IFA.

We are not recommending a similar bridge grant in Tripura. This is because we model the cost-effectiveness of Tripura as significantly lower (4x cash19 , due to difference in cost-per-person, which in turn is due to Tripura having a much smaller population than Karnataka) and so we think it is unlikely that we will fund IFA in Tripura in the future.

Risks and reservations

Our main reservations about this grant are:

• We may decide not to fund IFA programming in Karnataka after the bridge period. If the endline survey results from other states lead us to revise our cost-effectiveness estimates downward, or if other factors make the program less promising than we currently expect, we may decide not to recommend additional funding for IFA in Karnataka. This would mean the bridge funding did not lead to the expanded programming we think makes it worthwhile.
• Staff may leave despite the bridge funding. While we're providing this funding specifically to retain experienced Deworm the World staff for potential future IFA programming, staff might still choose to leave due to uncertainty about the program's future or other opportunities. This would mean the grant fails to preserve the expertise and networks we're trying to maintain.
• We might be underestimating the cost-effectiveness of Tripura. Our best guess is that at 4x cash, Tripura is unlikely to meet our funding threshold of 10x cash after we receive the results of the before-and-after surveys or conduct additional work on our cost-effectiveness model. We could be wrong about this (for example, if before-and-after surveys show larger positive effects than expected, combined with other updates to our model of the benefits of iron).
• We might be undervaluing the potential to learn from funding Tripura. We are interested in running an impact evaluation on the effect the IFA program has on anemia in Tripura and Karnataka. Not funding a bridge grant or future IFA programming in Tripura would mean not running an impact evaluation there.

  However, it's possible that we could fund an impact evaluation in other states. We're also unsure if Evidence Action will receive government approval to run the evaluation, so this is a somewhat speculative concern.

Plans for follow up

• We plan to review endline results from the coverage surveys in the five states we currently support and to make a decision on further funding in Karnataka by June 2025.

Internal forecasts

For this grant, we are recording the following forecast:

Confidence	Prediction	By time
60%	We recommend a >$2.5 million grant to support Evidence Action's IFA program in Karnataka.	December 2025

Our process

• We had several email conversations with Evidence Action.
• We completed a quick, back-of-the-envelope cost-effectiveness analysis of an IFA program in Karnataka and Tripura.
• We completed a shallow review of Evidence Action's impact evaluation concept note.

Relationship disclosures

None

Sources

Document	Source
Evidence Action, "Concept Note: Anemia Prevalence Surveys in IFA Expansion States in India"	Source
Evidence Action, “Deworm the World”	Source (archive)
Evidence Action, “IFA Staff List”	Source
Evidence Action, IFA investigation plan, 2022	Source
GiveWell, “Evidence Action — Coverage Surveys of Iron and Folic Acid Supplementation in Karnataka and Tripura, India (January 2024)”	Source
GiveWell, “Evidence Action — Impact Evaluation of Iron and Folic Acid Supplementation ("Phase 2")”	Source
GiveWell, “Evidence Action — Iron and Folic Acid (IFA) Supplementation in India (August 2022)”	Source
GiveWell, "Evidence Action Beta — iron and folic acid supplementation ('Phase 2')"	Source
GiveWell, “Evidence Action Beta — Iron and Folic Acid Supplementation”	Source
GiveWell, “GiveWell's Cost-Effectiveness Analyses”	Source
GiveWell, “Internal Forecasts”	Source
GiveWell, “Iron Supplementation for School-Age Children”	Source
GiveWell, “Room for More Funding”	Source

• 1

  "Iron supplementation is the oral consumption of iron-containing compounds, typically in pill form." GiveWell, "Iron supplementation for school-age children"
  "Based on the technical guidelines, children <5 are recommended to receive 2 doses of IFA syrup per week and children 5-19 years are recommended to receive one IFA tablet weekly." Evidence Action, IFA investigation plan, 2022 (unpublished)

• 2

  "With the IFA program, given it is a routine program that requires weekly/bi-weekly administration…" Evidence Action, IFA investigation plan, 2022 (unpublished)

• 3

  In the last grant we recommended to Evidence Action, we wrote, "In this report, we primarily discuss the effects of iron rather than folic acid.
  We have not carefully considered the potential benefits of folic acid as distinct from iron. Our understanding is that in some of the iron supplementation studies we rely on, folic acid is also part of the treatment. However, our rough impression from reviewing the folic acid literature is that most of the potentially important public health impacts of folic acid come from providing supplements to pregnant women to reduce birth defects,10 and we expect that pregnant women would be a small portion of beneficiaries targeted by this program.11
  To simplify our analysis, we have focused on the effects of iron. However, our analysis would be conservative if the public health effects of folic acid in this population are larger than we currently expect." GiveWell, "Evidence Action Beta — iron and folic acid supplementation ('Phase 2')"
  We are not aware of any further work on folic acid that has been conducted since.

• 4

  See this section of our previous grant page for more on the evidence behind IFA.

• 5
  • In March 2018, we recommended funding ($320,000) to the Evidence Action Accelerator to scope a technical assistance (TA) program for IFA supplementation in India.
  • Based on the results of this scoping work, we recommended a grant (approximately $3.4 million) in December 2018 to Evidence Action to scale a pilot of the IFA TA program and a grant in March 2019 ($800,000) to evaluate the program.
  • In August 2022, we recommended funding (approximately $9.2 million) to support the IFA TA program across five states in India (Haryana, Jharkhand, Madhya Pradesh, Rajasthan, and Uttarakhand).
  • $320,000 + ~$3,400,000 + $800,000 + ~$9,200,000 = ~$13,720,000.

• 6

  Source: unpublished conversations between GiveWell and Evidence Action.

• 7

  See additional details on these surveys in the "Plans for follow-up" section of this grant page.

• 8

  Source: unpublished conversations between GiveWell and Evidence Action.

• 9

  This understanding is based on a conversation with Evidence Action on April 4, 2022 (unpublished), and this IFA Staff List, which indicates shared staff with Deworm the World.

• 10

  Source: unpublished conversations between GiveWell and Evidence Action.

• 11

  Source: unpublished conversations between GiveWell and Evidence Action.

• 12

  Source: unpublished conversations between GiveWell and Evidence Action.

• 13

  Source: unpublished conversations between GiveWell and Evidence Action.

• 14

  Evidence Action’s shared direct costs cover finance, HR, operations, and administrative expenses for its India programs. These include national and state-level staff, office costs, and EAII-specific audit and legal fees. Costs are allocated monthly to projects based on actual program spending. Source: unpublished conversations between GiveWell and Evidence Action.

• 15

  EAII Advisors Private Limited (EAII) is a for-profit entity through which Evidence Action operates its programs in India. Due to India’s regulatory environment, many international non-profits set up for-profit subsidiaries to comply with local laws governing business operations. EAII handles the implementation of Evidence Action’s programs in India, including finance, HR, operations, and other administrative functions. Because EAII is structured as a for-profit entity, it is required to demonstrate that it operates like a traditional business, which includes applying a 10% fee on all direct costs. Evidence Action also consults tax experts regularly to ensure compliance with Indian business laws. Source: unpublished conversations between GiveWell and Evidence Action.

• 16

  Baseline results suggest that existing coverage of IFA supplements ranges from 14-26% depending on variant. It estimates that it projects that it will increase these coverage rates to 50-60% through two years of TA support. Source: unpublished conversations between GiveWell and Evidence Action.

• 17
  • Source for estimated cost-effectiveness of programs in Rajasthan, Madhya Pradesh, Jharkhand, Haryana, and Uttarakhand in 2022: GiveWell, Evidence Action IFA supplementation CEA, 2022
  • To date, GiveWell has used GiveDirectly's unconditional cash transfers as a benchmark for comparing the cost-effectiveness of different funding opportunities, which we describe in multiples of "cash” (more). In 2024, we re-evaluated the cost effectiveness of direct cash transfers as implemented by GiveDirectly and we now estimate that their cash program is 3 to 4 times more cost-effective than we’d previously estimated. (more)
  • For the time being, we continue to use our estimate of the effectiveness of unconditional cash transfers prior to the update to preserve our ability to compare across programs, while we reevaluate the benchmark we want to use to measure and communicate cost-effectiveness.
  • Note that a) our cost-effectiveness analyses are simplified models that are highly uncertain, and b) our cost-effectiveness threshold for directing funding to particular programs changes periodically. See GiveWell’s Cost-Effectiveness Analyses webpage for more information about how we use cost-effectiveness estimates in our grantmaking.

• 18

  Source: unpublished conversations between GiveWell and Evidence Action.

• 19

  This estimate for IFA in Tripura is the result of an unpublished internal analysis using the same basis as the figure for IFA in Karnataka above.