“The government is putting in place dedicated, preventive and promotive strategies to make India anaemia-free,” declared Preeti Sudan, secretary at the central ministry of health and family welfare, at the recently concluded 11th World Congress on Adolescent Health in New Delhi.

Making India anaemia-free is a tall order.

Anaemia is a condition in which a person has a lower-than-normal number of red blood cells or quantity of haemoglobin, which reduces the capacity of their blood to carry oxygen and can lead to a number of health problems, and even death. It is considered a severe public health problem if more than 40% of the population is diagnosed with anaemia. By that measure, anaemia in women and children has been a major problem in India for half a century.

Low haemoglobin levels lower productivity and cause illness and death, and thus impose an economic cost. The loss of gross domestic product to anaemia was estimated at $22.64 billion (Rs 1.50 lakh crore) in 2016, more than three times the health budget for 2017-18.

A flagship programme to address anaemia in women and children was introduced as far back as 1970, yet more than half the targeted population remained anaemic in 2015. As the health ministry ups its target to fully eliminate anaemia, IndiaSpend analyses the various strategies it must adopt to successfully fill the gaps in existing initiatives.

Anaemia prevalence

Men with haemoglobin levels of less than 13.0 grams (g) per decilitre (dL) are considered anaemic, as per World Health Organization norms. Women with levels lower than 12.0 g/dL are considered anaemic if they are not pregnant. Among pregnant women, levels lower than 11.0 g/dL signal anaemia.

Just over half (51%) of Indian women of reproductive age (15 to 49 years) are anaemic, according to the just-released Global Nutrition Report 2017. A similar number (53%) were estimated to be anaemic in the fourth National Family Health Survey (NFHS-IV) in 2015-16.

These estimates are only marginally lower than the 55% recorded in NFHS-III in 2005-06, and barely 10 percentage points lower than the 63.7% in a 1958 regional study, the earliest research on record in a WHO compendium.

A 1961 study conducted in present-day Telangana among children aged one to six found anaemia prevalence to be 52.2%. A pan-India study of the same age group in 2015 found the figure to be 58.4%.

Among men, 20% or one in five are anaemic, less alarming than the prevalence rate among women, but of no less concern. The fact that anaemia in men has not been addressed at all has kept the prevalence unchanged since 1958.

India's Anaemia Problem, 1958-2017
Segment Prevalence In %
1958 1961 2005-06 2015-16 2017
Women 63.7% NA 55.2% 53.1% 51.0%
Children NA 52.2% NA 58.4% NA
Men 22.3% NA 24.2% 22.7% NA

Source: World Health Organization (for 1958 and 1961); National Family Health Survey IV (for 2005-06 and 2015-16); Global Nutrition Report 2017. NA: Data not available.

Efforts so far

Nutritional deficiency is by far the most common cause of anaemia worldwide. Nearly half the cases of nutritional deficiency-related anaemia in India are caused by consuming too little iron. Inadequate intake of the vitamins B9 (folate) and B12 is also a frequent cause.

The flagship initiative to combat anaemia that started in 1970, the National Anaemia Prophylaxis Programme, concentrated on distributing iron and folic acid tablets among two vulnerable population segments--pregnant women, and children aged 1 to 5 years.

Despite the programme, iron-deficiency anaemia has remained India’s top cause of disability since 2005, IndiaSpend reported in October 2016. Disability in this context means the absence of good health. In fact, iron-deficiency anaemia was a bigger cause of disability in 2016 than in 1990, as per a new study in the medical journal Lancet.

Anaemia causes 20% of maternal deaths in India and was the associate cause in 50% of maternal deaths, IndiaSpend reported in October 2016. It causes low birth weight among babies, putting them at risk for lifelong issues involving cognitive development and physical growth. Anaemic children go on to earn 2.5% less as adults than their healthier peers.

Why anaemia persists

“Low political commitment” is the top reason that Sheila Vir, a public health nutrition specialist with over 30 years’ experience, cited in a conversation with IndiaSpend. “We have never taken the anaemia problem as seriously as we should have, and hence, we did not implement interventions effectively nor did we design interventions that looked at every possible means to enhance the dietary intake of iron such as food fortification in addition to iron and folic acid tablets.”

Taking issue with the name of the government’s foremost initiative to address anaemia, the National Anaemia Prophylaxis Programme, Vir explained that “prophylaxis” means preventive treatment, and said it was “non-serious” to think of the programme as merely a preventive intervention given India’s high rates of malnutrition and maternal mortality. “We needed and continue to need an all-out effort against anaemia to prevent as well as manage it,” she said.

Sustained advocacy helped to somewhat intensify the health ministry’s focus on anaemia. In 1991, the flagship programme was renamed National Nutritional Anaemia Control Programme and made part of the National Child Survival and Safe Motherhood Programme, which attempts to cater to the overall needs of mothers and children pertaining to health and disease. Dosages of iron-folic acid supplements were also increased.

Yet, anaemia persisted. The reason: The supplements failed to reach all the intended beneficiaries in adequate amounts, and not all beneficiaries who received the supplements actually ingested them.

Iron-folic acid supplements are meant to be distributed under the National Nutritional Anaemia Control Programme and the Weekly Iron and Folic Acid Supplementation (WIFAS) programme, an initiative introduced in 2013 to reduce adolescent anaemia, estimated to affect more than half of all adolescent girls and just under one in three adolescent boys.

Yet, among children aged 6-59 months, 95.4% were found not to be receiving iron supplementation during NFHS-III. Almost twice the proportion of urban children received the supplement as rural children, 7% as against 3.7%.

Fewer than one in three pregnant women have access to iron and folic acid supplements, according to NFHS-IV, even after the percentage of women consuming these supplements during pregnancy doubled between 2005-06 and 2015-16, from 15% to 30%.

Even three decades ago, experts had flagged this poor coverage, blaming gaps in availability of the supplement and health workers’ inability to identify potential beneficiaries. Inadequate and irregular supplies were the reason 81% of 487 pregnant women and 99% of children from 5,754 surveyed households did not receive iron and folic acid supplements, this 1990 study conducted in Andhra Pradesh and published in the Indian Journal of Paediatrics had found.

“The health functionaries were not properly oriented towards the programme, as many of them were not aware of all the beneficiaries under the programme,” the study said.

The situation had hardly improved by 2011, when this BMC Public Health study in Karnataka found poor coverage as well as disparity in distribution--children from poorer families were less likely to receive supplements, it found, a situation corroborated by NFHS-III.

In Bihar, this 2014 study found inadequate supply that varied widely across districts, while this 2016 Chandigarh-based study of pregnant women in Food and Nutrition Bulletin said stock-outs “pushed women to purchase iron and folic acid from chemist shops”.

A “new” plan

“Anaemia is a top priority of the government,” Ajay Khera, deputy commissioner for adolescent health at the central health ministry, told IndiaSpend. “We are committed to halve the prevalence of anaemia by 2025, which entails an annual decline of 5%.”

To better target anaemia prevention and treatment, the ministry is conducting a pan-India survey of 100,000 children and adolescents to check for vitamin B12 deficiency and worm infestation. A parasitic infestation can cause malabsorption of essential nutrients, which, in turn, can cause anaemia, which is why de-worming tablets are also distributed under the existing iron and folic acid supplementation programmes.

To improve the coverage of the WIFAS programme for adolescents, the ministry plans to use the Mid-Day Meal programme software that requires schools to update the number of beneficiaries every week. “We propose for schools to also report on the number of students being distributed the iron and folic acid supplements,” Khera said. “Through this, we aim to improve the coverage to 70-80%.”

Efforts to improve supply to women have been on since the launch of the National Iron Plus programme in 2013, under which the government provides supplements to all women of reproductive age irrespective of their haemoglobin levels and pregnancy status, unlike earlier initiatives.

What needs more emphasis is improved consumption; not all beneficiaries who receive these supplements consume them--often, they are unaware of the need to. At other times, they are put off by the side-effects such as nausea and dark stools.

As far back as 1996, a Task Force on Micronutrients (specifically iron and vitamin A) had emphasised the need for creating awareness to improve consumption of supplements. “We stressed information, education and communication as critical for creating demand for iron and folic acid and proposed the implementation of a mass communication plan,” said Vir, who was a member of the task force.

“If expectant mothers knew of the impact of anaemia on their baby, they would surely not forget to take the supplement,” Vir said. Anaemia hampers the development of the foetus’ brain while reducing the iron storage levels of newborns, impacting the child’s development. Low levels of folic acid can cause neural tube defects, which can affect the infant’s brain and spinal cord.

Informing women about the possible side-effects of these supplements, such as black stools and nausea, also helps improve compliance.

Creating awareness is particularly vital because anaemia can go undetected until it becomes severe. Milder forms of anaemia cause no symptoms, although severe anaemia--defined as haemoglobin levels below 8 g/dL in men and women who are not pregnant, and below 7 g/dL among pregnant women--can cause extreme fatigue, weakness, dizziness and drowsiness.

Greater awareness can boost community-wide demand for supplements, compelling wider distribution, as the experience of Assam shows: The state was able to halve anaemia in children, and reduce anaemia in women and men by a third between 2005-06 and 2015-16.

“Assam’s success is founded on mass education campaigns that informed the community about anaemia, making it a visible problem. People were explained what anaemia is, what it does, and how it can be cured,” said Khera.

Nevertheless, one in three Assamese children and close to half of its women were still anaemic in 2015-16, showing that Assam has much ground to cover still.

As does the rest of India. Two decades since the task force was constituted, general awareness about anaemia and the need to prevent it among young women remains low, Vir said.

Roughly one in four women surveyed in the Chandigarh-based study said they took iron-folic acid supplements with milk or tea, which hampers the absorption of the micronutrients, which are ideally consumed with foods rich in vitamin C.

Another 40% of women said they did not know why they were asked to take the tablets. And more than half the women who purchased supplements because of unavailability in government clinics ended up buying multivitamins or calcium supplements, highlighting the perils of inadequate awareness coupled with poor supply.

Perhaps a high-profile awareness campaign, along the lines of the Pulse Polio programme which has the actor Amitabh Bachchan as its brand ambassador, could be deployed.

However, it is in improving overall nutrition and eliminating hunger that the battle against anaemia will meet its toughest test. “Since vital micronutrients are found in nutritious food, in general, a diet that includes too few servings of fruits, vegetables, legumes and dairy can cause anaemia,” Prasanna Mithra P, associate professor, Department of Community Medicine, Kasturba Medical College, Manipal University, told IndiaSpend.

The just-released 2017 Global Hunger Index of the International Food Policy Research Institute (IFPRI) terms India’s condition hunger situation “serious”, as IndiaSpend reported on October 12, 2017. Eliminating hunger by 2030 in line with the Sustainable Development Goal under the United Nations Development Programme, will require wide-ranging and comprehensive interventions to create jobs and skill people to make them suitable for jobs on the one hand, as well as provide welfare support and benefits to correct market failures on the other, as IndiaSpend reported on October 14, 2017.

Another difficult terrain is of social attitudes; often, women’s nutritional needs are accorded the lowest priority. Women are the last to eat in traditional families, as IndiaSpend reported in July 2017, which reduces the amount of food women consume.

“First my husband and in-laws eat, then children, then I. Sometimes it happens that food is finished when it’s our turn to eat,” pregnant women from economically backward families, interviewed for the aforementioned Chandigarh study, said.

The need to change family food traditions is one more message to disseminate in mass anaemia-eradication awareness campaigns.

(Bahri is a freelance writer and editor based in Mount Abu, Rajasthan.)

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