Launching new anti-anaemia strategy without enough evidence could waste public funds, warn experts | India News
From fortification of rice with iron, as the focus shifts to double fortification of salt (DFS) with iron and iodine in a bid to tackle high incidence of anaemia, several public health experts have sounded a warning against introducing any intervention without enough evidence. The new national anaemia prevalence data is yet to be made public though the survey was completed in November 2025.In response to an RTI application, the National Institute of Nutrition had stated in September that the analysis of the data from the Diet and Biomarkers Survey of India (DABS-I) launched in December 2022 and completed three years later is still under progress. The DABS-I survey, now renamed Survey for Assessment of Markers of Population Health, Activity, Diet and Anthropometry (SAMPADA), has used venous blood samples or samples drawn from veins, said to be the gold standard to estimate anaemia. DABS-I, which covers only 2.6 lakh people in the survey, will give state level prevalence, unlike NFHS with a sample size of seven lakh, which gives district-level data.However, with the data from the survey not being made public, India has no anaemia data since the last NFHS survey in 2019-21. That NFHS survey showed an increase in anaemia over the last survey in 2115-16. The government rejected the anaemia data from the 2019-21 survey on the grounds that it used blood samples drawn from the tip of the finger, which studies have shown to be unreliable. The Comprehensive National Nutrition Survey (CNNS) of 2016-18 used venous blood samples. It showed lower prevalence of anaemia than the 2019-21 survey which was attributed to using venous blood samples. DABS-I/SAMPADA’s anaemia data, comparable to the CNNS survey data, is expected to show even lower prevalence. It could show whether areas where distribution of iron fortified rice was done successfully have witnessed significant reduction in anaemia prevalence.Tamil Nadu was a pioneer in distributing DFS through the school midday programme starting from 2004. Within a few years, it was expanded to include the public distribution system (PDS) and Integrated Child Development Services (ICDS). Yet, the NFH surveys of 2015-16 and of 2020-21 showed that more than 50% children and women of all ages in the state were anaemic. Over a quarter had moderate anaemia, while 3.5% of women and 1.8% of children up to 5 years were severely anaemic. While Tamil Nadu’s anaemia incidence is low compared to many northern states, it is much higher than in states like Odisha, Jharkhand, Kerala and Andhra Pradesh, according to the CNNS survey. Almost 41% of children in the 1-4 year age group and over 20% in the 5-9 year age group were iron deficient in TN, which is higher than the national incidence, showed the CNN survey.In 2017, DFS distribution started in Uttar Pradesh. A study funded by the Gates Foundation was conducted in May 2020 to ascertain evidence of effectiveness in use of DFS in large-scale programmes. It found that only two (Etawah and Auraiya) of the five intervention districts met the evaluability threshold of 50% DFS utilization. The study found that there was no difference in anaemia and iron deficiency anaemia (IDA) prevalence or in mean haemoglobin concentration between women of reproductive age in intervention and comparison districts. It concluded that DFS was effective in reducing risk of iron deficiency, but not anaemia or iron deficiency anaemia, among women of reproductive age. Some of the modest efficacy was attributed to supply chain interruptions over the course of the implementation period.Madhya Pradesh and Gujarat introduced DFS in PDS and ICDS in 2018. Despite an impact evaluation claiming high DFS uptake exceeding 90% in the two states, the NFHS-5 survey, which took place from January 2020 to April 2021 in Madhya Pradesh, two years after introduction of DFS in June 2018, found that the overall prevalence of anaemia in children (aged 6 months to below 5 years) had increased from 69% in the previous NFHS survey to 73%, of which 42% were moderately anaemic, while 3% were severely anaemic. About 27% of adult women had moderate anaemia, and 2% had severe anaemia. However, a survey in March 2021 to gauge the impact of DFS introduction commissioned by an international NGO, Nutrition International, which supports the introduction of DFS, claimed that there was a six-percentage point reduction in anaemia prevalence in the districts where baseline prevalence had been measured in 2018. Nutrition International’s website states that it is working with state governments “to increase the availability of fortified foods in social safety net programs” which means publicly funded programmes, where poor purchasing power of the consumers would not be a hurdle to DFS uptake.There is enough evidence to show that only about half the cases of anaemia are due to iron deficiency. Anaemia can also be caused by malaria, hookworms and other such worm infestation, other nutritional deficiencies, chronic infections, and genetic conditions. Apart from these, it can be caused by socio-economic factors such as underage or early marriage, adolescent pregnancy, untreated excessive blood loss during menstruation and under-nutrition.Even the government’s targeted intervention to address anaemia among pregnant women by ensuring consumption of iron folic acid, distributed for free as supplements, has done poorly. Over half the pregnant women in India consumed iron and folic acid for 100 days and less than 38% consumed it for 180 days, according to the 2023-24 NFHS. In high fertility states like Bihar and Uttar Pradesh, the share of pregnant women who took iron and folic acid was even smaller.“Very little is being done to address food availability, diversity and affordability; minimum wages; equitable land distribution; better employment and job opportunities; or even to make nutrient dense foods available at low costs or as subsidies. Fortification will only increase food costs and dependence on corporations, while reducing the shelf life of foods and taking away food sovereignty from communities,” said Dr Sylvia Karpagam, a public health expert, and Dr Veena Shatrugna, former deputy director of the National Institute of Nutrition (NIN) and Steering Committee Member of the Right to Food Campaign, in a statement flagging the problems with the universal use of DFS in social safety net programmes such as ICDS and the midday meal scheme.
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The government has already spent about Rs 2,700 crore on rice fortification every year for several years. Public health experts cautioned against one more universal scheme that could waste thousands of crores of rupees of public funds, which could be utilised for more localised evidence-backed interventions.
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