Why More Than Half the Population of India Remains Anaemic Despite Years of Intervention

• Anaemia prevalence estimates will now come from the Indian Council of Medical Research's (ICMR) Diet and Biomarkers Survey.

• For decades, India's anaemia strategy has been built around a relatively straightforward assumption: that anaemia is primarily an iron deficiency problem.

• Anaemia is a condition with multiple causes. Public health programmes should move beyond a one-size-fits-all approach.

When the National Family Health Survey (NFHS-6) released its latest findings this year, one key statistic was missing. For the first time in years, India did not receive a national estimate of anaemia, a condition that continues to affect more than half the country's women and children despite years of government intervention. The omission was deliberate. According to officials in the ministry of health and family welfare, haemoglobin testing was dropped over concerns about the capillary blood sampling method used in earlier surveys.

Instead, anaemia prevalence estimates will now come from the Indian Council of Medical Research's (ICMR) Diet and Biomarkers Survey, which uses venous blood sampling, considered the gold standard for accuracy, according to government sources.

But the missing number has done more than leave a statistical gap. It has reopened a fundamental debate about how India understands anaemia itself. 

Are We Estimating Anaemia Correctly?

The decision to exclude anaemia estimates from NFHS-6 was linked to the Indian Council of Medical Research's Diet and Biomarkers Survey in India (DABS-I), launched in December 2022 and later renamed SAMPADA. Conceived as a broader assessment of India's nutritional health, it examines diet, physical activity, obesity, diabetes, micronutrient deficiencies and other biological markers using more accurate methods.

Conducted across 183 districts and covering more than 81,000 households and 2.6 lakh individuals, the survey collected around 1.76 lakh venous blood samples, considered more accurate than the finger-prick method used in NFHS surveys. Its findings are yet to be released. According to Dr. Harshpal Singh Sachdev, paediatrician, nutrition epidemiologist, former member of the World Health Organisation (WHO) Guideline Development Group on anaemia, and adviser to several national nutrition and anaemia task forces, earlier surveys may have overstated India's anaemia burden because of methodological limitations.

The gold standard for diagnosing anaemia, he says, is haemoglobin estimation from venous blood analysed on an automated haematology analyser, used in laboratories to measure and size blood cells. He points to the Comprehensive National Nutrition Survey (CNNS) 2016–18, one of the largest studies of micronutrient deficiencies and malnutrition conducted in India. Led by the Health Ministry with support from Unicef and the Population Council, the survey covered more than 1.1 lakh children and adolescents across rural and urban areas in 30 states and relied on venous blood samples.

Its findings painted a different picture from later NFHS estimates. Anaemia prevalence exceeded 50 per cent among children below two years of age but declined steadily through childhood, reaching around 15 per cent by age 11. Among adolescents, girls continued to bear a significantly higher burden, with about 40 per cent found to be anaemic compared with roughly 18 per cent of boys. Overall, CNNS reported substantially lower anaemia levels than those later recorded in NFHS-5, adding weight to concerns that differences in blood collection methods may be influencing national estimates.

By contrast, NFHS-5 reported much higher levels of anaemia across age groups: 67.1 per cent among children aged 6–59 months, 59.1 per cent among adolescent girls aged 15–19 years, 57 per cent among women of reproductive age, and 52.2 per cent among pregnant women. Even among males, NFHS-5 estimated anaemia prevalence at 31.1 per cent among adolescent boys and 25 per cent among men aged 15–49 years.

“Without precise estimates, we may draw incorrect conclusions about the scale of the problem, whether programmes are working, or what is causing anaemia,” Sachdev adds. 

Beyond Iron Deficiency

For decades, India's anaemia strategy has been built around a relatively straightforward assumption: that anaemia is primarily an iron deficiency problem and, therefore, iron supplementation should be the centrepiece of the response.

That assumption shaped some of the country's largest public health interventions, from iron-folic acid supplementation programmes to the launch of Anaemia Mukt Bharat (AMB) in 2018. Millions of tablets are distributed annually through schools, anganwadis and health centres. According to data presented in Parliament in August 2024, 95 per cent of registered pregnant women and 65.9 per cent of lactating women received the recommended 180 iron-folic acid tablets under AMB during 2023-24, with national supplementation coverage rising from 35.5 per cent in 2018-19 to 57.6 per cent in 2022-23.

"People tend to think anaemia equals iron deficiency. That is not necessarily true," says Dr Soumya Swaminathan, former WHO chief. "Iron is important, but it is only one part of the picture.”

Emerging evidence suggests the picture may be considerably more complicated than policymakers once assumed.

According to Swaminathan, haemoglobin production depends on much more than iron alone. Protein, vitamin B12, folate and other micronutrients all play critical roles. A woman consuming a poor-quality diet, suffering repeated infections or living with chronic inflammation may remain anaemic despite receiving iron supplementation.

Analyses from the CNNS survey have also challenged the long-held belief that iron deficiency explains most anaemia in India. Sachdev says the contribution of iron deficiency varies substantially across populations. According to a study published in the European Journal of Clinical Nutrition in January 2025, conducted across eight Indian states, iron deficiency accounted for less than a third of anaemia cases, with other factors contributing to the majority.

"In some groups, iron deficiency may account for around half the anaemia burden. In others, it may explain only 15 to 20 per cent," says Sachdev, who was also part of the study.

The implication is significant. The remaining burden may be driven by a combination of deficiencies in vitamin B12 and folate, recurrent infections, inflammation, haemoglobin disorders such as thalassemia and sickle-cell disease, poor dietary diversity, environmental exposures and underlying health conditions.

“There is also inadequate public awareness about dietary practices that improve iron absorption. For example, consuming vitamin C-rich foods such as lemon, guava or oranges alongside iron-rich foods enhances iron absorption. Small, science-based dietary changes can make a significant difference,” says Swaminathan.

This does not mean iron supplementation is unnecessary. But experts argue that India's understanding of anaemia has evolved faster than its policy response.

William Joe, Associate Professor at the Population Research Centre, Institute of Economic Growth, and a member of NITI Aayog's nutrition strategy working group, argues that anaemia should no longer be viewed solely as an iron-deficiency problem. While iron remains the most well-established cause and continues to warrant policy focus, he says emerging evidence on other nutritional and non-nutritional causes should gradually inform future interventions.

Sachdev also points to environmental factors that can add to the anaemia burden, also flagged by Swaminathan. “A revised anaemia strategy should incorporate newer evidence on pollution, climate, infections and other contributors,” he says.

Recent studies, though limited, have linked long-term exposure to air pollution with lower haemoglobin levels and higher anaemia risk, including among Indian women. Researchers believe chronic inflammation caused by pollutants may interfere with the body's ability to utilise iron. A 2025 study by researchers at IIT Delhi found that women exposed to higher levels of air pollution faced a greater risk of anaemia, even when air quality remained within the same official Air Quality Index category. The study also found that the impact was more pronounced among poorer and less educated women. Evidence on heat exposure is less developed, but scientists are increasingly examining whether rising temperatures and heat stress could also influence haemoglobin levels and contribute to anaemia.

The most important shift, however, Sachdev says, should be towards greater precision, both at the national and local levels. “Anaemia patterns differ dramatically across states, districts, rural and urban areas, and population groups.”

Experts believe that the main lesson is that we need more precision. Anaemia is a condition with multiple causes. Public health programmes should move beyond a one-size-fits-all approach.

Women Behind the Numbers

The "6x6x6" strategy of AMB is aimed at reducing anaemia across six beneficiary groups through six interventions, including iron-folic acid supplementation, deworming, screening, behaviour change campaigns and food fortification through different health schemes.

Implementation has expanded considerably over the years and service delivery has remained, but gaps still remain. According to Unicef, nearly two-thirds of pregnant women still did not receive deworming medication despite improvements since 2015-16.

"Giving medicines is one thing," says Usha, an Asha worker. "Whether they take them, and whether they have enough food to eat, is another."

For many experts, anaemia in India is as much a story of gender inequality as it is of nutrition. ASHA workers and anganwadi workers see it every day. Women receive iron-folic acid tablets, but many struggle to afford nutritious food. Others juggle household responsibilities, childcare and work, leaving little time to prioritise their own health.

"The main issue is food," Usha, an Asha worker, says. "If a person has no food at home and is struggling physically, mentally and financially, what difference will a tablet alone make?"

Discussions around anaemia often overlook the realities of women's lives.

Poonam Muttreja, executive director of the Population Foundation of India, argues that anaemia reflects deeper inequalities within households and communities. Early marriage, adolescent pregnancy, unequal food distribution and women's limited decision-making power all contribute to the problem, she says.

"Anaemia cannot be significantly reduced without addressing social norms around women that are often underestimated," Muttreja says. Programmes that focus only on supplements while ignoring food access, workload, mobility, counselling and social norms are likely to have limited impact, she argues.

While programmes focus on tablets, testing and targets, social attitudes determine whether girls receive adequate nutrition, whether menstruation is openly discussed, whether women seek treatment, and whether chronic fatigue is recognised as a health problem rather than accepted as part of everyday life.

Experts say poverty compounds these challenges. Rising food prices have pushed many families towards cereal-heavy diets, while consumption of pulses, fruits, vegetables and animal-source foods remains inadequate. Seasonal migration, poor sanitation and repeated infections can further undermine nutritional status and the body's ability to absorb nutrients.

For researchers such as Dr. Kapil Yadav, the persistence of anaemia points to the limits of a health-sector-only approach. It is intertwined with food security, education, sanitation, gender norms and economic inequality. While supplementation and screening remain important, he says lasting reductions will require multiple ministries, from health and education to agriculture and women and child development, to work in tandem more aggressively.

As Swaminathan puts it, "You cannot solve it through one intervention alone."

A shorter, edited version of this appears in print

This article appeared in Outlook's July 6th, 2026 issue titled 'The Great Nicobar Debate,' which looks at the pros and cons of developing the eco-sensitive Nicobar Island.