Over half of all women and children in India are anaemic, and that number has increased in the last three years. Between 2005 and 2015, anaemia declined in India, albeit marginally. But the recent National Family Health Survey (NFHS-5) data shows a reversal of those gains — anaemia rates increased from 53 per cent to 57 per cent in women and 58 per cent to 67 per cent in children in 2019-21.
The WHO defines anaemia as a condition where the number of red blood cells or the haemoglobin concentration within them is lower than normal. This compromises immunity and impedes cognitive development.
What could be causing this calamitous result?
The breadth of the NFHS survey allows us to investigate factors traditionally used to explain the prevalence of micronutrient outcomes such as anaemia. Cereal-centric diets, with relatively less consumption of iron-rich food groups like meat, fish, eggs, and dark green leafy vegetables (DGLF), can be associated with higher levels of anaemia. However, the percentages of both children and women consuming iron-dense food groups have increased from NFHS-4 to NFHS-5. For instance, the proportion of women consuming DGLF has gone up from 49 per cent to 54 per cent, meat from 1.2 per cent to 1.5 per cent, eggs from 3.2 per cent to 4.8 per cent and fish from 4.18 per cent to 4.32 per cent. Similarly, the percentage of children consuming an adequate diet has increased from 9.6 per cent to 11.3 per cent and those being exclusively breastfed (under the age of six) has increased from 54.9 per cent to 63.7 per cent from NFHS-4 to NFHS-5.
High levels of anaemia are also often associated with underlying factors like poor water quality and sanitation conditions that can adversely impact iron absorption in the body. However, both these factors improved from NFHS-4 to NFHS-5. The percentage of the population living in households using improved sanitation facilities increased from 48.5 per cent to 70.2 per cent, while the percentage of households with access to improved drinking water sources improved from 94.4 per cent to 95.9 per cent.
Women’s empowerment is another factor that can play an important role in determining the quantity and quality of food intake within the household. Women’s ownership of assets (such as land or a house), ability to make decisions in the use of income, access to resources like savings or credit, and input in key household decisions can translate into improved awareness about, and access to, diverse, nutritious diets. But women’s empowerment in such domains has also improved from NFHS-4 to NFHS-5, suggesting that women’s decision-making alone cannot explain the rise in anaemia.
Finally, the delivery of health and nutritional interventions plays a significant role in the prevalence of anaemia. But women’s consumption of folic acid during pregnancy and access to ante-natal check-ups has improved over the last five years. It is surprising, then, how anaemia rates have gone up not just in mothers but also in children below the age of five.
The NFHS data on anaemia is an anomaly for several reasons, given that several factors that can explain changes in anaemia rates have improved since NFHS-4. Moreover, unlike anaemia, all other major undernutrition outcomes — for instance, stunting (low height-for-age), wasting (low weight-for-height), and underweight (low weight-for-age) — have improved over the past four to five years. It is imperative that this anomalous trend in anaemia is investigated, understood, and addressed as soon as possible.
We must also ask if this trend could be reflective of differences in data between NFHS-4 and NFHS-5. Or are some measurement issues plaguing the results? How accurately does the current method used for assessing haemoglobin concentrations compare to others that are available? A more nuanced measurement can aid our understanding of anaemia.
Investing in an enhanced understanding of the varied causes behind this increase in anaemia is also pertinent. At the very least, we should go beyond haemoglobin to include some other iron-specific biomarkers, like serum ferritin, as well as markers of inflammation, to identify the role of iron deficiency as a driver of anaemia. Simultaneously, the measurement of anaemia should account for non-iron nutritional deficiencies — like that of vitamin B12 in the case of India — and screening for genetic blood disorders, like thalassemia and sickle-cell anaemia. Similarly, expanding the NFHS data on food consumption to include information on portion size and frequency of consumption can help us accurately estimate the intake of various micronutrients and compare it against recommended intake.
The rising anaemia figures make it nearly impossible to achieve the targets under the Anaemia Mukt Bharat programme — a 3 per cent reduction per year in all age groups from 2015-16 to 2022. India is also off course in the achievement of the global nutrition target for anaemia in women of reproductive age — a 50 per cent decrease from the 2012 baseline by 2030.
We hope that this discussion on the rise in anaemia will serve as a starting point for rigorous research and informed policymaking involving varied stakeholders like public health professionals, programme implementers, policymakers, and other experts in this field. The data on anaemia tells us that something has gone wrong. It is critical that we discover what has changed and move quickly to address it.
Gupta is a research economist and Seth is a consultant at Tata-CornellInstitute (TCI), Cornell University