This document outlines India's intensified national initiative to address anemia, called "Anemia Mukt Bharat" or "Anemia Free India". It summarizes the high prevalence of anemia across different groups in India, the causes of anemia, and the public health implications. The initiative will use a 6x6x6 strategy involving 6 interventions delivered through 6 institutional mechanisms to reach approximately 450 million beneficiaries. The interventions include iron folic acid supplementation, deworming, behavior change communication, testing and treatment, and addressing non-nutritional causes in endemic areas. The goal is to reduce anemia prevalence by 3 percentage points per year.

1. Anemia Mukt
Bharat
-An Intensified National
Iron Plus Initiative
18th September, 2018
Ministry of Health and Family Welfare
Government of India

2. 58%
of children
(6-59 months)
54%
of adolescent
girls
(15-19 years)
29%
of adolescent
boys
(15-19 years)
53%
of women in their
reproductive age
50%
of pregnant women
58%
of breastfeeding
mothers
High Prevalence
across all ages
Slow progress in
most of the States
74 69.4
58.5
52 55.2 53.1
0
20
40
60
80
100
NFHS 2 NFHS 3 NFHS 4
Children
WRA (15-49 yrs)
Trend in
Prevalence of
Anemia among
Children and
Women
A Snapshot of Anemia in India v

3. Anemia prevalence
among Pregnant Women
(15-49 yrs)
States/ UTs
More than 50%
11 States and 2 UTs
Bihar, Himachal Pradesh, Jharkhand, Madhya Pradesh, Uttar Pradesh, Meghalaya
Tripura, Andhra Pradesh, Gujarat, Haryana, West Bengal
A & N islands and D & N Haveli
40% to 50%
10 States and 1 UT
Chattishgarh, Odisha, Rajasthan, Uttarakhand, Assam, Karnataka, Maharashtra,
Punjab, Tamil Nadu, Telangana
Delhi
Less than 40%
8 States and 2 UTs
Jammu & Kashmir, Arunachal Pradesh, Manipur, Mizoram, Nagaland, Sikkim,
Goa, Kerala
Lakhwadeep and Puducherry
v
Anemia Prevalence among Pregnant Women
(NFHS-4)

4. Low Iron
Stores
• During pregnancy in
anemic mothers
• Poor iron stores
from infancy,
childhood
deficiencies and
adolescent Anemia
Dietary
• Inappropriate IYCF
esp. Complementary
Feeding Practices
• Excessive
consumption of ‘Iron
Inhibitors’ (tea,
coffee, calcium-rich
foods) and low
intake of ‘Iron
Enhancers’ (Vitamin
C etc.)
• Low bioavailability of
dietary iron
• 50% of the
population is
consuming < 50%
Iron Loss
• Due to parasitic load
(malaria, intestinal
worms)
• Poor environmental
sanitation, unsafe
drinking water and
inadequate personal
hygiene
Maternal
Anemia
• Increased iron
requirement due to
tissue, blood
formation and
energy requirement
during pregnancy
• Iron loss from post-
partum
haemorrhage
• Teenage pregnancy
• Repeated
pregnancies with
less than 2 years
interval
Causes of High Burden of Anemia
v

5. Reduced physical
development
Impact on
pregnancy
outcomes
Reduced cognitive
development
Economic impact
• Diminished concentration, disturbance in perception, delayed
psychomotor development
• Impaired language and motor skills,
• Diminished IQ equivalent to a 5–10 point
• About 20 % of maternal deaths are caused by Anemia worldwide
• tube defects, infants of low birth weight and still births
• AnemiNeuralc pregnant women are more prone to increased morbidity
and ; there is a three times greater incidence of premature delivery in
severely anemic women
• Decreased work output and work capacity
• Physical and cognitive losses due to IDA in South Asia are staggering:
close to $ 4.2 billion annually in Bangladesh, India and Pakistan
• In the WHO/World Bank rankings, Iron Deficiency Anemia is the
third leading cause of DALYs lost for females aged 15–44 years and
1.18 % of Gross Domestic Product (GDP) loss. Median total loss
(physical and cognitive) combined are 4.05% of GDP in developing
countries.
Public Health Implications of Anemia v

6. Current – close to 1% Committed to achieve target – 3%
Short term, Long term and Intergenerational benefits
Enhances
health &
nutrition of
women and
children
World Health Assembly has proposed a target of 50% reduction in Anemia
among women by 2025 and
NHP 2017 commits to reduce anemia prevalence by 3% per year
Annual average rate of reduction (AARR) of anemia prevalence
v
Why Should We Address Anemia?
Improvements
enhance human
capital
Contribute to a
virtuous cycle by
fostering economic
development

7. Milestones in Control of Anemia in India v
1970
60 mg Iron supplementation
for PW and 20 mg for
1-5 yr X100 days
1991
60 mg Iron
changed to
100mg
2007
5-10 yrs age group
added
2013
Wkly and biwkly
supplementation.
Test and treat (NIPI)
Life cycle approach
2018
I-NIPI Program
intensification
(Anemia Mukt Bharat)
PLW 60mgX180 days,
IFS for WRA 6X6X6
strategy
Life cycle approach
• Anemia control efforts in India started in 1970 with
supplementation of Iron and folic acid across age groups
• Anemia level in various population groups remained high
• IFA coverages remained less than 30%
• More than 50% cases of anemia
attributed to Iron deficiency

8. > = 3 0 % d e c l i n e
1 4 - 2 8 % d e c l i n e
5 - 9 % d e c l i n e
55
45
35
25
15
-5
5
-15
-25
-35
-45
55
65
%decline
comparing NFHS-4,2015-16AND NFH-3,2005-06
D
e
l
h
i
H
.
P
.
P
u
n
j
a
b
U
.
P
.
B
i
h
a
r
T
r
i
p
u
r
a
M
.
P
a
r
d
e
s
h
U
t
t
a
r
k
h
a
n
d
M
e
g
h
a
l
a
y
a
J
h
a
r
k
h
a
n
d
I
n
d
i
a
W
.
B
.
M
a
h
.
G
u
j
a
r
a
t
T
.
N
a
d
u
H
a
r
y
a
n
a
R
a
j
a
s
t
h
a
n
K
a
r
n
a
t
a
k
a
G
o
a
M
a
n
i
p
u
r
O
d
i
s
h
a
J
&
K
K
e
r
a
l
a
C
h
h
a
t
t
i
s
g
a
r
h
A
r
.
P
r
a
d
e
s
h
A
s
s
a
m
M
i
z
o
r
a
m
S
i
k
k
i
m
Eight states >=30% decline (6 are eastern states)
Two States >=25% increase
Decadal change | Anemia in Pregnancy
Learning from Best Performing
States/ Districts v

9. States with >=30% Anemia Decline
What Did They Do? v

10. Anemia Mukt Bharat
will use a 6x6x6
strategy to
combat anemia
6
interventions
institutional
mechanisms
6X6X6
strategy
6
6
Anemia Mukt Bharat
v

11. 6
adolescent boys
and girls
(10-19 years)
Children
(6-59 months)
124
million
115
million
children
(5-9 years)
134
million
pregnant
women
30
million
lactating
mothers
27
million
women of
reproductive
age
(20-24 years)
17
million
Estimated
450 million
beneficiaries
Reaching nearly 50% of
the country’s population
Six Beneficiaries
v

12. To reduce
the
prevalence
of anemia
by 3
percentage
points per
annum
Beneficiary-wise Targets
Anemia reduction targets for 2022
Age group
Anemia prevalence (%)
Baseline
(NFHS 4) National target 2022
Children 6–59 months 58 40
Adolescent girls 15–19years 54 36
Adolescent boys 15–19 years 29 11
Women of reproductive age 53 35
Pregnant women 50 32
Lactating women 58 40
v

13. Six Interventions
v
1
Prophylactic iron folic acid
supplementation
3 Intensified year-round Behavior
Change Communication
Campaign Solid Body Smart
Mind ,delayed cord clamping
5
Mandatory provision of iron
public health programmes
ANGANWADI
2
Periodic deworming of children,
adolescents, pregnant women
4
Testing of anemia using digital
methods and point of care
treatment
HOSPI
TAL
6
Addressing non-nutritional causes
of anemia in endemic pockets,
with special focus on malaria,
haemoglobinopathies and fluorosis

14. Age group Dose
6 – 59 months
of age
• Biweekly, 1 ml Iron and Folic Acid syrup
• Each ml of Iron and Folic Acid syrup containing 20 mg elemental Iron +
100 mcg of Folic Acid
• Bottle (50ml) to have an ‘auto-dispenser’ and information leaflet as per
MoHFW guidelines in the mono-carton
5- 10 years
children
• Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 45 mg elemental Iron + 400 mcg Folic Acid
• Sugar-coated, pink colour
Intervention- 1
Prophylactic IFA supplementation- Regime
v

15. Age group Dose
Adolescent
girls and boys,
10-19 years of age
• Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 60 mg elemental iron + 500 mcg Folic Acid
• Sugar-coated, blue colour
Women of
reproductive age
(non-pregnant,
non-lactating)
20-49 years
• Weekly, 1 Iron and Folic Acid tablet
• Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid,
• sugar-coated, red colour
All women in the reproductive age group in the pre-conception period and up
to the first trimester of the pregnancy are advised to have 400 mcg of Folic
Acid tablets, daily
Pregnant women and
lactating mothers
(0-6 months child)
• Daily, 1 Iron and Folic Acid tablet starting from the fourth month of
pregnancy (that is from the second trimester), continued
• Throughout pregnancy (minimum 180 days during pregnancy)
• To be continued for 180 days, post-partum
• Each tablet containing 60 mg elemental Iron + 500 mcg Folic Acid
• Sugar-coated, red colour
Cont...
Prophylactic IFA Supplementation- Regime
v

16. Focus on Social mobilization and behaviour change: 4 key behaviours
1. Compliance to Iron Folic Acid supplements and deworming
2. Appropriate Infant and Young Child Feeding (IYCF)
3. Increase intake of iron-rich, protein-rich and vitamin C rich foods
through diet diversification and consumption of fortified foods.
4. Practice of delayed cord clamping in all health facility deliveries
followed by early initiation of breastfeeding within 1 hour of birth
Intervention 3
Intensified 360 Degree IEC/ BCC for Anemia
Prevention & BehaviourChange
v
Solid Body,
Smart Mind

17. Testing:
 Use of digital hemoglobinometers
 In two age groups- to begin with
 School-going Adolescent girls and boys 10-19 years, WIFS
beneficiaries, using RBSK mobile teams
 Pregnant women at all ANC contact points.
 At all high case load facilities at block level and above,
hemoglobin level estimation will be done using Semi-Auto
Analyzers
 This may be extended to all age groups, later
Intervention 4
Test and Treat Strategy v

18. Mild/moderate
First level of treatment
(at all levels of care)
Two IFA tablets (each with 60 mg elemental iron and 500 mcg
folic acid), once daily, for 3 months
Line listing of all anemic cases; Two Follow-ups
• First follow-up after 45 days and second follow-up after 90
days at nearest health facility
• If hemoglobin levels have come up to normal level, discontinue
the treatment and continue with the prophylactic IFA dose
If no improvement after first
level of treatment
If no improvement after three months of treatment, RBSK team
will refer the adolescent to First Referral Unit (FRU)/District
Hospital (DH)
Severe anemia Management to be done by medical officer at FRU/DH based on
investigation and diagnosis
Anemia Management Protocol for
Adolescents v

19. Management protocol for severe anemia contraindicated for patients of thalassemia major and sickle cell disease.
Anemia Management Protocol
forPregnant Women v
Mild/moderate
First level of treatment
(at all levels of care)
Two tablets of iron and folic acid tablet (60 mg elemental iron and
500 mcg folic acid) daily, orally given by the health provider
during the ANC contact.
* Parental iron (IV Iron sucrose or Ferric Carboxy Maltose may be
considered as the first line of treatment in pregnant women who
are detected to be anemic late in pregnancy or in whom
compliance is likely to be low (high chance of lost to follow-up).
Follow-up Every two months, during the ANC contact
If no improvement after first
level of treatment
If no Hb (<1g/dl) increase; Refer to FRU/DH (case may be
managed with IV Sucrose/FCM)
Severe anemia (5-6.9 g/dl) By medical officer, using IV Sucrose/FCM. Immediate
hospitalization if pregnant woman is in 3rd trimester.

20. 1
Intra-ministerial
coordination
2
National Anemia Mukt
Bharat Unit
3
National Centre
of Excellence and
Advanced Research on
Anemia Control
4
Convergence with
other ministries
5
Strengthening supply
chain and logistics 6
Anemia Mukt Bharat
dashboard and digital
Portal - one-stop shop
for anemia
Six Institutional Mechanisms v

21. Target based monitoring
SIX performance indicators v

22. Coordinated management efforts – intra & inter ministerial
Target based monitoring and KPI reviews and awards; Private
schools; 60 mg instead of 100 mg prophylactic dose, sugar coated.
Communication materials for extensive awareness, intensive 360
degree communication campaigns - Creating a Jan Andolan…
Use of digital methods of hemoglobin estimation and point of care
treatment, newer treatment strategies – IV Iron Sucrose and FCM
Linkage with Malaria; mandating use of fortified food in public
health programmes, specially double fortified salt (iron and iodine)
Linkage with academic – national and regional networks- (re)
learning and policy decisions
What’s New?
v

23. LET US MAKE
INDIA ANEMIA-FREE