A ready solution to tackle anaemia

Despite significant economic progress and sustained public health efforts, anaemia — driven significantly by iron deficiency — continues to be one of India’s most pressing public health challenges. Affecting over half of Indian women and almost three-fourths of children, anaemia contributes to maternal mortality, an intergenerational cycle of malnutrition, impaired cognitive development, reduced productivity and substantial economic losses. The Government of India’s 7X7X7 Anaemia Mukt Bharat (AMB) strategy, which was launched recently, rightly recognises the multifactorial nature of anaemia through a comprehensive approach spanning prevention, screening, treatment, dietary diversification and behaviour change. Yet, one proven preventive intervention remains significantly underutilised.

The promise of fortification

That intervention is Double Fortified Salt (DFS) — salt fortified with both iodine and iron. Salt offers an unparalleled opportunity to address iron deficiency. Consumed daily by virtually every household across India, in predictable quantities regardless of income or geography, it is uniquely suited to deliver a preventive nutrition intervention at population scale. DFS also addresses one of the fundamental challenges of anaemia control — sustained compliance.

Delivering iron through an everyday food complements interventions such as iron supplementation and dietary diversification, whose effectiveness depends on regular adherence. India already has one of the world’s most successful public health platforms in Universal Salt Iodisation, with around 95% of households consuming iodised salt. Building on this existing infrastructure, DFS is already distributed to an estimated 76 million people across four States through government safety-net programmes. Global and Indian evidence strongly support DFS. A global review has shown that DFS can reduce anaemia by up to 21%. Randomised controlled trials in Bengaluru, Darjeeling, and Punjab, along with large-scale implementation in Uttar Pradesh, have shown improvements in iron status and confirmed that, when manufactured to validated specifications, DFS is acceptable to consumers, reduces iron deficiency, and is highly cost-effective. A DFS standard has been issued by the Government of India’s Food Safety and Standards Authority (FSSAI), and the Government of India actually mandates DFS’ inclusion in the national school feeding programme (PM POSHAN and the national early childhood development programme- Integrated Child Development Scheme, or ICDS).

At an estimated cost of ₹14-₹20 per person annually, DFS represents one of the most affordable population-level nutrition interventions available, with a benefit-cost ratio of 4.2:1 for national DFS introduction, primarily driven by improved health outcomes and subsequent increases in labour productivity. India also possesses the manufacturing capacity to produce high-quality DFS at scale. Established fortification technologies, centralised salt production and existing laboratory infrastructure make quality assurance and regulatory monitoring simpler than for many other fortified foods.

What the barriers are

What has limited DFS from wider adoption? The barriers are now primarily institutional rather than technical. The next imperative is to accelerate its nationwide adoption and ensure last-mile access, particularly the Public Distribution System apart from social safety-net programmes, across all States through a central flagship scheme. Although DFS is recommended under PM POSHAN and ICDS, its integration into the largest safety net programme i.e., the Public Distribution System (PDS) — which reaches around 800 million beneficiaries — remains uneven because implementation depends largely on State governments. Greater policy commitment, dedicated financing, stronger quality assurance, wider commercial availability and consumer awareness are now needed to accelerate nationwide scale-up. These are implementation challenges — not technological ones — and are well within India’s capacity to address.

Like all public health nutrition interventions, DFS should be implemented within a robust regulatory framework. It should complement existing strategies under Anaemia Mukt Bharat, align with India’s sodium reduction goals, and continue to be accompanied by screening for haemoglobinopathies such as thalassaemia and sickle cell disease. These safeguards are well recognised through experience of rice fortification programme and can be readily integrated into implementation and monitoring systems.

The launch of the revised AMB strategy provides renewed momentum to strengthen the preventive pillar of India’s anaemia response and advance the vision of Viksit Bharat 2047.

Potential to be a global model

India has already shown the world how science, policy, public systems, and public awareness can transform nutrition through Universal Salt Iodisation. By scaling DFS nationally, India can not only accelerate progress towards Anaemia Mukt Bharat but also contribute to global efforts to reduce iron deficiency by demonstrating an affordable, scalable model for other low- and middle-income countries.

Marthi Venkatesh Mannar is former Senior Advisor, Tata Trusts; K.J. Alphons is a former Union Minister for State, Government of India; Jaykumar Menon is Co-Founder and Chair, Open Source Pharma Foundation; Dr. Rajiv Tandon is Executive Director, The Health Continuum, Adjunct Professor of Public Health Practice at the Public Health Foundation of India, Indian Institutes of Public Health, and Ruchika Arora is Technical Specialist, The Health Continuum and former national consultant for child health and Nutrition, Ministry of Health and Family Welfare, Government of India