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Editorial

Implimentation of National Iron Plus Initiative for Child Health:

Challanges Ahead
Anemia, a manifestation of undernutrition and poor
dietary intake of iron is a serious public health problem
among pregnant women, infants, young children and
adolescents1 in India. National Family Health Survey
(NFHS) 3 (2005-06) data depicts that seven out of every
10 children aged 6-59 months in India are anemic: 3%are
severely anemic, 40% are moderately anemic, and 26%
are mildly anemic. The prevalence of anemia has actually
increased from NFHS 2 (1998-99) to NFHS 3 (2005-06)
both in women and children.2
Anemia is often multi-factorial and, therefore, requires a
multi-pronged approach for its prevention and treatment.
Iron deficiency and infections are the most prevalent
aetiological factors. However, other conditions may have
a contributory role. The Copenhagen Consensus (2004)
panel of eminent economists deliberated upon the returns
of investing in micronutrient programs (including iron),
among a list of 17 possible development investments and
the benefit-to-cost ratio of iron interventions based on
resource savings, improvement in cognitive development
and schooling, and physical productivity was estimated
to be as high as 200:1.3
Success in prevention and control of anemia has shown
to contribute in reduction of maternal and child mortality
and improve health outcomes for population as a whole.
Though iron and folic acid (IFA) supplementation in
children, pregnant women, and lactating mothers were in
place under national health programme of our country for
the last few years, a comprehensive approach to combat
anemia has been missing.
Taking this into cognizance, Ministry of Health and
Family Welfare, GoI in 2013 launched the National
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Website: www.ijph.in
DOI: 10.4103/0019-557X.152844
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Iron Plus Initiative (NIPI) as a comprehensive strategy

to combat the public health challenge of iron deficiency
anemia prevalent across the life cycle, as iron deficiency
contributes more than 50% of anemia in our country. There
are age specific interventions with IFA supplementation
and deworming for improving the haemoglobin levels
and reducing the prevalence of anemia for all age groups,
i.e. children ages 6-59 months, children ages 5-10 years,
adolescent girls and boys ages 11-19 years, pregnant and
lactating women, and women in the reproductive age
group (20-49 years). The NIPI attempts to holistically
address both preventive and curative aspects of this
challenge across all life stages and at various levels of
care. The schedule of IFA supplementation has also been
reviewed to make both administration and compliance
much simpler. The age group specific interventions under
the NIPI are as follows:
1. For children 6-59 months:
Bi-weekly 1 ml of IFA syrup containing 20 mg
of elemental iron and 100 mcg of folic acid
throughout the year. The IFA bottles should have
an auto-dispenser so only 1 ml of syrup will be
dispensed at a time.
Bi-annual deworming for anti-helminthes control
(albendazole tablet 200 mg for children aged
12-24 months and albendazole tablet 400 mg
for children aged 36-59 months).
2. For children 5-10 years:
One weekly IFA tablet containing 45 mg
elemental iron and 400 mcg folic acid throughout
the year.
Albendazole (400 mg) tablets for deworming
are to be administered twice a year for antihelminthic treatment.
3. For adolescents (10-19 years): Weekly iron folic
acid supplementation (WIFS)
One weekly IFA tablet containing 100 mg
elemental iron and 500 mcg Folic acid.
Albendazole (400 mg) tablets for deworming
are to be administered twice a year for antihelminthic treatment.
4. For pregnant and lactating women:
Daily dose of one IFA tablet supplementation

Indian Journal of Public Health, Volume 59, Issue 1, January-March, 2015

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2

Deb: National Iron Plus Initiative

(100 mg elemental iron and 500 mcg of folic

acid) every day for at least 100 days, starting after
the first trimester at 14-16 weeks of gestation,
followed by the same dose for 100 days in postpartum period for lactating women.
5. For non-pregnant non-lactating women in
reproductive age (20-49 years):
One weekly IFA tablet containing 100 mg elemental
iron and 500 mcg of folic acid throughout the
calendar year, i.e., in all 52 weeks, each year.
Albendazole (400 mg) tablets for deworming
are to be administered twice a year for antihelminthic treatment.
In addition to this, 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 to reduce
the incidence of neural tube defects in the fetus.
NIPI is a recently launched programme and all states and
union terrorities (UTs) are in the process of budgeting
in their annual Programme Implementation Plans (PIPs)
under the National Health Mission and operationalizing
the scheme. A few of the states like Assam, West Bengal,
Uttarakhand, and Odisha have recently initiated biweekly IFA syrup supplementation to children aged
6-59 months. Almost all states and UTs are providing
IFA tablets to pregnant and lactating mothers as part of
their antenatal care package. Only Odisha and Assam
have started with weekly IFA supplementation to children
5-10 years old. IFA and bi-annual deworming in nonpregnant non-lactating women age group is yet to start
in program mode in any state or UT at this date.
There are few programmatic challenges that are being
faced in effective implementation of the interventions
under NIPI, including many states are not prioritizing the
interventions of both IFA supplementation and deworming.
Moreover, challenges lie in ensuring compliance of biweekly IFA syrup supplementation to children under 5
years old and weekly IFA to children 6-19 years old.
Ensuring supervised consumption of IFA supplements in
presence of Acredited Social Health Activist (ASHAs)
is a time and resource intensive activity, practically not
feasible to implement in view of work burden of ASHA,
though the central ministry has introduced the concept
of incentivizing the frontline workers for the same.
Moreover, procurement and logistics management of IFA
syrup, IFA tablet, and albendazole as well as reporting
formats is also difficult and transport of the same upto

each Anganwadi and School remains a herculean task.

Further, states have shared facing difficulty in getting
reports from schools in view of already burdened
school teachers. Indeed, effective coverage of children
under 5 years old, school going and out of school
children, pregnant and lactating women, and women
of reproductive ages calls for streamlined inter-sectoral
convergence between various line departments and
ministries like Ministry of Health and Family Welfare,
Ministry of Women and Child Development, Ministry
of Human Resource Department (Deptartment of School
Education and Literacy), Ministry of Tribal Affairs,
Rural Development, Urban Development, etc. which
is challenging to ensure and translate in to effective
implementation of all components.
Ministry of Health and Family Welfare, however, is
committed to reducing anemia across all life stages and
is constantly striving and putting efforts to streamline
effective implementation of this initiative. The launching
of National Deworming Day (February 10, 2015) in 11
states and UTs in the first phase, for ensuring coverage of
deworming intervention across all children 1-19 years old
through a fixed day strategy is one such step towards it.
Sila Deb
Dy Commissioner, Child Health,
Ministry of Health and Family Welfare, Govt. of India.
E-mail: siladeb@gmail.com

References
1.

2.

3.

Ministry of Health and Family Welfare. Govt of India.

Guidelines for control of anaemia: national iron plus initiative.
Available in: http://www.unicef.org/india/10._National_Iron_
Plus_Initiative_Guidelines_for_Control_of_IDA.pdf [Last
accessed on 2015 Feb 10].
International Institute for Population Sciences and Macro
International (September 2007). National Family Health
Survey (NFHS-3), 2005-06. Ministry of Health and Family
Welfare, Government of India. Available from: http://www.
measuredhs.com/pubs/pdf/FRIND3/FRIND NFHS - 3 2005 06. National Family Health Survey, 2005-06. [Last accessed
on 2015 Feb 23].
Behrmann JR, Alderman H, Hoddinott J. Copenhagen
Consensus hallenge Paper: The Challenge of Hunger
and Malnutrition. 2004. Available in http://www.
copenhagenconsensus.com/sites/default/files/CP++Hunger+FINISHED.pdf [Last accessed on 2015 Feb 10].

Cite this article as: Deb S. Implimentation of national iron plus initiative for
child health: Challanges ahead. Indian J Public Health 2015;59:1-2.
Source of Support: Nil. Conflict of Interest: None declared.

Indian Journal of Public Health, Volume 59, Issue 1, January-March, 2015