Beyond Iron Supplementation: A Narrative Review of the Structural Determinants of Anaemia in Pregnancy in India.

India's anaemia burden is not a single problem but at least four overlapping ones. The first is uncertainty in burden assessment, illustrated by substantially different capillary versus venous haemoglobin estimates and the removal of haemoglobin testing from the sixth National Family Health Survey (NFHS-6). The second is a biomedical framing miscalculation, in which iron deficiency anaemia is treated as synonymous with anaemia despite evidence that iron deficiency accounts for only about half of cases. The third is a health system design problem, reflected in repeated strategic overhauls of Anaemia Mukt Bharat itself. The fourth is a deep-seated sociostructural problem rooted in teenage marriage, intra-household food allocation, limited female autonomy, gender inequality, and cumulative iron deficits carried over from adolescence and from closely spaced prior pregnancies. We compared India's experience with selected anaemia-control approaches in Sri Lanka, Bangladesh, and the Philippines, which paired supplementation with food systems and empowerment-based interventions. We conclude that a supplementation-first model cannot resolve this burden, however robustly financed, and propose an approach that restores methodologically defensible surveillance, differentiates aetiology at the point of care, intervenes before conception rather than only at antenatal registration, and makes cross-sectoral governance enforceable. In the comparator countries, staple-food fortification, delivery across the reproductive lifecycle, and community engagement of households were central to their lower prevalence.