Duke-NUS Medical School, working with an international team of experts, has contributed to a new evidence-based plan to tackle anemia—a condition affecting nearly two billion people worldwide and a persistent obstacle to achieving global health goals.

Published in The Lancet Haematology, the study sets out expert consensus on the causes of anemia, identifies major data and knowledge gaps and recommends the most cost-effective strategies for reducing its global prevalence.

Anemia develops when the body lacks enough healthy red blood cells to carry oxygen. Iron deficiency is the leading cause, though other nutrient shortages, chronic diseases and infections such as malaria and hookworm play a role depending on local conditions. Despite its scale, anemia often receives less attention than other health threats, even though it undermines maternal health, child survival and economic growth.

In 2015, the United Nations set a target of halving anemia in women of childbearing age by 2030. Nearly a decade on, most countries remain far from this goal. The study shows why: in many low- and middle-income countries, recommended interventions are either unavailable, too costly or underused.

Assistant Professor Robin Blythe, from Duke-NUS Medical School’s Health Systems & Services Research Program, who led the economic modeling component of the study, said, “A one-size-fits-all approach to anemia does not work. Countries face very different challenges, from poverty and infectious diseases to food shortages. These realities are often overlooked in global health targets. We need goals that are ambitious yet realistic—and tailored to each country’s needs and resources.”

The team estimated how much progress each country could realistically achieve by 2030 using currently recommended measures such as staple food fortification, iron supplementation, and preventive malaria treatment in pregnancy.

They used country-specific data, including anemia prevalence, health system capacity and how much each country can cost-effectively afford to spend on public health. Their analysis shows the global Sustainable Development Goal (SDG) target of 50% reduction is not feasible with current tools and funding.

The study reveals a sharp contrast between countries. Singapore, for example, could achieve a 25% reduction among women of reproductive age—slightly above the global average but still only half of the SDG target. With an anemia prevalence of 18.4% among women of reproductive age, Singapore’s strong health system, high antenatal care coverage and ability to implement fortification programs put it in a strong position to make meaningful gains.

Most anemia cases in Singapore are mild (17%), with only 1.4% moderate cases and virtually no severe ones. The country’s ability to pay for public health programs, its high coverage of antenatal care, at 81% for iron supplementation, and its ability to implement food fortification programs put it in a strong position to reduce anemia further.

“Singapore has the capacity to make real progress,” said Asst Prof Blythe.

“By focusing on fortifying staple foods with iron and improving the uptake of supplements during antenatal care, the country can achieve real reductions in anemia while using resources efficiently. Unlike in malaria-endemic regions, preventive malaria treatments are not relevant in Singapore, so investments should go where the impact will be greatest.”

By contrast, Indonesia is projected to achieve only a 9% reduction due to constrained health care spending, while Malaysia could reach a 28% reduction. These variations underscore the need for country-specific goals rather than uniform global targets, ensuring public health resources are directed where they can make the most difference.

Professor Patrick Tan, Senior Vice-Dean for Research at Duke-NUS, said, “This study shows that solving major health challenges requires collaboration across disciplines and borders. By setting realistic targets based on local conditions and investing in proven programs, countries can accelerate progress and improve health for billions. These recommendations point to a more practical, evidence-driven path forward.”

The study also called for better data systems to track anemia and its causes. While many surveys measure how common anemia is, few gather information about its specific causes in each population. This makes it hard to plan effective responses. A global anemia database and expanded health surveys would help close this data gap and improve decision-making.

Asst Prof Blythe emphasized that setting more realistic targets is not about giving up on ambition. “When targets are set too high and countries fail to meet them, it can create frustration and even discourage continued efforts. Our approach provides a clear, data-driven way to set targets that reflect what each country can realistically achieve with current tools. This way, we can still drive progress while being honest about what is possible.”

The authors are now sharing their findings with the World Health Organization, with the hope that future health and nutrition targets will adopt a similar country-specific, evidence-based approach. With stronger data, better funding strategies and smarter policies, countries can make meaningful progress in reducing anemia and improving public health.