Why HbA1c remains the pragmatic choice for monitoring in India's public health system

We read with interest the Viewpoint by Samajdar et al. regarding the limitations of HbA1c for monitoring diabetes in South Asia. 1 While acknowledging the risk for misclassification, we contend that excluding HbA1c (glycated haemoglobin) from India's public healthcare system would exacerbate gaps in the diabetes care cascade by undermining diagnostic consistency and longitudinal monitoring for those seeking public care.Although anaemia is a recognized confounder, its population-level impact must be balance against its prevalence.Data from the Longitudinal Ageing Study in India (LASI) 2 show that severe anaemia (Hb < 8 g/dL)-the threshold where diagnostic precision is most compromised 3 -affects <2% of adults aged <70 years.These findings are corroborated by NFHS-5 data, indicating that severe anaemia is statistically infrequent across most Indian districts, 4 including high-haemoglobinopathy states like Odisha and Chhattisgarh.Thus, for the majority, it underscores that HbA1c remains a reliable metric for diabetes care.In resource-constrained rural settings, exclusive reliance on fasting or postprandial glucose for monitoring is logistically impractical, necessitating repeated visits that drive wage loss and therapeutic inertia. 5ather than abandoning HbA1C, we advocate resource-stratified diagnostic approach: while strengthening venous plasma glucose infrastructure where feasible, while deploying boronate affinity point-of-care (POC) testing would profoundly benefit the diabetes care.Boronate affinity-based POC mitigates analytical interference from prevalent haemoglobin variants, while its POC format circumvents pre-analytical delays. 6us, for most Indian patients, HbA1c remains the most pragmatic tool for longitudinal tracking monitoring.The sustainable path forward lies in algorithmic refinement and assay standardization.