On ‘International Universal Health Coverage Day’, December 12, 2020, the union Minister of Health and Family Welfare, Dr Harsha Vardhan released the first set of findings of the Fifth Round of the National Family Health Survey (NFHS-5), conducted in 2019–20.
The first phase of the survey included data for 17 states and five union territories, home to almost half of India’s population. The second phase of the survey will cover left out states such as Uttar Pradesh, Punjab, and Madhya Pradesh. Field work is expected to be over by February/March, 2021, and key indicators for second phase states/union territories will be available around May 2021. The national level indicators including most of the SDG health indicators are expected to be available by June/July, 2021. The data collection for the survey was suspended in May 2019 due to the COVID-19 pandemic and the final report comprising data for all states is yet to come.
The fifth NFHS was conducted after a gap of about three years. The first four NFHS are referred to 1992–93, 1998–99, 2005–06, and 2015–16 respectively. The preliminary results of NFHS-5 have been released with comparable data for the 2015–16 survey. Many indicators of NFHS-5 are similar to NFHS-4 but include some new focal areas like expanded domains of child immunisation, components of micro-nutrients to children, frequency of alcohol and tobacco use, additional components of non-communicable diseases, expanded age ranges for measuring hypertension and diabetes among all aged 15 years and above. This is to provide the requisite input for strengthening the programmes and coming up with strategies for policy intervention.
The NFHS-5 makes some startling revelations with some remarkable shift from the findings of the fourth NFHS. One major shift observed in several states is that of worsening levels of child malnutrition—a central issue despite marked improvements in sanitation and better access to fuel and drinking water. Under-5 mortality has made very little progress in many states and the numbers of stunted children has risen in many richer states.
The NFHS-5 is being conducted in around 6.1 lakh sample households to provide disaggregated data up to district levels. NFHS-5 factsheet provides state-wise data on 131 key indicators on population, health and family welfare, nutrition, and others to track progress of Sustainable Development Goals (SDGs). The parameters include questions like how many households get drinking water, electricity and improved sanitation, what is the sex rate at birth, what are infant and child mortality metrics, what is the status of maternal child health, how many have high blood pressure, etc.
NFHS-5 for the first time collects data on two specific indicators: percentage of women and men who have ever used internet. It also adds some new questions on the status of pre-school education, disability, access to a toilet facility, death registration, bathing practices during menstruation, and methods and reasons for abortion.
The four malnutrition parameters of child stunting, child wasting, share of children underweight and child mortality rate are considered key metrics, with the data relating to them used in global indices like the global hunger index.
Major Findings of NFHS-5
According toNFHS-5 factsheets, India’s population is stabilising and the total fertility rates (TFR) show a further decline in all states and union territories since NFHS-4. Except Bihar, Manipur, and Meghalaya, all other states have a TFR of 2.1 or less.
All states have witnessed an increase in the use of modern contraceptives of family planning. In Andhra Pradesh, Telangana, Kerala, Karnataka, Bihar, and Maharashtra, female sterilisation dominates the scene, with modern methods of contraception taking a lead role. Contraceptive prevalence rate (CPR) has increased in most states and union territories, Himachal Pradesh and West Bengal being the highest users. The proportion of women with unmet need for family planning has declined in all states, except Meghalaya and Andhra Pradesh.
Child Nutrition Child nutrition is a major concern and the latest survey shows a record surge, compared to NFHS-4. The first phase data shows that several states have either witnessed meagre improvements or sustained reversals on children under five years of age malnutrition parameters such as child stunting (low height for the age), child wasting, share of children underweight, and child mortality rate. States such as Telangana, Kerala, Bihar, and Assam as well as union territory of Jammu and Kashmir have witnessed an increase in the rate of child wasting whereas Maharashtra and West Bengal have shown sluggish growth. Children born between 2014 and 2019, i.e., 0 to 5 years of age, are more malnourished than the previous generation. The under-five mortalityrate, that refers to the probability of dying between birth and five years expressed per 1,000 live births, showed a fall in 18 of the states and union territories for which data was released. But the situation is not very different as compared to NFHS-4 data. In Maharashtra, under-five mortality rate is almost the same in NFHS-4 and NFHS-5; in Bihar, it has reduced by three per cent.
In 13 states, the share of stunted children has increased, while in 12 states, children are underweight. The share of low weight for their height has increased in 16 states. The share of underweight children increased in 16 states and of overweight children in 20 states. The share of underweight children has seen an increase in big states like Gujarat, Maharashtra, West Bengal, Telangana, Assam, and Kerala. The data on stunted children rise puts India at risk of reversing precious gains in child nutrition made over previous years. Tripura with eight percentage points occupies the first place in child stunting. There is an increase in child marriage in a number of states, highest being in West Bengal, Bihar, Tripura, Manipur, and Assam. There has been an increase in teen age pregnancies in the states of Manipur, Andhra Pradesh, Himachal Pradesh, and Nagaland.
Anaemia As per the survey, more than half of the children and women are anaemic in a majority of the 22 states and UTs. Children aged 6 months to 59 months and adults aged 15 to 49 years were tested for anaemia. In 15 states/UTs, over half of the children suffer from it; in 14 states/UTs over half of the women are anaemic. The proportion of anaemic children and women is comparatively higher in Ladakh, Gujarat, West Bengal, and other states, and lower in Kerala, Lakshadweep, and a majority of the north-eastern states. Anaemia has increased among pregnant women. Anaemia among men was less than 30 per cent in a majority of these states and union territories. The share of anaemic men and women was the highest in West Bengal, while Gujarat had the highest share of anaemic children. There was a significant rise of anaemic people in some states, like Assam, where the share of anaemic women rose by 20 percentage points.
The first round of the survey shows an increased share of men and women who were overweight or obese. Share of obese men increased in 19 of the states and union territories; and that of obese women increased in 16. The share of underweight men and women increased in most states.
Immunisation of Children Several states and union territories showed an increase in childhood immunisation. More than two-thirds of children are fully immunised in all the states and union territories except Nagaland, Meghalaya, and Assam. In three-fourth districts, 70 per cent or more children in the age group of 12–23 months are fully immunised against childhood diseases. The credit for this goes to Mission Indradhanus, launched in 2015. There has been a drop in neonatal mortality in 15 states, and a decline in infant mortality rates in 18 states.
Antenatal care (ANC) visits by pregnant women has increased in 13 states and union territories between 2015–16 and 2019–20. In most states and union territories, sex ratio at birth has remained unchanged or increased. The survey shows an increase of female population per 1000 males in 18 states. Sex ratio at birth is below 900 in Telangana, Himachal Pradesh, Goa, Dadra and Nagar Haveli, and Daman and Diu.
Institutional Births Institutional births have increased in 19 states and union territories. This is over 90 per cent in 14 states. However, the survey shows that caesarean delivery (C-section) in many states has remarkably increased, especially in private health facilities. While the average for other surveyed states remains around 30–40 per cent, in Telangana, it is over 60 per cent. There has been an increase in the levels of C-section in several Indian states like Andhra Pradesh (42.4 per cent), Kerala, and Goa. One of the highest figures of C-section is in Jammu and Kashmir—41.7 per cent. Caesarean delivery puts both the mother and baby in a huge risk with long-term effects for women.
Blood Glucose Levels There remains a lot of variation in the high or very high random bloodglucose levels across states and union territories. Men have slightly higher blood glucose level compared to women. Men with high or very high blood glucose is highest in Kerala followed by Goa. Hypertension among men is higher than women.
Spousal Violence There is an increase in spousal violence and a rise in obesity in women and children. Spousal violence has increased in five states: Sikkim, Maharashtra, Himachal Pradesh, Assam, and Karnataka. Karnataka witnessed the largest increase in spousal violence. Sexual violence has also increased in five states: Assam, Karnataka, Maharashtra, Meghalaya, and West Bengal.
Internet Use For the first time, NFHS-5 collected data on percentage of women who have ever used internet. This indicator was used to track the SDGs India aims to achieve by 2030. According to the survey, on an average, less than three out of 10 women in rural India and four out of 10 women in urban areas used the internet. In urban areas, 10 states and three union territories reported that more than 50 per cent women had used internet. The five states reporting the lowest percentage of women who ever used the internet in urban India are Andhra Pradesh, Bihar, Tripura, Telangana, and Gujarat. The five states with the lowest percentage of women who had ever used the internet in rural India were West Bengal, Andhra Pradesh, Telangana, Bihar, and Tripura. Only eight states reported over 50 per cent who ever used the internet. In urban India, the states reporting the lowest percentage of woman in this category were Andhra Pradesh, Bihar, Tripura, Telangana, and Gujarat. For men, the worst performing states were Bihar, Meghalaya, West Bengal, Andhra Pradesh, and Assam. The percentage of women who ever used the internet significantly dropped in rural areas.
Household Amenities Almost in all the 22 surveyed states and union territories, the percentage of households with improved sanitation facility and clean fuel for cooking has increased. The share of households having access to some basic amenities has increased in most of the states. Access to electricity increased in 19 states, share of the population living in households with improved sources of drinking-water increased in 20 states. In 21 states, the share of the population living in households with improved sanitation facilities increased and in all 22 states, the share of the population with clean cooking fuel increased. But more than one-fourth of the population (median value) still uses unclean fuel though it was said that the Pradhan Mantri Ujjwala Yojana had overshooted its target of giving 80 million free LPG connections to poor households. Likewise, the survey states that one-fourth of the population lives in households (median value) that do not have an exclusively used improved toilet even though government’s Swachh Bharat Mission shows that all of the country’s households have access to a toilet. The use of cooking fuel has increased more than 10 percentage point in all the states and union territories. Two states, Karnataka and Telangana, scored 25 percentage point increase.
Women empowerment indicators show satisfactory improvement across all the surveyed states and union territories. Financial inclusion among women has improved since last survey. Now, more than 60 per cent of women in every state and union territories have bank accounts of their own. Eighty to ninety per cent of female account holders run their accounts in 10 states and union territories. Property ownership data, which has been taken into consideration for the first time shows that Ladakh tops the list where 72.2 per cent women own a house.
Analysis
The unexpected revelation on under-5 malnutrition parameters such as stunted children and malnutrition can be attributed to global slowing down of economic growth accompanied with employment distress. These factors are directly related to hunger and nutrition. According to the 2017–18 National Sample Survey office report, India’s consumption expenditure dipped to the bottom for the first time in decades. The other crucial factors that contributed to children’s misery are gender disparity, poor education, and inadequate nutrition from childhood. But child stunting in many states, remaining a sustained phenomenon, is a cause of concern. Under-nourishment of children reflects poor maternal nutrition, widespread anaemia and insufficient breastfeeding. The problem of child malnourishment is not just a function of growth but it is tangled in other problems. There is inadequate nutrition from childhood which perpetuates under-nutrition. There is the government’s emphasis on vegetarian food habits that has led to several states removing eggs, which is a cheapest source of protein, off mid-day programmes in schools and anganwadi menus. The COVID-19 pandemic also disrupted mid-day programmes with the schools shut down.
The government needs to identify areas where anaemia and malnutrition are severe and work with communities to reduce stunting and wasting as they have long-term effects: lower abilities, vulnerability to diseases, chronic illness in adulthood, etc. Child nutrition is generally a result of various reasons including state of the income of a family, environmental factors, and governmental interventions.
As the survey was carried out at the time of the pandemic and India’s economy is showing a steady deceleration with rising joblessness and food insecurity, it is not clear how these factors contributed to child malnutrition. There is a need to scrutinise the present policy approaches on food security and agriculture which promotes a few crops at the expense of nutricereals.
The poor performance of Southern states in spite of their welfare programmes makes it imperative to critically assess the reach and efficacy of nutrition-centric programmes in the states.
However, it is a good sign that in several states childhood immunisation has increased and infant mortality rate declined. Analysing several indicators, it is observed that development in vital areas remains stagnant. According to experts, this is because of the COVID-19 pandemic and the subsequent lockdown.
The gender data shows that in seven states more than 25 per cent of women are subject to violence by a spouse; in eight states, the sex ratio has fallen, and in nine states, sexual abuse is rampant. But in other spheres, financial inclusion and hygiene gender data show a very positive outcome.
The first phase data of the NFHS-5 has brought out mixed results, some good and some bad, according to some. However health-wise, India has deteriorated since 2015 despite stated improvements in sanitation, cooking fuel availability, and water availability. Though NFHS-5 is not complete, there is enough data to frame positive intervention policies. Analysing some issues, it seems that poor performing areas need special attention even as some declining trends seem to be temporary. Once a full set of unit-level data is made available, can a proper analysis be conducted as to why the country has suffered major reversals despite government programmes over the last five years. However, the groundwork for analysis and suggesting remedial measures has already begun. In January 2021, the Ministry of Health and Family Welfare set up a technical expert group under Preeti Pant to examine the findings of the NFHS-5. It will provide suggestions and policy interventions to improve indicators regarding malnutrition, stunting, anaemia, and rise in caesarean delivery.
About the NFHS
The National Family Health Survey (NFHS) is a large-scale, multi-round, nationwide household survey. Earlier, the District Level Health Survey and Annual Health Survey were conducted by the health ministry. The integrated NFHS conducted by the Ministry of Health and Family Welfare has replaced them from 2015–16 onwards. It has a periodicity of three years. It provides data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, nutrition, fertility, infant and child mortality, the practice of family planning, maternal and child health, and family planning services. NFHS survey data is collected over multiple rounds. NFHS-5 survey covered seven lakh households using 67 indicators.
Ministry of Health and Family Welfare has entrusted International Institute for Population Science (IIPS), Mumbai, as the central agency to collect data; however, the survey is a joint effort of IIPS, Opinion Research Corporation (ORC Macro), Maryland (US), and the East-West Centre (Hawaii, US). The NFHS is funded by the United States Agency for International Development (USAID) with additional support from the United Nations International Children’s Emergency Fund (UNICEF).
Needs and Benefits
TheNFHS survey provides essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes. It also provides information on important emerging health and family welfare issues. Information on key indicators on population, health and family welfare, and nutrition, etc., helps track progress of sustainable development goals (SDGs).
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