National Family Health Survey

Context:

• Recently, the first-phase data of the National Family Health Survey-5 (NFHS-5) 2019-20 has been released by the Ministry of Health and Family Welfare.

Relevance: 

• GS Paper II>  Issues relating to the development and management of Social Sector/Services relating to Health, Education, Human Resources. Issues relating to poverty and hunger.

• The National Family Health Survey 2019-20 (NFHS-5), the fifth in the NFHS series, provides information on population, health, and nutrition for India and each state/union territory (UT). Like NFHS-4, NFHS-5 also provides district-level estimates for many important indicators. 

Wide Coverage

• NFHS-5 includes some new topics, such as preschool education, disability, access to a toilet facility, death registration, bathing practices during menstruation, and methods and reasons for abortion.
• The latest data pertains to 17 states-  including Maharashtra, Bihar, and West Bengal- and five UTs (including J&K) and, crucially, captures the state of health in these states before the Covid pandemic.
• Phase 2 of the survey, which will cover other states such as Uttar Pradesh, Punjab and Madhya Pradesh, was delayed due to the covid and its results are expected to be made available in May 2021.

NFHS origin and its evolution:

• The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India.
• The Ministry of Health and Family Welfare (MOHFW), Government of India, designated International Institute for Population Sciences (IIPS) as the nodal agency, responsible for providing coordination and technical guidance for the NFHS.
• IIPS collaborated with a number of Field Organizations (FO) where each FO was responsible for conducting survey activities in one or more states covered by the NFHS.  
• The First National Family Health Survey (NFHS-1) was conducted in 1992-93.
• Second Round of NFHS conducted in 1998-99
• Third Round of NFHS conducted in 2005-06
• Fourth Round of NFHS conducted in 2015-16
• Fifth Round of NFHS conducted in 2018-19

The Total Fertility Rates (TFR)

• The total fertility rate (TFR) is defined as the average number of children that would be born to a woman by the time she ends childbearing.
• Sikkim recorded the lowest TFR, with one woman bearing 1.1 children on average; Bihar recorded the highest TFR of three children per woman.
• The Total Fertility Rates (TFR) has further declined since NFHS-4 in almost all the Phase-1 States and UTs. The replacement level of fertility (2.1) has been achieved in 19 out of the 22 States/UTs and only 3 states viz. Manipur (2.2), Meghalaya (2.9) and Bihar (3.0) have TFR above replacement levels now.
• Overall Contraceptive Prevalence Rate (CPR) has increased substantially in most States/UTs and it is the highest in HP and WB (74%). Use of modern methods of contraception has also increased in almost all States/UTs.
• Unmet needs of family planning have witnessed a declining trend in most of the Phase-1 States/UTs. The unmet need for spacing which remained a major issue in India in the past has come down to less than 10% in all the States except Meghalaya and Mizoram.

Immunisation

• Full drive among children aged 12-23 months has recorded substantial improvement across States/UTs/districts. More than two-thirds of children are fully immunized in all the States and UTs except Nagaland, Meghalaya and Assam.  In almost three-fourths of districts, 70% or more children aged 12-23 months are fully immunized against childhood diseases.
• On comparing NFHS-4 and NFHS-5 data, the increase in full immunization coverage is observed to be expeditious in many states and UTs; in 11 out of the 22 states/UTs, the increase was to the tune of over 10 percentage point and in another 4 states/UTs between 5 to 9 percentage point over the short span of 4 years.
• This can be attributed to the flagship initiative of Mission Indradhanush launched by the government since 2015.
• There is an increase in the % of women receiving the recommended four or more ANC visits by health providers in many States/UTs. This percentage has increased in 13 States/UTs between 2015-16 to 2019-20.

Institutional births

• Institutional births have increased substantially with over four-fifth of the women delivering in institutions in 19 States and UTs.  Institutional delivery is over 90 % in 14 out of the total 22 States and UTs. Almost 91% of districts recorded over 70% institutional deliveries of births in the 5 years preceding the survey.

Hunger 

• The proportion of stunted children has risen in several of the 17 states and five UTs surveyed, putting India at risk of reversing previous gains in child nutrition made over previous decades.
• The share of underweight and wasted children has also gone up in the majority of the states.
• Worryingly, that includes richer states like Kerala, Gujarat, Maharashtra, Goa and Himachal Pradesh.

Sex ratio at birth

• Sex ratio at birth has remained unchanged or increased in most States/UTs. Majority of the states are in a normal sex ratio of 952 or above. SRB is below 900 in Telangana, Himachal Pradesh, Goa, DNH & DD.

Under-5 and infant mortality rate (IMR) 

• The Under 5 and infant mortality rate (IMR) has come down but in parallel recorded an increase in underweight and severely wasted under 5 children among 22 states that were surveyed.
• These states are Goa, Gujarat, Himachal Pradesh, Kerala, Maharashtra, Meghalaya, Mizoram, Nagaland, Telangana, Tripura, West Bengal, Lakshadweep and Dadra & Nagar Haveli and Daman and Diu.
• Child malnutrition parameters — such as infant and child (under 5 years of age) mortality, child stunting (low height for one’s age), child wasting ( low weight for one’s height) and proportion of underweight children — several states have either been stagnant or worsened.
• In other words, children born between 2014 and 2019 (that is, 0 to 5 years of age) are more malnourished than the previous generation. The reversal in the proportion of children who are stunted is the most worrisome because unlike wasting and being underweight (which can be due to short term reasons and represent acute malnutrition), stunting represents chronic malnutrition. Reversals in stunting are unheard of in growing economies with stable democracies.

What can be done?

• The government must begin identifying areas where malnutrition and anaemia among children are severe and work with communities and civil society to improve nutrition and food security policies. Stunting and wasting have long-term effects which include lower abilities in school, increased child mortality, vulnerability to diseases, and chronic illness in adulthood among others.
• The paradox, in a sign of glaring inequality, is that this is accompanied by a rise in obesity, especially among women and children. Even before the pandemic, the trend towards obesity was driven by the lack of awareness of good food habits resulting in greater consumption of high-fat, high-sugar foods and sedentary lifestyles. Increasing obesity will exacerbate conditions such as cardiovascular disease, diabetes and hypertension.

• When it comes to rural IMR, the situation is almost the same as IMR and the overall U5MR trends. Tripura, Manipur and Kerala have shown a worsening of U5MR in 2019 when compared to 2015. In addition to Meghalaya, which showed near-stagnation, large states like Bihar and Maharashtra showed very little improvement.

• Comparison of trends in urban U5MR revealed similar findings as well. A total of seven out of 17 states had their urban IMR worsen between 2015 and 2019. Maharashtra joined the bigger states like Bihar, Andhra Pradesh, West Bengal, Karnataka and Telangana where U5MR worsened, apart from Tripura and Meghalaya. Other than Mizoram, where urban U5MR improved from 35 in 2015 to 21.8 in 2019, and Kerala, where urban U5MR halved from 8 to 3.9, the improvements across the remaining states were relatively modest.

Child nutrition indicators

• Child nutrition indicators show a mixed pattern across states. While the situation improved in many States/UTs, there has been a minor deterioration in others. Drastic changes in respect of stunting and wasting are unlikely in a short period.

Anaemia among women and children

• Anaemia continues to be a cause of concern. More than half of the children and women are anaemic in 13 of the 22 States/UTs. It has also been observed that anaemia among pregnant women has increased in half of the States/UTs compared to NFHS-4, in spite of a substantial increase in the consumption of IFA tablets by pregnant women for 180 days or more.
• For both women and men, there is a lot of variation in the high or very high random blood glucose levels across States/UTs. Men are more likely to have slightly higher blood glucose levels in the range of high or very high compared to women. The percentage of men with high or very high blood glucose is highest in Kerala (27%) followed by Goa (24%). Prevalence of elevated blood pressure (hypertension) among men is somewhat higher than in women.

Improved sanitation facility

• The percentage of households with improved sanitation facility and clean fuel for cooking has increased in almost all the 22 States/UTs over the last four years (from  2015-16  to  2019-20).
• The Government of India has made concerted efforts to provide toilet facilities to maximum households through Swachh Bharat Mission, and improved household environment through Pradhan Mantri Ujjwala Yojana in the country. For instance, the use of cooking fuel has increased more than 10 percentage point in all the States and UTs during the last 4 years with over 25 percentage point increase in states of Karnataka and Telangana.
• Improved sanitation facilities include flush to the piped sewer system; flush to septic tank; flush to pit latrine; ventilated improved pit/biogas latrine; pit latrine with slab; twin pit / composting toilet that is not shared with any other household.
• But the rural-urban divide persists widely across several states. People residing in urban areas had relatively higher access to unshared and quality sanitation facilities in a majority of the states except for Manipur, Meghalaya, Sikkim, Nagaland and Kerala, where the urban population was more deprived. 
• The highest rural-urban gap was observed in Gujarat, Bihar, West Bengal and Karnataka.

Access to improved drinking water 

• Across all 22 surveyed states, urban residents had better access to improved drinking water sources in comparison to the rural population. Manipur, Meghalaya, Tripura and Maharashtra reported widest rural-urban disparity. Access to water facilities needed work in certain districts in the Northeastern states and Maharashtra. 
• Access to improved drinking water sources increased across all states and UTs except Sikkim, which registered a five% fall in the population living in households with an improved drinking-water source in the last half-a-decade.
• Manipur, Meghalaya and Nagaland witnessed significant improvement among the 22 surveyed states in last five years. Bihar topped the list with 99% population having access to improved drinking water sources.
• Except for Manipur, Meghalaya, Assam, Tripura and Ladakh, all other 17 states and UTs recorded above 90% population having access to improved sources of drinking water.
• Improved sources of drinking water include piped water into dwelling/yard/plot, piped to a neighbour, public tap/standpipe, tube well or borehole, protected dug well, protected spring, rainwater, tanker truck, a cart with a small tank, bottled water and community reverse osmosis plant.
• It is, however, noteworthy that it is not necessary that water obtained from improved sources would not have a negative impact on the health of those consuming it. The factsheet does not give any information on the distance of the improved water sources from the household.
• Across all 22 surveyed states, urban residents had better access to improved drinking water sources in comparison to the rural population. Manipur, Meghalaya, Tripura and Maharashtra reported widest rural-urban disparity. Access to water facilities needed work in certain districts in the Northeastern states and Maharashtra. 
• The United Nations-mandated sustainable development goal 6.1 aims to achieve universal and equitable access to safe and affordable drinking water for all by 2030. SDG 6.2 targets to achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and of those in vulnerable situations by 2030.
• The strides made by some states in this regard are particularly encouraging. Several states, however, have been lagging behind the universal targets

Women’s empowerment

• Women’s empowerment indicators portray considerable improvement across all the States/UTs included in Phase 1. Considerable progress has been recorded between NFHS-4 and NFHS-5 in regard to women operating bank accounts.  For instance, in the case of Bihar, the increase was to the tune of 51 percentage point from 26% to 77%. More than 60% of women in every state and UTs in the first phase have operational bank accounts.
• It may also be stated that recurrent floods in Kerala during the time of survey as well as the previous year may have affected the utilization of maternal care services and hence, it may have some unusual/unexpected trend in some of the maternal care indicators for some of the districts.

Gaps in internet use

• In 2019, for the first time, the NFHS-5 sought details on two specific indicators: Percentage of women and men who have ever used the Internet.
• On average, less than 3 out of 10 women in rural India and 4 out of 10 women in urban India ever used the Internet, according to the survey.
• First, only an average of 42.6%of women ever used the Internet as against an average of 62.16%among the men.
• Second, in urban India, average 56.81%women ever used the Internet compared to an average of 73.76% among the men.
• Third, dismal 33.94% women in rural India ever used the Internet as against 55.6% among men.
• In urban India, 10 states and three union territories reported more than 50% women who had ever used the Internet: Goa (78.1%), Himachal Pradesh (78.9%), Kerala (64.9%), and Maharashtra (54.3%).
• The five states reporting the lowest percentage of women, whoever used the Internet in urban India were Andhra Pradesh (33.9%), Bihar (38.4%), Tripura (36.6%), Telangana (43.9%) and Gujarat (48.9%).

• Worsening child malnutrition, as well as rising levels of anaemia in women (especially pregnant ones), points to Indian children born in the past 5 years likely suffering from both cognitive and physical deficiencies.
• India continues to grapple with a high rate of undernutrition. Stunting has lifelong consequences on human capital, poverty and equity. The 2019-20 Sustainable Development Goals Index has also indicated poor performance on the goal of Zero Hunger. India falls under ‘serious hunger’ category as per the 2020 Global Hunger Index, with 14% of the population being undernourished.
• A double whammy, with reversing trends in progress to achieving the Sustainable Development Goal (SDG) on Zero Hunger due to the due to the pandemic. With a recent report indicating a rise in pandemic related malnutrition and adding to the number of children suffering from wasting. POSHAN Abhiyaan’s ambitious target for stunting set at 25% by 2020 seems far to reach looking at the data trends.
• While at the national level there has been a stagnation in urban IMR, the state-level analysis revealed an even more worrying picture in study—11 out of 20 bigger states and 15 out of 20 urban populations within those states did not show improvements in IMR between 2016 and 2017 or 2017 and 2018. The study concluded that IMR declines slowed down, stagnated, or reversed in many parts of India, more so in urban areas.
• However, rural populations fared slightly better with 9 out of 20 bigger states showing stagnation in IMR. The study had hypothesised that the setbacks were at least partly attributable to the “startling experiment” of demonetisation in 2016.

• The latest results show that health-wise, India has taken a turn for the worse since 2015 despite improvements in water availability and sanitation methods.
• Health outcomes such as child malnutrition data are the result of a complex set of reasons — ranging from the state of a family’s income generation to environmental factors to government interventions.
• Though NFHS-5 is not complete, there is enough data to frame positive intervention policies.
• Community health workers have been in the frontline of the fight against Covid-19.
• For a start, better nutrition, health and awareness programmes can be mainstreamed into their efforts to begin the process of reversing some of the problems identified in NFHS-5.