National Family Health Survey (NFHS)-5 Phase 2 Analysis

Context:

• The key results from India and Phase-II States/UTs NFHS-5 Factsheets areas below.

Relevance:

• Mains GS II– Issues Relating to Development & Management of Social Sector/Services

About:

• The NFHS provides estimates on key indicators related to population, family planning, child and maternal health, nutrition, adult health, and domestic violence, among others.
• NFHS-5 was conducted in two phases between 2019 and 2021 and covered 650,000 households from 707 districts of the country.
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• As in the earlier rounds, the Ministry of Health and Family Welfare, Government of India, designated the International Institute for Population Sciences, Mumbai, as the nodal agency to conduct NFHS-5. 
• The States and UTs that were surveyed in Phase-II are Arunachal Pradesh, Chandigarh, Chhattisgarh, Haryana, Jharkhand, Madhya Pradesh, NCT of Delhi, Odisha, Puducherry, Punjab, Rajasthan, Tamil Nadu, Uttar Pradesh and Uttarakhand.
• The NFHS-5 survey work has been conducted in around 6.1 lakh sample households from 707 districts (as of March 2017) of the country; covering 724,115 women and 101,839 men to provide disaggregated estimates up to district level.

Population

• India is still poised to be the most populous country in the world with the current projection by the United Nations population division forecasting that India's population will peak around 1.6 to 1.8 billion from 2040-2050.
• A Government report last year projected that India would overtake China as the world’s most populous country around 2031- almost a decade later than the United Nations projection of 2022.
• The most positive headline news from NHFS-5 is that the total fertility rate (TFR) has been falling over time and is now just below the replacement rate of 2.1. This means that the total population has stabilised. 
• It is important to note that, the share of the population under the age of 15 years, which was 34.9% in 2005-06, has come down to 26.5% in 2019-21.
• India is still a young country — a median age of 24 years in 2011 according to the Census figures — but it is ageing, and that comes with the associated policy challenges.
• A comparison of NFHS-5 with NFHS-4 (2015-16) reveals improvement in several dimensions such as educational attainment, institutional deliveries, vaccinations, infant mortality and much more.

Sex Ratio

• The sex ratio at birth for children born in the last five years improved from 919 per 1,000 males in 2015-16 to 929 per 1,000, underscoring that boys, on average, continued to have better odds of survival than girls. 
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• The difference in Sex Ratio at Birth and at Adulthood: For the first time in India, between 2019-21, there were 1,020 adult women per 1,000 men. However, the data shall not undermine the fact that India still has a sex ratio at birth (SRB) more skewed towards boys than the natural SRB.
• There are 933 women per 1,000 men according to the 2011 Census of India.
• Most states and Union Territories (UTs) had more women than men, the NFHS-5 shows.
• States that had fewer women than men included Gujarat, Maharashtra, Arunachal Pradesh, Haryana, Madhya Pradesh, Punjab and Union territories such as Jammu & Kashmir, Chandigarh, Delhi, Andaman and Nicobar Islands, Dadra and Nagar Haveli, and Ladakh.
• The sex ratio at birth in Maharashtra has dipped by 11 points and is now at 913 girls/1000 boys.
• All other of these States and UTs, however, showed improvements in the population increase of women.
• A skewed sex ratio at birth shows a strong preference for a male child and continued sex-selective practices in the country, the Population Foundation of India has said.

Fertility Rate

• The Total Fertility Rates (TFR), the average number of children per woman has further declined from 2.2 to 2.0 at the national level and all 14 States/UTs’s ranging from 1.4 in Chandigarh to 2.4 in Uttar Pradesh.
• All Phase-II States have achieved replacement level of fertility (2.1) except Madhya Pradesh, Rajasthan, Jharkhand and Uttar Pradesh.
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• Except for Bihar, Manipur and Meghalaya, all 22 states and UTs surveyed in the first phase of NFHS-5 have a TFR of 2.1 or less.

• A notable exception is Kerala, a state with among the highest ratios of women to men at 1,121 and an improvement over 1,049 recorded in the NFHS-4.
• However, the TFR in Kerala has increased to 1.8 from 1.6. The State has also reported a decline in the sex ratio of children born in the last five years. There are 1,047 females per 1,000 males in 2015-16 that has now declined to 951 per 1,000 males.
• Only six states- Bihar, Meghalaya, Manipur, Jharkhand and Uttar Pradesh have a TFR above two.
  • Bihar has a TFR of three which, however, is an improvement from the 3.4 of the NFHS-4. Again, much like the broader trend towards feminisation, the TFR in all States has improved in the last five years.

• Overall Contraceptive Prevalence Rate (CPR) has increased substantially from 54% to 67% at an all-India level and in almost all Phase-II States/UTs with the exception of Punjab. The use of modern methods of contraceptives has also increased in almost all States/UTs.
• Unmet needs of family Planning have witnessed a significant decline from13 per cent to 9% at an all-India level and in most of the Phase-II 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 Jharkhand (12%), Arunachal Pradesh (13%) and Uttar Pradesh(13%).
• Full immunization drive among children aged 12-23 months have recorded a substantial improvement from 62% to 76% at all-India levels. 11out of 14 States/UTs has more than three-fourth of children aged 12-23 months with full immunization and it is highest (90%) for Odisha.
• On comparing NFHS-4 and NFHS-5 data, the increase in full immunization coverage is observed to be expeditious in many states and UTs; More than 50% of Phase-II States/ UTs are sharing over 10 percentage points during the short span of 4 years.
• This can be attributed to the flagship initiative of Mission Indradhanush launched by the government in 2015.
• There is an increase from 51% to 58% of women receiving the recommended four or more ANC visits by health providers at the all-India level.
• Also, all the Phase-II States/UTs have shown improvement except Punjab between 2015-16 to2019-20.

Institutional births

• have increased substantially from 79% to 89% at all-India levels. Institutional delivery is 100% in Puducherry and Tamil Nadu and more than 90% in 7 States/UTs out of 12 PhaseII States/UTs.
• Along with an increase in institutional births, there has also been a substantial increase in C-section deliveries in many States/UTs, especially in private health facilities.

Child Nutrition indicators

• The three indicators of malnutrition- stunting (low height-for-age), wasting (low weight-for-height) and underweight (low weight-for-age)- show an overall improvement.
• These conditions often occur together. Together, these reflect chronic or recurrent undernutrition, usually associated with poverty, poor maternal health and nutrition, frequent illness and/or inappropriate feeding and care in early life.
• These prevent children from reaching their physical and cognitive potential.
• There is a slight improvement at an all-India level as Stunting has declined from 38 to 36%, wasting from 21% to 19% and underweight from 36% to 32% at all India levels.
• In all phase-II States/UTs situation has improved in respect of child nutrition but the change is not significant as drastic changes in respect of these indicators are unlikely in a short span period.
• Anaemia among children and women continues to be a cause of concern. The incidence of anaemia has worsened in under-5 children (from 58.6 to 67%), women (53.1 to 57%) and men (22.7 to 25%) in all states of India.
• Anaemia has debilitating effects on overall health, which is why the World Health Organization characterises it as a serious public health concern; 20%-40% incidence is considered moderate.
• The Indian States show variation- from 39.4% in Kerala to 79.7% in Gujarat- but barring Kerala, all States are in the “severe” category. It is tempting to think of the worsening as the COVID-19 effect.
• More than half of the children and women (including pregnant women) are anaemic in all the phase-II States/UTs and all-India levels compared to NFHS4, in spite of the substantial increase in the composition of Iron-Folic acid (IFA) tablets by pregnant women for 180 days or more.

• Exclusive breastfeeding to children under age 6 months has shown an improvement in the all-India levels from 55% in 2015-16 to 64 % in 2019-21. All the phase-II States/UTs are also showing considerable progress.
• Women’s empowerment indicators portray considerable improvement at all India levels and across all the phase-II States/UTs. Significant progress has been recorded between NFHS-4 and NFHS-5 in regard to women operating bank accounts from 53% to 79% at the all-India levels.
• For instance, in the case of Madhya Pradesh, the increase was to the tune of 37% points from 37% to 75%. More than 70% of women in every state and UTs in the second phase have operational bank accounts.

Limitations to NFHS-5:

Exclusion of Micronutrients

• In addition to anthropometric measures, lack of adequate nutrition is also measured by micronutrient deficiencies, i.e. lack of vitamins and minerals that are essential for body functions such as producing enzymes, hormones and other substances needed for growth and development.
• The NFHS does not have data on micronutrients.

Flawed approach for Monitoring Dietary Intake

• Indian diets display a rich diversity. Many traditional diets reflect both local climatic conditions as well as a multiplicity of sources of essential nutrients, such as proteins, fats etc.
• Policing of diets, by imposing an unnatural uniformity, and preventing access to animal protein for large sections of Indians that are not traditionally vegetarian is likely to reduce micronutrient diversity and contribute to poor health outcomes.

Some analyses have suggested that the rate of progress has slowed down, based on comparisons between NHFS-4 and NHFS-5 to the improvements between the two previous rounds.

This cannot be substanstiated since comparing changes over a 10-year interval (between NFHS-3 in 2005-06 and NFHS-4) to a five-year interval (between NFHS-4 and NFHS-5) is misleading.

Some have argued that the poor health outcomes reflect the effect of COVID-19. The data for the second phase of NFHS-5 have been, to a large extent, collected during the highly unusual conditions of the COVID-19 pandemic, but as the evidence on anaemia shows, the deterioration in public health indicators cannot be attributed entirely to the pandemic.

COVID-19 might have added fuel to the fire of poor public health, but it did not cause the fire.

Policy Interventions

• The overall evidence is compelling and clear- health ought to be a matter of concern for all political parties and all governments- national and State.
• The survey highlights deep inequalities in health outcomes. An action plan to improve India’s health needs to be inclusive, firm in its commitment and backed by solid resources.

Addressing Unethical Delivery Practices

• The survey focuses on women's empowerment, autonomy and mobility indicators and shines a spotlight on women’s reproductive health.
• However, as per data, cesarean births have increased dramatically, in private health facilities, 47.5% of births are by C-section (14.3% in public health facilities).
• These figures are highly unnatural and call into question unethical practices of private health providers who prioritise monetary gain over women’s health. Actions are needed to restrict such practices. 

Investing in female education & health

• The NFHS findings are a reminder of the urgent need to close gaps in girls’ education and address the pathetic nutritional status of women and children.
• The impact of the pandemic may also be noted, the disruption it caused to services such as balanced nutrition for children must be acknowledged.
• Such scenarios underscore the need for building resilient and fortified systems capable of delivering in the most trying circumstances.

Collaboration in Health Sector

• Current times require integrated and coordinated efforts from all health institutions, academia and other partners directly or indirectly associated with the health care services to make the basic as well as advanced health services accessible, affordable and acceptable to all.

Behaviour-Change Communication Strategy

• Female sterilisation continues to dominate as the modern method of contraceptives in States like Andhra Pradesh (98%), Telangana (93%), Kerala (88%), Karnataka (84%), Bihar (78%) and Maharashtra (77%).
• Male engagement in family planning continues to be limited as seen by the low uptake of condoms and male sterilisation across the States. This data calls for awareness campaigns and strategies to bring behavioural change.
• The Government must adopt a targeted social and behaviour-change communication strategy to ensure that men also take responsibility for family planning.

Conclusion:

• The NFHS is second only to the exhaustive data that the decennial population census provides. It ought to be treated as an important turning point for policy-making in India.
• For India to utilize its sweet spot of population stabilization and demographic dividend, investing in youth and especially girls would go a long way in ensuring economic and social development. 
• The greater idea for the states as well as the centre is to recognise it as a matrix to work on and improve the development indicators further.