NFHS-4 Phase-I Results

The first phase results of the National Family Health Survey (NFHS-4), which was conducted in 2015-16, were released in January, 2016. The NFHS-4 survey interviewed men of 15-54 years age and women of 15-49 years age. The first phase results covered 13 states and 2 union territories. The NFHS-4 is for the first time collecting data from all 29 states and all 7 Union Territories. For the first time, the NFHS-4 will provide estimates at the district level. Given the wide intra-state variations, the disaggregated data at the district level helps in better understanding of the data and future policy formulation.

The key take away from this survey is that a large part of India has shown substantial improvement in health of its citizens over the past decade.

About NFHS

The NFHS is a large-scale, multi-round survey conducted across India in a representative sample of households. The survey collects information about various parameters such as fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services. The first NFHS was conducted in 1992-93. The NFHS-2 and NFHS-3 were conducted in 1998-99 and 2005-06 respectively.

Observations from NFHS-4 data

Child mortality

• Infant mortality rate is the number of deaths of infants under one year per 1,000 live births.
• Child mortality rate is the number of deaths in children under five years per 1,000 live births.

The survey shows that all 13 states and 2 union territories have IMR of less than 51 deaths. Andaman and Nicobar Islands has the lowest IMR of 10 deaths whereas Madhya Pradesh has the highest IMR of 51 deaths. India’s current IMR is 37.

Comment

The comparison among the all the four surveys shows that there has been a gradual decline in both infant mortality rate and child mortality rate across the country. It is an good news. The comparison also shows that some states improved much better than other states. For example, Tamil Nadu and West Bengal have two-thirds reduction, where as other states have halved. It indicates the effect of social protection plans in West Bengal and Tamil Nadu.

While there is an overall decline in child mortality, all regions in India still lag behind not just high income countries but also behind the many low and middle income countries. For example, Sri Lanka’s child mortality rate is 10 in 2015. The countries which faced natural calamities, internal wars, and political upheaval have done better than India. But India with its economic reforms since 1991 is yet to improve in social parameters.

Sex ratio

The data on sex ratio at birth (females per 1,000 males) shows mixed trends. While the earlier worse performing states like Haryana, Tamil Nadu, and Bihar have showed significant improvement, the states like MP, Karnataka and West Bengal, which performed better earlier, have declining sex ratios. This is a worrying factor as killing of unborn girl child might have spread to newer areas.

The data from 11 states shows that there are 985 females per 1,000 males in 2015-16 compared to 1000 females per 1000 males in 2005-06. Only in Uttarakhand, sex ratio increased from 996 to 1,015 females per 1,000 males. Meghalaya saw its sex ratio stabilise at 1,005 females per 1,000 males. All other states saw a disturbing fall in sex ratio.

Child nutrition, stunting and underweight

The data also highlights the double burden of malnutrition in India. While there is a widespread undernourishment, there is also a sharp rise in the number of obese people.

The NFHS–4 data also shows a decline in stunting among children under five from 43% to 32%. Similarly there is a decline in prevalence of underweight children under five from 39% to 29%. But there are stark regional differences. The poorer states continued to have low levels of health and nutrition. Poor nutrition is less common than reported in the last round of the National Family Health Survey. In nine states and union territories, fewer than one-third of children are found short for their age. In Bihar, Madhya Pradesh and Meghalaya, more than 40% children are still stunted.

In all the states (except Goa) more than 50% of children and women are anaemic. To be more precise 50 per cent of the children under five are anaemic in 10 states.

Comment: Tackling Malnutrition in India

Tackling malnutrition in India has for long been a laggard. Former PM Manmohan Singh had said in January 2012 that India’s levels of malnutrition were a “national shame”. Many reasons are attributed to this and dietary lacunae is one of the primary reasons. Since diet has regional, cultural, religious and economic dimensions, it becomes a tough job in addressing them. The NFHS-4, however, suggests that change will happen in spite of all this. In addition, decades of slow economic growth and inefficient primary healthcare in India had worse malnutrition statistics than even some of the sub-Saharan countries.

Immunisation coverage

According to the National Family Health Survey, 2015-16, at least six out of 10 children received full immunization in 12 of the 15 states and union territories. In Goa, West Bengal, Sikkim, and Puducherry, more than four-fifths of the children have been fully immunized.

Due to the launch of the programmes like National Rural Health Mission after NFHS-3, the improvements in public health systems have shown some results. While there is an improvement in immunisation coverage in many states, few states have shown slight decline. There is an urgency to include new vaccines in the national programme.

Maternal mortality rate (MMR)

There is a reduction in maternal mortality rates due to various measures introduced to improve the care given to pregnant women and attention on nutritional requirement of adolescent girls. There is a significant increase in the number of institutional deliveries in many states with more than 90% institutional births in eight of the 15 states. The delivery in an institution improves the post-natal care also and thus helps in reduction of infant and maternal mortality rates. According to the survey, almost all mothers have received antenatal care for their most recent pregnancies and an increasing number of women are receiving the recommended four or more visits by the service providers. More and more women now give birth in healthcare facilities, and rates have more than doubled in some states in the last decade.

The highest jump has been seen in institutional deliveries. Institutional deliveries in Bihar rose three-fold—from 19.9% in 2005-06 to 63.8 % in 2014-15. Similarly, over the same period, institutional deliveries rose from 35.7% to 80.5% in Haryana and 26.2% to 80.8% in Madhya Pradesh.

Data shows that infant mortality rates (IMR) declined in all the states and union territories surveyed—ranging from a low of 10 in Andaman and Nicobar Islands to a high of 51 deaths per 1000 live births in Madhya Pradesh.

Women’s health

Anaemia is usually associated with factors related to diet, nutrition and cultural practices, which are in turn linked to education and socio-economic backgrounds. It was also found that 50 per cent of the women are anaemic in 11 of the 15 states surveyed in the first phase.

Fertility rates

The total fertility rate represents number of children born per woman. And it ranges from 1.2 in Sikkim to 3.4 in Bihar. It declined from 2.1 children per woman to 1.8 children per woman during the corresponding period. All first phase covered states and union territories except Bihar, Madhya Pradesh and Meghalaya had either achieved or maintained replacement level of fertility. Except in Madhya Pradesh, Meghalaya and Bihar, all states and the union territories have achieved replacement level of fertility. According to experts, declining fertility rates was a big achievement.

Alok Banerjee, a member of government’s technical committee on family planning adds: “Institutional deliveries have increased because of cash incentives that were introduced as part of the Janani Suraksha Yojana (JSY) in 2005. All stakeholders—the pregnant woman, accredited social health activists (ASHA workers) and empanelled private doctors—are paid incentives”. This has encouraged deliveries in health facilities, as against deliveries in homes.

A decline in fertility rates may imply that women are trying to exercise control over their bodies and that families are coming to a different understanding of both health and economics.

Family planning methods

While almost all states depict a decline in fertility rates, the survey also shows a decline in use of family planning methods. There is an increase in use of modern family planning methods in states such as Meghalaya, Haryana, and West Bengal. But in states such as Goa, Karnataka and Tamil Nadu, there is a decline in use of modern family planning methods.

Population below 15 years

The population below 15 years, which is considered a part of demographic dividend, has decreased in the past 10 years. Sikkim has topped the list of states with decrease of population aged below 15 years, to 23.1% in 2015-16 from 30.7% in 2005-06. Sikkim was followed by Madhya Pradesh in the list with a decrease of seven percentage points in the period.

Health care expenditure

There is a concern over increasing cost of care in public health facilities. In spite of launching programmes such as Janani-Shishu Suraksha Karyakram to provide free and cashless services for pregnant women and new-born children, the NFHS-4 data indicates that women are spending anywhere between Rs.1,258 (Andaman & Nicobar) and Rs.7,772 (West Bengal) for a delivery in a public health facility. The government should focus more on reducing the high out-of-pocket expenditures on health.

Tobacco and alcohol consumption patterns

The data on tobacco consumption front is welcoming. Awareness Campaigns through street-plays and short documentaries have yielded the desired results in educating people on the negative impact of tobacco consumption. However, it should not be forgotten that there is still a lot of ground to cover as smoking is becoming popular among the youth, affecting adversely their health and education.

When it comes to alcohol, it may be noted that in many States, 25 is the legal age for consumption but there are many instances in which the pubs and bars serve liquor to teenagers. Also, an increase in use of other tobacco products like gutka must be of great concern among authorities. The government and the non-governmental organisations (NGOs) have now started to shift their focus to rural areas where a major proportion of tobacco-consuming population still exists.

Obesity

In the past 10 years, the number of obese people has doubled in the country. Among women, obesity levels increased from 13.92 per cent in 2005-06 to 19.56 per cent in 2015-16 and among men, the rise from the last decade has been from 10.35 per cent to 18.04 per cent.

With the exception of Puducherry, states showed a sharp rise in obesity levels among both men and women. States like Tamil Nadu and Andhra Pradesh have almost one in three women overweight. In Andhra Pradesh, 45.6 per cent of the total women surveyed in urban areas were found to be overweight, which is the highest in the country. Obesity among rural women in Andhra Pradesh was also found to be higher at 27.6 per cent, though it may not appear alarming, but is still high compared to other rural parts.

While rural Bihar recorded the fewest number of women suffering from obesity among the 15 States. Obesity is the major reason for developing different types of diabetes mellitus. As for blood sugar levels, urban centres records more cases of high blood sugar than the rural areas. The few exceptions have been recorded in various parts of the country. For instance, in Goa the number of women in rural areas with high blood sugar was more than in urban Goa. The same trend was mapped in Puducherry. In Tripura and also in Haryana, more men in rural areas had high blood sugar than men in urban parts. Thus, the government needs to focus on promoting good quality diverse diets.

Hypertension

It has been found that the number of people suffering from hypertension in rural India is higher than in urban parts. Higher stress levels in rural India and faulty diet in cities have thrown up two most disturbing health trends. Health experts have suggested that the overall obesity in urban India and rising hypertension in rural India was indicative of the faulty diet of people.

In Bihar, more women in rural parts were found to have hypertension compared to urban parts of Bihar. In Andaman and Nicobar, more men and women in rural parts were found to be suffering from hypertension than in urban centres, which is also the case in Meghalaya.

A health expert who was the former deputy director of the National Institute of Nutrition, Hyderabad adds: “High stress levels in rural areas are rooted in income, agriculture and high cost of healthcare. Also on the food front, there is lack of potassium-rich food like fruits and vegetables.”

Schemes in operation to address nutritional challenges

There are numerous health-related schemes. Prominent among them are Integrated Child Development Scheme, which was started in 1975 to look into the health and well-being of mothers and children. The National Mid-Day Meal Scheme, the National Rural Health Mission and the Public Distribution System have had overlapping nutrition objectives. The National Nutritional Anaemia Prophylaxis Programme meant to maintain the adequate amount of iron and folate in expecting lactating mothers, children from aged 1-5 and anaemic adolescents was implemented as early as 1970.

Criticisms: Absence of standardisation in data collection

The way India collects its data on malnutrition leads to results that often point in different directions. The collection of nutrition data suffers from a lack of standardisation, as a result of which no two sets of data are comparable and leads to several data gaps, and experts cannot say for sure whether a particular policy was responsible for the improvements or not.

Some experts like Aparna John and Purnima Menon highlight this issue in Global Nutrition Report 2015. For instance, since 1992, several major nutrition surveys have been conducted in India, which includes:

• Three National Family Health Surveys (NFHS) — 1992-1993 (Round 1), 1998-1999 (Round 2), and 2005-2006 (Round 3);
• Four District-Level Health Surveys (DLHS) — 1998-1999, 2002-2004, 2007-2008, and 2012-2013.
• Three Annual Health Surveys (AHS) — 2011, 2012, 2013.
• One-time surveys — UNICEF’S RSOC (2015), and hungama survey by the Nandi Foundation (2011).

A study of all these surveys shows wide variations across their geographical coverage, frequency of data collection, etc. It may be pointed out that neither the NFHS nor the DLHS have any comparability when it comes to the targeted respondents among women. Researchers claim that with this confusing data, it becomes difficult to base policy prescription. Similarly, the shifting reference points for child anthropometry (which includes collecting data on stunting and wasting) makes it difficult to come to a conclusive conclusion and clear deduction in the scale of improvement. The same holds true for the frequency of the surveys.

It has been cited that instead of offering a clear direction for future policymaking, the latest data has only muddied the debate on malnutrition in India. Not surprisingly the result of all the above surveys results in confusion about the true state of malnutrition in India. Until last year, NFHS-3 (2005-06) data was held as the only one that could be quoted. NFHS-4 was delayed, and the results of DLHS-4 (2014) or HUNGaMA (2011) were not comparable to NHFS-3 because they did not cover the whole country. In addition, the results of DLHS-4 and HUNGaMA contradicted each other. Even with the introduction of RSOC data, it is difficult to say anything conclusively. This is due to the fact that RSOC is a one-time data set, and the government has itself put a question mark over it by not releasing the detailed state-level factsheet. According to a Ministry press release, a technical committee is reviewing the data.

Way forward

Overall, the data presents a mixed picture. It is a well known fact that nutrition in the first two or three years of children’s life has a lasting impact on their development and the care given in later years cannot undo the setback caused by neglect during this foundational phase. So, it becomes imperative for a new policy course to provide access to nutrition and health as a right for all. To assert this right, there is a need to strengthen the schemes like Integrated Child Development Services scheme in all States, particularly those with a higher proportion of underweight and stunted children. Problem areas should be holistically addressed as even within the ICDS, there is a clear deficit in caring for the needs of children under three. Other important areas requiring intervention are access to antenatal care, reduction of high levels of anaemia among women, and immunization.

Also, there is a need to assess the health of citizens more frequently than the current NFHS cycle of seven to 10 years allows. Data gathered at short intervals such as every two or three years would help make timely policy corrections.

The Indian health system needs to address its structural and operational deficiencies. Millets and fortified food should be incorporated in midday meals to tackle the problem of hidden hunger (micronutrient deficiency). Fortification helps in enhancing the nutrients present in salt, rice, wheat, milk and so forth, and the fact that millets have higher nutrient levels than cereals should not be ignored.

Conclusion

World Health Organization (WHO) has set three goals for a country’s health system must aim for: to improve health, to be responsive to legitimate demands of the population and to ensure no one is at risk of serious financial losses because of ill health. If India has to reap its demographic dividend in an ageing world, it should have its citizens hale and healthy. The survey records changes that might ultimately speed up the improvement in health. At the same time, availability of latest data helps in taking corrective measures at regular intervals. It cannot be denied that sustained economic growth is not possible without state support to achieve the well-being of the population, especially women and children.