The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India. It is carried on by Ministry of Home & Family Welfare to bring out reliable data on emerging health and family welfare issues. The coordinating and implementing agencies that are helping the ministry to bring out this NFHS round are:

• International Institute for Population Sciences, Mumbai
• A group of survey organizations and Population Research Centres

ICF International is providing technical assistance for the NFHS 5 while the United States Agency for International Development is providing financial assistance.

Which Agencies Provided the Funding for NFHS?

Many international agencies and the Central Government Ministry have provided the necessary funds to carry out the survey.

1. United States Agency for International Development (USAID)
2. United Nations Children’s Fund (UNICEF)
3. Bill and Melinda Gates Foundation
4. United Nations Population Fund (UNFPA)
5. MOHFW, Government of India

The NFHS-5 has captured the data during 2019-20 and around Seven lakh households are being covered to collect the data. 67 indicators are being used to cover the NFHS 5 data. The list of important indicators is mentioned below:

• Population and household profile
• Marriage and fertility
• Family planning
• Contraception
• Maternal and child health
• Delivery care
• Vaccinations
• Treatment of childhood diseases
• Nutrition and feeding practices
• Anemia
• Diabetes
• Hypertension and
• Cancer examination

History of National Family Health Survey

• The First National Family Health Survey (NFHS-1) was conducted in 1992-93.
• The Second National Family Health Survey (NFHS-2) was conducted in 1998-99 in all 26 states of India. The project was funded by the USAID, with additional support from UNICEF.
• The Third National Family Health Survey (NFHS-3) was carried out in 2005-2006. NFHS-3 funding was provided by the USAID, the Department for International Development (UK), the Bill and Melinda Gates Foundation, UNICEF, UNFPA, and the Government of India.
• The Fourth National Family Health Survey (NFHS-4) in 2014-2015, the fourth National Family Health Survey (NFHS-4) was conducted.

National Family Health Survey Objectives

The Objective of conducting the NFHS is to collect information of the following

1. Fertility
2. Maternal and Child Health
3. Reproductive Health
4. Nutrition
5. Anaemia
6. Infant and Child Mortality
7. Family Planning

Key Findings of the Survey

1. Decline in Total Fertility Rate (TFR), a Major Positive: 

• The Total Fertility Rate (TFR) has been falling over time and has now reached (at 2.0) just below the replacement rate of 2.1. Most states have seen a decrease in the total fertility rate (TFR).  
• Bihar’s TFR has declined from 3.4 (in NFHS-4) to 3.  All other medium and large states in the survey (i.e., population above 1 crore) have a TFR below the replacement level rate of 2.1.
• This is true across all States of India which means that the total population has stabilised.

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 (which is 952 girls per 1000 boys).
• Uttar Pradesh, Haryana, Punjab, Rajasthan, Bihar, Delhi, Jharkhand, Andhra Pradesh, Tamil Nadu, Odisha, Maharashtra are the major states with low SRB.
• In three states, the ratio is below 900 (Goa: 838, Himachal Pradesh: 875, and Telangana: 894).
• The ratio has declined in seven states.  The most notable decline was in Goa (from 966 to 838), and Kerala (from 1,047 to 951).  Only Tripura has a sex ratio at birth above 1,000 (i.e., more females born than males).

Poor Performance in Dealing with Anaemia: 

• The incidence of anaemia in under-5 children (from 58.6 to 67%), women (53.1 to 57%) and men (22.7 to 25%) has worsened in all States of India (20%-40% incidence is considered moderate).

• Barring Kerala (at 39.4%), all States are in the “severe” category.

Performance of Malnutrition Indicators:

• Child nutrition indicators show a mixed pattern across states. While the situation improved in many States and Union Territories, there has been minor deterioration in others.
• Malnutrition has worsened. Stunting has risen in 11 out of 18 states. Wasting was going up in 14 states.
• Stunting: 13 out of 22 states and UTs surveyed, recorded a rise in the percentage of stunting in children.  In Bihar and Gujarat, 40% or more of the children under the age of five years are underweight.
• Wasted: 12 out of 22 states and UTs surveyed, recorded a rise in the percentage of children under five years who are wasted in comparison to NFHS-4.
• Overweight: 20 states and UTs have recorded a rise in the percentage of children under 5 years who are overweight.
• Diarrhoea: Children with diarrhoea in the two weeks preceding the survey also jumped to 7.2% from 6.6%.

Infant & Child Mortalities

• Neonatal Mortality Rate, Infant mortality Rate, and Under 5 Mortality Rate – Infant and child mortality rates across most Indian states have declined.
• Sikkim, Jammu & Kashmir, Goa and Assam were the best performers as they witnessed a steep reduction in neonatal mortality rate (NMR), infant mortality rate (IMR) and under-five mortality rate (U5MR).
• Tripura, Andaman & Nicobar Island, Meghalaya and Manipur recorded a spike in all three categories of child mortality.
• Assam has seen one of the largest drops in IMR, from 48 deaths (per 1,000 live births) to 32 deaths.  
• IMR remains high in Bihar (47 deaths per 1,000 live births) while Kerala reported the lowest death rates.
• The child mortality rate of Maharashtra remained unchanged in the last five years.

Child Marriages:

• There has been an increase in child marriages in Manipur (16.3% from 13.7% in 2015-16), Tripura (40.1% from 33.1% in 2015-16), and Assam (31.8% from 30.8 % in 2015-16).
• Also, states such as Andhra Pradesh, Himachal Pradesh, Tripura, Manipur, and Nagaland have shown an increase in pregnancy of teenagers.

Spousal Violence  

• It has witnessed an increase in five states, namely Sikkim, Maharashtra, Himachal Pradesh, Assam and Karnataka where Karnataka witnessed the largest increase in spousal violence, from 20.6% in NFHS 4 to 44.4% in NFHS-5.

Issues Associated

Non-Inclusion 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.
• ‘One Size Fits All’ 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.

Covid-19 Blame Game: 

• The poor health outcomes have been argued to reflect the effect of Covid-19 as the data for the Phase-2 of NFHS-5 have been, to a large extent, collected during the highly unusual conditions of the COVID-19 pandemic.
• However, the deterioration in public health indicators cannot be attributed entirely to the pandemic.
• The Pandemic might have added fuel to the fire of poor public health, but it did not cause the fire.

Unethical Delivery Practices Affecting Women Health: 

• 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% 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.

Limited Male Engagement in Family Planning:

• 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.

Way Forward

• Policy Interventions to Address Health Concerns: The survey highlights deep inequalities in health outcomes. The overall evidence is compelling that health ought to be a matter of concern for the governments at national and state level.
• An action plan to improve India’s health needs is required which also needs to be inclusive, firm in its commitment, and backed by solid resources.
• Lessons to be taken from NFHS: 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: 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.
• 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.

By: Shahid Ali