A close reading of the NFHS-5, the health of India

Context: A close reading of the NFHS-5, gives a mixed verdict, containing both cheer and alarm in abundant measure given how little the country spends on health and education as a share of GDP.

Key results from National Family Health Survey (NFHS 5) survey

• Improvement in several dimensions such as educational attainment, institutional deliveries, vaccinations, infant mortality etc.
• Population has stabilised: Total fertility rate (TFR), across all States of India has been falling over time and is now just below the replacement rate of 2.1.
• Improvement in sex ratio: Data on sex ratio reveals that nationally, there are 1,020 adult women per 1,000 men for the first time. 

Notes of caution from (NFHS 5) survey

• Probability of data discrepancy on adult sex ratio: Data on adult sex ratio is based on pervasive sex selective abortions .But adult sex ratio is shaped by many factors other than sex selective abortion.
  • In household surveys, the adult sex ratio might also be affected by sampling errors, arising, for instance, from undercounting migrant males.
• Persistent son preference:  That is likely to impede the improvements in SRB.
  • Natural SRB translates to 952 girls per 1,000 boys. Nationally, the SRB has improved from 919 in 2015-16 to 929 in 2019-21, but it is still short of the natural SRB.
  • Major States with low SRBs are spread all over the country: Uttar Pradesh, Haryana, Punjab, Rajasthan, Bihar, Delhi, Jharkhand, Andhra Pradesh, Tamil Nadu, Odisha, Maharashtra.
  • While many States have seen an improvement in their SRBs, some have also witnessed a worsening, e.g. Maharashtra, Tamil Nadu and Odisha.
• Worsening key health indicators like anaemia 
  • Incidence of anaemia that is a serious public health concern is 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.
  • Indian States show variation in incidence of anaemia: From 39.4% in Kerala to 79.7% in Gujarat: but barring Kerala, all States are in the “severe” category.
• Increase in the proportion of overweight children, women and men. Being overweight also reflects malnutrition, with serious health consequences in the form of non-communicable diseases.
• Data on three indicators of malnutrition masks an anomaly: 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. But these conditions often occur together. 
  • In Phase 1 of survey , several States revealed a worsening in one or more of these, whereas in Phase 2, none of the States showed a worsening. 
  • There may be possibility that novel coronavirus pandemic affected the survey in Phase 2, leading to undercounting of incidence. 
• Apprehension that rate of progress on key health in has slowed down, based on comparisons between NHFS-4 and NHFS-5 to the improvements between the two previous rounds.
• Data on caesarian births calls into question unethical practices of private health providers who prioritise monetary gain over women’s health and control over their bodies.
  • As caesarian births have increased dramatically: In private health facilities, 47.5% births are by C-section (14.3% in public health facilities)

Way forward:

• Increase spending on health and education as a share of GDP to improve their infrastructure.
• Policy focus should be on urgent health matters: As population has stabilised politicians should devote their energies to urgent health matters, instead of raising the bogey of population explosion to justify coercive population policies.
• Focus on traditional Indian diets to reduce micronutrient deficiencies: As these diets reflect both local climatic conditions as well as a multiplicity of sources of essential nutrients, such as proteins.
• To reduce 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. And,
  • Health ought to be a matter of concern for all political parties and all governments.

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