India's health check

NFHS points to new demographic challenges

The fifth edition of the National Family Health Survey (NFHS-5) offers clues to the future direction of policy-making that, if read correctly, could help India maximise a shortening window of demographic opportunity that is open to it. The headline finding — that for the first time the proportion of women exceeded men at 1,020 against 1,000 —is heartening, not least because it reverses and improves on previous trends. In the 2005-06 NFHS, the ratio had been at parity before declining sharply to 991:1,000 in the 2015-16 NFHS, a period that saw India grow more prosperous. The marginal improvement in the sex ratio at birth from 919:1,000 in the earlier edition of the survey to 929:1,000 in the latest one for 2019-21, but still lower than the natural sex ratio at birth of 952: 1,000, however, suggests that India has some way to go before the social bias for the boy child disappears. From a long-term perspective, the demographic transition implicit in the decline in the total fertility rate (TFR) to 2, below the replacement rate of 2.1 should be of some concern because it suggests that India is ageing faster than anticipated. The proportion of the population below 15 years of age has dropped precipitately from 35 per cent in NFHS 2005-06 to 25.5 per cent in the latest survey.
 

These broad findings raise two key concerns. One is the multiple divides implicit in the disaggregated data. The obvious one is the urban-rural divide with the TFR in the former at 1.6 against 2.1 in rural India. The second is the north-south divide in terms of the sex ratio with most states north of the Vindhyas reporting fewer women than men. The picture we have, then, is a younger and male-dominated society in the north relative to the south and northeast, and this has worrying electoral and economic implications. Some of these tensions were evident in protests when the 15th Finance Commission used the states’ demographic performance as a criterion for devolution. Two, having made progress on fertility, the need for quickly ramping up social infrastructure, including health, education, and water, becomes even more urgent. In this context the picture of general ill-health among India’s population, especially children, is concerning.

More adult Indians are overweight and anaemic. Though the share of underweight men and women has fallen, the share of overweight Indians and those who are anaemic has risen. As with earlier surveys, the proportion of anaemic women is higher than that of men, but both genders have shown an increase in the latest survey. Undernutrition in children has fallen at a slower pace: Between the 2005-06 and 2015-16 surveys, the incidence of stunting in children below five years of age fell a sharp 10 percentage points. In the latest survey, the drop has been just three percentage points. The trend is similar when it comes to child mortality. These findings appear out of sync with the remarkable increases in households with access to clean fuel, sanitation, bank accounts, and the use of hygiene products by women. They are pointers perhaps to limitations in the reach and coverage of sanitation (the lack of which has been a major cause of stunting) and other welfare schemes. Rather than making serial announcements of grand new schemes, focusing on maximising the efficiency of the ones we already have should be the priority.