State of health

Family Health Survey offers clues about what worked, what didn't

The fact sheet of the fourth round (2015-16) of the National Family Health Survey (NFHS-4) has a wealth of information that policymakers would do well to study in detail. The results show widespread improvements over the earlier such survey done in 2005-06 in health and nutrition parameters such as infant mortality and under-five mortality as well as the percentage of children under five who are stunted and underweight. Critical indicators of women’s empowerment such as literacy and economic empowerment (women with bank accounts/mobile phones) have shown a dramatic improvement and domestic violence and child marriages are down. The data also showed that of the mothers who participated in the survey, more than half provided immunisation to their children, across all categories based on caste and education. A big debate in the decade between the two NFHS rounds was centred on the efficacy of government schemes and a preliminary reading of the data suggests that such interventions have worked. For instance, a key mandate of the National Rural Health Mission was to increase institutional births, which as the latest survey shows, have improved from 38.7 per cent to 78.9 per cent. 

There are some worrying trends, too. For example, the percentage of children under five who are suffering from “wasting” and “severe wasting” has increased. Another significant data set pertains to the sex ratio at birth for children born in the past five years. While the all-India ratio has improved from 914 females per 1,000 males to 919, urban India is pegged at 899, lower than even the all-India level from a decade ago. Interestingly, the survey shows that the use of family planning methods by currently married women between 15 years and 49 years of age has fallen over the decade. Also, nutritional status varied among the categories: Stunted growth was seen in children of around 51 per cent of the uneducated women compared with 31 per cent in children of the educated women. About 47 per cent of the uneducated women had underweight children. 

In the intervening 10 years between NFHS-4 and NFHS-3, there have been numerous surveys, both private and public, yet they were difficult to compare. For instance, since 1992, India has had three rounds of NFHS, four rounds of district-level health surveys, three annual health surveys, and some standalone one-time ones. But given the methodology adopted, these surveys showed wide variations across geographical coverage and frequency of data collection. For instance, when it came to the targeted respondents among women, some would report on “all women” in an age group, others on “currently married” and still others on “ever married”. 

Thus, one of the most important contributions of NFHS-4 is that it provides some clarity to the entire process. The other surveys in the intervening years often offered contradictory results; for instance, one survey suggested that the proportion of underweight children in 2012-13 was more or less the same as it was in 2005-06. This result was contradicted by a Unicef survey in 2015, leading to uncertain policy analysis. It can now be hoped that as researchers analyse largely comparable granular data – NFHS-4, for the first time, provides district-level estimates for many important indicators – governments, both at Centre and states, will be able to figure out which policy tool worked and which did not. Only a comprehensive scrutiny of these results will help improve public health care programmes.