Population-based surveys form the bedrock of the country’s health information systems. Use of accurate and nationally representative data can be instrumental in policy planning, programme design, health system monitoring and management of financial and human resources. Hence, the release of the National Family Health Survey-round 5 (NFHS-5), which covers about 6.1 lakh sample households to provide estimates for 707 districts, serves as a litmus test to evaluate India’s prospects for achieving improved health and well-being for its population. In the first phase, data from 22 states and UTs has been released from the latest survey conducted in 2019-2020.
The biggest highlight comes from the data on Total Fertility Rate (TFR), which has come down to 2.1 or below (replacement level) in all states and UTs, except Bihar (3), Meghalaya (2.9) and Manipur (2.2). This finding is substantial given India’s longstanding investment in population control, which has also been instrumental in our poverty alleviation efforts. This correlates with the data on the overall use of modern methods of contraception, which has increased in 20 out of 22 states, though female sterilisation continues to be the most dominant method. Since universal uptake of contraception in developing countries may take more time, other socio-demographic variables like age at marriage play an equally important role in reducing fertility rates. The data show that the number of women marrying before the legal age has fallen in 17 out of 22 states and UTs, with Nagaland, Maharashtra, Jammu & Kashmir and Sikkim as the top performers. Also, indicators on teenage marriage and childbearing have improved in 17 states/UTs.
In terms of antenatal care, 17 of 22 states/UTs saw an increase in ANC visits during the first trimester with Nagaland, Bihar and West Bengal demonstrating the highest increase. But when we look at the data on interventions for anaemia reduction in mothers, consumption of IFA tablets by pregnant women for 180 days or more has increased in almost all states/UTs (except Karnataka), though this has not resulted in a parallel reduction in anaemia levels among pregnant women. These findings do reflect the need to consider complementing IFA tablets with the provision of more natural sources of iron, folic acid and other micronutrients in the diet.
A case where maternal and child health interventions have translated into improved health outcomes is the uptake of institutional deliveries. According to the WHO, nearly 3/4th of the neonatal deaths are attributable to preterm births, intrapartum complications and sepsis — most of which can be addressed through appropriate medical care at the time of delivery. In this regard, there has been a consistent increase in institutional delivery, with 14 out of 22 states and UTs having more than 90 per cent of newborns being delivered in institutional facilities. Similarly, 14 out of 22 states/UTs have seen a decline in neonatal mortality.
While women’s empowerment is a wide construct, indicators like household decision making, control over personal hygiene choices and assets like bank accounts and mobile phones are good proxies for evaluation. As per the NFHS-5 data, majority of women (80 per cent) participated in at least three household decisions. More than 64 per cent of younger women in each of the 22 states/UTs, except Bihar at 59 per cent, are now using hygienic methods of protection during menstruation. More women now own a personal mobile phone and the percentage of women with bank accounts has jumped to over 70 per cent across each of the 22 states/UTs of India (except Nagaland) in 2019-2020.
It is heartening to see almost all states and UTs report a drastic increase in the number of households with a constructed toilet, improved drinking water as well as clean cooking fuel. All three indicators are critical in improving public health in India, especially for women. While indoor air pollution has been linked with major respiratory disorders with women being disproportionately affected, population-level coverage of sanitation facilities has been associated with a reduction of infectious disease like diarrhoea, which can take a substantial toll on child mortality. Additionally, women are spending more time in school with the percentage of women who completed at least 10 years of schooling jumping by at least 6 per cent points in the past five years across states and UTs, except Daman & Diu and Tripura.
While states have shown an increase in exclusive breastfeeding and adequacy of diets, about half of them have shown an increase in rates of malnutrition, wasting and underweight children. To act upon the underlying determinants, we have to understand that indicators like stunting, for example, can be multifactorial. Stunting can be affected by variables like indicators of the mother a child is born to, economic situation of the household, adequacy of diets, water and sanitation facilities, as well as interventions for nutrition promotion and health. An encouraging example is from Bihar, which has shown a decline of stunting rates by about 5.4 per cent points over the past five years.
At the same time, NFHS-5 data also show an increase in the rates of obesity in children and risk factors for chronic diseases in adults like hypertension and blood glucose, which represent the flip slide of the malnutrition problem.
In conclusion, we should fall short of generalising these results for the country both because data from phase 2 is yet to come and summary figures may overlook how contextual health and nutritional outcomes of the population can be. Though overall trends do suggest an improvement in population control, use of modern contraception, reproductive and child health, immunisation and social determinants of health, a complete overhaul is needed to identify and address the multidimensional aspects of child malnutrition.
This article first appeared in the print edition on January 7, 2021 under the title ‘Health of a nation’. The writer is assistant director, research & government partnerships, Harvard School of Public Health-India Research Centre
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