In Retrospect

Maladies of 'rising India'

Against the rampant celebrations around reduced TFR and population stabilization, lay the anaemic mothers and their stunted kids — wanting nutrition and cure, alongside attention from policymakers

Maladies of rising India

Health is one of the two core sectors that determine the foundational strength of an economy — the other being education. The centrality of these sectors stems from the fact that their status is directly linked to the personal development of humans.

After the release of National Family Health Survey-5 phase-II data, some have sprung into the business of praising positive outcomes while others took on to shaming the government on account of dismal faring on nutritional parameters.

However, amid this debate around positive and negative attributes of the survey findings, the real motive must not be lost — that of relating the numbers to the ground experiences and formulating policies thereafter to make society a better place to live in.

In this article, with the help of findings of NFHS-5, we shall retrospect where we, as a society, stand today in terms of basic health parameters. What are the areas that reflect grave shortcomings? And finally, how can these shortcomings be removed by deploying existing or prospective policies? But first, we shall briefly take a glimpse into what the NFHS is.

What is NFHS?

NFHS is an extensive survey carried out collaboratively by the International Institute of Population Sciences (IIPS), Mumbai; ICF, Maryland, USA and the East-West Center in the USA. It would be pertinent to clear at the outset that data presented by the survey is not exact data. These are instead representative or sample data.

NFHS-5 was conducted in two phases — phase-1, released in December 2021, and phase-2, released recently. A total number of 2,81,429 households, 3,07,422 women, and 43,945 men were surveyed across 17 states. The data is no doubt useful for serving as a basis of policy formulation but it should be read being mindful of its limitations. In the first place, it does not cover all the states, second, the sample of the survey, though significant, comprises just a small portion of the population and households. Third, the data may be missing out crucial insight as the pandemic has triggered a widespread undocumented socio-economic change. Fourth, the survey has been largely focused on women, though men have been included significantly in recent surveys.

On the positive side, the credibility of the data can be gauged from the fact that it is assisted, backed and funded by some of the world's leading and most responsible agencies including UNICEF, UNFPA, USAID etc. These surveys are conducted in collaboration with a large number of Field Organizations (FO) and Population Research Centers. Most importantly, the survey is backed by the Ministry of Health and Family Welfare.

NFHS-1 was conducted in 1992-93. Then, after a gap of almost six years, NFHS-2 was conducted in 1998-99. NFHS-3 was conducted in 2005-06 and the NFHS-4 was conducted after a long gap of almost 10 years in 2015-16. All throughout, new players and new parameters have been added to the survey. Discussions are in place to increase the frequency of the survey, and rightly so.

Women lead the sterilization drive

Riding on the shoulders of Indian women, the nation could attain the intended fertility rate, as recorded in the latest NFHS Survey. Though there has been an increase in sterilization rates, the discrepancy between male and female sterilization continues unabated.

The female sterilization rate for women has slightly improved from 36 per cent in NFHS-4 to 38 per cent in NFHS-5. Compare this with the male sterilization rate which strictly remains stuck at 0.3 per cent. So, while 36 of 100 women undergo sterilization, only three out of 1,000 men go for sterilization. The figures more or less remain the same for both rural and urban areas — with only a slight difference.

This disproportionate burden on the part of women could likely affect their health in the longer term. Despite an improvement from 5.6 per cent to 9.5 per cent between NFHS-4 and NFHS-5, the use of convenient male-oriented family planning methods like condoms is far from satisfactory. The use of condoms among the rural male population is only 7.6 per cent. Also, the use of pills and IUD/PPIUCD continues to hover below the five per cent range. And the share of injectables has not yet hit a unit of percentage.

The problem in establishing parity around the two genders in terms of sterilization arises on account of two factors — first, the myth surrounding sterilization among the male population, and second, faulty policy targeting female sterilization. A 2019 study by the Population Foundation of India (PFI) had found 80 per cent of the funds available for family planning is directed towards terminal methods (surgical and mostly non-reversible) of preventing conception, specifically female sterilization, reported Indiaspend.

Further, modern methods of contraception are also targeted towards women, while those for males, including vasectomy and condoms, remain largely ignored. There is an urgent need to communicate with the male population through effective mediums ranging from interpersonal communication to social media communication. But before that, there is a need for policy course correction on this front.

Child marriage

Child marriage is among the biggest evils of 21st-century India. An evil that destroys not just the lives of millions of young Indians, silently, but also kills the spirit and growth prospects of a large number of Indian families in several ways. Child marriage means:

✼ That the kids would have to give up their studies prematurely

✼ With every marriage, particularly that of a girl, smaller families are pushed back to ages

✼ The coming generation will most likely be weaker and have lesser chances of receiving proper education

At the time of the survey, 6.8 per cent of the women aged 15-19 in India were already mothers or pregnant. The corresponding number in rural India was 7.9 per cent. The percentage has come down slightly from the NFHS-4 data, but it is still problematic. Almost one out of four women aged 20-24 at the time of the survey were married before they had turned 18. While the percentage of such women in urban areas was 14.7 per cent, it was 27 per cent in rural areas.

The numbers were only slightly good for men aged 25-29 years at the time of the survey who were married before the age of 21 years — 21 per cent in rural areas and 11.3 per cent in urban areas.

These trends throw a negative reflection on the implementation of the Prohibition of Child Marriage Act, 2006. The Act prohibits the solemnization of child marriages. Section-9 of the Act states that marriage by an adult male to a girl child shall be considered an offence. States are required to ensure stricter implementation of the law. Further, studies have found a direct correlation between the education levels and the extent of prevalence of child marriages. A targeted response for vulnerable regions could help create awareness among families, encouraging them to educate their girl child and avoid child marriages.

Health of the nation

The darkest revelation put forth by the NFHS-5 is the whopping increase in the percentage of anaemic population. Shockingly, the number of anaemic children aged 6-59 months has increased from 58.6 per cent in NFHS-4 to 67 per cent in NFHS-5. This presents a horrible implication — among three children in India, two are anaemic! This casts a dark shadow on our present and the future.

The disheartening result, however, would seem obvious if we analyze the data for women. The percentage of anaemic women aged 18-49 years has increased from 53 per cent to 57 per cent; for pregnant women, it has increased from 50.4 per cent to 52.2 per cent. At the same time, the percentage of anaemic men (18-49 years) has also increased from 22 per cent to 25 per cent.

The existence of an anaemic population across gender and age groups is problematic but the NFHS findings suggest that there is a greater need to focus on women and children. Women, in particular, represent a critical group as their health status influences the health and well-being of children. Variations among rural and urban populations are visible but since the proportion is large in both categories, uniform policies may help.

To demonstrate the horrible state of the nation's health, we have another set of data around child stunting and child wasting. Among children below the age of five years, 19.3 per cent are wasted, and 7.7 per cent are severely wasted. The stunting rate among the same age group is as high as 35.5 per cent — slightly down from the 38.4 per cent in NFHS-4. The percentage of underweight children is 32 per cent and that of overweight children is 3.4 per cent.

There could be no denying the fact that malnourishment is rampant in India, and it sets in at the very early phase of a child's life. While children receive some of the deficiencies from malnourished mothers, others are acquired on account of under-nourishment at an early age. Less than half of the total children under three years of age (41.8 per cent) were breastfed within one hour of birth. Lactation within one hour of birth provides a child with colostrum which prevents the newborn baby from a variety of diseases like sepsis, pneumonia, diarrhoea, hypothermia etc.

The situation gets, even more, worse as the child grows. NFHS data shows that only 12 per cent of non-breastfeeding children aged 6-23 months received an adequate diet. Conversely, this means that 88 out of 100 children remain bereft of adequate diets in India.

Mothers who consumed iron-folic acid for 100 days during pregnancy increased from 30.3 per cent in NFHS-4 to 44.1 per cent in NFHS-5, and those who consumed IFA for 180 days or more increased from 14.4 per cent in NFHS-4 to 26 per cent in NFHS-5. However, there has been a considerable gap between rural and urban consumption of IFA. Perhaps a differential strategy is required at this juncture. There has been some improvement in antenatal care but that needs to be taken forward.

Institutional birth has seen a rise from 78.9 per cent to 88.6 per cent. Improvement is visible in both the rural and urban areas. Institutional birth in public facilities has also increased from 52.1 per cent to 61 per cent. Interestingly, the percentage for rural areas (65.3 per cent) has been better than the urban population (52.6 per cent). The quality and scale of public facilities need to be strengthened in the rural areas so that greater trust is maintained among people. In other words, the dependence of the rural population on public health facilities must be respected.

While the births delivered by cesarean section have increased moderately from 17.2 per cent to 21.5 per cent, the discrepancy between cesarean section births in the public and private sector is telling. The percentage of birth in public health facilities delivered by cesarean section has been 14.3 per cent against 47.4 per cent in private facilities. The trend has been similar for both rural and urban areas. This reflects a lack of trust in public health facilities, which could have larger socio-economic fallout, as the poor will be forced to go for larger expenses in private facilities which they ill-afford.

The NFHS-5 data also shows that even in public facilities the average out-of-pocket expenditure per delivery has marginally reduced from Rs 3,197 to Rs 2,916. For rural areas, it is Rs 2,770 and for urban areas, it is Rs 3,197. This cost needs to be reduced further. Affordability of the core sector of health is elemental to the growth of the nation.

Literacy and digital literacy

NFHS-5 presents some interesting facts about the quality of the population in India. While the literacy rate for men and women is 84.4 per cent and 71.5 per cent respectively, the gap is exacerbated mainly on account of the lower literacy rate among rural women. The percentage of literate urban men is 89.6 per cent and that of urban women is 83 per cent. However, in the case of rural areas, men have a fairly decent literacy rate of 81 per cent but women lag far behind with a mere 65.9 per cent literacy rate. It won't be wrong to state that selective focus needs to be given to educating rural women to improve the overall outlook of literacy in rural areas.

When it comes to internet usage, we face a dual dichotomy based on region and gender. The percentage of rural men who have ever used the internet is 48.7 per cent, which is way lower than the percentage of urban men who have ever used the internet (72.5 per cent). And then the percentage of rural women who have ever used the internet is half the percentage of rural men, i.e., 24.6 per cent. It can easily be noticed that numbers are unsatisfactory on an overall basis. Aspiration of weaving of a digital India must take these numbers seriously, and strive to improve these.


There is no doubt that findings of NFHS-5 mark an improvement over the findings of NFHS-4 but the fact remains that the gap between the two surveys is that of 5-6 years — even smaller gains may appear extrapolated. While it is too early to celebrate the outcomes of population stabilization, we appear to be too late in accelerating our actions towards fulfilling the basic nutritional requirements of women and children in our country. More than being an object of celebration, NFHS is a document loaded with policy insights. Let's learn our lessons.

Views expressed are personal

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