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

Given how little the country spends on health and education as a share of GDP, the improvements seem remarkable

November 27, 2021 12:02 am | Updated November 28, 2021 07:24 am IST

KOKRAJHAR, ASSAM, 27/12/2014: A little Bodo boy takes nap in his mother's lap at the New Basbari relief camp in Kokrajhar district of Assam on December 27, 2014. After killing of 76 Adivasi villagers by the NDFB (S) militants in two district of Assam on 23 December 2014, villagers of both Adivasi and Bodo community are taking shelter in relief camps for safety of their lives. Photo: Ritu Raj Konwar

KOKRAJHAR, ASSAM, 27/12/2014: A little Bodo boy takes nap in his mother's lap at the New Basbari relief camp in Kokrajhar district of Assam on December 27, 2014. After killing of 76 Adivasi villagers by the NDFB (S) militants in two district of Assam on 23 December 2014, villagers of both Adivasi and Bodo community are taking shelter in relief camps for safety of their lives. Photo: Ritu Raj Konwar

The national health and demographic report card is finally completely out. The results from the first phase (conducted between June 2019 and January 2020) of the fifth round of the National Family Health Survey (NFHS-5) were released in December 2020. We now have the key results from the second phase (conducted between January 2020 and April 2021).

How did India fare? It is a mixed verdict, containing both cheer and alarm in abundant measure. Before going into details, we should note that the results of the NFHS are worthy of our attention because it is not a hastily put together state-of-health index. Together, the two phases provide a detailed, comprehensive, multi-dimensional report card on the state of India’s demographic and health trajectory.


Population has stabilised

There are many pluses in the report card. A comparison of NFHS-5 with NFHS-4 (2015-16) reveals improvement in several dimensions such as educational attainment, institutional deliveries, vaccinations, infant mortality and much more. We can debate later whether the improvements are good enough given the scale and depth of what needs to be done. For now, we need to appreciate the progress, especially given the abysmal state of India’s health infrastructure, which has been tragically apparent since the COVID-19 pandemic hit. Given how little India spends on health and education as a share of GDP, these improvements are particularly remarkable.

The biggest positive headline news from NHFS-5 is that the total fertility rate (TFR), which is the average number of children born to a woman during her lifetime, has been falling over time and is now just below the replacement rate of 2.1. This is true across all States of India. This means that the total population has stabilised. Therefore, politicians can strike one thing off their to-do list and devote their energies to urgent health matters, instead of raising the bogey of population explosion to justify coercive population policies. There is absolutely no evidence to justify tying welfare support measures or holding elected office to the number of children.

Data on sex ratio

Another headline reveals that nationally, there are 1,020 adult women per 1,000 men for the first time. Does this mean that Indian women are no longer “missing”, i.e. does this signal the beginning of the end of another tenacious problem — that of deep-rooted son preference which leads to illegal but pervasive sex-selective abortions as parents repeatedly try for at least one son?

Editorial | Measuring progress: On the lessons of National Family Health Survey-5

To gauge this, the key metric to examine would be the sex ratio at birth (SRB). The natural SRB is 105 boys to 100 girls, which typically stabilises to a 50-50 adult sex ratio. If there are pervasive sex selective abortions, leading to a masculine SRB (i.e., more than 105 boys to 100 girls), a part of this imbalance would carry forward into adulthood. But adult sex ratio is shaped by many factors other than sex selective abortions. In household surveys, the adult sex ratio might also be affected by sampling errors, arising, for instance, from undercounting migrant males.

The 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. Therefore, we need to recognise that the move to a small family size combined with persistent son preference is likely to impede the improvements in SRB.


Anaemia and malnutrition

A key health indicator that has worsened is the incidence of anaemia 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. Anaemia has debilitating effects on overall health, which is why the World Health Organization characterises it as a serious public health concern; 20%-40% incidence is considered moderate. Indian States show variation: from 39.4% in Kerala to 79.7% in Gujarat: but barring Kerala, all States are in the “severe” category. It is tempting to think of the worsening as the COVID-19 effect.

However, comparing the changes in anaemia in Phase 1 States (survey done pre-COVID) to Phase 2 States, we see that if anything, the increase in the former (which include Andhra Pradesh, Assam, Bihar, Gujarat, Kerala, Maharashtra, West Bengal, among others) is on average higher than the increase in Phase 2 States (Delhi, Uttar Pradesh, Chhattisgarh, Jharkhand, Rajasthan, Haryana, Tamil Nadu, Madhya Pradesh, Odisha, Punjab, among others). The discrepancy between Phase 1 and Phase 2 could reflect differences in actual incidence or survey-related issues.


There are other instances of clear differences between Phase 1 and Phase 2 results. 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. These conditions often occur together. Together, these reflect chronic or recurrent undernutrition, usually associated with poverty, poor maternal health and nutrition, frequent illness and/or inappropriate feeding and care in early life. These prevent children from reaching their physical and cognitive potential.

However, the overall reduction in national estimates of these three measures masks an anomaly. In Phase 1, several States revealed a worsening in one or more of these, whereas in Phase 2, none of the States showed a worsening. It would be good to understand if the novel coronavirus pandemic affected the survey in Phase 2, leading to undercounting of incidence, or whether by pure chance, all States in Phase 2 happen to be better performers on the malnutrition count (something that could not have been known at the start of the survey in 2019).

Also, along with an improvement in these three indicators, we see an 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.


In addition to anthropometric measures, lack of adequate nutrition is also measured by micronutrient deficiencies, i.e. lack of vitamins and minerals that are essential for body functions such as producing enzymes, hormones and other substances needed for growth and development. While the NHFS does not have data on this, the issue of micronutrients is related to diets. It would be good to note here that Indian diets display a rich diversity.

Many traditional diets reflect both local climatic conditions as well as a multiplicity of sources of essential nutrients, such as proteins. Policing of diets, by imposing an unnatural uniformity, and preventing access to animal protein for large sections of Indians that are not traditionally vegetarian is likely to reduce micronutrient diversity and contribute to poor health outcomes.

Notes of caution

Some analyses have suggested that the rate of progress has slowed down, based on comparisons between NHFS-4 and NHFS-5 to the improvements between the two previous rounds. We would not be able to claim this yet, since comparing changes over a 10-year interval (between NFHS-3 in 2005-06 and NFHS-4) to a five-year interval (between NFHS-4 and NFHS-5) is misleading.

Some have argued that the poor health outcomes reflect the effect of COVID-19. The data for the second phase of NFHS-5 have been, to a large extent, collected during the highly unusual conditions of the COVID-19 pandemic, but as the evidence on anaemia shows, the deterioration in public health indicators cannot be attributed entirely to the pandemic. COVID-19 might have added fuel to the fire of poor public health, but it did not cause the fire.


There is much more in the NHFS-5 survey that needs more than a short piece. The survey focuses on women’s empowerment, autonomy and mobility indicators. It shines a spotlight on women’s reproductive health, and reveals, for instance, that caesarian births have increased dramatically. In private health facilities, 47.5% births are by C-section (14.3% in public health facilities). These figures are highly unnatural and call into question unethical practices of private health providers who prioritise monetary gain over women’s health and control over their bodies.

The overall evidence is compelling and clear: health ought to be a matter of concern for all political parties and all governments: national and State. The survey highlights 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.

Ashwini Deshpande is Professor of Economics and Director, Centre of Economic Data and Analysis (CEDA) at Ashoka University

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