The health system in India has been facing unprecedented stress during the COVID-19 pandemic which includes the looming Omicron threat now on the horizon. Against this backdrop, the recently released fifth edition of the National Family Health Survey (NFHS)-5 brings some positive news. NFHS-5, which presents a bird’s eye view of the state of the nation’s health and related development indicators, looks encouraging on several fronts: population growth is stabilising, family planning services have improved, and health systems are delivering better.
However, it also highlights the need for further improvement to address gender-based violence and harmful practices against women and girls, such as child marriage and gender-biased sex selection. These have been exacerbated by discriminatory social norms and practices hindering the achievement of the Sustainable Development Goals (SDG) 2030 Agenda and India’s development goals.
Population is stabilising
The good news is that India’s population growth appears to be stabilising. The Total Fertility Rate — the average number of children born per woman — has declined from 2.2 to 2.0 at the national level. A total of 31 States and Union Territories (constituting 69.7% of the country’s population) have achieved fertility rates below the replacement level of 2.1.
The main reasons for decline in fertility include: Increase in adoption of modern family planning methods (from 47.8% in 2015-16 to 56.5% in 2019-21) and a reduction in unmet need for family planning by 4% points over the same period. This indicates significant improvements in access to family planning related information and services.
Increased reach of the health system to more non-user couples with information about family planning (from 18% in 2015-16 to 24% in 2019-21). Further, 62% of current users have received information about the side-effects of contraceptives — a crucial indicator of the improved quality of family planning services.
Significant improvements in female literacy, with 41% women having received 10 or more years of schooling (compared to 36% in 2015-16). Girls who study longer have fewer children, and are also more likely to delay marriage and find employment. In other Asian countries too, fertility decline has taken place alongside notable improvements in access to quality education, especially girls’ education.
Improved health delivery
Maternal health services are steadily improving. Antenatal care in the first trimester has increased by 11.4% points (from 2015-16 to 2019-21) to reach 70%; the recommended four antenatal care check-ups have increased by 7% points to reach 58.1% and postnatal care visits have gone up by 15.6% points to reach 78%. Institutional births were accessed by 88.6% of women in 2019-21, marking an increase of 9.8% points from 2015-16. There has also been an increase in institutional deliveries in public health facilities (52.1% to 61.9%), demonstrating an improvement in quality of services.
The survey indicates a worrisome figure of 11% of pregnant women who were still either unreached by a skilled birth attendant or not accessing institutional facilities. Further analysis reveals an institutional delivery rate of under 70% in 49 districts of India. Over two-thirds (69%) of these districts are from five States (Nagaland, Bihar, Meghalaya, Jharkhand and Uttar Pradesh), indicating the need for an area-specific approach to improving maternal health services. Teenage pregnancy has declined marginally by 1% point, and 7.9% of women in the age group of 15-19 years who were already mothers or pregnant at the time of the survey. This highlights the need to invest in comprehensive sexuality education as a key component of life-skills education for both in school and out-of-school adolescents, and ensuring access to quality sexual and reproductive health services for them. A very small segment of the population is currently accessing the full range of sexual and reproductive health services such as screening tests for cervical cancer (1.9%) and breast examinations (0.9%). These services should be included while expanding the basket of reproductive health services.
Discriminatory social norms
Evidence indicates significant progress where women have the right to bodily autonomy and integrity, and the ability to take decisions about their lives. It is heartening to see that the proportion of women (aged 15-24 years) who use menstrual hygiene products has increased by almost 20% points between 2015-16 and 2019-21 and currently stands at 77.3%. The proportion of women who have their own bank accounts has gone up by 25.6% points over the same time period to reach 78.6%. Around 54% of women have their own mobile phones and about one in three women have used the Internet. This, coupled with the increase in the proportion of women with more than 10 years of schooling, lays the building blocks for women’s empowerment. In the next few years, the combination of mobile technology, banking, education and women’s economic empowerment will be significant drivers to address informal discriminatory norms.
To empower women and ensure gender justice, it is imperative to address harmful practices, such as child marriage and gender-biased sex selection. The prevalence of child marriage has gone down marginally from 26.8% in 2015-16 to 23.3% in 2019-21. Similarly, sex ratio at birth has shown slight improvement (from 919 to 929 over the same time period). One in three women continue to face violence from their spouse. Hence, there is a need to enhance the value of women and girls by working on transforming unequal power relations, structural inequalities and discriminatory norms, attitudes and behaviours.
Promote gender-equal values
Women’s participation in the economy continues to remain low (only 25.6% women engaged in paid work, a meagre increase of 0.8% point). Women still bear a disproportionate burden of unpaid domestic and care work, hindering their ability to access gainful employment. This points to the need for engaging with men and boys, particularly in their formative years, to promote positive masculinities and gender-equal values.
The pace of progress between one NFHS and the next should be accelerated by devising targeted strategies based on specific indicators and regions that are currently lagging. Convergence among multiple stakeholders is critical to bring about the desired change. Together, we must challenge discriminatory social norms that drive gender-based violence and harmful practices, and empower women to exercise agency and autonomy in all spheres of life. Women and girls having agency and bodily autonomy is not only the foundation for a better future; it is a fundamental human right.
Sriram Haridass is UNFPA Representative India and Country Director Bhutan a.i.