Here is what NFHS-5 tells us about India

The Union Ministry for Health and Family Welfare (MoHFW) released the findings of the second phase of the fifth round of National Family Health Survey (NFHS-5) in November 2021. The findings of the first phase of NFHS-5 were released in December 2020. The survey was conducted between 2019 and 2021. While the first phase covered 17 states and 5 union territories (UTs), the second phase covered the remaining 11 states and 3 UTs. Phase 1 of the survey was conducted before the Covid-19 pandemic while Phase 2 was conducted during the pandemic. 

With NFHS-5 findings for all the states and UT available now, it is possible to see the national picture on demographic, health, and family welfare indicators. The national and state/UT fact sheets provide information on 131 key indicators. Therefore, the NFHS provides a a comprehensive, multi-dimensional report card on the state of India’s demographic and health trajectory. While the MoHFW press release mentions headline findings from these factsheets, let us take a closer look at some of the data.

No population explosion

NFHS-5 lays to rest the worries about an impending population explosion in the country. As per the latest data, the national Total Fertility Rate (TFR) is now at only 2.0 (down from 2.2 in NFHS-4, conducted in the year 2015-16). According to the UN Population Division, a TFR of 2.1 is considered replacement level TFR. It means that at a TFR of 2.1, a population successfully replaces itself without growing or degrowing. Therefore, a TFR of 2.0 (as per NFHS-5), shows that fears of a population explosion in India may have been unfounded.

However, this is not a surprising number. India’s TFR in NFHS-4 was at 2.2, inching towards replacement TFR. In the five years since NFHS-4, it has reached 2.0. As per NFHS-5, urban India has a TFR of only 1.6 while rural India’s TFR is 2.1. Figure 1 shows state-wise TFR from NFHS-1 to NFHS-5. Now, India has only five states which have a TFR higher than 2.1. These are Bihar (TFR: 3.0), Meghalaya (2.9), Manipur (2.2), Jharkhand (2.3), and Uttar Pradesh (2.4). Two states, Kerala, and Tamil Nadu have registered an increase in their TFR in NFHS-5 as compared to NFHS-4. Kerala’s TFR has increased from 1.6 (NFHS-4) to 1.8 (NFHS-5) while Tamil Nadu’s has increased from 1.7 to 1.8. However, both states’ TFR has remained below replacement TFR.

Even Bihar and Uttar Pradesh have shown significant improvement in their TFR over the last decade and half. In NFHS-3 (2005-06), Bihar had a TFR or 4 which came down to 3.4 in NFHS-4 (2015-16) and has now reached 3. Uttar Pradesh’s TFR was 3.82 in NFHS-3 which got reduced sharply in NFHS-4 to 2.7 and is now at 2.4 in NFHS-5. This shows that even for the most populous Indian states, TFR has registered a sharp decline since 2005-06. This trend should put to rest any fears of a population explosion in India.

India’s sex ratio of total population improves

According to NFHS-4, India had a sex ratio of 991 women per 1000 men. This has now improved considerably to reach 1020 women per 1000 men. It is important to note that this is sex ratio of total population and not sex ratio at birth. Figure 2a shows sex ratio of total population in states and UTs covered in NFHS-5 phase 1. Figure 2b shows the same for states and UTs covered in phase 2 of NFHS-5.

As per NFHS-5, there are 23 states and UTs in the country which have a sex ratio of more than 1000 women per 1000 men for the total population. NFHS-4 had 18 such states and UTs. Among large states, Kerala has registered the highest improvement in sex ratio in NFHS-5 (1121) over NFHS-4 (1049) at 7 percent. Karnataka and Tamil Nadu’s sex ratio for total population has also improved by 6 percent and 5 percent to 1034 and 1088 respectively. Himachal Pradesh is the only large state in the country to witness a decline in its sex ratio of total population from 1078 (NFHS-4) to 1040 (NFHS-5).

Sex ratio at birth improves, but marginally

India’s sex ratio at birth (SRB) for children born in the last 5 years has also registered an improvement, albeit marginally. It has improved from 919 female births per 1000 male births, in NFHS-4 to 929 in NFHS-5. The natural SRB is 952 girls per 1000 boys, which translates to a 50-50 adult sex ratio. Thus, India’s SRB of 929 is still considerably short of the natural SRB of 952.

As per NFHS-5, only 17 states and UTs have an SRB of more than 952. This is an improvement, as NHFS-4 showed this to be the case for 11 states and UTs. Among larger states, Uttarakhand has seen its SRB improve from 888 (NFHS-4) to 984 (NFHS-5). Karnataka has improved from 910 (NFHS-4) to 978 (NFHS-5). Among north Indian states, both Punjab and Haryana have improved their SRB but continue to have a low sex ratio at birth. Punjab has a SRB of 904 (up from 860 in NFHS-4) while Haryana has a SRB of 893 (up from 836 in NFHS-4).

Unlike sex ratio of total population, sex ratio at birth has seen a decline in some states between NFHS-4 and NFHS-5. Among larger states, Kerala’s SRB has declined from 1047 (NFHS-4) to 951 (NFHS-5). Similarly, Tamil Nadu has seen its SRB decline from 954 (NFHS-4) to 878 (NFHS-5).

Figure 3a shows sex ratio at birth in Indian states and UTs covered in NFHS-5 phase 1 while Figure 3b shows the same for states and UTs covered in phase 2.

Institutional births all the way?

When a baby is delivered in a medical institution under the supervision of trained health personnel, it is defined as an institutional birth. As per NFHS-3 (2005-06) only 38.7 percent of all deliveries in the country were institutional deliveries. This proportion jumped to 78.9 percent in NFHS-4 (2015-16). The rising trend has continued in NFHS-5, which shows that now 88.6 percent of all deliveries in the country are institutional deliveries. According to NFHS-4, only 14 states or UTs saw more than 90 percent institutional deliveries. This has improved to 23 states or UTs in NFHS-5. This is a positive and welcome development. 

We see substantial improvement even in states that are considered laggard in terms of socio-economic indicators. Uttar Pradesh, which saw only 26.2 percent institutional deliveries in NFHS-3 improved to 67.8 percent institutional deliveries in NFHS-4 and has now recorded 83.4 percent institutional births in NFHS-5. Among other north Indian states, Rajasthan and Haryana had 94.9 percent institutional births, as per NFHS-5, which is a substantial improvement from NHFS-3, when Haryana was at 35.7 and Rajasthan at 29.6 percent, respectively. 

NFHS-5 shows that now there are only 6 states in the country with less than 80 percent institutional deliveries. 4 of these are the north-eastern states of Manipur (79.9 percent), Arunachal Pradesh (79.2 percent), Meghalaya (58.1 percent), and Nagaland (45.7 percent). The remaining two states are Bihar (76.2 percent), and Jharkhand (75.8 percent).

Another change is the rise in institutional births in public facilities. While NFHS-4 recorded 52.1 percent of all institutional births taking place in public facilities, NFHS-5 has seen this rise to 61.9 percent.

Figure 4 shows the percentage of institutional births in each state or UT in NFHS-3, NFHS-4, and NFHS-5.

Children’s health

NFHS also provides data related to the health of India’s children. 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. 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. 

Figure 5a shows the state-wise numbers for stunting, wasting and underweight children in NFHS-4 and NFHS-5 for states and UTs covered in Phase 1 of NFHS-5. Figure 5b shows the same for states and UTs covered in Phase 2.

Figure 5a

Figure 5b

Stunting shows a decline of 7.6 percent in NFHS-5 (over NFHS-4). While NFHS-4 reported that 38.7 percent of Indian children (less than 5 years old) were stunted (had a lower height for their age). This percentage has declined marginally to 35.5 in NFHS-5.

While overall India saw a small reduction in incidence of stunting in NFHS-5, this hides the fact that 13 states or UTs saw an increase in percentage of stunted children since NFHS-4. This includes states like Gujarat (increased by 1.3 percent), Maharashtra (up by 2.3 percent), and Kerala (up by 18.8 percent). All the states and UTs which saw an increase in stunting in NFHS-5 were included in phase 1 of the survey. All the 14 states and UTs which were covered in phase 2, saw the incidence of stunting decrease in NFHS-5 over NFHS-5. States like Haryana, Uttarakhand, and Rajasthan saw stunting incidence decline by as much as 18-19 percent in NFHS-5 over NFHS-4.

Thus the phase-wise results of the three measures mask 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). 

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 NFHS 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.

According to NFHS-4, 21 percent of Indian children were wasted. This declined marginally to 19.3 percent in NFHS-5. However, like stunting, wasting also saw state level variations. 12 states or UTs saw their wasting numbers worsen in NFHS-5. This includes states like Kerala, Bihar, Telangana, and Himachal Pradesh. Once again, all the states or UTs which saw an increase in percentage of children who are wasted were surveyed in phase 1 of NFHS-5. All the states or UTs which were surveyed in phase 2 of NFHS-5 saw a decline in percentage of children who were wasted. The highest improvement was seen in states like Haryana, Punjab, Rajasthan, Tamil Nadu, Madhya Pradesh, and Uttarakhand. Haryana saw the percentage of wasting decline from 21.2 percent in NFHS-4 to 11.5 in NFHS-5.

The percentage of children who were underweight for their age declined from 35.8 percent in NFHS-4 to 32.1 percent in NFHS-5. Here too, the overall number hides state level variations. 16 states or UTs (all covered in phase 1) saw the percentage of underweight children increase in NFHS-5 over NFHS-4. This includes states like Kerala, Maharashtra, Gujarat, Assam, West Bengal, and Telangana. On the other hand, all the states that were covered in phase 2 of the survey saw their numbers improve. States like Haryana, Punjab, Rajasthan, Odisha, and Tamil Nadu saw the percentage of underweight children decline substantially in NFHS-5 over NFHS-4.

A population gaining weight

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. While 2.1 percent children (less than 5-years old) were overweight in India, as per NFHS-4, this has now risen to 3.4 percent in NFHS-5. In case of women, 24 percent are found to be overweight (or obese) in NFHS-5 as compared to 20.6 percent in NFHS-4. For men, the percentage of overweight population has increased from 18.9 percent in NFHS-4 to 22.9 percent.

Only 3 states and UTs out of 36 show a decline in percentage of overweight children in NFHS-5 over NFHS-4 while all the remaining states/UTs show a substantial increase. Among large states, Rajasthan and Jharkhand have the lowest percentage of men and women who are overweight. In Rajasthan only 12.9 percent women are overweight in NFHS-5 (down from 14.1 percent in NFHS-4) while in Jharkhand only 11.9 percent women are overweight in NFHS-5. However, in Jharkhand’s case this is an increase from 10.3 percent in NFHS-4.

An anaemic population

Anaemia refers to a condition when the body lacks enough red blood cells to supply oxygen to the body’s tissues. Among adults this can result in issues like fatigue and weakness. The WHO classifies anaemia as a serious global health problem. It also estimates that globally 42 percent of children under the age of 5 and 40 percent of pregnant women are anaemic. Anaemia in children can hamper development of their motor skills. NFHS provides us information regarding the percentage of Indian children, men, and women who are anaemic.

According to the WHO, less than 5 percent incidence of anaemia in a country is not a public health concern. 5-19 percent incidence would make it a mild public health problem, 20-39 percent incidence would make it a moderate public health problem, and 40 percent or more would make it a severe public health problem.

NFHS-5 paints a grim picture of the anaemia problem in the country. It shows that 67.1 percent of children under the age of 5, 57 percent of women aged between 15 and 49, and 25 percent of all men aged 15 to 49 have anaemia. Not only does India have a severe anaemia problem, NFHS-5 reveals a worsening position when compared to NFHS-4.

Figure 6a shows the state-wise numbers for anaemic children, men and in NFHS-4 and NFHS-5 for states and UTs covered in Phase 1 of NFHS-5. Figure 5b shows the same for states and UTs covered in Phase 2.

Figure 6a

Figure 6b

NFHS-4 showed that 58.6 percent of children in the country were anaemic. This has now increased to 67.1 percent. Kerala is the only state in the country where the percentage of anaemic children is less than 40 percent. Only 8 states or UTs in the country saw the percentage of anaemic children decline in NFHS-5 over NFHS-4. These states or UTs are spread over both phases of NFHS-5. The highest increase in anaemic children is seen in north-eastern states.

When it comes to anaemic women (aged 15-49 years), 13 states or UTs saw an improvement in NFHS-5 when compared to NFHS-4 however there are only 6 states or UTs where the percentage of anaemic women is less than 40 percent in NFHS-5. Kerala is the only large state in the country with the percentage of anaemic women is less than 40 percent. 

There is a clear gender gap in the prevalence of anaemia. Despite an increase in incidence of anaemia overall in NFHS-5, only 25 percent Indian men are found to be anaemic, compared to 57 percent Indian women. Even though India saw the percentage of anaemic men increase in NFHS-5, 18 states or UTs (across both phases) bucked the trend and saw their numbers decline. States like Andhra Pradesh and Tamil Nadu saw the percentage of anaemic men decline by 40 percent and 25 percent respectively.  

Conclusion

The National Family Health Survey can be called the health and demographic report card of the country. A survey of NFHS’ scale presents its own challenges, but NFHS-5 faced an added challenge of the Covid-19 pandemic. The pandemic split it into two phases. While Phase 1 covered 22 states and UTs before the country was struck by the jolt of the pandemic, Phase 2 (covering the remaining 14 states and UTs) was conducted during the pandemic. Not only would the pandemic affect data collection for the survey, but it would also affect health and dietary indicators for those affected by the lockdown and its economic impact. However, NFHS-5 data doesn’t reveal a relative worsening of health indicators for states or UTs covered in Phase 2 (i.e., during the pandemic). This also means the worsening of some of India’s health indicators like stunting, wasting, underweight children, anaemic population was a trend even before Covid-19 struck. Covid-19 might have made matters worse when it came to public health, but it didn’t cause it.

The biggest positives that NFHS-5 reveals are the decline in India’s TFR to below replacement level and the increase in institutional births in the country. The decline in TFR has implications for both politics and policy. Various political leaders have suggested coercive measures to control a feared population explosion like China’s one-child policy imposed in the 1990s (and reversed recently) while others have suggested tying welfare support measures or holding electoral office to the number of children. With the decline in India’s TFR, all such fears and debates can be put to rest.

The increase in institutional births across all of India from NFHS-3 to NFHS-4 and NFHS-4 to NFHS-5 suggests an improvement in India’s healthcare system. While India’s healthcare spend remains abysmally low, this is a positive trend which can ensure the well-being of both mother and newborn. However, institutional births are but one aspect of maternal care.

What NFHS-5 highlights – as the previous round of NFHS did – is the public health challenge that Indians, especially women and children face. It reveals deep inequality across states. While some states like Kerala compete with advanced economies in health outcomes, others find themselves at par with sub-Saharan Africa. NFHS-5 underlines the need for ramping up India’s public health expenditure and a focus on ensuring improvements in health outcomes in states that still languish.