The sixth round of the National Family Health Survey (NFHS-6, 2023-24), released recently, does not present a flattering picture of the nation’s health, and of women’s and child health in particular. Indicators such as body mass index levels lower than normal for both men and women show that nutrition for neither is anywhere near ideal. The survey factsheets, released nearly two years after the fieldwork was completed in mid-2024, should have been out within months. The delay has never been explained.
A researcher familiar with data collection said that since the survey uses Computer Assisted Personal Interviewing (CAPI), all estimates can be released within two to three months of data gathering. The previous round, NFHS-5, released in 2022, was conducted under the massive constraints of Covid, yet both NFHS-4 and NFHS-5 came out on time. No comparable constraints existed this time. It has also emerged that questions were raised over the questionnaire and the substantially reduced number of indicators in NFHS-6.
Information this time was gathered from 6,79,238 households, covering 101 indicators—30 fewer than the last round. Yet since some indicators were retained from NFHS-5 (2019-21), comparison across select indicators remained possible. The sample size was larger than that of NFHS-5, which covered 6,36,699 households.
Both NFHS-4 and NFHS-5 included data on sanitation, clean fuel, anaemia, haemoglobin levels for women and children, number of deaths in the household in the years preceding the survey, sex ratio, sexual behaviour, infant and child mortality, and perinatal mortality. NFHS-6 factsheets contain none of these.
The NFHS factsheets in general carry estimates of population, health, family planning, and nutrition-related indicators—fertility, maternal and child health, adult health, women’s and child nutrition. Figures from these large household surveys help policymakers design and direct programmes for better outcomes, and frequently serve as a mirror held up to government flagship initiatives. As always, the survey was conducted by the International Institute for Population Sciences (IIPS). But for the first time, it was conducted without any technical or financial support from external organisations—a point the report emphasises.
External support in the previous round came from the USAID-supported Demographic and Health Surveys Programme, ICF, and the Pune-based National AIDS Research Institute (NARI). Barring USAID, whose funding to Indian programmes was bound to be affected following massive cuts by the United States government, NARI could hardly be called an external institute. It is no surprise, then, that outside contraceptive usage, indicators on sexual behaviour, methods and reasons for abortion, attitudes towards and knowledge of HIV/AIDS are absent from this round.
NFHS-5 had introduced new topics as well: pre-school education, disability, access to toilet facilities, and death registration. Its data was intended to identify new programmes with an area-specific focus, to reach the groups most in need of essential services. Like earlier rounds, it had data on fertility, infant and child mortality, perinatal mortality, high-risk sexual behaviour, tuberculosis, non-communicable diseases (NCDs), safe injection practices, and use of emergency contraception.
A detailed exercise
The Clinical, Anthropometric and Biochemical (CAB) component of NFHS-5 was designed to provide estimates of the prevalence of malnutrition, anaemia, hypertension, high blood pressure, waist-hip circumference, Vitamin D3, HbA1c, and malaria parasites through a series of biomarker tests and measurements. Some NCD indicators using the CAB component are present in NFHS-6, but the indicators tracking malnutrition, anaemia, Vitamin D3, and malaria parasites have been dropped.
NFHS-5 also collected basic demographic and socioeconomic data: marital status, age, sex, literacy, occupation, employment, schooling, ownership of Aadhaar cards, relationship to head of household, tobacco use, alcohol consumption, exposure to mass media, and household characteristics—water, sanitation, hygiene, water treatment, type of toilet facilities, type of cooking fuel, materials used for walls, floors, and roofs, and ownership of mosquito nets.
The women’s questionnaire in NFHS-5 covered current pregnancy and terminations, prevalence of hysterectomy, post-partum amenorrhoea, use of ICDS services, age of first intercourse, recent sexual activity, number and type of partners, and gender preferences for children. The men’s schedule asked about fertility preferences, attitudes towards gender roles, sexual behaviour, and knowledge of tuberculosis. The biomarker schedule covered haemoglobin levels for men, women, and children; blood samples were taken by a finger-prick or heel-prick (for children aged 6-11 months), with haemoglobin analysis conducted on site. Respondents, including pregnant women with severe anaemia, were referred to a health facility for further evaluation and treatment.
For malaria—prevalent in Odisha, Chhattisgarh, Jharkhand, Madhya Pradesh, Tripura, and Meghalaya—a Dried Blood Spot collection method using random sampling was used in NFHS-5 to detect symptomatic and asymptomatic malaria, including markers of anti-malarial drug resistance. Data collection for malaria is not part of NFHS-6.
What NFHS-5 revealed
NFHS-5 found that 69 per cent of households used an improved sanitation facility; 19 per cent had no facility at all and practised open defecation. Eighty-three per cent had access to a toilet facility; only 59 per cent of households used clean fuel for cooking; 58 per cent did not treat their water before drinking; 26 per cent of the population had no water, soap, or any cleansing agent for handwashing on the premises. Forty per cent of boys and girls in the 2-4 age group attended pre-school; school attendance ratios showed steeper falls at middle, secondary, and higher secondary levels, with students citing lack of interest in studies. Wealth quintile data found that 71 per cent of Scheduled Tribe households and 49 per cent of Scheduled Caste households were in the lowest two quintiles.
Indicators for both birth and death registration are missing from NFHS-6. Birth registration had registered an increase between the two rounds; death registration data would have been particularly useful for policymakers. NFHS-5 found that death registration rates were higher in wealthier households, and more common in urban areas and among males than females. Here was data that could have informed policy corrections.
No explanation has been offered for the dropped indicators. The argument that the Sample Registration Survey (SRS) and a national report based on NFHS and SRS would provide a consolidated picture of all relevant indicators does not hold. The SRS, as its name suggests, is a sample survey. The NFHS, by contrast, is the largest household survey in the world. In India, only the Census surpasses the NFHS in terms of coverage.
Discouraging findings
Even for the indicators that remain, the overall picture is not reassuring. The data shows that the percentage of households consuming iodised salt has gone down; households using an improved drinking water source improved only marginally; 18.8 per cent of women owned property or land, either solely or jointly; 47 per cent of children in the 2-4 age group attended pre-school; the number of women using the internet had nearly doubled; and 20.1 per cent of women were married before the age of 18.
The total fertility rate held at 2.0—the same as in NFHS-5—though wide differentials between States persist. 6.7 per cent of women in the 15-19 age group were already mothers or pregnant at the time of the survey, a decline of barely one percentage point since the last round, indicating that adolescent pregnancies have barely shifted. Female sterilisation declined marginally and male sterilisation, while fractionally higher, remained under 1 per cent of total sterilisations—showing that the burden of contraception continues to fall overwhelmingly on women.
Only 76.2 per cent of mothers had antenatal check-ups in the first trimester. Just 54.9 per cent had consumed iron folic acid for 100 days—crucial for the baby’s growth and for protection against maternal anaemia and low birth weight—and an even smaller proportion, 37.8 per cent, for the recommended 180 days. Institutional births increased, which was positive, but more were taking place in the private sector. Births by Caesarean section stood at 27.2 per cent—a rise of around 6 percentage points over NFHS-5—with 54.1 per cent of C-section births in private facilities, against 16.9 per cent in public health facilities. Wide urban-rural differentials persist: the C-section rate in rural births was roughly half that in urban areas.
Stagnant breastfeeding, soaring C-sections
Despite marked improvements in measles, polio, and rotavirus vaccination rates, immunisation coverage is nowhere near 100 per cent. Child vaccination fares considerably better in the southern States than in north and central India.
One troubling finding of NFHS-6 is the fall in the rate of children exclusively breastfed for six months, indicating that infants are being given either infant formula or other milk substitutes. Similarly, only 50.1 per cent of children were breastfed within one hour of birth. Arun Gupta, a paediatrician and founder of the Breastfeeding Promotion Network of India (BPNI), who has long campaigned for breastfeeding promotion, finds it difficult to explain why breastfeeding should decline when institutional births are rising. If India could achieve 63 per cent exclusive breastfeeding in NFHS-5, what accounts for the fall, he asks.
Inadequate support for breastfeeding in facilities, and the aggressive commercial marketing of infant milk substitutes and baby foods, undermine optimal feeding practices. Such marketing normalises formula feeding, weakens confidence in breastfeeding, and undermines the Infant Milk Substitutes Act. While a few States have shown improvement in early exclusive breastfeeding, many have reported sharp declines, Gupta said. He called on the Health Ministry to take the trend seriously and initiate a public discussion. Caesarean deliveries, he added, are known to interfere with the early initiation of breastfeeding.
Another figure that troubles him is the very small proportion of children in the 6-23 months age group—15.3 per cent—who received an adequate diet, meaning 85 per cent were deprived of nutritionally adequate complementary feeding. Child under-nutrition, though showing modest improvement in stunting, wasting, severe wasting, and underweight, remains at unacceptably high levels. Among adult nutrition indicators, the percentage of women and men with a body mass index lower than normal levels increased between the two rounds. A nutritionist, speaking on condition of anonymity, said this was possible if parents were cutting back on food to provide adequately for their children, or if food inflation had pushed household diets below adequate thresholds. “When fertility declines and so do incomes, all resources are invested in children,” she said.
The cost of the exclusions
A social scientist associated with NFHS-5 said on condition of anonymity that CAPI was a robust and efficient system, and there was no reason why data on all 130 indicators from NFHS-5 could not have been collected using it. He was surprised at the exclusion of anaemia measurement, on the grounds that the testing system was not accurate.
“The survey is complete but the factsheets are not. A comparison of trends won’t be possible with previous surveys. If the capillary method of testing for anaemia was not reliable, a different technology could have been used. Excluding neonatal mortality rates and the sex ratio at birth are very serious omissions. Anaemia should have been included. Trends give an idea of whether a programme is working. What is convenient to the government is included; what is not is left out,” he said, referring to the thirty-odd dropped indicators. Many government schemes—the Anaemia Mukt Bharat, Poshan Abhiyaan, Swachh Bharat Mission, the Ujjwala scheme distributing LPG cylinders to Below Poverty Line women—could have been assessed in NFHS-6 had data for those schemes been collected.
The NFHS is a principal source of information on maternal and child health and household characteristics. After the NDA came to power in 2014, the District Level Household and Facility Survey—which had been providing critical data on maternal, child, and reproductive health, mortality, living conditions, and socioeconomic status—was discontinued. The delay in NFHS-6 results was widely attributed to the fact that 2024 was an election year. That may also account for the reduction in critical indicators. In its present form, stripped of data and scope, NFHS-6’s principal casualty is policy—no longer informed by robust evidence, but by political expediency.
[T.K. Rajalakshmi is Senior Deputy Editor with Frontline. Courtesy: Frontline, a fortnightly English language magazine published by The Hindu Group of publications headquartered in Chennai, India.]
