National Family Health Survey

Falling short

Print edition : April 14, 2017
The latest national family health survey results underline the need for the government to play a greater role in strengthening the infrastructure to ensure accessible and affordable health care for all.

ON MARCH 6, a leading news agency reported that the Union Cabinet had deferred a decision on the National Health Policy (NHP) for the second time; the first postponement was on February 15. The policy, which aimed at providing assured health services to all, has been hanging fire for the last two years. The much-awaited policy was finally cleared by the Cabinet 10 days later on March 16.

The fact that a health policy was required was underscored by the recent results of the National Family Health Survey (NHFS), which indicated that there was an urgent and immediate need to spruce up health accessibility and affordability at every level.

Other than the usual indicators of mortality and morbidity, the survey includes data on malaria prevention, migration, abortion, and violence during pregnancy. For the first time, district-level indicators relating to information on population, health and nutrition have been provided.

The survey results, which come on the cusp of India’s 70th year of independence, remain far from satisfactory. The results are a reflection of the state of the country’s health, especially that of its children, adolescents and women. It is also a testimony to the country falling short of ensuring basic entitlements, including nutritional requirements for its young children and expectant mothers. While there appears to be an improvement in certain indicators, including sanitation, the survey includes the caveat that the figures for NFHS 3 and NFHS 4 may not be strictly comparable owing to the difference in the sample size. The latest survey was conducted between January 20, 2015, and December 4, 2016.

Decline in adult sex ratio

While there has been a marginal improvement in the child sex ratio (CSR) at birth, from 914 in NFHS 3 to 919 in NFHS 4, the adult sex ratio plummeted by nine points from 1,000 to 991. The abysmally slow improvement in the CSR at birth has a direct connection to the implementation of the Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act, 1994 . The number of convictions under the Act as a whole for the country has been very low, belying the success of the much-touted Beti Bachao Beti Padhao campaign of the government. A significant improvement in the households using improved facility of sanitation, a decline in the total fertility rate that should allay the fears of a population explosion, an increase in the percentage of women in the 20-24 age cohort having 10 years or more of schooling, a decline in the number of women getting married under the age of 18, and an improvement in the infant mortality rate (IMR), from 57 to 41 per 1,000 live births, and the under-five mortality rate (U5MR), from 74 to 50, are some of the positives.

Yet, only 24 per cent of all children had received a health check-up within two days of birth. Maternal health continues to be neglected. The negatives include the low percentage of mothers (21 per cent) who receive full antenatal care, although this is an improvement over NFHS 3; the low rate of women who consumed iron folic acid tablets (30.3 per cent) for a hundred days or more when they are pregnant; the high out-of-pocket expenditure per delivery, and the negligible rates of children born at home and taken to a health facility within 24 hours of birth. While institutional deliveries had gone up in the period between the two surveys, births in public facilities were around 52 per cent, which meant that the rest were either at private facilities or at home.

The number of births by caesarean section doubled in the private facilities but declined in public facilities. The growth of the private health care sector is a matter of deep concern as it indicates the public’s dependence on it for the treatment for maternal health-related issues.

However, public facilities are in far greater demand for vaccinations, which shows that public health facilities are widely sought after if they are present in adequate numbers.

There was a serious drop in the number of children in the zero to six age group who received solid or semi-solid food and breast milk between the two surveys. The percentage of breast-fed children from six to 23 months who received an adequate diet was only 8.7 per cent while 14.3 per cent of non–breast-fed children in the same age group received an adequate diet. While there was a fall in the percentage of children under five who were stunted or underweight, there was a rise in the case of children who were wasted and severely wasted. According to UNICEF, wasting (low weight for height) was a strong predictor of mortality for children under five and occurs mainly because of food shortage or disease. Some 43 per cent of Scheduled Caste (S.C.) children, 44 per cent of Scheduled Tribe (S.T.) children and 39 per cent of Other Backward Class (OBC) children were stunted; 39 per cent of S.C. children and 45 per cent of S.T. children were underweight.The more serious negatives include the high rate of female sterilisation as opposed to male sterilisation, which shows that the burden of terminal forms of contraception continues to be more on women than men. In the backdrop of the deaths of 13 women, including several tribal women, after they were sterilised in a government camp in Takhatpur block of Chhattisgarh’s Bilaspur district, (“Anatomy of a tragedy”, Frontline, November 29, 2014), and the subsequent exoneration of the doctor who conducted the operations, the high rate of female sterilisation leaves a question mark over the government’s approach to permanent forms of contraception and the skewed burden on women. The doctor was exonerated by the High Court on February 15, 2017, on the technical ground that the State government had not sanctioned the prosecution of the doctor, a government employee.

It would do well if the NFHS data also capture morbidity and mortality owing to quasi-successful sterilisation procedures and other forms of invasive contraception. It is a fact that such procedures are encouraged more among the poor in the name of either an unmet need or meeting the targets of population stabilisation. Figures available with Frontline show that until February 2017, as many as 27,27,046 female sterilisations were done compared with 58,883 for men. The government also plans to enhance the compensation for sterilisations.

Anaemia rates high

The other issue relating to women’s health in general and maternal health in particular is anaemia, which continues to be high among both women and children. The all-India average is a cause of serious worry despite better performing States like Kerala, which has a favourable child and adult sex ratio and where the focus on primary care has been mainly in maternal and child care services. The State ranks best in terms of decrease in IMR and MMR and high life expectancy, according to the report of the expert committee on health for the 12th Five-Year Plan. Nationally, nearly 53 per cent of all women between 15 and 49 years of age are anaemic (the figure was 55.3 per cent in NFHS 3), which shows that there has been little improvement over the last one decade.

As much as 58.4 per cent of children in the age cohort of 6-59 months were found to be anaemic, while anaemia among men was 22.7 per cent. Comparatively, in Kerala, which has a robust public and private health care system, the latter having grown after the 1980s, anaemia among children, women and men was much below the national average, at 35.6 per cent, 34.2 per cent and 11.3 per cent respectively.

The treatment of childhood diseases (for children under five), child immunisation rates and vitamin A supplementation, child feeding practices, and the nutritional status of children and adults are all several points better than the national average. Anaemia among children and adults was found to be nearly 20 points lower than the national average, although a slight increase in anaemia among non-pregnant women and men was noticed. Yet, maternity care and delivery care remain far better than the national average.

In fact, the State reported 100 per cent performance of assisted births by a doctor, nurse or trained birth attendant. The drop in the IMR (6 per 1,000 births; 15 reported in NFHS 3) and U5MR (7 per 1,000 births; 6 in NFHS 3) in Kerala roughly corresponds with the health and nutritional indicators of children and women and the availability of quality health services. In comparison, some of the high per capita income States like Haryana and Gujarat fared poorly. In Haryana, the IMR and the U5MR were 33 and 41 for every 1,000 births while in Gujarat the corresponding figures were 34 and 43 respectively. Delhi, despite being the national capital, had an IMR and U5MR of 35 and 47 respectively, but lower-than-national average rates of stunted, wasted and underweight children. The U5MR was the same as that during the previous NFHS. The percentage of stunted, wasted and underweight children in Gujarat was found to be higher than the national average. In Haryana, 71.7 per cent of children were anaemic and so were 62.7 per cent of women in the 15-49 age group.

The adult and child sex ratios of both Haryana and Gujarat were much lower than the national average. In fact, the CSR for Delhi was much worse than the two States, perhaps indicative that a fairly advanced and undetected system of sex selection was prevalent. While Haryana’s CSR showed an improvement from 762 in NFHS 3 to 836 in NFHS 4, despite being much less than Kerala where the CSR was 1,047, the decline in the CSR of Delhi has been surprising, from 840 in 2005-06 to 817 in 2015-16. According to a Press Information Bureau (PIB) release in March 2015, 206 convictions under the PCPNDT Act were secured until December 2014, with 54 in Haryana, 11 in Bihar, two in Madhya Pradesh, 61 in Maharashtra, 28 in Punjab, 37 in Rajasthan and one each in Uttar Pradesh, Delhi, Jammu and Kashmir and Himachal Pradesh.

Lower budget outlay

The expenditure on health in India is abysmally low. As per the Economic Survey 2016-17, the combined expenditure on health by the Centre and State governments was 1.4 per cent of the gross domestic product (GDP) for 2016-17. It cannot be left to the private sector to address the shortfall in health infrastructure, access and treatment. The outlays under the National Health Mission or NHM, as per the demand for grants 2017-18 available with Frontline, for the 12th Five-Year Plan show that the actual expenditure has been much less than the Revised Estimates (RE) and the Budget Estimates (BE) cumulatively since the beginning of the Plan period. The RE for 2016-17 is lower than the BE for 2012-13. In a reply to a questionnaire on demand for grants (2017-18) pertaining to the NHM, the government accepted that the Plan allocation for the different components of the NHM, at Rs.21,940.70 crore, was less than the projected requirement of Rs.34,315.66 crore. It also accepted that the reduction would affect the strengthening of health facilities as per Indian Public Health Standards and the establishment of sub health centres, community health centres and primary health centres as well as the rollout of universal health coverage pilots.

According to the National Health Accounts 2013-14, the out-of-pocket expenditure on health was 64 per cent of the total expenditure on health. Of the 192 countries ranked in terms of such expenditure, India ranked 183 while its BRICS counterparts performed much better. The per capita health expenditure in terms of purchasing power parity was very low at $267 compared with $1,318 in Brazil, $1,148 in South Africa, $731 in China and $1,836 in Russia. As health is a State subject, the State governments bear the larger burden of the share of health expenditure.

The draft national health policy had envisaged raising public health expenditure to 2.5 per cent of the GDP. The policy itself is nowhere in sight. It is no surprise, therefore, that India is nowhere near achieving quality health care and nutrition for all despite the rhetoric.

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