Families in distress: Latest NFHS findings paint bleak picture

The latest NFHS findings point to many areas that need improvement, but the Central government decides to give the whole report a positive spin, underplaying the harsh realities.

Volunteers checking malnourished children’s weight at Bhospada, a village with little primary health care, in Maharashtra’s Palghar district in September 2016.

Towards the end of November 2021, the Ministry of Health and Family Welfare released two interesting documents. The first pertained to the findings of the fifth round of the National Family Health Survey (NFHS) and the second was the report of the National Health Accounts (NHA) estimates for India, 2017-18. In both cases, the government projected an optimistic scenario on public health, government expenditure, and so on.

The document on NHA claimed a significant decline in per capita out-of-pocket expenditure on health. A closer look at the two reports showed that the optimism may be premature and the claims unfounded.

Health expenditure

It is a rather a mixed story that emerges from the fourth and fifth NFHS rounds of 2015-16 and 2019-2021. Also, the rural-urban gap has been a rather noticeable feature in the latest findings.

The report on NHA claimed that the share of the government’s health expenditure in the total gross domestic product (GDP) increased from 1.15 per cent (2013-14) to 1.35 per cent in 2017-18. Likewise, it said, the share of total government expenditure in total health expenditure had risen to 40.8 per cent (2017-18) from 28.6 per cent (2013-14). The per capita out-of-pocket expenditure declined from Rs.2,336 to Rs.2,097 over the same period.

The choice of the period for comparison (2013-14 and 2017-18) was clearly an attempt to show that things had improved during the rule of the National Democratic Alliance (NDA) under the leadership of Prime Minister Narendra Modi as compared to the situation during the rule of the United Progressive Alliance (UPA). This implies that people had become healthier during the Modi years, were spending less on health in the private sector and were relying more on the government for health care owing to an expanded network of government services. In reality, the situation is very different.

According to the National Statistical Office’s (NSO) household consumption data related to health in 2019, data for which was collected between July 2017 and June 2018, public hospitals accounted for 42 per cent of in-patient hospitalisations while private hospitals and charitable institutions accounted for 55 per cent and 2.7 per cent, respectively. Government hospitals were the main service provider for only 30 per cent of ailments while private doctors, clinics, hospitals, informal health care providers accounted for the rest. The average medical expenditure per hospitalisation was Rs.4,452 in government/public hospitals and a whopping Rs.31,845 in private hospitals. In rural India as a whole it was Rs.16,676 and Rs.26,475 in urban India.

Positive spin

The Central government’s presentation of the evidence emerging from the NHA estimates for India, 2017-18, is a typical example of its tendency to underplay harsh realities and give a positive spin to everything.

This is reflected in the fact that it is celebrating the decline in health-related out of pocket expenditure of households between 2013-14 and 2017-18, both in absolute terms and as a share of total health expenditure from government and private sources (down to 48.8 per cent in 2017-18 from 64.2 per cent in 2013-14). In interpreting the meaning of this, however, it ignores two other facts present in the same reports.

The first is that total health expenditure as a percentage of GDP fell from 4.0 per cent in 2013-14 to 3.3 per cent in 2017-18. The second is that real per capita total health expenditure (adjusted for inflation and population change) remained virtually unchanged between these two years.

Against this background, the fall in out-of-pocket expenditure can hardly be a cause for celebration because it could well be a reflection of economic distress in the aftermath of demonetisation and the introduction of Goods and Service Tax (GST) and of persisting agrarian crisis and industrial stagnation.

What lends support to this observation is the the government’s decision to withhold the consumption expenditure data. The 75th round of the National Sample Survey (NSS), which included the survey from which the NHA obtained its figure of out-of-pocket expenditure for 2017-18 also included a concurrent Consumer Expenditure Survey, the latest of the periodic surveys on which poverty estimates, among other things, are based.

The government decided to not release the results of this survey claiming that its results were inconsistent with other indicators. Media reports based on leaked data (which were never explicitly denied) indicated the nature of this alleged discrepancy: a decline in average real per capita expenditure in comparison with the previous survey conducted in 2011-12.

The much-delayed release of the Primary Labour Force Survey (PLFS) results, which were originally withheld because it was contrary to the official narrative on the state of the economy, also confirmed the picture of growing economic distress.

NFHS-5 showed a decline in out-of-pocket expenditure per delivery in a public health facility, from Rs.3,197 in the previous survey to Rs.2,916 in the latest one. This decline was most probably the result of less money in the hands of the common man.

NFHS-5 provides data on 131 key indicators such as household characteristics, land ownership, pre-school attendance, ownership of physical and economic assets by women, death registration, reasons for abortion, domestic violence against women during pregnancy apart from the standard indicators of infant mortality, fertility, age of marriage, and contraceptive usage.

The survey was conducted in two phases. After the first phase in 2019-20 (from June 2019 until January 2020) in 14 States and Union Territories, the government halted the survey in early 2020 owing to the pandemic. It resumed the survey later in the year and continued it until April 2021in the remaining States.

The survey came with a disclaimer that it would be difficult to draw comparisons between States as some of them had a smaller sample size. It also said that since Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY), the government’s universal health insurance scheme, and Pradhan Mantri Surakshit Matritva Abhiyan, its antenatal care scheme for women, were not fully rolled out at the time of the survey, the figures might not reflect the number of households with any usual member covered under a health insurance or health financing scheme and the proportion of all women who had received four antenatal check-ups under the relevant scheme.

The government launched Ayushman Bharat in September 2018, with Prime Minister Narendra Modi calling it a game-changer for the poor. He also said then that it was the world’s biggest health-care scheme, with the number of beneficiaries equal to the combined population of Canada, Mexico and the United States. In September 2021 he announced the full rollout of the scheme and in October 2021, the government launched the PM Ayushman Bharat Health Infrastructure Mission to fill the gaps and strengthen the primary, secondary and tertiary health-care systems. The Matritva Abhiyaan scheme was launched in 2016.

Critical findings

The very first indicator on the NFHS data sheet—the proportion of girl children over six years who have ever attended school—shows a minor increase between the two surveys, from 68.8 per cent to 71.8 per cent, but the figure for rural girls is lower than the total average.

While the adult sex ratio seemed to favour women for the first time (1,020 women for every 1,000 men), the sex ratio at birth was still skewed against the girl child (929 for every 1,000 male children born) even though it recorded a marginal improvement over the previous survey. Wide differences between States in the sex ratio at birth were noted, with southern States such as Kerala and Tamil Nadu performing much better than northern States.

The overall positives in NFHS-5 include a 10 percentage point increase in birth registration—from 79.7 per cent in NFHS-4 to 89.1 per cent in the latest survey. The survey also mapped death registration percentages for the first time. A fairly high proportion of deaths (70.8 per cent) were registered in the last three years. Likewise, the number of households with power connection and improved drinking water sources had gone up between the two surveys.

However, only 58.6 per cent of households were using clean fuel for cooking . Even though this was an improvement over the previous survey’s findings, it was still quite low. Also, the rural-urban gap was very stark: 89.7 per cent of urban households had access to clean fuel compared to only 43.2 of rural households, which was 15 percentage points less than the national average.

In sanitation, the proportion of population in households with improved sanitation rose to 70.2 per cent, from 48.5 per cent in NFHS-4, but again the urban-rural divide was very stark. Close to 81.5 per cent of urban population had improved sanitation, while only 64.9 rural households could claim an improvement; again, the figure was less than the national average.

The government’s high-decibel sanitation campaign (Swacch Bharat) that began in 2014 itself does not seem to have brought about major change in rural areas. Likewise, despite the hype over health insurance, not many households were found with even a single member registered under a health insurance or health financing scheme, private or public. Although the numbers recorded an increase between the two surveys, from 28.7 per cent to 41 per cent, they were still below the 50 per cent mark. This also meant that 59 per cent of households in India did not have a single member covered under a health insurance or health financing scheme, implying a high out-of-pocket expenditure on health care.

Interestingly, the survey data showed that more rural households (42.4 per cent) were covered under health insurance as compared to urban households (38.1 per cent). This meant that a large proportion of urban households did not have a single member covered under any health insurance or health financing scheme.

With India in its 75th year of Independence, one would have expected the government to conduct a concerted drive to achieve 100 per cent literacy. The percentage of literate women in India was 71.5 per cent as a whole, with wide contrasts between urban and rural India, with the latter registering a figure less than the national average. Literacy among rural and urban women was 65.9 per cent and 83 per cent, respectively. Only 41 per cent of women had 10 years or more of schooling. Within this, 56.3 per cent of urban women and only 33.7 per cent of rural women had completed more than 10 years of schooling. However, this was no deterrent to Internet usage. Among women, 33.3 per cent said they used the Internet; the figure was 57.1 per cent among men.

While overall literacy rates for men were higher, there was a rural-urban skew here as well. In several States, literacy rates had crossed over 90 per cent, with States like Kerala having achieved 100 per cent literacy decades ago. The northern States have mostly continued to drag the overall figures down.

The percentage of women in the 20-24 age group who were married before the age of 18 was 23.3 per cent, a marginal dip from 26.8 per cent reported from the previous survey. Although this is encouraging, the figure is still rather high. Early marriage means early pregnancies, which affect the overall health and reproductive health of women, deprive them of an education and other opportunities and also impact the health of the children born.

On the other hand, the total fertility rate (TFR) or the number of children a woman gives birth to, had dropped to 2 from 2.2 in NFHS-4. India had done better than the globally accepted replacement level fertility rate of 2.1, that is, the TFR at which a population exactly replaces itself. While a declining TFR is welcome and points to the irrelevance of aggressive population policies, there is a legitimate concern that the decline may have happened at the cost of the girl child. It may also have happened at the cost of terminal methods of contraception, female sterilization in particular, which showed a rise since the previous survey. In fact, if there was any indicator where the gender bias was so pronounced, it was this and the sex ratio at birth.

Mortality rates

The latest findings also showed that the neonatal mortality rate or deaths per 1,000 live births was 24, the infant mortality rate was 35.2 and the under-5 mortality rate was 41.9. Although these figures were lower than in the previous survey, they were still quite high.

As per the survey, only 58.1 per cent of all women received four antenatal care visits. This did not signify a major improvement over the previous survey, where 51.2 per cent women had received such care. In the introduction to the survey, the Health Ministry reasoned that the figures might not reflect actual coverage as the PM Surakshit Matritva Abhiyan was not fully rolled out when the survey was on. Interestingly, the campaign was launched in November 2016, three years before the survey for NFHS-5 began. There is no reason why the present data do not reflect the impact, if any, of the campaign. Nowhere was it stated at the time of the launch that it was a partial rollout.

While the number of institutional births as a whole had risen, the private sector still accounted for almost 39 per cent of them. The number of births through Caesarean method had risen both in private and public health facilities as compared to the previous survey. The rise was steeper in private facilities.

The survey’s child nutrition statistics showed that only 41.8 per cent of children under three years were breastfed within one hour of their birth, which was almost the same level as that observed in the previous survey. Some 63.7 per cent of children under six months were exclusively breastfed, but only 11.1 per cent of breastfed children in the age group of 6-23 months received adequate diet.

Also, only 11.3 per cent of all children in the age group of 6-23 months received an adequate diet. Around 35.5 per cent of children under five were stunted; 19.3 wasted; 7.7 per cent severely wasted and 32.1 per cent underweight.

A very high proportion of anaemia was detected among children and women. Around 67.1 children under five were anaemic (58.6 per cent in NFHS-4), while 52.2 per cent of pregnant women were anaemic. Around 57 per cent of women in the 15-49 age group and 59.1 per cent in the 15-19 age group were anaemic.

Screening for cancer among both men and women was abysmal. Only 1.9 women had been screened for cervical cancer; 0.9 per cent for breast cancer and 0.9 per cent for oral cavity cancers. Among men, only 1.2 per cent were screened for oral cancer.

A large proportion of children under five were deprived of adequate diet, and anaemia had increased across the board among men, women and children. Most experts believe that this was reflective of a lack of access to a diverse and affordable diet rather than anything else.

In fact, NFHS-3 had pointed out the importance of a well-balanced diet and recommended a wide variety of nutritious foods that were important for both men and women. It asked respondents how often they consumed various types of food and found that women’s consumption was less balanced as compared to that of men. It brought out wide gender differentials in the consumption of basic foods such as leafy vegetables, fruits, and milk. Men’s diets were better but still not up to the desired levels. The government would have done well to include questions on dietary intakes in the NFHS-5 survey.

In the ongoing winter session of Parliament, Bharati Pravin Pawar, Minister of State for Health, informed the Rajya Sabha that the share of the government’s health expenditure had risen to 1.35 per cent in 2017-18.

According to the 2019 data put out by web portal Statista, the government’s expenditure was 16.8 per cent in the U.S.; 11-11.7 per cent in Germany, Switzerland, France and Japan and 10-10.9 per cent in the Scandinavian countries, the United Kingdom, Austria, Belgium and Canada. India’s health expenditure as a percentage of its total GDP was nothing to brag about.

According to World Bank data for 2018, the governments of Sri Lanka, Nepal, Maldives and even Afghanistan spent more on health as a share of their GDP than India.