The National Family Health Survey (NFHS) data on sanitation reveal that 19 per cent of households still have no toilet facility, which means that they are defecating in the open. Further, only 59 per cent of households used a source of clean fuel for cooking, which effectively means that 41 per cent do not have such access. In the country’s 75th year of independence, such statistics are dismal, but overall, the survey reflects mixed progress on various fronts.
The NFHS, one of the largest household surveys in the world, is jointly conducted by the Health Ministry and the Indian Institute of Population Science. The study, which is funded by the Central government and USAID, provides key data on the social and economic determinants of health. Over the years, several new parameters have been included, making it one of the most comprehensive health and family welfare surveys in the country. NFHS-5, the fifth such round, provides similar data from 6,36,699 households—comprising 7,24,115 women and 1,01,839 men—with information on a wide spectrum of indicators, from preschool attendance, access to toilets, death registration, disability, insurance coverage, and ownership of assets by women to domestic violence during pregnancy, bathing practices during menstruation, and methods and reasons for abortion.
The data, according to the authors, will provide a yardstick to measure the progress made towards the UN’s Sustainable Development Goals. The fieldwork itself was done in two phases. The first covered 17 States and five Union Territories between June 2019 and January 2020. The second phase covering 11 States and three Union Territories was conducted between January 2020 and April 30, 2021.
While some of the findings are encouraging, such as the ones on extent of electrification, Aadhaar card coverage, and households having a bank or postal account,several others are not, such as the data on sanitation. While birth registration rates of children under 5 have improved, the death registration rate is about 71 per cent. School attendance rates, especially in preschool and higher secondary schools, are discouraging. Only 40 per cent of boys and girls in the age group of 2-4 years attended preschool, and the net attendance ratio showed a marked dip from 83 per cent in primary school to 71 per cent in middle, secondary, and higher secondary schools. As for the young population, the much-mentioned demographic dividend, 27 per cent are under the age of 15. Those above the age of 60 constitute 12 per cent of the population
The survey covered all 28 States and eight Union Territories and 707 districts in total. There were 131 key indicators at the State level and 104 at the district level.
The survey debunks several established stereotypes about fertility rates being unnaturally high among certain communities, a theory that has been used ad nauseam to caricature one community in particular. Fertility overall had decreased in the last five years and household sizes had shrunk between the two rounds, 2015-16 (NFHS-4) and 2019-21 (NFHS-5), from 4.6 to 4.4 persons. Interestingly, the number of households headed by women had increased from 15 per cent to 18 per cent between the two NFHS rounds, which could be an indicator of increased male migration for work.
Access to sanitation and water
Even though a general urban-rural skew existed in access to toilet facilities, there were wide inter-State and intercommunity variations in several indicators. Access to a toilet facility was lowest in Bihar (only 62 per cent had access) followed by Jharkhand (70 per cent) and Odisha (71 per cent) respectively. Kerala and Lakshadweep had the highest percentage of households with access to basic sanitation facilities, at 98.7 per cent and 99.8 per cent respectively, whereas less than 70 per cent of the households had similar services in Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Jharkhand, Odisha, West Bengal, Assam, and Manipur. In Bihar, it was below 50 per cent. Substantively, not much had changed apparently in the States that the demographer Ashish Bose had named BIMARU States (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh; Odisha was added later).
While improvement in basic sanitation facilities was noticeable, less than 80 per cent of households in these States had such basic services when compared with States in the south, where it was more than 90 per cent on average. Among religious groups, toilet facilities were highest among Sikhs and Jain households, followed by Christians, Muslims, and Hindus. Among social groups, it was lowest among the Scheduled Tribe (ST) and Scheduled Caste (SC) categories. Some 58 per cent of households did not treat their water before drinking and about 16 per cent used material other than soap and water, such as ash, mud, or sand, for washing. Around 26 per cent did not have any cleansing agent on their premises for safe handwashing. It was more a case of not being able to afford it rather than a question of choice.
There were disparities in the use of cooking fuel as well. Only 55.5 per cent of households surveyed used LPG, while 33.4 per cent used wood, 4.8 per cent dung cakes, and a meagre 0.6 per cent depended on electricity as a source of fuel for cooking. Some 95.4 per cent of households still used chullahs (the traditional mode of cooking) using either wood, charcoal, or dung cakes.
The survey also captured data on disparities in the ownership of consumer items denoting wealth status. Some 71 per cent of ST households and 49 per cent of SC households occupied the two lowest wealth quintiles. The States with the highest percentages of their populations falling in the lowest wealth quintiles were Jharkhand, Bihar, and Assam.
Among religious groups, 80.1 per cent of Jains fell in the highest wealth quintiles followed by 59.1 per cent of Sikhs, 25.6 per cent of Christians, 19.3 per cent of Muslims, and 19.1 per cent of Hindus. Among caste groups, almost 50 per cent of SCs and over 70 per cent of STs were in the lowest two wealth quintiles. Only 12.3 per cent of SCs and 5.4 per cent of STs were in the highest wealth quintile, whereas Other Backward Classes (OBCs) tended to cluster around the middle, with only 16.3 per cent falling in the lowest wealth quintile and 19.2 per cent in the top quintile.
Only 59 per cent of the overall population lived in pucca houses, defined as those where high-quality material was used throughout. Inter-State disparities showed that less than 50 per cent of the households surveyed lived in such houses in Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Jharkhand, Bihar, Sikkim, and Tripura. In the south, the percentage of people dwelling in pucca houses was over 80 per cent.
In birth registration rates, while most States had rates above 90 per cent, the registration rate was below the national average in Uttar Pradesh, Bihar, and Jharkhand, along with four north-eastern States. Among religious groups, the birth registration rates were the same among Hindus and Muslims but lower than Sikhs, Christians, Jains, or Buddhists. Besides, higher the wealth quintile, higher were the birth and death registration rates. Uttar Pradesh, Bihar, Jharkhand, Arunachal Pradesh, Manipur, and Nagaland were among those with the lowest death registration rates. The States in the south fared much better in this regard.
Literacy and education
There were wide disparities in literacy and school education too. Overall literacy rates for men and women were 84 per cent and 72 per cent respectively. Bihar and Kerala “provided two contrasting profiles”, according to the survey. Literacy among men and women in Bihar was 76 per cent and 55 per cent respectively, whereas in Kerala it was near universal or cent per cent.
Overall, 50 per cent of men and 41 per cent of women had more than 10 years of schooling, which meant that half of the male population and 59 per cent of the female population had less than 10 years of schooling. Only 10 per cent of women and 13 per cent of men had completed 10-11 years of schooling. But 17 per cent of women and 23 per cent of men had completed 12 years of schooling.
The median number of years of schooling was higher for men, which indicates that the government needs to do more, going beyond catchy slogans for its Beti Padhao (educate the girl child) campaign. The broad trends showed that educational attainment had increased between the two rounds. However, it was directly proportional to the increase in household wealth.
The median number of years of schooling for STs, SCs and OBCs was lower than for other social groups, which also drew a link between educational attainment, class, and caste. Among religious groups, it was lower among Muslims, which was also indicative of the link between educational attainment and income. But there were bound to be inter-State variations here. The educational attainment of Muslims in Kerala was definitely bound to be higher than that of Muslims in Bihar or Uttar Pradesh. The same social groups that had lower educational attainment also had lower preschool attendance rates among their children. The economic determinant of education did play a role in educational attainment levels.
The data on disability levels showed that only 1 per cent of the de jure population suffered from some kind of disability, though in sheer numbers it was still quite high. Disabilities were more common in rural settings.
With regard to consumption of tobacco and alcohol, the region-wise disaggregated data showed that the there was no region where both men and women did not consume tobacco or alcohol. On use of tobacco, the survey found that 11 per cent of women in rural areas and 6 per cent in urban areas consumed tobacco. Usage of tobacco was prevalent across India.
Nationally, slightly more than 1 per cent of women drank alcohol compared with 19 per cent among men. The consumption of alcohol among tribal women was higher as compared with other social groups. It was highest in terms of percentage of population in Arunachal Pradesh and Sikkim.
Among women, the consumption of alcohol varied from as low as 0.3 per cent in some States to 5.5 per cent in Goa, 6.3 per cent in Tripura, 7.3 per cent in Assam, 7.6 per cent in the Andaman and Nicobar Islands, 9.1 per cent in Telengana, 16.2 per cent in Sikkim, and 24.2 per cent in Arunachal Pradesh where it was the highest.
The number of female-headed households had increased since the last round, from 15 per cent to 18 per cent in the latest round. Whether this was due to migration by men for work was not clear but it could well be a reason. The average household size had decreased from 4.6 to 4.4 persons, but preference for sons continued to play a major role in establishing fertility rate. Although 86 per cent of women with two living children did not want more children, 81 per cent of women aged 15-49 wanted at least one son, while 79 per cent wanted at least one daughter. Both men and women wanted an average of 2.1 children, which was almost the same as the current fertility rate, but preference for sons dominated in the choice of children.
The median birth intervals were highest among Hindus and lowest among Jains. In wealthier households, the birth intervals were likely to be greater. Women with no schooling had an average of 2.8 children, compared with 1.8 among women who had more than 12 years of schooling.
Women in the lowest wealth quintile had an average of 1.0 children more than those in the higher wealth quintiles. Therefore, wealth and education played a role in determining family size and the agency of women in deciding how many children they preferred to have. The survey emphasised that the total fertility rate (TFR) had declined “noticeably” over time. It was 2.0, lower than the replacement level fertility rate of 2.1.
The median age at first birth was 21.2 years, although teenage child-bearing had declined by one percentage point between the fourth and fifth rounds. Yet, in the three decades from 1992-93 to 2019-21, the TFR had declined from 3.4 to 2.0 children. It had declined in rural areas from 3.7 to 2.1 and from 2.7 to 1.6 in urban areas. The decline was sharper in rural areas.
Among religious groups, the highest fertility rate was observed among Muslims, followed by Hindus. However, there were wide variations across the country: the Muslim-majority Jammu and Kashmir recorded a fertility rate of 1.41, lower than the national TFR of 2.0, and much lower than the TFR of Uttar Pradesh (2.35), Bihar (2.98), Meghalaya (2.91), Haryana (2.05), and Rajasthan (2.01).
West Bengal and Kerala, which have sizeable Muslim populations, recorded fertility rates below the replacement level fertility rate of 2.1. Evidently, the level of economic development and other social determinants of well-being played a role in determining fertility rates.
Despite the hype of women’s empowerment by various governments, female sterilisation continues to be the most common form of contraception even though comparatively, male sterilisation is deemed to be medically far safer. Wealth also played a role in the use of modern contraceptive methods.
A woman’s burden
Only 62 per cent of women who used modern contraceptive methods were told about side effects, and the percentage of women who were told what to do if they experienced side effects was low in every State, in itself a matter of concern. There were inter-State variations here as well. The survey also captured men’s perceptions of contraception.
At an all India level, some 35.1 per cent men believed that contraception was a woman’s business and 19.6 per cent felt that it may lead to promiscuity. Inter-State variations ranged from 6.2 per cent to as high as 44 per cent of men who held the belief that women might become promiscuous if they used contraceptives.
The median age at first marriage was 18.8 for women and 24.9 years for men. Some 38 per cent of women in the 20-49 age group got married before the age of 18 and 23 per cent of men before the legal age of 21. The median age was higher among Jain, Sikh, and Christian women when compared with other religious groups.
There was a correlation between education, wealth, and age of marriage. The percentage of women marrying before reaching the legal age of 18 was lowest in Lakshwadweep, Kerala, Jammu & Kashmir and Ladakh, Goa, Nagaland, Himachal Pradesh, and Puducherry. Among religious groups, the median age at first marriage in the 45-49 age group was lowest among Hindus (18.2), followed by Muslims (18.3), Buddhists (18.6), Sikhs (20.4), and Christians (21.5), and highest among Jains (22.1).
However, in the 20-49 age group, the median age of marriage was the same for both Hindus and Muslims (19.1), followed by Buddhists, Sikhs, Christians, and Jains in that order. It was lower among ST and SC communities. Some 11 per cent of marriages were consanguineous, prevalent in several States in the south.
One of the new areas that the survey sheds some light on is the pattern of teenage childbearing.
Again, where economic status and levels of schooling were better, teenage childbearing was likely to be nominal. The highest rates were observed among Muslims and ST communities. There were strong correlations between wealth status and aspects such as menstrual hygiene. The survey found that women in the highest wealth quintile were twice as likely to use safe hygienic methods of menstrual hygiene as compared with women in the lowest wealth quintiles.
The scenario on infant and child mortality rates continues to be dismal. The under-5 mortality rate (U5MR) was high at 42 deaths per 1,000 live births as was the infant mortality rate (IMR) at 35 deaths per 1,000 live births. Uttar Pradesh had the highest U5MR followed by Bihar, whereas the lowest rates were in Puducherry followed by Kerala. Perinatal mortality (stillbirths) was highest in Uttar Pradesh, followed by Bihar, while it was the lowest in Goa. The U5MR rates were far higher for SCs, STs, and OBCs. Household wealth and education played a role here too.
On anaemia, the survey found that 67 per cent of children in the 6-59 months age group were anaemic, as were 57 per cent of all women and 25 per cent of all men in the 15-49 age group. This was bound to happen as only 11 per cent of all children in the 6-23 months cohort were fed the minimum acceptable diet. Inter-State variations showed that in Meghalaya, 29 per cent of children received such a diet, whereas in Uttar Pradesh and Gujarat it was as low as 6 per cent. Food habits showed that, overall, 29 per cent of women and 17 per cent of men were vegetarians. Thus, India is largely a non-vegetarian country. Diet deficiencies due to low consumption of fruits, milk, and curd were more widespread in poorer communities and the ST community.
A voluminous effort, the survey contains more than 700 pages of data, aggregated and disaggregated as well, given the wide variation among social and religious groups. It establishes beyond doubt that a correlation exists between wealth and education levels and parameters of health, decision-making by women, age of marriage, number of children, food consumption, and so on.
It also shows that groups belonging to the same wealth quintiles are likely to share common characteristics. They are also likely to have similar IMRs and U5MRs and similar nutritional status, sanitation levels, and food consumption patterns.
The emphasis on behavioural change by earlier governments and policymakers has been proven wrong as the NFHS lays bare the root cause without saying it in so many words that economic well-being was a crucial determinant for better health outcomes in all social groups. It is this correlation that the government needs to address through greater public spending to bridge the disparities. The NFHS-5 provides the adequate background for such policy interventions.