Public health

Skewed progress

Print edition : February 16, 2018

AT The ill-equipped primary health centre at Bonakal in Khammam district of Telangana, where patients get treated outdoors. A file picture. Photo: G.N. Rao

children having their midday meal at a primary school at Gorakhpur village in Rayagada district of Odisha. Photo: Biswaranjan Rout

Women with empty pots wait for drinking water at a public tap in a village near Dindigul, Tamil Nadu, on November 11, 2017. Photo: G. KARTHIKEYAN

The latest National Family Health Survey underscores the need for greater focus on improving the quality of life for the majority of the population and not just for a few.

THE latest edition of the National Family Health Survey (NFHS), which enables the authorities to frame policies, particularly on health, on the basis of key indicators and trends, broadly confirms the existence of a substantial young population.

Nearly 29 per cent of India’s population is under 15 years of age while only 10 per cent is over 60, indicating a low life expectancy. The demographic dividend of a substantial able and working population is to the country’s advantage. Yet, there is a wide variation in the distribution of the population, depending on varied levels of development and access to determinants such as income, health and education, which are functional in determining overall mortality rates at birth and after birth.

The NFHS is more than just about fertility rates, which has in any case been coming down over the decades for all groups with the expected inter-State and inter-group variations.

Basic amenities

Almost all of urban India and rural India have some source of access to drinking water. However, the report reveals that only 18 per cent of rural households get piped water as compared with 52 per cent of urban households. The disparity continues—58 per cent of rural households get water delivered to their homes compared with nearly 82 per cent of urban households. This means that 42 per cent of rural households fetch water from sources outside. And much of this fetching is done by women.

Unclean drinking water remains a major issue, particularly in rural areas, as 71 per cent of rural households consume untreated water as opposed to 47 per cent of urban households. As the state abdicates its responsibility of providing clean drinking water, the onus shifts to individual investments, which are a drain on the already low incomes of the urban and rural poor.

According to the survey, 39 per cent of the population continues to practise open defecation, with only half of Indian households (48 per cent) having non-shared toilet facilities. While the percentage of households practising open defecation has come down from 55 to 39 per cent, the figure still continues to be high and it is not difficult to see why. Some 56 per cent of Indian households are pucca while 35 per cent are semi-pucca. Any realistic campaign on toilets should also factor in these elements. The emphasis on “behavioural norms” by high-octane campaigns is not enough to bring about the radical change required. Public provisioning of those facilities has to occupy centre stage as much as clean drinking water and publicly funded sewerage systems.

Wealth inequities

The survey, which maps household wealth by residence, has found that 56 per cent of rural households fell in the two lowest wealth quintiles and that Delhi, Chandigarh and Punjab had the highest percentage of populations in the highest wealth quintile. In contrast, households falling in the lowest wealth quintile were found in high proportions in Bihar and Jharkhand. Worryingly, among socio-economic groups, 51 per cent of Scheduled Caste (S.C.) and 71 per cent of Scheduled Tribe (S.T.) households fell in the lowest wealth quintiles. The unequal distribution and concentration of wealth since the 1990s has been a matter of academic preoccupation for social scientists, who have also warned against the obsession with economic growth figures as opposed to the distribution of that very growth.

Educational levels

The educational attainment levels are also a matter of concern. One third of women were found to have completed only seven years of schooling or less. Overall, only 14 per cent of women and 20 per cent of men have completed 12 years of schooling. These figures are alarming given the fact that a Right to Education Act has been in place for several years now. The survey correctly brings out the correlation of educational attainment with wealth, stating that women in the lowest wealth quintile have completed a median year of zero years of schooling compared with a median of 9.1 years for women in the highest wealth quintile.

Likewise, the median number of schooling is highest for those not belonging to the S.Cs, the S.Ts and Other Backward Classes (OBCs). It was also the lowest among Muslims compared with other religious groups. Income and wealth are clearly determining factors. Among the reasons for dropping out of school, the cumulative percentage of those children dropping out owing to cost factors and household work responsibilities was higher (33.8 per cent) than those stating that they are “not interested in studies” (24.8 per cent).

Interestingly, among religious groups, it was seen that both Hindu and Muslim men had almost an equal number of years of schooling until the age of 14, but there were markedly fewer Muslim men who had completed 10th standard and beyond.

Among the minorities, 57 per cent of Jain men completed 12 years of schooling, much more than even Hindu men.

The number of Muslim women who completed six years of schooling is much lower compared with other groups, but the literacy levels among them—the ability to read more than a sentence or part of a sentence—are comparatively higher than other religious groups.

There seems to be also a direct correlation between exposure to mass media and income levels among both men and women. Some 47.5 per cent of men and 70.6 per cent of women in the lowest wealth quintile have no exposure to any kind of mass media.

Birth registration is lowest in Bihar and Uttar Pradesh (61 and 60 per cent respectively), while in 20 States it is over 90 per cent. Overall, birth registration figures have doubled since the previous survey, the NFHS-3 for 2005-06.


As mentioned, NFHS-4 data are not only about demographic trends or fertility levels. The survey, which comprised a robust sampling method, throws up far more important details that policymakers can ill afford to ignore. For instance, employment levels have decreased for both men and women over the last decade.

Some 36 per cent of women were employed in 2005-06 as compared with 24 per cent; the corresponding figure for men fell from 85 per cent to 75 per cent. Agriculture continued to be the primary source of employment, with 48 per cent of women and 32 per cent of men engaged in agricultural work. An equal percentage of men were “production workers”.

A large majority of farm workers (81 per cent women and 90 per cent men) earned cash for their work, which points to the fact that cash payments are the dominant mode of transaction in the unorganised sector.

Declining fertility rates

Notwithstanding the bogey of population explosion, in particular that of certain groups, the good news that NFHS-4 brings is that the total fertility rate (TFR, the average number of children a woman is likely to have) is 2.2, slightly higher than the replacement level of 2.1. The fertility rate in 23 States and Union Territories, including all the southern States, is below the replacement rate of 2.1 children per woman. However, there is a distinct rural-urban divide, with rural women having a higher fertility rate than urban women. The survey makes a direct correlation between the years of schooling and the number of children a woman has.

The median age at first birth seems to be determined by the number of years of schooling. The longer the time spent in school, the higher the median age at first birth and the longer the birth interval. More than education or schooling, income is the key determining factor. Women in the lowest wealth quintile have a TFR of 3.2 children, compared with 1.5 children among women in the highest wealth quintile. Some 26.9 per cent in the lowest wealth quintile have more than four children; overall, 39 per cent of women have one child each; 32.6 per cent two, 15 per cent three and 13.5 more than four. These figures indicate a substantial decline from NFHS-3.

Among Muslims, 33.3 per cent women had one child, 28.5 per cent two, 16.9 per cent three and 21.3 per cent more than four.

Women from the wealthy quintiles are four times more likely to observe menstrual hygiene than women from the lowest wealth quintile. Affordability is a factor in the use of menstrual hygiene products, as 62 per cent of respondents stated that they used cloth rather than sanitary pads.

Among contraceptive methods, female sterilisation remains the most “popular” method among currently married women in the 15-49 years age cohort. It would be incorrect to assume that sterilisation is a naturally popular method among women; the same “popularity” is not detected among men, for whom it is easier and less complicated. A direct correlation between the method used and wealth was seen, as modern contraceptive methods were used by those in the higher wealth quintiles.

Among religious groups, 65 per cent of Sikh, Buddhist and neo-Buddhist women were found using modern contraceptives as opposed to 38 per cent of Muslim women. Interestingly, around 82 per cent of modern contraception was sourced from the public health sector and this was in the form of sterilisation. A very high percentage of women were found to be using injectables (a non-permanent method) sourced from the private sector. Likewise, emergency contraceptive pills are sourced from the private sector.

Only 46.5 per cent of women were told about the side effects of any kind of contraception, permanent or non-permanent—a matter of concern. Among States, in awareness among women on the side effects, the lowest percentages were seen in Andhra Pradesh and Telangana and the highest in Punjab and Tamil Nadu. Among subgroups, almost an equal number of men among Hindus, Muslims and Christians believe that women who use contraceptives may become promiscuous. Interestingly, more Hindu and Sikh men than Muslims believe that contraception is a woman’s business and that men should not bother about it, thereby placing the onus on women.

The report also records data on the continued prevalence of consanguineous marriages, particularly in the south.

Some 14 per cent of all married women were related to their husbands before marriage; 12 per cent of the marriages were consanguineous marriages, the most common type among them being marriages between first cousins. The percentage is significantly higher than the national average (between 25 per cent and 34 per cent) in the southern States, barring Kerala.

In fact, the data sheet showed that there was no State that did not report the incidence of such marriages. It also cuts across all religious and caste subgroups.

Mortality rates

While the under-5 mortality rate has declined, the wide variation in the progress made by individual States has ensured that the overall infant mortality rate (IMR) remains high for the country. Infant mortality and under-5 mortality rates are important indicators of a country’s socio-economic development and quality of life.

Uttar Pradesh recorded the highest under-5 mortality rate of 78 per 1,000 live births, while Kerala recorded the lowest of 7 per 1,000 live births. Similarly, perinatal deaths, or deaths occurring in the seven months of pregnancy, are highest in Uttar Pradesh and the lowest in Kerala, which says a lot about the health care and health delivery mechanisms in the two States.

The under-5 mortality rate for the country is 50 deaths per 1,000 live births, which means that one in 20 children dies before their fifth birthday, while the IMR is 41 for every 1,000 live births. Rural-urban variations in IMR are high. Household wealth and education are determining factors for high or low IMR. Unsurprisingly, higher mortality rates for all age groups were found among S.Cs, S.Ts and OBCs. Boys are slightly more likely to die before their fifth birthday.

Among religious subgroups, neonatal and under-5 mortality rates are the highest among Muslims, followed by Hindus; the rates for Muslims and S.Cs are at similar levels.

States with low IMR and under-5 mortality rates reported low maternal mortality rates and superior access to health care and health delivery mechanisms.

Preference for sons

Male child preference continues to prevail, according to the survey, which found that women with no sons were more likely than women with one or two sons to have ultrasound tests. Between the latest survey and the previous one, the proportion of pregnancies with ultrasound tests increased from 24 per cent to 61 per cent. Between Census 2001 and Census 2011, the child sex ratio also worsened.

The latest survey does not make a link between the fall in the child sex ratio and increased ultrasound tests, but it is not difficult to draw inferences from the data provided. Women with no sons who had an ultrasound test were “much more likely” to have the pregnancy end in the birth of a son than the birth of a daughter, the survey said. “For example, for women with no sons and three daughters who had an ultrasound test, 53 per cent of their pregnancies resulted in the birth of a son and 34 per cent resulted in the birth of a daughter.

The results provide clear evidence of the existence and impact of son preference in India.” Among subgroups, Jain women reported the largest proportion of ultrasound tests (93.2 per cent), followed by Sikh (89.1 per cent) and Buddhist (78.7 per cent) women. Fewer daughters were born to Jain and Sikh women compared with other groups. More daughters were also born to women in the lower wealth quintiles as compared to their wealthier counterparts. Thus, 37.7 per cent of women in the highest wealth quintiles (who also had a high percentage of pregnancies with ultrasound tests) had daughters compared with 41.6 per cent of women in the lowest wealth quintiles.

Some 30 per cent of women did not receive the mandated postnatal check-up in spite of delivering at a public health facility. The average out-of-pocket expenses for delivery was Rs.7,938. While delivery in a public health facility cost around Rs.3,198, it cost Rs.16,522, almost five times as high, in a private health facility. Some 23.7 per cent of men reported that the reason the child’s mother did not receive antenatal care was “high costs”.

Anaemia prevalence

Anaemia levels among men and women have barely changed since the previous survey; 53 per cent of women and 23 per cent of men were found to be anaemic. While the levels among children have declined, the overall prevalence continues to be high. On the whole, 58 per cent of children are anaemic.

The highest levels of anaemia were found in Haryana, followed by Jharkhand and Madhya Pradesh. Anaemia is known to impair cognitive development, stunt growth and increase morbidity from infectious diseases. Some 38 per cent of children under five years were stunted owing to chronic undernutrition, 21 per cent were wasted owing to acute undernutrition, and 36 per cent were underweight. Only 2 per cent were overweight. As in other indicators, stunting declined with rising income.

Some 51 per cent of children in households falling in the lowest wealth quintiles were found to be stunted as opposed to 22 per cent in households in the highest wealth quintiles. Among States, Kerala and Goa reported the lowest levels of stunting while Uttar Pradesh, Jharkhand, Meghalaya and Bihar reported the highest.

Food consumption patterns have an outcome on overall health and nutrition. The survey found that only 45 per cent of women consumed either milk or curd and pulses daily; 54 per cent did not consume fruits even once a week. Diet deficiencies were related to income levels; the most common deficiencies were related to consumption of fruit, milk or curd by poorer households, including those in the S.C. and S.T. subgroups.

If overall health parameters are a cause of worry, including high out-of-pocket expenditure, health insurance coverage stands at very poor levels. Only 20 per cent of women and 23 per cent of men were covered by a health scheme or health insurance. There was low coverage in the lowest wealth quintile. Some 67 per cent of women reported one impediment or the other in accessing medical care. This ranged from cost of health care to distance, transport issues and lack of availability of drugs and health providers, including female health providers.

Domestic violence

According to the survey, the percentage of ever-married women aged 15-49 who have experienced spousal physical or sexual violence has declined to 29 per cent from 37 per cent in NFHS-3.

However, it also found that 52 per cent of women and 42 per cent of men believed that wife-beating by a man was justified in at least one of seven specified circumstances. There was also a significant decline in the percentage of women seeking help to stop physical or sexual domestic violence, from 24 per cent to 14 per cent. “An important indicator of empowerment is the rejection of norms that underlie and reinforce gender inequality,” the survey says.

Of the women interviewed, 27 per cent in the 15-49 age cohort had experienced physical violence since they were 15 and 19 per cent had experienced physical violence in the 12 months preceding the survey.

Women who were employed (especially women employed for cash) were more likely to experience physical violence than women who were not (35 per cent versus 24 per cent).

Among married women who had experienced sexual violence, 83 per cent stated their husbands were the main perpetrators. Fear of husband and spousal violence were highly correlated.

Women who said that they were afraid of their husbands most of the time were most likely to have experienced spousal violence (56 per cent), followed by women who were sometimes afraid of their husbands (30 per cent). Among women who were never afraid of their husbands, 17 per cent had experienced spousal violence. Some 65 per cent women sought help from their families, followed by the husband’s family, or a friend; only 4 per cent went to the police.

As for violence by women against their husbands, 3 per cent reported having initiated violence when the husband was not already beating or physically hurting them.

The data based on respondent surveys reveal a close connection between health outcomes and income levels. However, better class status does not automatically result in a better deal for women or children, although it does indicate improved access to health, education and other entitlements.

It is a matter of concern that there has not been a significant decline in various indicators such as high infant and maternal mortality rates in several States. Equally worrisome is the inadequate nutritional intake for most Indian men and women. Fertility rates are on the decline as a whole, but it is unacceptable to have a skewed sex ratio at the cost of a smaller population.

What matters ultimately is the quality of life for the majority of the population and not just for a few, and this is what needs greater focus.

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