The summary findings of the fifth round of the National Family and Health Survey (NFHS-5), conducted in two phases between 2019 and 2021 and released on Wednesday, paint a mixed picture of India’s progress on the health front. While there have been significant advances in several areas and discernible shifts on the demographic front, there are also several areas of concern, which point to both significant policy gaps and failures of execution at the ground level. The NFHS provides by far the most comprehensive insight on health, demographic and related socio-economic indicators in the country.
Although a sample survey, and therefore inherently prone to risks of bias and errors in sample selection and assessment, nevertheless, the findings are significant enough to call for urgent rethink on several key policy imperatives, which may require a rethink in view of the findings. While the results of the first phase, covering data for 22 states and Union territories were released in December last year, and had caused considerable consternation, particularly in reference to child malnutrition and stunting, the country-level data now available paints a relatively better picture than the interim findings, although the overall progress remains less than satisfactory in many areas.
But there are three radical developments on the demographic front, all of which point to a rapidly changing society, and also call for a paradigm shift in our approach to population control, public health and nutrition, particularly woman and child nutrition. The standout finding on the population front is that for the first time since data had started being collected, India’s fertility rate -- defined as the number of children each woman was likely to bear in her lifetime -- has fallen below the replacement level fertility rate of 2.1. This is a sharp reduction from the 2.7 fertility rate recorded in the 2005-06 survey.
With a fertility rate of 2.0 as per the latest survey, India’s population problem will no longer be one of explosive or uncontrolled growth. In fact, only five states had fertility rates above two, including two in the thinly-populated North East, which needs a higher population for development. Only Bihar (3), UP (2.4) and Jharkhand (2.3) continue to be laggard on this front.
The second significant development is that India now has more women than men. From a skewed 927 women per 1,000 men in 1990, the ratio has swung to 1.020 women per 1,000 men. Both the drop in the fertility rate and the improved sex ration can be attributed to better education, particularly among women. This underscores the need for stressing education for the girl child, which has beneficial outcomes beyond mere employability.
The third significant revelation is that our so-called ‘demographic dividend’ is peaking. The share of the population under the age of 15 years has dropped to 26.5 per cent from 34.9% in 2005-06. We are still a young country, but with a growing older population, policymakers will have to factor in the elderly in welfare and other support measures.
However, the most serious, if not downright alarming findings, relate to nutrition, particularly among children. Here the progress has been niggardly, and has actually worsened on some fronts. The numbers for wasting -- which indicates undernutrition -- and stunting, which shows malnutrition, have both barely improved over the 2015 numbers. Over 35% of children under five years of age are stunted, compared to the 38.4% in the 2015-16 survey. The comparable number for wasted children is 19.3, a small drop from 21% in the previous survey. The figure for severe wasting has actually risen from 7.5 to 7.7% this time, pointing to the impact that the pandemic and related economic slowdowns have had on child nutrition in particular. It is a shame that a fifth of the way into the 21st century, every third Indian child is still undernourished and every fifth child severely malnourished, pointing to a systemic failure of plans and programmes aimed at improving the welfare of women and children.
Another area of concern is rampant anaemia, once gain pointing to both inadequate and improper diet. More than one in two women aged 15-49 (57%) were anaemic in 2019-21, compared to 53% in 2015-16. Anaemia among men also rose but most worryingly, more than two out of three children aged 6-59 months (67.1%) were anaemic. This calls for a radical redrafting of the food security programme. The focus has to shift from providing a basic calorific intake to providing a more nuanced and balanced diet to address anaemia, undernutrition and malnutrition.
The lack of balanced diets is also reflected in paradoxically higher numbers for obesity among men and women, as well as a worryingly high prevalence of hypertension and diabetes, pointing to imminent public health challenges. Overall, the findings are a wake-up call for our policymakers. The focus has to shift from preventing mortality to ensuring a healthier and better quality of life.