Some Good News

-Economic and Political Weekly

Health and nutrition indicators have improved, but remain unacceptably low.

After a hiatus of a decade, we now have up-to-date information on the health and nutrition status of the population. Preliminary results for 13 states and two union territories of the much awaited National Family Health Survey–4 (NFHS–4) which was conducted in 2015–16—the first after NFHS–3 of 2005–06—have just been released. In a welcome development, NFHS–4, for the first time, will also provide estimates at the district level. Given the wide intra-state variations, for meaningful programming it is imperative that disaggregated data is available. Such data needs to be collected at regular intervals so that there is some basis on which policies are formulated and investments made.

The data presents a mixed picture of substantial improvement in certain aspects and stagnation in other areas. While the data from all the states will only be available later this year, the positive news is that there is some improvement in fertility rates, infant mortality rates and the malnutrition situation among children. A simple average for the states for which data is available in NFHS–4 shows a decline in stunting among children under five from 43% to 32%. These seem to reinforce the findings from the Rapid Survey on Children, 2013–14 (RSoC), which showed a decline in stunting among children under five to about 38%. A similar decline is seen in the prevalence of underweight children under five from 39% to 29% (42% to 29% at the all-India level according to the RSoC).

Such an improvement represents a break from the past since very little progress was made between 1998–99 and 2005–06. However, the message also is that malnutrition remains a serious concern. Further, stark regional differences remain with poorer states continuing to have very low levels of health and nutrition, despite making strong gains. The NFHS–4 figures are that 48% of children in Bihar and 42% in Madhya Pradesh are still stunted (44% and 43% are underweight, respectively) as compared to 27% in Tamil Nadu and 28% in Telangana. In all the states (except Goa) more than 50% of children and women are anaemic.

This survey also highlights the double burden of malnutrition in India where along with widespread undernourishment, there is also an increasing prevalence of obesity. While there is a decline in the number of women with a low body mass index in all the states, there is also an increase in the proportion of women who are overweight or obese in all the states, with Tamil Nadu and Andhra Pradesh having almost one in three women overweight. This indicates that along with ensuring nutrition security for all, the government needs to focus on promoting good quality, diverse diets.

The decade between NFHS–3 and NFHS–4 was also when the National Rural Health Mission was introduced, leading to a number of reforms in the public health system which have shown some results. There is a rise in full immunisation coverage in most of the states (33% to 62% in Bihar and 40% to 54% in Madhya Pradesh) but some states such as Uttarakhand, Tamil Nadu and Haryana show a slight decline. There has been an impressive increase in institutional births in many states (for example, 23% to 68% in Bihar, and 26% to 80% in Madhya Pradesh) with more than 90% institutional births in eight of the 15 states. While it is assumed that delivery in an institution improves delivery and postnatal care, thereby contributing to declines in maternal and infant mortality, it is equally important that women receive proper antenatal care (ANC) in order to have safe and healthy pregnancies.

In this regard, the NFHS–4 data shows a poor state of affairs. Only 3% and 11% of women in Bihar and Madhya Pradesh, respectively, received full ANC. Even in Goa, which is the best state, more than one-third of the women did not receive full ANC. Similarly other indicators such as early initiation of breastfeeding (35% in Bihar) and proportion of children receiving adequate diet remain low.

An important concern is the rising cost of care in public health facilities. Out-of-pocket expenditure on health is one of the leading causes of pushing people into poverty in India. Reducing catastrophic expenses therefore should be one of the primary objectives of public health policy. With the introduction of the Janani-Shishu Suraksha Karyakram in 2011, the government has guaranteed free and cashless services for pregnant women and newborn children. Yet, the NFHS–4 data shows that on an average a woman spent anywhere between Rs 1,258 (Andaman & Nicobar) and Rs 7,772 (West Bengal) for a delivery in a public health facility. Despite this, the rise in institutional delivery is a clear reflection of rising demand for public health facilities.

Some encouraging data from the NFHS–4 relates to indicators of women’s empowerment. Along with a rise in female literacy, there is a rise in the proportion of women possessing bank or savings account in all the states (16% to 77% in Tamil Nadu and 8% to 26% in Bihar). There is also a reported fall in the percentage of women who have ever experienced spousal violence in most states.

With this National Democratic Alliance government’s second budget coming up in less than a month, the NFHS–4 results set out some clear areas of priority. While there has been some improvement in health and nutrition, especially where the government has made special efforts as in the case of institutional deliveries, a lot more needs to be done. Access to public health facilities might have improved, but much more needs to be done to improve quality so that there is an impact in outcome indicators.

The need is therefore not only to restore the funds for the Integrated Child Development Services and health programmes (which saw massive cuts last year) but also to provide additional resources to consolidate the gains made so far. Moreover, rather than piecemeal approaches a big push is required in a comprehensive manner to ensure that India gets onto a sustained path of better human development outcomes.