The Union health ministry released the summary findings of the fifth round of the National Family and Health Survey (NFHS-5), conducted in two phases between 2019 and 2021, on November 24. NFHS is the most comprehensive survey on socio-economic and health indicators in the country. While the results of the first phase were released in December last year, country-level statistics were released only on Wednesday. The previous four rounds of the NFHS were conducted in 1992-93, 1998-99, 2005-06 and 2015-16.
The results of the survey show some surprising demographic transitions, such as women outnumbering men, and some expected ones, such as fertility rates declining. They also highlight the health challenges that remain, such as moving towards addressing nutrition deficiency apart from just food adequacy. And they offer a more sobering picture of the impact of government’s schemes on access to basic amenities such as clean cooking fuel and improved sanitation. Here are four charts that show this.
Women outnumber men, fertility has decreased, and India is getting older
NFHS-5 data shows that there were 1,020 women for 1000 men in the country in 2019-2021. This is the highest sex ratio for any NFHS survey as well as since the first modern synchronous census conducted in 1881. To be sure, in the 2005-06 NFHS, the sex ratio was 1,000 or women and men were equal in number.
The improved sex ratio is not the only big demographic transition that the latest round of NFHS has revealed. The Total Fertility Rate (TFR) has also come down below the threshold at which the population is expected to replace itself from one generation to next. TFR was 2 in 2019-2021, just below the replacement fertility rate of 2.1. To be sure, in rural areas, the TFR is still 2.1. In urban areas, TFR had gone below the replacement fertility rate in the 2015-16 NFHS itself.
A decline in TFR, which implies that lower number of children are being born, also entails that India’s population would become older. Sure enough, the survey shows that the share of under-15 population in the country has therefore further declined from 28.6% in 2015-16 to 26.5% in 2019-21.
Children’s nutrition improved but at a slower pace
The share of stunted (low height for age), wasted (low weight for height), and underweight (low weight for age) children have all come down since the last NFHS conducted in 2015-16. However, the share of severely wasted children has not, nor has the share of overweight (high weight for height) or anaemic children. The share of overweight children has increased from 2.1% to 3.4%. The share of anaemic children has increased from 58.6% to 67.1%. Another cause of worry for children’s nutrition is that the pace at which the share of stunted and underweight children decreased in the latest NFHS was less than the pace at which it did between the 2005-06 and 2015-16 surveys. The share of stunted children decreased by 20% between NFHS-3 and NFHS-4, but only by 7.6% between NFHS-4 and NFHS-5. The corresponding numbers for underweight children are 15.8% decline between NFHS-3 and NFHS-4 and 10.3% decline in the latest round. A similar challenge remains in reducing mortality rates of children. All such indicators suggest a declining rate of mortality, but the pace at which it declined in the last round has come down.
Chart 2A: Share of stunted, wasted, severely wasted, underweight, overweight children
Chart 2B: NNMR, IMR, U5MR
India might be food secure, but nutrition is a problem for adults too
For children and their mothers, there are at least government schemes such as Integrated Child Development Services (ICDS) that seek to address the nutritional needs at the time of childbirth and infancy. However, there is a need to address the nutritional needs of adults too. In October 2020, a paper by Kalyani Raghunathan published in the Food Policy journal (and reported in this paper) showed that though India might have achieved food security, 60% of Indians cannot afford nutritious diets. This is reinforced by the results of the latest NFHS. While the share of women and men with below normal Body Mass Index (BMI) has decreased, the share of overweight and obese (those with above normal BMI) and the share of anaemic has increased between 2 and 4 percentage points. The problem of anaemia is more prevalent among women. In 2015-16, 53% women were anaemic compared to 23% men in the 15-49 age group. These numbers have now increased to 57% and 25% for women and men respectively.
Challenges remain on open defecation and use of clean fuel
Availability of basic amenities such as improved sanitation facilities clean fuel for cooking, or menstrual hygiene products can improve health outcomes. There has been an improvement on indicators for all three since the last NFHS. However, the degree of improvement might be less than claimed by the government. For example, only 70% population had access to an improved sanitation facility. While not exactly an indicator of open defecation, it means that the remaining 30% of the population has a flush or pour flush toilet not connected to a sewer, septic tank or pit latrine, uses a public toilet or still practices open defecation. The share of households that use clean cooking fuel is also just 59%. The schemes of the NDA government under Narendra Modi for financial inclusion, however, seem to have worked better. The share of women having a bank account that they themselves use has increased from 53% to 79%. Households’ coverage by health insurance or financing scheme also has increased 1.4 times to 41%, a clear indication of the impact of the government’s health insurance scheme.