The good, bad, and sober news that the NFHS data presents

As always, national averages belie inter-state differentials. Of note is the change in such differentials over the 2005-20 period

The National Family Health Survey (NFHS 5) data presents both good and sobering news. On the one hand, it has shown progress during 2015-2020 on demographic and health indicators such as the total fertility rate (TFR), women’s education, child mortality rates, pointing to coverage of immunisation, antenatal care (ANC), institutional deliveries, and other indicators. On the other, it shows poor performance on women and child nutrition, with a marginal reduction in stunting. The most sobering news from the survey results points to rising cases of anaemia (14.5 percentage points rise since the 2014-15 survey), and incidence of overweight children.

Maternal health is one of the factors behind child undernutrition and mortality, and anaemia in pregnant women is linked with a negative impact on foetal growth, child birth weight, and maternal health (AFP/Representative Image)

As always, national averages belie inter-state differentials. Of note is the change in such differentials over the 2005-20 period. While the gap between states between this period has decreased for neonatal mortality rate (NMR), infant mortality rate (IMR), under-five mortality rate (U5MR), wasting and stunting, the gap in the case of anaemia, for women and children, has increased, as has that for ANC. Progress on family health indicators has been greater in the empowered action group (EAG) states — Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, and Uttar Pradesh.

With the increase in institutional deliveries has been an increase in Caesarean section births. While states with higher sociodemographic profiles (Kerala, Tamil Nadu), crossed the World Health Organization (WHO) norm for Caesarean births in 2015, the rate of change in EAG states is rising. This is concerning with Caesarean births linked tomaternal and child mortality, and child obesity.

Though the decline in mortality rates across successive NFHS surveys signals a move in the right direction, is the country moving at the right pace? India lags in achieving targets set in the National Health Policy 2017, which set IMR, NMR, and U5MR targets at 28 by 2019, 16 by 2025, and 23 by 2025. These currently stand at 35.4, 24.9, and 41.9 respectively. The rate of decline for mortality and stunting has slowed between the 2005-15 and 2015-20 periods.

The worsening of anaemia levels is a critical issue, in its implications for health, productivity and income and intergenerational impact. Maternal health is one of the factors behind child undernutrition and mortality, and anaemia in pregnant women is linked with a negative impact on foetal growth, child birth weight, and maternal health. The moderate ANC coverage at 58 percentage, with variations across states, continues to pose questions on related policy interventions.

India’s rapid demographic transition, with below 2 Total Fertility Rate for several high performing states, will pose different challenges for the health system. Resources for the non-communicable disease (NCD) burden in these states and a stronger primary care system that can prevent and manage NCDs will take on a greater need. The 15th Finance commission recommendation, of allocating 67% of total health expenditure to primary care is yet to be achieved; it is currently at 55%. The recommendation of 8% allocation to health at the state level also remains unmet, with the current average at 6%. Health trajectories across states vary. Kerala has a high level of institutional deliveries, but poor outcomes in anaemia and NCDs. Yet, allocations incentivising institutional deliveries continue resulting in approved budgets for this programme being 183 times the required resources.

There are at least four key implications reinforced through the recently released data sets. One, the need for greater fiscal flexibility for states to innovate and design their own responses to the specific needs of the state. Two, increased expenditure on and attention to primary care. Three, an increased allocation by the states to health. Four, a gendered approach to health delivery.

Sandhya Venkateswaran is senior fellow and Alok Kumar is research associate at the Centre for Social and Economic Progress The views expressed are personal