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NFHS-5: A Closer Look

  • 27 Nov 2021
  • 9 min read

This article is based on “A Close Reading of the NFHS-5, the Health of India” which was published in The Hindu on 27/11/2021. It talks about the key findings of the latest National Family Health Survey (NFHS-5) and causes behind lack of improvement in various key sectors.

The National Family Health Survey (NFHS) is a large-scale, multi-round survey conducted in a representative sample of households throughout India.

The key results from the second phase of the latest NFHS (NFHS-5, 2019-21) have been released which comes out as a mixed verdict, containing both cheer and alarm in abundant measure.

These results, in particular, are of great significance and must be given appropriate attention as it is not a hastily put together state-of-health index but a detailed, comprehensive, multi-dimensional report card on the state of India’s demographic and health trajectory.

Key Findings of the Survey

  • NFHS 4 & 5, a Comparison: There are many pluses in the report card of NFHS-5.
    • Improvements have been witnessed in several dimensions such as educational attainment, institutional deliveries, vaccinations, infant mortality etc.
    • Irrespective of the pace, the progress shall be appreciated especially given the abysmal state of India’s health infrastructure which has been tragically apparent since the COVID-19 pandemic hit.
  • Decline in TFR, a Major Positive: The Total Fertility Rate (TFR) has been falling over time and has now reached (at 2.0) just below the replacement rate of 2.1.
    • This is true across all States of India which means that the total population has stabilised.
  • Difference in Sex Ratio at Birth and at Adulthood: For the first time in India, between 2019-21, there were 1,020 adult women per 1,000 men.
    • However, the data shall not undermine the fact that India still has a sex ratio at birth (SRB) more skewed towards boys than the natural SRB (which is 952 girls per 1000 boys).
    • Uttar Pradesh, Haryana, Punjab, Rajasthan, Bihar, Delhi, Jharkhand, Andhra Pradesh, Tamil Nadu, Odisha, Maharashtra are the major states with low SRB.
  • Poor Performance in Dealing with Anaemia: The incidence of anaemia in under-5 children (from 58.6 to 67%), women (53.1 to 57%) and men (22.7 to 25%) has worsened in all States of India (20%-40% incidence is considered moderate).
    • Barring Kerala (at 39.4%), all States are in the “severe” category.
  • Performance of Malnutrition Indicators: The three indicators of malnutrition, stunting (low height-for-age), wasting (low weight-for-height) and underweight (low weight-for-age), show an overall improvement.
    • However, this overall improvement creates an anomaly as in Phase 1 of the NFHS-5, several States revealed a worsening in one or more of these indicators, whereas in Phase 2, none of the States showed a worsening.
      • It might be possible that the covid-19 affected the survey in Phase 2, leading to undercounting of incidences.
    • Additionally, an increase is witnessed in the proportion of overweight children, women and men which also reflects malnutrition leading to serious health consequences in the form of non-communicable diseases (NCDs).

Issues Associated

  • Non-Inclusion of Micronutrients: In addition to anthropometric measures, lack of adequate nutrition is also measured by micronutrient deficiencies, i.e. lack of vitamins and minerals that are essential for body functions such as producing enzymes, hormones and other substances needed for growth and development.
    • The NFHS does not have data on micronutrients.
  • ‘One Size Fits All’ Approach for Monitoring Dietary Intake: Indian diets display a rich diversity. Many traditional diets reflect both local climatic conditions as well as a multiplicity of sources of essential nutrients, such as proteins, fats etc.
    • Policing of diets, by imposing an unnatural uniformity, and preventing access to animal protein for large sections of Indians that are not traditionally vegetarian is likely to reduce micronutrient diversity and contribute to poor health outcomes.
  • Covid-19 Blame Game: The poor health outcomes have been argued to reflect the effect of Covid-19 as the data for the Phase-2 of NFHS-5 have been, to a large extent, collected during the highly unusual conditions of the COVID-19 pandemic.
    • However, the deterioration in public health indicators cannot be attributed entirely to the pandemic.
    • The Pandemic might have added fuel to the fire of poor public health, but it did not cause the fire.
  • Unethical Delivery Practices Affecting Women Health: The survey focuses on women's empowerment, autonomy and mobility indicators and shines a spotlight on women’s reproductive health.
    • However, as per data, cesarean births have increased dramatically, in private health facilities, 47.5% births are by C-section (14.3% in public health facilities).
    • These figures are highly unnatural and call into question unethical practices of private health providers who prioritise monetary gain over women’s health.
  • Limited Male Engagement in Family Planning: Female sterilisation continues to dominate as the modern method of contraceptives in States like Andhra Pradesh (98%), Telangana (93%), Kerala (88%), Karnataka (84%), Bihar (78%) and Maharashtra (77%).
    • Male engagement in family planning continues to be limited as seen by the low uptake of condoms and male sterilisation across the States.

Way Forward

  • Policy Interventions to Address Health Concerns: The survey highlights deep inequalities in health outcomes.The overall evidence is compelling that health ought to be a matter of concern for the governments at national and state level.
    • An action plan to improve India’s health needs is required which also needs to be inclusive, firm in its commitment, and backed by solid resources.
  • Lessons to be Taken from NFHS: The NFHS findings are a reminder of the urgent need to close gaps in girls’ education and address the pathetic nutritional status of women and children.
    • The impact of the pandemic may also be noted, the disruption it caused to services such as balanced nutrition for children must be acknowledged.
    • Such scenarios underscore the need for building resilient and fortified systems capable of delivering in the most trying circumstances.
  • Collaboration in Health Sector: Current times require integrated and coordinated efforts from all health institutions, academia and other partners directly or indirectly associated with the health care services to make the basic as well as advanced health services accessible, affordable and acceptable to all.
  • Behaviour-Change Communication Strategy: The Government must adopt a targeted social and behaviour-change communication strategy to ensure that men also take responsibility for family planning.


  • The NFHS is second only to the exhaustive data that the decennial population census provides. It ought to be treated as an important turning point for policy-making in India.
  • The greater idea for the states as well as the centre is to recognise it as a matrix to work on and improve the development indicators further.

Drishti Mains Question

“The National Family Health Survey (NFHS) is second only to the exhaustive data that the decennial population census provides. It ought to be treated as an important turning point for policy-making in India”. Comment.

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