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National Family Health Survey-4 (2015–16)

The authors of the article are: F Ram (fram@iips.net) (who was with the International Institute for Population Sciences or IIPS, Mumbai), B Paswan, S K Singh, H Lhungdim, Chander Sekhar, Abhishek Singh, Dhananjay W Bansod, Manoj Alagarajan, L K Dwivedi, Sarang Pedgaonkar, Manas R Pradhan (from IIPS, Mumbai) and Fred Arnold from ICF International, United States.

The fourth round of National Family Health Survey (2015–16) is discussed with a brief exposition of the trends in household environment and sanitation, fertility, child health and child mortality, nutrition, health, and status of women between 2005–06 (NFHS-3) and 2015–16 (NFHS-4).

The fact sheet of the fourth round of the National Family Health Survey (NFHS-4) conducted during 2015–16, containing some key indicators that reflect the country’s present status on critical population and health indicators, was released in New Delhi on 1 March 2017 by the Ministry of Health and Family Welfare (MHFW). This article explores key emerging issues with policy implications essential to monitor the country’s progress towards achieving the Sustainable Development Goals (SDGs) by 2030, particularly on population and health.

Four rounds of NFHS (1992–93, 1998–99, 2005–06 and 2015–16) have been implemented in India under the aegis of MHFW along with additional financial support from international organisations. As in the case of the earlier rounds, NFHS-4 is conducted by the International Institute for Population Sciences (IIPS), Mumbai with technical support from the ICF International (US), and the National AIDS Research Institute (NARI), Pune, for the human immunodeficiency virus (HIV) component.

In order to better understand and interpret the findings of the NFHS-4 (2015–16), it is important to briefly describe the survey, particularly its scope, content, and coverage, which is distinctive from previous rounds. For instance, NFHS-4 for the first time provides district-level estimates for a number of important indicators, which necessitated expanding the sample size nearly sixfold compared to NFHS-3. The NFHS-3 was conducted in 2005–06, shortly after the National Rural Health Mission (NRHM) was launched. However, the main objective of NFHS-4 remains to provide essential data on indicators crucial to population and health, including family welfare and other emerging issues like non-communicable diseases. Therefore, data of the current round will be useful in setting a benchmark and examining the progress in health sector that the country has achieved over time. Besides providing evidence for the effectiveness of the ongoing programmes, the data will also facilitate in identifying emerging issues for new programmes with areas of specific focus.

The contents of the previous rounds of the NFHS are generally retained but additional components are added from one round to another. The new information included in NFHS-4 relates to malaria prevention, migration (in the context of HIV), abortion, violence during pregnancy, ownership of assets by women, etc. Besides, the scope of clinical, anthropometric, and biochemical (CAB) testing or biomarker component is also expanded to include measurement of blood pressure and blood glucose levels.

Sampling Design and Survey Instruments

In NFHS-4, a two-stage sampling design is adopted in the rural and urban areas of each district of India to provide district-level estimates. The NFHS-4 interviewed 6,01,509 households, 6,99,686 women, and 1,03,525 men from 28,583 primary sampling units (PSU) composed of villages in rural areas and census enumeration blocks (CEB) in urban areas spread across 640 districts of India.

Four survey schedules—household, woman’s, man’s and biomarker—were canvassed in local languages using computer-assisted personal interviewing (CAPI) technique. In the household schedule, information was collected on all usual members of the household and visitors who stayed in the household the previous night. In addition, information was collected on the socio-economic characteristics of the household, water and sanitation, health insurance, number of deaths in the household in the three years preceding the survey, etc. Information on the woman’s characteristics, marriage, fertility, children’s immunisations and childcare, nutrition, contraception, reproductive health, sexual behaviour, HIV/acquired immune deficiency syndrome (AIDS), domestic violence, and other important issues was canvassed in the woman’s schedule. The man’s schedule covered the characteristics, marriage, number of children, contraception, fertility preferences, nutrition, sexual behaviour, attitudes towards gender roles, and HIV/AIDS details of men. The biomarker schedule covered measurements of height, weight and haemoglobin levels for children; measurements of height, weight, haemoglobin levels, blood pressure, and random blood glucose level for women aged 15–49 years and men aged 15–54 years. In addition, women and men were requested to provide a few drops of blood from a finger prick for laboratory testing of HIV.

Survey Results

Household Environment and Sanitation

An important indicator of improved household environment is the type of fuel used for cooking. The NFHS-4 reveals that the percentage of households using clean fuel for cooking has increased by 18 percentage points at the national level between 2005–06 (NFHS-3) and 2015–16 (NFHS-4). The percentage of households using clean fuel has also increased in most states. The increase ranges between 42 percentage points in Tamil Nadu and 1 percentage point in Meghalaya. Kerala and Punjab also registered higher improvements in use of clean fuel for cooking.

The NFHS-4 shows substantial increase in the proportion of households using improved sanitation facilities in India since 2005–06, by 19 percentage points at the national level. The increase in the proportion of households using an improved sanitation facility ranges from a maximum of 39 percentage points in Haryana, followed by Himachal Pradesh (34% points) and Punjab (31% points), to 8 percentage points in Kerala and Mizoram (both states that already had a very high proportion of households using improved sanitation facilities in 2005–06).

Maternal Healthcare

The Government of India has launched a number of programmes like the Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), etc, to improve the maternal and child health in the country in keeping with the SDGs. NFHS-4 shows some improvement in both antenatal care and institutional births compared to NFHS-3.

 

Antenatal care visits: The proportion of women who received at least four antenatal care visits for their last birth has increased by 14 percentage points at the national level between 2005–06 and 2015–16. In fact, this proportion went up in almost all the states with a substantial part in rural areas compared to urban areas. The increase is substantial (10–20 percentage points) in 10 states and by more than 20 percentage points in six states—West Bengal, Chhattisgarh, Himachal Pradesh, Odisha, Assam and Jammu and Kashmir (J&K). A few states—Kerala, Goa, Uttarakhand and Tamil Nadu—registered a decline in the proportion of women receiving four or more antenatal visits.

The utilisation of antenatal care varies significantly by the socio-economic characteristics of the mothers. For example, mothers who have completed secondary or more schooling are far more likely to avail four or more antenatal visits (68% versus 28%) than mothers who have no schooling. The utilisation of antenatal care also depends on the wealth status of the household. Mothers residing in lowest wealth quintile households (bottom 20%) are far less likely to avail four or more antenatal visits compared to mothers residing in the highest wealth quintile households (25% versus 73%). Interestingly, the utilisation of antenatal care is considerably higher for mothers not belonging to Scheduled Caste (SC), Scheduled Tribe (ST) and Other Backward Classes (OBCs) compared to the other three groups.

 

Institutional delivery: Institutional births have increased by 40 percentage points since 2005–06. The Empowered Action Group (EAG) states and Assam have experienced more than 40 percentage point increase in institutional births. A substantial proportion of institutional births that took place in a private health facility were caesarean. Notably, the proportion of caesarean deliveries exceeded 70% in J&K, Telangana, Tripura and West Bengal.

Institutional births vary considerably by the mother’s schooling. Of the mothers with no schooling, 62% delivered in a medical institution. In comparison, 90% of women who completed secondary education delivered in a medical institution. Institutional births is seen to vary by the wealth status of the household. In the lowest wealth quintile households, 60% of mothers delivered in a medical institution as opposed to 95% of mothers residing in the highest wealth quintile households (top 20%).

Fertility and Family Planning

 

Age at marriage: The NFHS-4 reveals substantial increase in women’s age at marriage in India and its states. At the national level, the proportion of women aged 20–24 years who got married before age 18 years has declined by 21 percentage points since 2005–06. Particularly large declines are noted in Chhattisgarh (34 percentage points), Rajasthan (30), Jharkhand (25), Madhya Pradesh (23), Haryana and Bihar (21 each).

 

Family planning methods: There is only a little change in the use of various methods of family planning in the country since 2005–06. The contraceptive prevalence rate (CPR) has decreased by 2 percentage points, and the decline is noticed in 20 states. Manipur and Mizoram witnessed maximum decline (25 percentage points each) with Goa (22 percentage points). An increase in CPR is noticed in Punjab, Rajasthan, Odisha, J&K and Jharkhand.

 

Sex ratio: For children under six, NFHS-4 shows a minor increase in sex ratio at birth, from 914 to 919 (female per 1,000 male) at the national level since 2005–06. It is encouraging to note that the sex ratio at birth has improved in 14 of the 30 states of India. The sex ratio at birth is the highest in Kerala (1,047), followed by Meghalaya (1,009) and Chhattisgarh (977), and lowest in Sikkim (809), Delhi (817), Haryana (836), Punjab (860), Rajasthan (887) and Uttarakhand (888).

Total fertility rate: At the national level, fertility has declined from 2.7 children per woman to 2.2 children per woman since 2005–06. There has been a considerable decline in total fertility rate (TFR) in all the 30 states of India. The maximum decline in TFR is observed in Uttar Pradesh (1.1), followed by Nagaland (1.0), Arunachal Pradesh and Sikkim (0.9 each) and Rajasthan, Madhya Pradesh and Meghalaya (0.8 each). The level of fertility declined by 0.5 children per woman between 2005–06 and 2015–16. Overall, the TFR has declined by 1.2 children per woman between 1992–93 (NFHS-1) and 2015–16.

Child Health and Nutrition

Immunisation is one of the most cost-effective public health interventions to prevent a series of major illnesses among children and is responsible for improving nutritional status. NFHS-4 provides detailed information on child health based on children born in last five years preceding the NFHS-4.

 

Childhood vaccinations: At the national level, the percentage of children aged 12–23 months who are fully immunised (one dose of Bacillus Calmette–Guérin (BCG), three doses of diphtheria, pertussis and tetanus (DPT) vaccine, and one dose of measles vaccine) increased by 18 percentage points from 44% in 2005–06 to 62% in 2015–16. The percentage of children who are fully vaccinated ranges between 36% in Nagaland and 89% in Punjab. The coverage of full immunisation has improved since 2005–06 in all states except Haryana, Tamil Nadu, Uttarakhand, Maharashtra and Himachal Pradesh. Full immunisation coverage has increased substantially in Punjab, Bihar and Meghalaya (29 percentage points each), followed by Rajasthan, Uttar Pradesh, Jharkhand and Chhattisgarh (28), Odisha (27) and West Bengal (20).

Full immunisation coverage varies substantially by socio-economic groups. Of children with unschooled mothers, 52% are fully immunised, as against 67% of children with mothers who have completed secondary schooling. Among the STs, 56% children received full vaccination compared to 62%–64% of children of other castes. The coverage of full vaccination increases with increasing wealth status of household—63% of children from those in the lowest wealth quintile households are fully vaccinated compared to 80% of children from households in the highest wealth quintile.

 

Anaemia: Anaemia is characterised by a low level of haemoglobin in the blood, and is a major health problem in children in developing countries. The NFHS-4 shows substantial decline in the prevalence of anaemia in children aged 6–59 months in India, down from 69% in 2005–06 to 58% in 2015–16. However, the prevalence of anaemia is particularly high in several states. It ranges from as high as 72% in Haryana, followed by 70% in Jharkhand, 69% in Madhya Pradesh and 64% in Bihar, to 18% in Mizoram, followed by 22% in Nagaland, and 24% in Manipur. In 19 out of 30 states in India, over half of children aged 6–59 months are anaemic. It is worth noting that there has been a considerable decline in the prevalence of childhood anaemia since NFHS-3, with the maximum decrease in Assam (34 percentage points), followed by Chhattisgarh (30), Mizoram (26) and Odisha (20). A decline of 10 or more percentage points in childhood anaemia is noted in 10 states during this period.

 

Breastfeeding: In the past one decade, the percentage of children under three years who are breastfed within one hour of birth has increased substantially at the national level (by 19 percentage points). The proportion has also increased considerably in almost all the states of India. However, the current levels are still quite low in many states like Delhi, Punjab, Rajasthan, Uttar Pradesh and Uttarakhand, where less than one-third of children are breastfed within an hour of birth.

 

Malnutrition in children: The data on the nutritional status of children are collected by measuring the height and weight of all the children under five years in the surveyed households. The NFHS-4 shows that the percentage of children under five years who are stunted and underweight has declined in India (by 10 and 7 percentage points respectively) and in all the states of India since 2005–06, showing improvement in the nutritional status of the children. The maximum decline in stunting is found in Chhattisgarh (15 percentage points), followed by Arunachal Pradesh (14), Gujarat (13), Himachal Pradesh, West Bengal, Maharashtra, Mizoram and Haryana (12 each), and Tripura, Meghalaya, Punjab, Odisha, Uttarakhand and Uttar Pradesh (11 each). The decline is lowest in Tamil Nadu (4), Jharkhand, Rajasthan, Kerala and Goa (5 each). The maximum decline in the percentage of underweight children is found in Meghalaya (20 percentage points), Madhya Pradesh (17), Tripura (16) and Himachal Pradesh (15), Arunachal Pradesh (13) and Bihar (12). The smallest decline is noted in Maharashtra and Goa (1 percentage point each), followed by Karnataka (2), and Uttar Pradesh, Punjab and Rajasthan (3 each).

Stunting and underweight vary considerably by mother’s schooling and wealth status of households. Of children of mothers with no schooling, 51% are stunted compared with 31% of children whose mothers have secondary (or more) schooling. Likewise, 47% of children of mothers with no schooling are underweight compared to only 29% of children of mothers having secondary (or more) schooling. The prevalence of stunting and underweight is highest in children of SC and ST mothers compared to their counterparts. The level of stunting and underweight are highest in children residing in lowest wealth quintile households.

 

Infant mortality rate: The infant mortality rate (IMR) in India has declined from 57 per 1,000 live births to 41 between 2005–06 and 2015–16. IMR has decreased substantially in almost all the states during this period. IMR has dropped by more than 20 percentage points in Tripura, West Bengal, Jharkhand, Arunachal Pradesh, Rajasthan, and Odisha.

Non-communicable Diseases

Due to the ongoing demographic and epidemiological transitions in the country, India is currently experiencing a major shift in disease pattern. The prevalence of non-communicable diseases is increasing and the prevalence of communicable diseases is decreasing. For the first time in the NFHS series, NFHS-4 measured blood pressure and random blood glucose of eligible men and women residing in sampled households using portable devices. Likewise, NFHS-4, for the first time in the NFHS series, collected information on tobacco and alcohol consumption by eligible adult men and women. Like in the previous rounds of the survey, NFHS-4 measured the height and weight of eligible men and women in the sampled households.

 

Tobacco use: Smoking and use of smokeless tobacco, which is one of the leading causes of cancer among adult men and women in India, has declined substantially in India since the previous round of survey. At the national level, use of any kind of tobacco among men aged 15–49 years declined from 57% to 45% between 2005–06 and 2015–16. Among men, the maximum decline in use of any kind of tobacco is reported in Sikkim (22 percentage points) followed by Kerala (18) and Bihar (16). The decline in the prevalence of use of any tobacco among men is the least in Arunachal Pradesh and Mizoram (3 percentage points each). Notably, the prevalence of any tobacco use among men has increased since NFHS-3 in Meghalaya, Nagaland, Manipur and Himachal Pradesh (1–3 percentage points). Only 7% of women use any type of tobacco in NFHS-4, down from 11% in NFHS-3.

 

High blood glucose: The prevalence of very high blood glucose levels (more than 160 mg/dl) in India is 4% for men and 3% for women aged 15–49 years. The highest prevalence among men is found in Goa (7%), followed by Kerala, West Bengal, Odisha and Tamil Nadu (6% each). The prevalence of high blood glucose among adult women aged 15–49 years is lower than that for adult males in all the states of India. Statewise variation in prevalence of very high blood glucose among women aged 15–49 years reveals a similar pattern with higher prevalence in Goa and Kerala (5% each), followed by Delhi, Tripura, Tamil Nadu and Mizoram (4% each).

 

Hypertension: Hypertension is considered as a precursor of cardiovascular disease. According to NFHS-4, 2% of women and 3% of men aged 15–49 years have moderately high or very high levels of hypertension. The prevalence of moderately high and very high hypertension among men aged 15–49 years is considerably higher in Nagaland (6%), Telangana and Arunachal Pradesh (6% each), and Andhra Pradesh, Assam, Himachal Pradesh and Mizoram (5% each). The prevalence of hypertension among men is lowest in Delhi (1%). The estimated prevalence of hypertension among adult women aged 15–49 years is lower than that of men in all the states of India, except Meghalaya and Delhi. Among women, the prevalence of moderately high or very high levels of hypertension is highest in Nagaland (6%), Sikkim and Arunachal Pradesh (5% each), and Assam (4%).

 

Overweight and obesity: Being overweight or obese increases vulnerability to various non-communicable diseases/illness. The prevalence of being overweight or obese among men and women aged 15–49 years has increased in India and all its states between 2005–06 and 2015–16.

Among women aged 15–49 years, it has increased by 8 percentage points (from 13% in NFHS-3 to 21% in NFHS-4), and is highest in Delhi (35%), followed by Goa (33%), Kerala (32%), Punjab and Tamil Nadu (31% each). It is lowest in Jharkhand (10%), followed by Bihar, Chhattisgarh and Meghalaya (12% each), Assam (13%), Madhya Pradesh and Rajasthan (14% each). It has increased by 15 percentage points in Himachal Pradesh, which is the highest, followed by Goa and Manipur (13 each).

The prevalence of being overweight or obese among men aged 15–49 years has doubled from 9% in 2005–06 to 19% in 2015–16 in India, and is the highest in Sikkim (35%), followed by Goa (33%), Kerala (29%), Tamil Nadu and Punjab (28%). Overweight and obesity are lowest in Meghalaya and Chhattisgarh (10%), followed by Madhya Pradesh and Jharkhand (11% each); and Uttar Pradesh, Bihar, Assam, and Rajasthan (13% each). Over the last decade, Sikkim has experienced the highest increase of 23 percentage points in the prevalence of overweight or obesity among men, followed by Goa (17 percentage points), J&K, Arunachal Pradesh and Tamil Nadu (14 percentage points each).

Empowerment of Women

An important indicator of women’s empowerment is whether women have a bank account or a savings account that they themselves use. The percentage of women aged 15–49 years having a bank or savings account that they operate has increased by 38 percentage points since 2005–06. The proportion of such women is highest in Goa (83%), followed by Tamil Nadu (77%), Kerala (71%), Himachal Pradesh (69%), and Delhi (64%). Since 2005–06, the maximum increase is noticed in Tamil Nadu (61 percentage points), followed by Rajasthan (51), Mizoram (49), Himachal Pradesh (47), Odisha (46), Punjab (44), and Kerala (44). The smallest increase in the proportion of women having a bank or saving account that they themselves operate is in Bihar (18 percentage points), Maharashtra (25), Manipur (27), and Madhya Pradesh (28).

The NFHS-4 shows substantial increase in the proportion of women who participate in household decision-making. Between 2005–06 and 2015–16, the percentage of currently married women who usually participate in household decisions has increased considerably in India (by 7 percentage points), and across all states, with over 80% of women reporting that they participate in household decision-making. This is true for all states except Haryana (77%), Bihar (75%), and Delhi (74%).

The NFHS-4 shows a small decrease in the proportion of ever-married women aged 15–49 years reporting spousal physical or sexual violence. Spousal violence decreased by 4 percentage points, from 33% to 29%, at the national level, and declined in all states except Meghalaya, Delhi, Manipur, Chhattisgarh and Haryana. The decline in spousal violence is highest in Rajasthan (21 percentage points), followed by Tripura and Bihar (16 percentage points each) and Assam and Uttarakhand (15 percentage points each).

Key Policy Concerns

The NFHS-4 data shows considerable improvements in the key indicators of population and health in India. However, there are a number of pressing issues which the policymakers and programme managers must take note of. In spite of implementation of the Swachh Bharat Abhiyan by the Government of India, many states still lack basic household sanitation, improved source of drinking water, and use of clean fuel, which have direct linkages with health of women and children.

With respect to maternal healthcare conditions, a substantial improvement is reflected in the last one decade. However, tremendous inequality by wealth and social groups still prevails. The use of modern methods of contraceptives has remained almost unchanged at the national level and declined in a number of states. Hence, there is a need to reposition family planning programme with special focus on modern spacing methods.

There has also been a sizeable improvement in childhood vaccinations among children under five years. However, the percentage of children not getting the recommended doses of vaccinations varies considerably across states and among socio-economic groups. In particular, about half of the children of STs did not receive the recommended childhood vaccinations. The current level of initiation of breastfeeding within an hour is still quite low, despite a remarkable increase in institutional deliveries across the states. Although there is a decline in malnutrition among children below age five during the last decade, the levels are still considerably high, particularly in certain socio-economic groups.

The NFHS-4 results illustrate that India has made considerable progress in many domains, yet there are grey areas that need further attention. In particular, the pervasive inequality among socio-economic groups is a matter of great concern, and needs attention if India aims to achieve the SDGs by 2030.

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