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Falling Fertility and Rising Anaemia?

A significant drawback of the National Family Health Survey, including the third survey of 2005-06, is the lack of district-wise data as the sample size does not permit generalisation at the district level. While the fall in the total fertility rate in the five states for which NFHS-3 results have been released is to be welcomed, one cannot draw any general conclusion until the data for the BIMARU states comes in. The data on anaemia prevalence among women and children, however, is disturbing.

Falling Fertility andRising Anaemia?

A significant drawback of the National Family Health Survey, including the third survey of 2005-06, is the lack of district-wise data as the sample size does not permit generalisation at the district level. While the fall in the total fertility rate in the five states for which NFHS-3 results have been released is to be welcomed, one cannot draw any general conclusion until the data for the BIMARU states comes in. The data on anaemia prevalence among women and children, however, is disturbing.


he first results of NFHS-3 were announced recently in an impressive ceremony in New Delhi (August 17, 2006), presided over by the secretary, ministry of health and family welfare. Fact sheets giving an array of provisional data were distributed. In this round, only five states, namely, Chhattisgarh, Gujarat, Maharashtra, Orissa and Punjab were covered, based on data collected from November 2005 to March 2006, by five different agencies. The nodal agency for conducting NFHS-3 was the International Institute for Population Studies (IIPS), Mumbai which was also involved in similar work for NFHS-1 and NFHS-2. Technical assistance was provided by ORC-Macro in US while assistance for the HIV component was provided by National Aids Control Organisation (NACO) and National Aids Research Institute (NARI) (with funding from the Bill Gates Foundation). NFHS-3 was largely funded by USAID, as on previous occasions, supplemented by Department for International Development (DFID), United Nations Chindrens Fund (UNICEF), United Nations Population Fund (UNFPA) and Avahan: India AIDS Initiative.

This exercise is a massive international effort to get detailed data on India’s health and family planning scenario. The government of India has a less than marginal role, either in funding or in technical assistance except that a number of institutions and NGOs were involved in data collection in all the states in India. But the shots were called by the American corporation which fielded 122 page questionnaires (in three parts)!

The best thing about the release of NFHS-3 data was the speed with which the data were tabulated. Timeliness in disseminating the results of national surveys is essential for planners and policy-makers. Lengthy time lags between data collection and tabulation invariably make the data obsolete, though these are important for researchers. The IIPS, Mumbai and ORC-Macro in US must be congratulated for bringing out the first results of NFHS-3 so speedily.

A significant drawback of NFHS is the lack of district-wise data (because the sample size does not permit generalising at the district level). India’s incredible diversity makes such data an absolute necessity to get at reality. State level data have limited value for decentralised planning and also for monitoring and assessing the impact of numerous developmental programmes. Why are we then continuing with NFHS rounds every few years? Perhaps these data are very useful for international agencies for market research.

In a matter of the next few decades, India will be the most populous country in the world and, therefore, will have the largest market in the world for any product, at least in terms of the number of consumers (though not in terms of purchasing power). Judging by the speed with which American aid agencies and big corporations are making inroads into India’s health and pharmaceutical sector and also the food processing (rather packing!) industries, one can safely predict that NFHS will be a permanent feature of India’s health administration. In this context one regrets that though the union ministry of health and family welfare has been sponsoring

Economic and Political Weekly September 16, 2006 very useful district level surveys, (initially called Reproductive and Child Health (RCH) Surveys and now called District Level Health Surveys or DLHS), and the data generated by these surveys are far more useful than NFHS data, they have been relegated to the background and NFHS is played up. Such is the impact of money power! This has also created an unhealthy divide between NFHS investigators who are well-paid and DLHS investigators who get much lower remuneration.

A word of caution is called for first. In my demographic analysis for policy-makers, the highest priority has been accorded to what are the BIMARU states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh). Of course, one has to add the three new states carved out of Bihar, Madhya Pradesh and Uttar Pradesh. All these seven states are demographically sick (they account for roughly 40 per cent of India’s population). I have called Orissa an ‘ati’ BIMARU (extremely sick) state as it has the highest mortality and shockingly high infant mortality rate (IMR). It is disappointing that the first-round NFHS-3 data dissemination has ignored BIMARU states (except for the small state of Chhattisgarh which was a part of Madhya Pradesh), and therefore, one cannot draw any general conclusion about the demographic scene in India. What was the need then to present data for the three progressive states (demographically speaking) like Maharashtra, Gujarat and Punjab? This may be flattering for the ministry of health and family welfare, and in particular, the outgoing secretary of the ministry who presided over the function in New Delhi.

The prime minister could perhaps consider entrusting the task of overseeing NFHS to the Planning Commission instead of the ministry of health and family welfare as per the present practice, if at all it is decided to continue with these surveys in future. The Planning Commission would be able to utilise the data much more effectively than the ministry of health and family welfare. This would also help the Planning Commission to monitor the family welfare programme which has become deadwood, guided by foreign ‘kubuddhi’ (bad advice) for decades. The Planning Commission should also take a view on the need for continuing NFHS with foreign expertise and foreign funding to study India’s primary healthcare. If the government considers the country’s healthcare to be important, there should be no problem in mobilising our own resources and expertise for conducting health surveys. India is a land of eminent statisticians and there is no dearth of institutes and experts.

Total Fertility Rate

Let me now present some data from NFHS-3 fact sheets. I have arranged the five states in order of their population size (according to the Census 2001 which gives an indication of their statistical weightage). For example, Maharashtra has 9.4 per cent of India’s population while the share of Chhattisgarh is only 2 per cent. In short, the mixed bag of IIPS of five states can mislead people! Let us look, therefore, at individual states. The total fertility rate (TFR) denoting the number of children

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Economic and Political Weekly September 16, 2006

born per woman is considered by demographers to be a good indicator of the success of the family welfare programme (which again is not quite true because it cannot be argued that the TFR goes down only because of government intervention). I may also add that TFR of 2.1 is considered as a good cut-off point as it puts the state on the road to population stabilisation. For example, Kerala and Tamil Nadu have already achieved this level. NFHS-3 data show that Punjab and Maharashtra have done well on this front, followed by Gujarat and Orissa with Chhattisgarh lagging behind (Table 1).

At the data release function, there was a sense of smug satisfaction about the decline in TFR. While the fall in TFR is welcome, one must get the data for BIMARU states before one feels cheerful about the demographic future of India, which largely depends on the performance in BIMARU states. In statistical terms, the demographically shining state of Kerala really does not matter!

Anaemia among Women and Children

The NFHS-3 data on anaemia among children (6-35 months) as reflected in Table 2 and also anaemia among women, especially pregnant women, is disturbing, not so much at the absolute values as in the adverse trend of increasing incidence of anaemia (Table 3).

How come, the comparatively prosperous states of Punjab and Gujarat, along with the backward tribal state of Chhattisgarh have such a high percentage (over 80 per cent) of children who are anaemic? Is it a data problem or does it reflect reality? Gopalan, the president of the Nutrition Foundation of India (NFI), and also Prema Ramachandran who was earlier adviser (health) in Planning Commission shed some light on this. Much to my dismay, I learn that according to various scientific surveys on anaemia and nutrition, the incidence of anaemia is higher than what is reflected in NFHS! What is happening to our children?

With women, the situation is equally depressing. Again, I am told that the NFHS data on anaemia are underestimates! All this is very confusing. I am not concerned here about the absolute level of anaemia but the adverse trend reflected in NFHS-3 data. Are our children (6-35 months) and pregnant women, the most vulnerable sections of our population, suffering more and more in an era of globalisation and liberalisation? Besides, high under-nutrition and malnutrition increase the chances of getting infections. This hits the most vulnerable population of children and pregnant women and leads to high mortality levels, especially infant mortality and maternal mortality.

Table 3 indicates that in Gujarat, the incidence of anaemia has gone up from

74.5 per cent (NFHS-2) to 80.1 per cent (NFHS-3). In this state, the incidence of anaemia among women has gone up from

46.3 per cent (NFHS-2) to 55.5 per cent (NFHS-3) and among pregnant women (15-49 years), the incidence has gone up from 47.4 per cent (NFHS-2) to 60.8 per cent (NFHS-3), an increase of 13.4 per cent points between 1998-99 and 2005-06!

Gopalan has a word of caution: one must look into the technology adopted for collecting data on haemoglobin in NFHS-2 and NFHS-3. If NFHS-3 has used improved technology and has shown a higher incidence of anaemia, it probably reflects reality more accurately than before. Gopalan also expressed his concern about American entry in a big way in the health sector in India and also the recent trend

Table 1: Comparison of TFR, NFHS-2 and NFHS-3

States NFHS-3 NFHS-2 Variation (2005-06) (1998-99) (Col 2-Col 3)

Maharashtra 2.1 2.5 -0.4 Gujarat 2.4 2.7 -0.3 Orissa 2.4 2.5 -0.1 Punjab 2.0 2.2 -0.2 Chhattisgarh 2.6 2.8 -0.2

Table 2: Incidence of Anaemia among Children (6-35 Months)

NFHS-3 NFHS-2 Variation (Col 2-Col 3)

Maharashtra 71.9 76.0 -4.1 Gujarat 80.1 74.5 5.6 Orissa 74.2 72.3 1.9 Punjab 80.2 80.0 0.2 Chhattisgarh 81.0 87.7 -6.7

of their increasing involvement in supporting some institutions and persons.

Prema Ramachandran offers considerable material on nutrition. To quote from just one such report published by NFI: “Comparative data on prevalence of anaemia in pregnant women in seven states from NFI and DLHS phase 1 (2002) survey of ministry of health and family welfare show that both DLHS and NFI survey reported higher prevalence of anaemia than NFHS-2...In all these surveys except NFHS, cyanmethaemoglobin method was used for the estimation of haemoglobin” [Agarwal et al 2005]. The issue therefore is that if NFHS-3 has used this advanced technology, then the figures are not strictly comparable with NFHS-2. And if they have not adopted better technology, what is the use of figures which are underestimates? Why should NFHS collect data on anaemia at all when there are already specialised institutes which are conducting scientific surveys which are far more reliable than NFHS? Some competent person should undertake an exercise in validation of NFHS, National Nutrition Monitoring Bureau (NNMB), Indian Council of Medical Research (ICMR), NFI and other data on anaemia before we can take a firm stand on this issue. We should not be whistling in the dark.

Finally, I talked to Mira Shiva, a medical scientist and well known health activist about the rising incidence of anaemia. I asked her: “Has the incidence of anaemia among women and children gone up”! She was very forthright and asked me a series of counter questions: “Has the price of dal (pulses), the major source of protein supply for the poor not gone up steeply? Have vegetable prices not gone up? Is dal not becoming a luxury for the poor? And so also vegetables, the source of iron and vitamins? What is the impact of radio and TV propagating processed food and soft drinks? How many ‘pyaos’ (places where drinking water is available) has the corporation put up for poor workers like

Table 3: Anaemia among Women

(Per cent)

Ever Married Women Pregnant Women
(15-49 Years) (15-49 Years)
States NFHS-3 NFHS-2 Variation NFHS-3 NFHS-2 Variation
(Col 2-Col 3) (Col 5-Col 6)

Maharashtra 49.0 48.5 0.5 57.8 52.6 5.2 Gujarat 55.5 46.3 9.2 60.8 47.4 13.4 Orissa 62.8 63.0 -0.2 68.1 60.5 7.6 Punjab 38.4 41.4 -3.0 41.6 37.1 4.5 Chhattisgarh 57.6 68.7 -11.1 63.1 68.3 -5.2

Economic and Political Weekly September 16, 2006 rickshawallas and hawkers ? Is it not implied that they should buy bottled water and soft drinks? Is this what globalisation and the growing entry of foreign multinationals is doing for better health in India?”

The answer to all these questions is in the affirmative. Mira Shiva is also deeply concerned with increasing prices of drugs and our irrational drug policies. She was pained to note that both Lok Sabha and Rajya Sabha have passed the Food Safety and Standards Act, 2006 without any discussion in Parliament! Are our parliamentarians being taken for a ride by powerful international lobbies?

In conclusion, I refer to my article in Economic and Political Weekly (November 25, 2000) titled ‘Population ‘Data Mela’: Dissemination before Assimilation’ where I said “It will be a blunder if the NFHS-2 set-up starts getting busy lobbying for NFHS-3 after five years, without assimilating NFHS-2 data”. My comment remains the same as before: the NFHS-3 set-up will now start lobbying for NFHS4! Indian demographers should assert themselves and conduct studies which the country really needs and refuse to be taken for a ride on the pretext of gathering scientific data which really is market research, best left to business schools. One could of course start courses in business demography in a big way or make money in consultancy.




Agarwal, K N, D K Agarwal, Anshu Sharma (2005):

‘Anaemia in Pregnancy: Interstate Differences’,

NFI Scientific Report 16, p 11.

Economic and Political Weekly September 16, 2006

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