Why in the News?

• The Union Health Ministry has released NFHS-6 fact sheets revealing notable gains in maternal care and child nutrition, but with a net reduction of 30 indicators, including critical metrics like anaemia, mortality, and sex ratio at birth.

What’s in Today’s Article?

• About NFHS (Background, Previous Surveys, etc.)
• Changes in NFHS-6 (Gains, Loses, Implications, Significance)

About NFHS

• The National Family Health Survey (NFHS) is a large-scale, multi-round household survey conducted by the Ministry of Health and Family Welfare, with the International Institute for Population Sciences (IIPS), Mumbai, as the nodal agency.
• It provides reliable data on population, health, and nutrition indicators.

• NFHS-4 (2015-16): Introduced district-level estimates and tablet-based digital interviewing, measuring 114 indicators.
• NFHS-5 (2019-21): Expanded to 131 key indicators, introducing new topics like preschool education, disability, and menstrual practices.
• NFHS-6 (2023-24): Covered nearly 6.8 lakh households across all states and UTs except Manipur.

• Historically, the NFHS has been additive by design, retaining previous questionnaires and adding new ones.
• However, NFHS-6 marks a departure, for the first time, the survey has subtracted overall.

What NFHS-6 Gained?

• NFHS-6 introduced several new dimensions:

• Direct Benefit Transfers (DBT)
• Self-Help Group (SHG) memberships
• Digital literacy
• Financial transactions
• Hepatitis-B and Hepatitis-C testing among women and men
• Dried blood spot collection from children aged 4-5 for Hepatitis-B testing
• Biological HIV testing has been brought back as part of clinical and biochemical testing

• Improvements in Key Indicators

• Mothers receiving at least 4 antenatal check-ups: Up about 7 percentage points from NFHS-5.
• Institutional births: Increased to 90.6% from 88.6%.
• Women's Internet use: Notable increase across states.
• Stunting among children under 5: Declined by over 6 percentage points, compared to under 3 percentage points between NFHS-4 and NFHS-5.
• Spousal violence: Dropped from 29.3% to 22.3%.

• State-Level Highlights

• Health insurance coverage in West Bengal rose from 33.7% to 88.2%, the largest increase.
• Women's Internet use in Andhra Pradesh jumped from 21% to 63.6%, the steepest rise.
• However, the share of women classified as overweight or obese increased in every state.

What NFHS-6 Lost?

• The preliminary fact sheet of NFHS-6 has only 101 indicators, compared to 131 in NFHS-5, a net reduction of 30 indicators (43 dropped, 13 added).
• Anaemia Dropped
  • Anaemia had shown a worsening picture between NFHS-4 and NFHS-5:

• Children: 58.6% to 67.1%
• Women aged 15-49: 53.1% to 57%
• Pregnant women: 50.4% to 52.2%
• The rise was near-universal, with child anaemia increasing in 28 states/UTs despite the Anaemia Mukt Bharat campaign (2018).

• Why dropped? NFHS measured haemoglobin from a finger-prick blood sample read on a portable analyser, which several nutrition researchers argued overstated anaemia compared to venous blood drawn by other surveys.
• Replacement: Anaemia will now be tracked through the Diet and Biomarkers Survey, launched in December 2022 at the ICMR-National Institute of Nutrition, Hyderabad. This survey uses venous blood instead of the finger-prick method and tracks obesity alongside anaemia for the first time. Data collection is complete but yet to be released.

• Mortality Indicators Removed
  • Three mortality indicators have been cut:

• Neonatal mortality
• Infant mortality
• Under-five mortality

• These will now be tracked by the Sample Registration System (SRS), whose latest bulletin pegged infant mortality at 24 per 1,000 live births. However, SRS does not provide district-level data or socio-economic breakdowns available in NFHS.

• Sex Ratio Indicators Removed
  • Both the sex ratio of the total population and the sex ratio at birth (929 females per 1,000 males in NFHS-5) are absent.
  • This removes a key signal of sex-selective practices in the country.
• Sanitation and Clean Cooking Fuel Dropped
  • Two indicators closely tied to flagship government programmes have been removed:

• Access to sanitation facilities: NFHS-5 recorded 70%, a measure linked to the Swachh Bharat Mission and the 2019 declaration of India as open defecation-free.
• Clean cooking fuel use: 58.6% in NFHS-5, a direct measure of the Pradhan Mantri Ujjwala Yojana's success.

• Cancer Screening Indicators Gone
  • Four cancer-screening indicators covering cervical, breast, and oral cancer, introduced for the first time in NFHS-5, have been dropped after a single round.

Implications of the Changes

• Data Gaps: The removals leave no current survey-based national figure for:

• Infant mortality with district-level breakdowns
• Sanitation coverage
• Sex ratio at birth
• Cancer screening rates
• Comprehensive HIV knowledge

• These are gaps that no other single source fills at the same scale.

• Concerns Over Programme Evaluation
  • The removal of indicators tied to flagship schemes, sanitation, clean cooking fuel, anaemia, limits the ability to:
    • Independently evaluate the effectiveness of programmes like Swachh Bharat Mission, Ujjwala Yojana, and Anaemia Mukt Bharat.
    • Track district-level disparities that aggregate statistics cannot reveal.
    • Identify socio-economic patterns in health outcomes.

• Trade-offs in Survey Design
  • The shift represents a fundamental change in NFHS philosophy, moving from an additive design to a more selective approach.
  • While this may reduce respondent burden and improve data quality, it also reduces the survey's role as a single comprehensive source of health and demographic data.

Significance of NFHS-6 Changes

• Methodological Improvements
  • The dropping of finger-prick anaemia measurement in favour of venous blood methods reflects efforts to improve data accuracy.
  • The reintroduction of biological HIV testing addresses a gap from NFHS-5.
• New Areas of Inquiry
  • The addition of digital literacy, DBT, and SHG indicators acknowledges the changing landscape of welfare delivery and women's empowerment in India.
• Concerns Over Transparency
  • The lack of a published rationale for many changes raises questions about:

• Transparency in survey design decisions.
• Consistency in measuring progress over time.
• Continuity of long-term data series critical for policy evaluation.