What is lost and gained in NFHS-6

India’s latest National Family Health Survey (NFHS-6) records gains in child nutrition, maternal care, institutional deliveries and women’s internet use. However, the preliminary information sheet is also thinner than the last round; There are 101 indicators compared to 131 indicators in NFHS-5.

What indicators were removed from NFHS-6?

Key indicators such as anemia, mortality, sex ratio at birth, sanitation and clean cooking fuel were excluded from the survey.

The Union Health Ministry released the fact sheets of NFHS-6 covering the year 2023-24 on May 29. The survey recorded data from around 6.8 lakh households in every State and Union Territory except Manipur.

Preliminary findings show clear gains on several measures, including mothers having at least four prenatal checkups, an increase of nearly seven percentage points over NFHS-5, an increase in institutional births, and women’s internet use. It also marks a nearly eight percentage point drop in several measures, such as exclusive breastfeeding of babies under six months, and a drop in the use of modern birth control, from 56.4% to 52.7%.

NFHS was commissioned by the Ministry of Health and Family Welfare, which commissioned the International Institute of Population Sciences (IIPS) to conduct the research. Over the years the scope of the survey has increased by design, maintaining and adding to the previous survey.

NFHS-4 introduced tablet-based digital interviewing for district-level estimates and survey collection in 2015-16. NFHS-5 further advanced indicators, including new topics such as pre-school education, disability, access to toilets, death registration, bathing practices during menstruation, methods and causes of abortion. Additionally, blood pressure and blood glucose measurements were expanded from adults ages 15 to 49 to all adults ages 15 and older. In the survey, key indicators increased from 114 in NFHS-4 to 131.

While the HIV testing component was removed from NFHS-5, questions regarding HIV/AIDS knowledge, attitudes, previous testing, sexually transmitted infections, and sexual behaviors remained. In NFHS-6, biological HIV testing was reinstated as part of the clinical, anthropometric, and biochemical testing program.

The NFHS-6 fact sheet does not specifically state whether all HIV/AIDS knowledge and attitude questions have been retained.

NFHS-6 also added new questions about direct benefit transfers, self-help group memberships, digital literacy, and financial transactions. It also includes testing for Hepatitis-B and Hepatitis-C in men and women, as well as taking dried blood from children aged 4-5 for Hepatitis-B testing.

However, for the first time, the survey also made general inferences, showing a net decrease in 30 indicators in preliminary results. Among the indicators removed, the most notable ones such as anemia, infant and child mortality, sex ratio at birth, use of clean cooking fuel and sanitation have appeared at least since NFHS-4.

Why did anemia drop?

Anemia relief depends on how it is measured. The indicator had been showing a deteriorating picture for a long time. Anemia increased overall between NFHS-4 in 2015-16 and NFHS-5 in 2019-21. The prevalence of anemia in children increased from 58.6 percent to 67.1 percent, in women aged 15-49 from 53.1 percent to 57 percent, and in pregnant women from 50.4 percent to 52.2 percent.

The increase in anemia was almost universal across the country; Childhood anemia increased in 28 States and Union Territories, with huge jumps in some cases, from 35.7% to 68.4% in Assam and from 19.3% to 46.4% in Mizoram. Such deterioration was reported despite the government launching the Anemia Mukt Bharat campaign in 2018, aimed at combating anemia. The reason for leaving this as an indicator then had to do with how the data was collected.

NFHS measured hemoglobin from a fingerstick blood sample read on a portable analyzer; many nutritional researchers claim that anemia is an exaggeration compared to venous blood taken in other studies. IIPS eliminated the anemia survey when NFHS-6 fieldwork begins in 2023. The official line is that this condition will now be tracked separately through a dedicated Diet and Biomarkers Survey under the National Institute of Nutrition, using a method that advocates consider more accurate.

The Diet and Biomarkers Survey in India was not a hasty change and was launched at the ICMR-National Institute of Nutrition in Hyderabad in December 2022, before the NFHS-6 field study began.

The survey recorded data on individual nutritional intake across age groups, paired with blood and urine biomarkers.

According to the organizers, this application was also built on monitoring obesity, as well as nutritional deficiencies and anemia, for the first time. Data for anemia were collected from venous blood rather than the finger prick method used by NFHS. Data collection has been completed but has not yet been published.

What other changes have been made?

A line-by-line comparison of the two fact sheets, NFHS-5 and NFHS-6, shows that the net decrease of 30 actually combines 43 falling and 13 added indicators. Many of the deletions were long-running series, and a few were closely related to the government’s signature programs.

Prime Minister Narendra Modi’s government had announced in 2019 that India would be defecation-free. NFHS-5 noted that 70% of the country’s population lives in households with access to sanitation facilities. This data point has also been removed.

The share of households using clean fuel for cooking (58.6% in NFHS-5) is gone; this is a direct measure of the success of the Pradhan Mantri Ujjwala Yojana.

Three mortality indicators (newborn, infant and under-five) have also been cut, but these will be tracked by the Sample Registration System, which in its last bulletin said the infant mortality rate was 24 per 1,000 live births.

However, the Registry does not carry the district-level data and socio-economic breakdowns available in the NFHS.

The sex ratio in the total population and the sex ratio at birth (929 females per 1000 males in NFHS-5) are not available, ruling out a standard signal of sex-selective practices. Only the four cancer screening indicators introduced in NFHS-5, covering cervical, breast and oral cancer, disappear after a single round.

The few changes are redefinitions rather than cuts. Women’s individual ownership of a house or land became a measure at the household level. The three-dose hepatitis B limit became the birth dose measure and changed the age ranges of preschool attendance, targeting a younger demographic. IIPS has not issued a justification for the broader list.

In total, these removals leave no survey-based national figures for infant mortality, sanitation coverage, sex ratio at birth, cancer screening rates, or comprehensive HIV knowledge; It leaves gaps that no other source can fill at the same scale.

How did the survey results change between NFHS-5 and NFHS-6?

NFHS-6 reported that the number of women experiencing intimate partner violence decreased from 29.3% to 22.3%. The number of stunted children aged five and under has also decreased. The drop from NFHS-4 to NFHS-5 was just under three percentage points, but NFHS-6 saw a drop of over six percentage points.

State-level changes are sharper for certain indicators.

Health insurance coverage increased the most in West Bengal, rising from 33.7 percent of households in NFHS-5 to 88.2 percent of households in NFHS-6. Women’s internet usage saw the largest increase in Andhra Pradesh, from 21% to 63.6%. Haryana recorded the sharpest decline in exclusive breastfeeding among babies under six months, from 69.5% to 41.2%. The share of women classified as overweight or obese increased in every state.