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Economics and Political Weekly Vol. 56, Issue No. 49, 04 Dec, 2021

The NFHS-5 hides more than it reveals on the demographic and health indicators.

Views expressed are personal and do not represent those of the institution/employer of the authors.

The National Family Health Survey (NFHS)-5 is the fifth in a row to offer population and health indicators for Indian states and districts. Having commenced in the early 1990s, over the three decades of periodic enquiry, the NFHS has not only facilitated gauging the trends in population and health para­meters, but also many other programme-related performance indicators. In fact, the most recently held monitoring exercise of the Sustainable Development Goals (SDGs) as well as the assessment of the Multidimensional Poverty Indices for the Indian states and its districts has been largely facilitated by the indicators offered by the latest NFHS. Given the significance and credibility of the indicators offered by consecutive rounds of the NFHS in monitoring the progress on the population and health fronts, the recently released NFHS-5 findings have brought out surprises on the attainment of various targets as well as the progress made on varied domains. Although a range of 131 indicators is offered by this survey, the indicators that received attention relate to the female population sex ratio, the attainment of replacement-level of fertility and the future of the population control policy.

Though age–sex composition of population along with other information collected from the households form the fundamental basis of the NFHS-5, the basic indicators like sex ratio and age composition based on this survey may not be the best alternative to the census enumeration. The NFHS-5 (2019–21) findings highlight a feminine population sex ratio of 1,020 when compared to the 991 obtained in the NFHS-4 (2015–16)—a 29 points improvement in just five years. In the absence of a 2021 Census, the 2011 Census reported 940 females per 1,000 males—an 80 points improvement in 10 years. This improvement once acknowledged can have its own interpretation in the improved status of women to gendered advantage. However, before jumping to conclusions on this improved sex ratio shifting from a masculine to a feminine one, we should revisit the results from varied perspectives. The main objective of the earlier four rounds of the NFHS as well the current one is to provide high-quality data on reproductive health and family welfare indicators and not on the population sex ratio. The overall sex ratio of the NFHS-5 need not necessarily be taken on its face value. Further, the recent experience of fertility transition has implication for the number of children with a skewed sex composition and the skewed presence of elderly individuals in the surveyed households. Given these complexities, a survey-based population sex ratio being feminine need not be highlighted to comment on its popular derivatives. We have to wait for the 2022 Census to examine the overall sex ratio.

The second most important highlight has been the attainment of a total fertility rate (TFR) of 2.0, implying a below replacement level of fertility for the Indian population. While the TFR is a marker of fertility decline and the success of long-standing antenatal policies, its implication for population replacement has a lag given the momentum of population growth on the one hand and the characteristic differential on the other. The aggregate low fertility may well be a reality, but its distribution represents infertility on one extreme and fertility level above this norm on the other. Though Kerala achieved a replacement level of fertility as early as 1987, it is expected to stabilise around 2030. Hence, the attainment of below replacement level of fertility would perhaps have its implication for population growth and composition in terms of attaining stabilisation following a sustained low fertility for a while. Apart from celebrating this success, it is pertinent to recognise strategies to mitigate consequences of low fertility as well. With low fertility, the experience of infertility is on a rise and needs attention, and at the same time, the implication of low fertility on the emergence of future inequality (particularly owing to differential endowments among children and families) should also be a matter of concern. Given the economic gradient of fertility differential and clusters of fertility above the low fertility normative, its inequality derivatives are imminent.

Apart from these two indicators, a host of indicators concerning maternal and child health, nutrition, women’s autonomy, gender-based violence along with the use of tobacco and alcohol are also obtained. A significant share of these indicators display an improvement over the last survey figures offering optimism regarding the success of government programmes as well as the changing population health environment at large. Many of these indicators as defined are simple headcount ratios for varying denominators, making their comparison across situations questionable, given the magnitude of the phenomenon on the one hand and the attained level of success on the other. Besides the national-level comparison of trends, the same across states and districts would perhaps require greater caution to comment on improvement/deterioration overlooking the raised concern mentioned above. Further, these indicators may also have a compositional structure in terms of various characteristics with a range of vulnerability differences that would be masked in these aggregates and may have a bearing on their progress towards their betterment. Such cautions are necessary, given the tendency of using this information base for the assessment of progress towards betterment.

On the whole, the generation of the host of indicators at a disaggregated level with characteristic differences is quite encouraging in terms of gauging performances and progress, but many of these indicators will have the limitation of being defined in a dichotomous construct with their characteristics and compositional differences that will compromise their robust comparison.