What is lost and gained in NFHS-6 

Why in the News?

The preliminary fact sheets of NFHS-6 (2023-24) have been released by the Ministry of Health and Family Welfare, covering nearly 6.8 lakh households across all States and Union Territories except Manipur. For the first time, several critical health and demographic indicators have been omitted from the preliminary release.

What is the National Family Health Survey (NFHS)?

It is a large-scale, multi-round household survey conducted across India to collect comprehensive data on population dynamics, health, nutrition, and family welfare. Launched in 1992-93, it acts as a critical health “dashboard” that helps the Ministry of Health and Family Welfare (MoHFW) and other agencies evaluate existing government schemes, set development benchmarks, and design new public health policies.

Key Features & Objectives

1. Nodal Agency: The International Institute for Population Sciences (IIPS), Mumbai, coordinates and provides technical guidance for the survey. 
2. Policy Support: It supplies high-quality, reliable, and comparable data to track progress toward the global Sustainable Development Goals (SDGs). 
3. Granular Scope: The survey covers national and state levels, and since NFHS-4, it provides highly localized estimates down to the district level.

How has NFHS evolved as India’s principal health and demographic database?

1. Coverage: NFHS-6 collected information from nearly 6.8 lakh households across India, excluding Manipur.
2. Policy Significance: Provides nationally representative data for health, nutrition, fertility, gender and social indicators.
3. Survey Expansion: NFHS has progressively expanded its scope while retaining previous questions for comparability.
4. Digital Transformation: NFHS-4 introduced district-level estimates and tablet-based data collection.
5. Expanded Domains: NFHS-5 added education, disability, access to toilets, health insurance, bank accounts, bathing practices during menstruation, abortion-related indicators and age coverage up to 49 years for women and 54 years for men.
6. Broader Adult Coverage: NFHS-6 expanded adult measurements to all individuals aged 15 years and above.

Why has the reduction in indicators in NFHS-6 generated concern?

1. Indicator Reduction: NFHS-6 preliminary fact sheet contains 101 indicators compared to 131 in NFHS-5, representing a reduction of nearly 23% in reported indicators.
2. Net Change: 43 indicators were dropped and 13 were added, producing a net reduction of 30 indicators.
3. Data Continuity Issue: Several long-running indicators are unavailable in the preliminary release.
4. Policy Monitoring Gap: Removal affects trend analysis across survey rounds.
5. Comparability Challenge: Limits direct comparison of progress in key health and demographic outcomes.

Which important indicators have been removed from the preliminary fact sheets?

Health Indicators

1. Anaemia: Removed from preliminary fact sheets despite being a major public health concern.
2. Mortality Indicators: Infant mortality, neonatal mortality and under-five mortality are absent.
3. Sex Ratio at Birth: No current survey-based estimate available.
4. Cancer Screening: Indicators covering cervical, breast and oral cancer screening removed.
5. Comprehensive HIV Knowledge: Certain HIV-related indicators no longer available in the fact sheet.

Living Conditions Indicators

1. Sanitation Coverage: Household sanitation data absent.
2. Clean Cooking Fuel Usage: Indicator removed from preliminary release.
3. Internet Access: Household-level population living in households with internet access not reported.

Why was anaemia removed and what does the evidence show?

1. Worsening Trend: Anaemia has consistently shown deterioration in previous survey rounds.
2. Children’s Anaemia: Increased from 58.6% (NFHS-4, 2015-16) to 67.1% (NFHS-5, 2019-21).
3. Women’s Anaemia: Increased from 53.1% to 57% among women aged 15–49 years.
4. Pregnant Women: Rose from 50.4% to 52.2%.
5. Geographic Spread: Anaemia increased in 28 States and Union Territories.
6. Severe Burden States: Assam recorded 35.7% to 68.4%; Mizoram recorded 19.3% to 46.4%.
7. Policy Importance: Anaemia was a major target of the Anaemia Mukt Bharat campaign launched in 2018.
8. Measurement Method: Earlier surveys measured haemoglobin using finger-prick blood samples.
9. Methodological Concerns: Researchers questioned the reliability of portable analysers used for anaemia estimation.
10. Future Tracking: Anaemia will now be monitored separately through the Diet and Biomarkers Survey under the National Institute of Nutrition.
11. Alternative Data Collection: NFHS-6 collected venous blood and urine biomarkers instead of finger-prick methods.
12. Additional Biomarkers: Survey collected information on nutritional deficiencies and obesity.
13. Pending Release: Detailed biomarker dataset has not yet been released.

What new themes and indicators have been introduced in NFHS-6?

Digital Inclusion

1. Digital Literacy: Introduced new questions assessing digital capabilities.
2. Internet Use: Expanded assessment of digital access and usage patterns.
3. Financial Fraud Awareness: Added questions on awareness of digital and financial fraud.

Social and Economic Inclusion

1. Direct Benefit Transfers (DBT): Added questions on DBT access and receipt.
2. Self-Help Group Membership: Introduced indicators on SHG participation.

Public Health

1. Hepatitis-B Testing: Included testing among men and women.
2. Hepatitis-B Child Testing: Included dried blood spot collection among children aged 4-5 years.
3. Expanded Biomarkers: Added broader nutritional and obesity-related measurements.

What methodological and definitional changes have occurred in NFHS-6?

1. HIV Module Revision: HIV testing component removed from survey implementation.
2. Knowledge Questions Retained: HIV/AIDS knowledge, attitudes and behaviour questions retained.
3. Ownership Redefinition: Women’s ownership of house or land shifted to a household-level measure.
4. Hepatitis-B Classification: Moved from individual measure to birth-dose measure.
5. Education Indicator Revision: Pre-school attendance reclassified into younger age bands.
6. Demographic Revisions: Several indicators modified through definitional changes rather than removal.

What do NFHS-6 findings reveal about maternal and child health outcomes?

Maternal Healthcare

1. Antenatal Care: Mothers receiving at least four antenatal check-ups increased by about seven percentage points compared with NFHS-5.
2. Institutional Deliveries
   1. Institutional Births: Continued improvement in institutional delivery coverage.
3. Child Nutrition
   1. Stunting Reduction: Number of children under five who are stunted declined.
   2. Exclusive Breastfeeding: Declined among infants under six months.
4. Contraception
   1. Modern Contraceptive Use: Declined from 56.4% to 52.7%.

How have gender and social indicators changed between NFHS-5 and NFHS-6?

1. Women’s Empowerment
   1. Internet Usage: Significant increase in women’s internet use.
   2. Spousal Violence: Women reporting spousal violence declined from 29.3% to 22.3%.
2. Health Insurance
   1. Coverage Expansion: Increased from 33.7% to 88.2% of households in West Bengal.
   2. Largest State-Level Improvement: Andhra Pradesh increased from 21% to 63.6%.
3. Nutrition Transition
   1. Overweight and Obesity: Share of women classified as overweight or obese increased in every State.

What policy gaps emerge from the omission of key indicators?

1. Mortality Monitoring Gap: Absence of infant and child mortality data weakens health assessment.
2. Gender Monitoring Gap: Missing sex ratio at birth limits monitoring of gender discrimination.
3. Nutrition Monitoring Gap: Lack of anaemia data affects evaluation of Anaemia Mukt Bharat.
4. Environmental Health Gap: Missing sanitation and cooking fuel indicators weaken tracking of Swachh Bharat and clean energy transitions.
5. Cancer Surveillance Gap: Absence of screening indicators limits preventive healthcare assessment.
6. Evidence Gap: No alternative survey currently provides many of these indicators at NFHS scale.

Conclusion

NFHS-6 presents a mixed picture of India’s health transition. Improvements in maternal healthcare, institutional deliveries, health insurance coverage and digital inclusion indicate progress in human development outcomes. However, the omission of critical indicators such as anaemia, mortality and sex ratio at birth creates significant gaps in public health monitoring and long-term trend analysis. The challenge before policymakers is to balance methodological improvements with a continuity of data. This will ensure that India’s most important health survey remains both scientifically robust and policy relevant.

PYQ Relevance

[UPSC 2022] In a crucial domain like the public healthcare system, the Indian State should play a vital role to contain the adverse impact of marketisation of the system. Suggest some measures through which the State can enhance the reach of public healthcare at the grassroots level.

Linkage: Public healthcare delivery depends on robust health data for identifying gaps, targeting interventions and evaluating outcomes. NFHS-6 is a key instrument for evidence-based public health policymaking; therefore, the omission of indicators such as anaemia, mortality and sex ratio at birth may weaken assessment of healthcare outcomes and grassroots service delivery.