The NFHS-5 factsheets for India and all states and Union territories are now out. At first glance, it appears to be a mixed bag — much to cheer about, but concern areas remain.
The good news is that there seems to be a change in our demographic trends, particularly in the sex ratio. For the first time since the NFHS 1992-93 survey, the sex ratio is slightly higher among the adult population. It is also for the first time in 15 years that the sex ratio at birth has reached 929 (it was 919 for 1,000 males in 2015-16).
The total fertility rate has also dropped from 2.2 per cent to a replacement rate of 2 per cent, albeit with not much change in the huge fertility divide between the high and low fertility states. It appears that states which were already experiencing a decline in fertility rates have continued to do so, without much change in the trends in the higher fertility states. This fertility divide can have several socio-economic and political repercussions in any society. One assumes that adequate attention will be given to this challenge at the policymaking and social levels after the detailed report is out. But, clearly, policies and programmes for the girl child and women’s empowerment have produced positive results, and a direct correlation between higher female literacy, the improvement in the sex ratio, and the decrease in the total fertility rate can easily be drawn.
There has been an appreciable improvement in general literacy levels and in the percentage of women and men who have completed 10 years or more of schooling, which has reached 41 per cent and 50.2 per cent respectively. Of course, much remains to be done, especially because these figures imply that around half of our workforce still does not have the qualifications and skills to achieve upward mobility and escape the poverty trap.
The health sector deserves credit for achieving a significant improvement in the percentage of institutional births, antenatal care, and children’s immunisation rates. There has also been a consistent drop in neonatal, infant and child mortality rates — a decrease of around 1 per cent per year for neonatal and infant mortality and a 1.6 per cent decrease per year for under five mortality rate.
Now turning to the areas of concern — nutrition or nutrition-related indicators. To begin with, India has become a country with more anaemic people since NFHS-4 (2015-16), with anaemia rates rising significantly across age groups, ranging from children below six years, adolescent girls and boys, pregnant women, and women between 15 to 49 years. Almost half our human capital lacks iron power.
The insidious, adverse effects of anaemia affect all age groups — lower physical and cognitive growth and alertness among children and adolescents, and lesser capacity to learn and play, directly impacting their future potential as productive citizens. Lower capacity to work and quick fatigue for adolescents and adults, translates into lower work output and lesser earnings. Further, anaemia among adolescent girls (59.1 per cent) advances to maternal anaemia and is a major cause of maternal and infant mortality and general morbidity and ill health in a community.
Though there has been some improvement, an area of concern is the poor consumption of IFA tablets by pregnant women. Perhaps the detailed report will explain why a dedicated programme like Anaemia Mukt Bharat which focused on IFA consumption failed to gain impetus.
Equally worrying is the exceedingly slow pace of improvement in nutritional indicators across all age groups. Between NFHS 4 and NFHS 5, the percentage of children below five years who are moderately underweight has reduced from 35.8 per cent to 32.1 per cent, moderately stunted children have fallen from 38.4 per cent to 35.5 per cent, moderately wasted from 21 per cent to 19.3 per cent and severely wasted have increased slightly from 7.5 per cent to 7.7 per cent. Details regarding severely stunted and underweight children will be published in the detailed report.
The root cause for this is that the percentage of children below two years receiving an adequate diet is a mere 11.3 per cent, increasing marginally from 9.6 per cent in NFHS-4. This foundational nutritional deficit which ought to be considered an indicator of great concern, is generally ignored by policy makers and experts. Unless this is addressed, rapid improvement in nutritional indicators cannot happen.
India’s nutrition programmes must undergo a periodic review, just as our health programmes did right from the Reproductive and Child Health (RCH) programme in 1997 to the present National Health Mission (NHM), addressing gaps such as institutional delivery, ambulance services, adolescent anaemia, and additional health volunteers. The Integrated Child Development Services (ICDS), which is perceived as the guardian of the nation’s nutritional well-being must reassess itself and address critical intervention gaps, both conceptually and programmatically, and produce rapid outcomes. Ad hoc add-ons are just not enough, and smartphones, tweets and webinars cannot substitute hard action on the ground.
This column first appeared in the print edition on January 7, 2021 under the title ‘A foundational deficit’. The author is a retired Secretary to Government of India