India has been trying to tackle the problem of population through improved use of family planning methods since before the Emergency rattled the political system. Family planning and contraception methods, attack the very root of beliefs of several major sections of the Indian society and hence the issue of population control continues to challenge the nation’s policy makers and implementers. But until 1992-93 the national census was the only source of statistics, which reported only the growing numbers and not the factors involved. Detailed statistics regarding utilization of family planning measures, reasons for non-use of available methods, types of methods preferred etc were all unaccounted for. Today the policy makers can say whether it is popular belief, lack of access, lack of awareness or familial disapproval that keep both men and women from implementing family planning measures. All of this is being made possible through extensive sample surveys conducted by Ministry of Health and Family Welfare (MOHFW) called the National Family Health Survey (NFHS).
What is NFHS?
NFHS was started by Government of India in 1992-93 as the first large-scale, multi-round household survey conducted at a national level. It was done in a representative sample of households throughout India and has been conducted thrice since then.
What data does it collect and how?
NFHS was the first survey to collect information on fertility, infant and child mortality, the practice of family planning, maternal and child health, reproductive health, nutrition, anaemia, utilization and quality of health and family planning services.
The International Institute for Population Sciences (IIPS) Mumbai, as the nodal agency provides coordination and technical guidance for the survey. The survey is conducted through three questionnaires:
- Household Questionnaire
- Woman’s Questionnaire
- Village Questionnaire (for rural areas alone)
The NFHS-3 added men age 15-54 and never married women age 15-49, as well as ever-married women in its survey population unlike the previous surveys. Softer, untouched areas such as perinatal mortality, male involvement in maternal health care, adolescent reproductive health, higher-risk sexual behavior, family life education, safe injections, and knowledge about tuberculosis were covered in this survey. NFHS-3 also set the benchmark by being the first in India to conduct a “population-based HIV prevalence” survey.
The sample size of NFHS-4 is approximately 568,200 households, which is a significant increase from about 109,000 households in NFHS-3. Data is being collected using Computer Assisted Personal Interviewing (CAPI) on mini-notebook computers.
How is this data used?
These surveys primarily serve to provide essential data on health and family welfare for policy making and planning, and throw light on important emerging health and family welfare issues. Besides providing information to the home agencies, the NFHS surveys update the DHS (Demographic and Health Surveys) funded by the USAID. This organization’s analyses are in turn used by the WHO, UNICEF, World Bank, etc.
Impact of social system on national health policies
While observing the data obtained from NFHS we often gain insights that we did not expect to find. When women with two children were asked about their wish to have a third child, the numbers of positive responses have steadily declined from NFHS-1 to NFHS-3. But, if we look closely, we find that the women who have two daughters make up a larger portion of the women who want a third child as compared to the women with two sons or one son. This makes us wonder whether all our population control measures directed towards family planning methods are being nullified by the strong patriarchal social system.
The section for treatment of childhood diseases tells us that healthcare advice seeking behavior is higher in parents with children suffering from respiratory infections (70%) than diarrhea (61%), which is a more significant killer of children under 5. Besides, only 26% of people are utilizing ORS at home. This clearly calls for a need for understanding cultural beliefs about diarrhea and spreading correctional awareness wherever necessary.
Shortcomings of NFHS
The NFHS-4 got delayed when the UPA government decided to scrap it altogether and replace it with some extra questions in the population census. However it was later decided to keep the surveys going. Neighboring nations such as Pakistan, Bangladesh and Nepal have conducted two surveys in the meantime. Currently NFHS-4 is in the field work phase which will be followed by a long phase of analyses, sorting, correcting and the complete district wise results will not be ready until 2016. Even the international agencies such as WHO and UNICEF have been deprived of data due to this delay. The delay in conducting these surveys affected the policy makers as their efforts were driven by ten-year-old information. It is common knowledge that the last ten years has seen the fastest change in several aspects, so there is reason to believe that a lot of health policies are being directed in the wrong direction.
2. Quality of data: dealing with sensitive data
India is a country where sex education is sometimes considered socially inappropriate, even between a medical professional and his/her patients. This burden of social pressure slows down the probing and progress in several issues. With no promise of privacy, questions on sexually transmitted diseases, HIV, domestic violence, and sexual intimacy are asked in the NFHS questionnaires. Often the questions are conducted improperly because the field workers are common people with no medical background and no experience of questioning in this field. Concerns of privacy also leave many windows for data to be inaccurate as people often try to respond with socially acceptable answers. To ensure better quality of such sensitive data, training of field workers needs to be improved. On the contrary, it has been reported that during the training period if the workers raised concerns about how to go about the sensitive questions, the responses were in the line of “this has been done before; do it the same way”.
3. Methodology: data collection
The tender for research work in the latest NFHS has not been given to some of the population research centers that were hired for NFHS-3. In spite of these centers being more qualified, experienced and better equipped with research resources and infrastructure, organizations with little experience and minimal infrastructure have been given the mammoth responsibility.
4. Managing field staff
There are a few reports of cases of rights violation for field workers in ways such as salary withdrawals and delays. There training is most often conducted in English when that is not the first language for any of them.
Owing to the extensive nature of these questionnaires (up to 837 questions in one survey alone), the accuracy of the answers comes under question. It takes several hours to finish each questionnaire, which is a burden for the respondent, many of whom are daily wagers. Finding ways to simplify these questionnaires without losing the impact and extensive coverage of these surveys is the need of the hour.
The disability sector has been unexplainably kept out of NFHS and must be included in the upcoming surveys as India has no national data in this.
India continues to have unacceptable statistics in health and nutrition by international standards. With its staggering numbers of malnourished children India loses 1.3 million children to diarrhea, malaria and pneumonia. Also, the prevalence of anaemia in children has been on a rise since NFHS-2 (79% between 6-35 months of age from the 74% earlier).
(This map has been built on viz.socialcops.com)
But the problem-solving barely begins till problems are quantified. NFHS is the answer to the right questions which we should have asked ourselves decades ago. But there is always hope.
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