During an event, the founder of an NGO working with migrant labourers was asked how her approach to care had evolved over the years. In reply, she described how she used to give away high-quality personal care products without realising that they were not impacting the beneficiaries’ quality of life as intended. She later learnt that these products were being sent to the labourers’ native countries as gifts for their families. With constant feedback from the recipient community, the NGO has evolved and become more people-centric and effective.

The District Level Household & Facility Survey (DLHS) has been incorporated into the health machinery of India to provide similar feedback for government initiatives.

Overview

DLHS uses Rapid Household Surveys (RHS) conducted at a nationwide level to gain district-level data about service coverage of mother, child, and reproductive health initiatives. It is designed to provide information from the grassroots on family planning, maternal and child health, and reproductive health of married women and adolescent girls. Its most salient feature is gathering data on utilization and the perceived quality of maternal and child healthcare services.

This biphasic survey covers all the districts of the country every four years since 1998-99. For ease of logistics, all the states are divided into 15 regions. Each selected district is divided into 50 Primary Sampling Units (PSUs) adopting probability proportional to size (PPS) sampling. The sample size was fixed at 1000-1500 households with approximately 20 households from each PSU. The survey is conducted by 12 research organizations, including Population Research Centres (PRCs).

Previously, the survey’s primary respondents were currently married women aged 15-44. This was changed in DLHS-3 to married women aged 15-49 and never-married women aged 15-24. The questionnaires contain questions on maternal care, immunization and childcare, contraception and fertility preferences, and knowledge about RTI/STI and HIV/AIDS. The unmarried women’s questionnaire adds questions on family life education, as well as awareness about reproductive health and contraception. The village questionnaire consists of information on availability and continual access of health, education and other facilities in the village. The health facility questionnaire, added since DLHS-3, covered population-linked health services. It reported on the Community Health Centres (CHC), District Hospital, Sub-Centres, and Primary Health Centres (PHC) that were expected to serve the population of the selected PSU.

Changes in health data collection in the last 15 years

Evolving alongside the health policies of the country, the fourth round of DLHS (2012-13) is more elaborate than its forerunners. Since the third round, DLHS has been modified to be sensitive to indicators that help gauge the efficiency of the National Rural Health Mission (NRHM) such as performance of Accredited Social Health Activists (ASHA) and the utilization of Janani Suraksha Yojana (JSY). DLHS also expanded to survey the unmarried women who make the mothers of tomorrow. This happened simultaneously with maternal and child health care expanding to include adolescent girls. Areas such as unmarried women’s knowledge about the legal age of marriage, methods of contraception, etc. were tested through these surveys, which have enhanced our understanding of women’s awareness on these critical issues.

Why keep the low performing states out of health data collection?

The 9 worst performing states of DLHS-3 have been excluded from DLHS-4.

This seems equivalent to the paradoxical punishment of keeping under-performing kids out of class to improve their academic performance in the future.

These states will be covered in the larger annual health surveys instead.

DLHS objectives claim to assess the impact of the National Rural Health Mission (NRHM) initiatives, but a lack of continued data from these nine states would mean an absence of impact assessment for the worst performing states. This move has been largely criticized because DLHS-3 was conducted at a time when NRHM was just put in place. Conducting impact assessment through DLHS-3 would have been an ideal recipe for redesigning the NRHM.

Janani Suraksha Yojana’s impact assessed through DLHS health data

The JSY scheme was instituted in 2005 to reduce the maternal mortality rate by promoting institutional deliveries. Trends in the data make it clear that the monetary incentives have improved institutional deliveries drastically in low performing states over the years. The ratio of government centres to private institutions has also tipped toward the former over the last 6 years.

Awards and incentives using health data

Punjab has been awarded the best performing state, based on its reduction of the infant mortality rate (IMR) from 44% in 2005 to 26% in 2012 according to SRS data. This correlates with the remarkable improvement in the number of institutional deliveries in the state from 63.3% in DLHS-3 to 82.7% in DLHS-4.

The DLHS divides all its states on the basis of performance and awards are given in separate categories, depending on state performance in each group. This practice helps create realistic, achievable incentives for all states regardless of their past performance.

Underutilised gems in the survey

The district-level detailed reports generated by the DLHS survey are the perfect tool for identification of outlier regions. If used wisely, health efforts can be redirected to outliers at district level to achieve tangible and quick outcomes. For example, the percent of children aged 12-23 months who are fully immunized in Bihar ranges from 67% in the Saran district to 19% in Jamui. The overall average of the state hangs at 41.4% against the country wide average of 54%.

In addition, the awareness questionnaires about polio, HIV, tuberculosis, acute respiratory infections, sexually transmitted infections can be crucial in channeling money for awareness programs. These questionnaires are based on vital information gathered through the 3rd and 4th surveys.

Lastly, recording the availability of human and infrastructure resources at rural and community levels could prove crucial in building a case for strengthening government health setups and making certain communities more attractive to medical professionals.

The road ahead

The data generated by DLHS is indispensable for tracking the steady reduction in infant and maternal mortality, as well as numerous other essential health indicators. It is now the policy maker and the government’s responsibility to not let the survey quality be marred by political interests. DLHS must be wisely invested in and strengthened to further its potential for driving better health policy in India.


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