Some cheer, some gloom

India has become a more anemic country since the NFHS-4 survey (2015-16), with anaemia rates rising significantly across age groups

The latest National Family Health Survey (NFHS-5) Factsheets for India and all States and Union Territories are now out and the full report should also be in the public domain shortly. At a glance, one can see that it is a mixed bag — much to cheer about but also some spots of gloom.

The good news is that there seems to be some change in our demographic trends, particularly the sex ratio. For the first time since the first NFHS in 1992-93, the sex ratio of females to males 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 1000 males in NFHS-4 of 2015-16).

We are also happy that the Total Fertility Rate has dropped from 2.2% to a replacement rate of 2.00%, albeit with not much change in the huge fertility divide between the high and low fertility states. It appears that the 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, and one presumes that adequate attention will be given to this at policy-making and social levels after the detailed report is out.

Clearly, our advocacy, policies and programmes for the girl child and women’s empowerment throughout the country have borne positive results, and a direct correlation between higher female literacy, improvement in the sex ratio and decrease in the total fertility rate can very easily be drawn.

There has been 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% and 50.2%, respectively. Of course, there is a long way to go since these figures imply that around half of our workforce or demographic dividend still does not have the qualifications and skills to achieve upward mobility from casual labour or lowly paid blue-collar jobs and escape poverty trap.

The health sector deserves credit for achieving significant improvement in an increased percentage of institutional births, antenatal care and children’s immunisation rates (around 2% increase per year). There has also been a consistent drop in neonatal, infant and child mortality rates - around 1% decrease per year for neonatal and infant mortality and a 1.6% decrease per year for under-five mortality rate.

Now, turning to the areas of gloom - they continue to be nutrition or nutrition related-indicators, our constant Achilles heel. To begin with, India has become a more anaemic country since the NFHS-4 survey (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, translating into lower work output and lesser earnings. Further, anemia among adolescent girls (59.1%) advances into maternal anemia and is a major cause of maternal and infant mortality and general morbidity and ill health in a community.

Though improved from the previous survey, a disappointing area of the report is the poor consumption of IFA (iron-folic acid) tablets by pregnant women (44.1% took it for 100 days plus and 26% took it for 180 days plus). Perhaps the detailed NFHS-5 report will explain why a dedicated programme like Anemia Mukt Bharat which focused on IFA consumption failed to gain impetus.

Underweight, stunted

Equally worrisome is the exceedingly slow pace of improvement, (approximately 0.5% per year) 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% to 32.1%, moderately stunted children from 38.4% to 35.5%, moderately wasted children from 21.0% to 19.3% and severely wasted have increased slightly from 7.5% to 7.7 %. Details regarding severely stunted and underweight children will be published in the detailed report.

Undoubtedly, the most proximate and root cause for this, being documented for the second time since NFHS-4, is the fact that the percentage of children below two years receiving adequate diet is a mere 11.3%, having increased from 9.6% in NFHS-4. This foundational nutritional deficit which ought to be considered an indicator of great concern, is generally ignored by policymakers, experts or custodians of the subject. Unless this indicator of concern is substantially addressed, rapid improvement of our nutritional indicators cannot happen.

A look at some development indicators of our neighbours might chasten us – China has 100% literacy, both male and female; 16% women between 15-49 years suffer from anaemia and stunting and wasting of children is at 5% and 2%, respectively. Bangladesh which was far behind us in all indicators has now caught up with us and surpassed many of our indicators.

India’s nutrition programmes must undergo periodic review, just as our health programmes did right from the Reproductive and Child Health programme in 1997 until the present National Health Mission, addressing several gaps such as institutional delivery, ambulance services, adolescent anemia, and additional health volunteers. The Integrated Child Development Services, which is perceived as the guardian of the nation’s nutritional well-being must reassess itself and address the 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.

(The writer is a retired Secretary to Government of India)

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