Professor TV Sekher has written and edited 10 books and published over 100 research articles in national and international journals. He was a Fulbright-Nehru Senior Fellow at Cornell University in 2016-2017. In an email interview with First lineProf. Sekher reviewed some of the important findings from the National Family Health Survey (NFHS-5). (The NFHS is the most in-depth survey of health and nutrition indicators of Indian citizens and the second phase of NFHS-5, conducted in 2019-21, was released on November 24, 2021.) Excerpts:
How important and relevant has the NFHS been to Indian citizens and government health program planning over the years?
Since 1992-93, the NFHS has provided various indicators of health, nutrition, family and social well-being at regular intervals, allowing us to have an independent assessment of the effectiveness of the program. As part of the Global Demographic Health Surveys (DHS) carried out regularly in a large number of countries, the NFHS serves as a mirror of India’s achievements and concerns in maternal and child health compared to other countries. The five cycles of the NFHS over the past three decades have made it easier to understand the demographic and health changes that have taken place in a large and diverse country like India. No other survey in India outside of the NFHS has attracted the same attention from policymakers and researchers. This is a major exercise as it surveys some 640,000 households to produce comparable indicators for more than 700 districts of the country on various aspects of antenatal care, institutional delivery, child immunization, malnutrition, age at marriage, fertility, contraception, sexual behavior. , gender-based violence, empowerment of women and access and use of health services.
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The incorporation of modern technology and other innovations in survey methodology have helped the NFHS generate data of acceptable quality, but there is still room to improve its value and standards.
How important is the achievement of the replacement fertility level (that is, a total fertility rate of 2.0 per woman) for the country as a whole?
It is a well-documented fact that between 1970 and 2020 fertility declined in all countries of the world, and India is no exception. The fertility transition is moving in the expected direction and most countries, including those in Asia, have experienced declining fertility rates. With the increase in the number of women having access to education, thus increasing their participation in the labor market, and in a context of universal knowledge of family planning methods and an increase in contraceptive prevalence, families prefer to have less. of children.
Studies have also shown that the rising cost of raising children also prompts many parents to limit the number of children to one or two. The percentage of couples deliberately choosing to have only one child has increased dramatically in urban India. In a city like Kolkata, it is close to 25 percent, according to NFHS-4. The proportion of one-child families is higher among urban, educated and employed women.
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As fertility levels have fallen below the replacement level in the country in a majority of states, “the population explosion” is no longer a concern today. It also shows that there is no need for population policies that stress two-child standards, either through incentives or sanctions. Although the NFHS-5 indicates that India has reached a replacement fertility level, the unmet need for contraception (although slightly reduced) remains high in many states (for example, it is 13% in the Uttar Pradesh), and this is where the government should be focusing its energies now. More concerted efforts are needed to provide access and availability to quality contraceptive services in states such as Bihar, UP, Rajasthan and Madhya Pradesh. At the same time, many states and communities are increasingly concerned about the long-term implications of declining fertility. This is seen in the southern states which were the forerunners of the fertility transition from the early 1980s. Recently, the Catholic Church in Kerala has offered many incentives such as free education and job opportunities. employment for families with more children.
Looking through NFHS data, what has been the country’s biggest healthcare gain over the past decade?
In my opinion, the most remarkable achievement of our healthcare system over the past decade is that 90% of births take place in healthcare facilities. The figure was only 39 percent in 2005-06 (NFHS-3). Conditional cash transfer programs such as Janani Suraksha Yojana (JSY) have played a major role in bringing more women, especially in rural areas, to hospital to give birth. It has also helped to significantly reduce infant and maternal mortality.
Despite the introduction of many policies and programs aimed at increasing the age of marriage for women, changes have been very slow in this regard. How do you see this aspect?
Age at marriage remains a major concern. Almost a quarter of women in India still marry before the age of 18. This despite a significant improvement in girls’ education and the implementation of many government programs (e.g. Laadli Laxmi programs in many states) in which financial incentives are provided to girls to marry only afterwards. the age of 18. Many sociocultural norms prevalent in some communities lead to early marriages and, consequently, teenage pregnancies.
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Child marriage has serious repercussions on girls as it affects their personal freedom, education and expectations in life and leads to discrimination and violence. All of a sudden, imposing a marriage partner on a girl means that her childhood is cut short and her basic rights are compromised. But what is not noticed in the debate on age at marriage in India is the fact that a significant proportion of men also marry before reaching the legal minimum age of marriage of 21 years old.
According to the NFHS-5, it is 18% for India and 23% for Uttar Pradesh. Research in India has largely been directed towards understanding the causes and consequences of early marriage among girls while ignoring the plight of the large number of âmarried childrenâ.
There are many âhot spotsâ in India where early marriage for boys is an accepted norm. In these regions, raising the age of marriage for boys will automatically increase the age of marriage for girls (the preference and traditional practice of Indian men being to marry younger women). The early marriage of boys, often without their consent and against their will, forces many boys to drop out of school and take menial jobs to support their wives and children. While the problem of “married children” in India must be tackled, the presence of “married children” can no longer be ignored. It is high time that we realized that early marriage is a problem not only for girls but also for boys in many parts of rural India.
How do you rate the gender empowerment indicators as presented by NFHS-5 compared to previous NFHS cycles?
Although there is an improvement over previous surveys, a significant gap continues to exist between men and women in terms of ownership, operation of bank accounts or cellphones, showing that patriarchal norms are still prevalent. Unless and until the daughters also inherit parental property and gain financial independence, their ability to negotiate in household decision-making processes will be affected.
In addition, according to the NFHS-5, nearly a third of women have been victims of domestic violence. Awareness-raising programs and legal remedies are needed to combat the discrimination women face at different stages of their lives (childhood, adolescence, motherhood and old age).
One of the areas of concern for NFHS-5 is the poor nutritional indicators of women and children, which has been highlighted by many analysts. How do you see this important question?
The discrimination one faces in childhood, manifested in a lack of medical care, nutrition and education, continues into adulthood in many ways. However, it is crucial to examine why, despite a large number of dietary supplementation programs, anemia in children and women shows no improvement at all. Almost half of all pregnant women are anemic, despite many large-scale incentive programs such as the Pradhan Mantri Matru Vandana Yojana (PMMVY). It is possible that although women and children receive food through Integrated Child Development Services (ICDS) and school lunch programs, the nutritional value is not. taken into account when choosing the menu.
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In general, the economic situation of most Indian households has shown no improvement over the past decade or has deteriorated; it could also have led households to devote less resources to food and nutrition. It is also a fact that remarkable progress in some of these indicators may not be possible in a short period of time. The reason for this persistent malnutrition needs to be further investigated.
Women’s access to health care is limited for various reasons such as distance from health facilities, lack of support from men to use health services and financial factors. Many women also ignore their own health issues while remaining concerned about the health of their children. Improving health insurance coverage, which is low as shown by NFHS-5, is critical to increasing the use of health services by women.
NFHS-5 says women outnumber men in India. What is your opinion on this finding?
Some media have misinterpreted this conclusion. What is given in the NFHS information sheet is the sex ratio of people living in the households surveyed. The NFHS is a household survey and a large number of people living in institutions or homeless populations are not included in the survey. Please wait for the next census to give us precise data on the sex ratio. I do not see the possibility that women will outnumber men in India in the near future.