National family health survey-5 and Assam

Udayan Hazarika

(The writer can be reached at udayanhazarika@hotmail.com)

Union Health Minister Harsh Vardhan has recently (12th December 2020) released the fifth National Family Health Survey (NFHS-5) Factsheet. The fact sheet is the compilation of the findings of household level surveys conducted under the Ministry of Health and Family Welfare covering 6.1 lakh households on various vital issues namely health, family planning, nutrition, etc. The present Fact Sheet labelled as Phase –I covers 22 States and Union Territories namely Assam, Bihar, Manipur, Meghalaya, Sikkim, Tripura, Andhra Pradesh, Andaman and Nicobar Islands, Gujarat, Himachal Pradesh, Jammu & Kashmir, Ladakh, Karnataka, Goa, Maharashtra, Telangana, West Bengal, Mizoram, Kerala, Lakshadweep, Dadra Nagar Haveli and Daman & Diu. As survey could not be completed in the remaining 12 States and five Union Territories due to Covid-19 pandemic, the report in respect of these States and UTs is expected in May next. As such, the usual practice of publishing the national data (national Fact Sheet will be available only after May 2021. In this discussion we shall cover the segment of the report concerning nutritional status of children and their mortality part.

The available trends as presented in the report from the 22 States and UTs show that infant mortality rates (IMR) and mortality rate of those under 5 years of age has fallen in 18 States and union territories. This indicates availability of adequate nutrition and accessible healthcare facilities. But in 16 of these States percentage of children under 5 years of age who are underweight and micronutrient deficient have risen significantly. Another alarming fact in this context is that in 16 of the 22 locations surveyed, there has been a rise in the percentage of children who are under five years of age and who are stunted compared to the ratio revealed by the NFHS -4. Child stunting refers to a child who is too short for his or her age and is the result of chronic or recurrent malnutrition. Stunting is a contributing risk factor to child mortality and is also a marker of inequalities in human development. Stunted children fail to reach their physical and cognitive potential. Child stunting is one of the World Health Assembly nutrition target indicators. Thus, the rise in stunting as reported by NHFS-5 is alarming and needs specific intervention. On the other hand 12 of the 22 surveyed States and UTs have registered a rise in the percentage of children under 5 years of age who are wasted compared to ratio recorded in NFHS-4. Wasting in child indicates low weight-for-height where a child is thin compared to his/her height but not necessarily short. It is also known as acute malnutrition indicating thereby that a child is in immediate increased risk of morbidity and mortality. Studies reveal that wasted children have a 5-20 times higher risk of dying from common diseases like diarrhoea or pneumonia than normally nourished children. As per Global Nutrition report (2017), there was an estimated 52 million wasted children of which 16 million were severely wasted and as much as 155 million stunted children in the world. The most dangerous fact is that each year, "approximately 800,000 deaths are attributable to wasting, 60% of these attributable to severe wasting (SAM), and over one million deaths are attributable to stunting" (2017). The current survey indicates that of the 22 locations, sixteen states and UTs have registered a rise in the percentage of children under five years who are severely wasted and underweight in comparison to NFHS-4.

The neonatal period is marked by the first 28 days of life of a child. According to WHO, this is the most vulnerable time for a child's survival. As per 2019 data, globally at an average of 17 deaths per one thousand live births occur in the neonatal period. In India about 7.5 lakh neonatal deaths occur every year which is highest for any country in the world. The NFHS-5 works out that neonatal mortality rate declined in 15 States and UTs in comparison to NFHS-4. Similarly, in regard to infant mortality rates (IMR) which indicates number of children per 1000 live births who die before reaching one year of age is 28.3 which is in declining trend. The NFHS-5 worked out that of the 22 States and UTs surveyed so far, both IMR and under five morality rates have fallen in 18 States and UTs but Manipur, Meghalaya, Tripura and Andaman and Nicobar Islands have recorded a rise in the both IMR and UMR in comparison to NFHS-4.

Lets us now have a look at the situation in Assam. In Assam the study was conducted covering 30,119 households with response from 34,979 women. The sample of this size appears to be quite small (0.22%) considering the total female population having the size of 1.52 crore as per 2011 census i.e. not even one per cent of the total population taken for the survey. Assam has a diverse population pattern and distinguished way of life of each cultural group. Cultural canvas varies between people living in hills and plains, in Brahmaputra valley and Barak Valley, in normal plains and sars in urban and rural areas, etc. Then again there are religious divides. Thus, with such diverse population pattern, a sample of this size cannot be taken as representative. However, let us for the purpose of academic interest examine the findings of NFHS-5 in relation to Assam.

The fact sheet of NFHS-5 shows that sex ratio of Assam has increased to 1012 (2019-20) from 993 in NFHS-4(2015-16). This estimation appears to be towards the higher side. The sex ratio in Assam was 958 in 2011 census and if the present estimate of NFHS-5 (2019-20) is to be correct then something around 5.6 per cent increase in the sex ratio would be required to get a figure in and around 1012 in 2021 census. Moreover, trend behaviour of this indicator also doesn't show such increase even in decades since 1901. Highest increase was achieved during 1961 and 1971 when there was a 03.4 per cent increase in the ratio.

As per NFHS-4 estimation, children per woman were 2.2 which as per NFHS-5 has declined to 1.9 per woman. This indicates that the two children norm is gradually fading away although in reality it is not so. This marginal decrease in less than four year's period (time leg between NFHS-4 and NFHS-5 survey-November 2015 and June 2019) can be said to be reasonable.

The estimated neonatal mortality rate was 32.8 in NFHS-4 which decreased to 22.5 in NFHS-5. This shows an unprecedented decline and considering the state of health care facilities in rural areas in Assam and that too in such a short period (less than 4 years) cannot be said to be reasonable one. Similar is the case with IMR which has registered a fall from 47.6 to 31.9 per thousand and under five mortality rates to 56.5 from 39.1.

In the areas of nutritional status of children, it appears that Children under 5 years who are stunted (height-for-age have fallen marginally from 36.4 per cent to 35.3 per cent but in case of wasted children the ratio has increased from 17.0 per cent to 21.7 per cent. Similar is the case with children under 5 years of age who are underwent has increased from 29.8 per cent in (2014-15) to 32.8 per cent in 2019-20. All these rates indicate clearly that immediate intervention in the nutritional front in the State in necessary. As the nutrition standard appears to be falling drastically despite Government of India's various nutrition schemes, the State Government must come forward with a strategic planning in this area. The Fifteenth Finance Commission has already allocated an addition fund for this purpose which needs to be spent sensibly.