A Digital India Initiative

Health Indicators to address social problems in India: National Family Health Survey-4

July 12, 2018

Author: DrJaideep Misra and Shubhadip Biswas


Data from National Family Health Survey 4 (2015-16) (NFHS-4), conducted by MoHFW have been analyzed to study how it could help to address social problems. The National Family Health Survey’s fourth round was held during 2015-16, which presents critical information on mother and child health, reproduction information, health parameters, including socio-economic data of the household members and visitors, water and sanitation, nutrition, family planning, fertility, medical insurance, diseases , deaths, lifestyle, HIV/AID  and many other topics . The data of the NFHS-4 improve India’s demographic and health database, and the data serves as a standard for the government’s initiatives to attain the Sustainable Development Goals (SDG) by 2030.

After analyzing the NFHS 4 data, we have highlighted few significant points as follows:

  • The ratio of households using open defecation reduced from 55% in 2005-06 to 39% in 2015-16, 48% of Indian households have improved non-shared toilet facilities. It can save people from coming into contact with human wastage and can prevent the transmission of typhoid, cholera, and other diseases.
Source: Department of Health and Family Welfare


  • Household educational level has enhanced substantially between 2005-06 and 2015-16. The median of years of schooling for males has increased from 4.9 years from 2005-06 (NHFS-3) to 6.9 years in 2015-16 (NHFS-4). The median of years of education for females has increased from 1.9 years from NHFS-3 to 4.4 years in NHFS-4. During 2005-06 and 2015-16, the proportion of women with no education reduced from 42% to 31% and the ratio of males with no education reduced from 22% to 15%. Since 2005-06, a substantial rise has been observed for a percentage of women and men aged 15-49 going to school and achieving higher levels of education, and the gap in higher education between women and men has reduced during this tenure. The percentage of women and men finishing 12 or more years of schooling has improved by approximately 10% points. Bihar has the lowest literacy of 49.5% women and 77.8% men, while Kerala has the lowest literacy of 97.9% women and 98.7% men.
  • The Total Fertility Rate (TFR) has dropped noticeably during 1992-93 and 2015-16. During this period, TFR has fallen from 3.4 children in 1992-93 to 2.2 children in 2015-16. The TFR among women in rural and urban areas has dropped from 3.7 children and 2.7 children in 1992-93 to 2.4 children and 1.8 children in 2015-16 respectively. Irrespective of residence place, the fertility rate peaks at the age of 20-24, after which it shows declining trend.
Source: Department of Health and Family Welfare


  • The neonatal mortality rate in the five years before the NFHS survey dropped from 49 deaths in 1992-93 to 30 deaths per 1,000 live birth in 2015- 16. The infant mortality rate in the five years before the NFHS survey dropped from 79 deaths in 1992-93 to 41 deaths per 1,000 live births in 2015-16. During the same duration, the under-five mortality rate also fell from 109 deaths to 50 deaths per 1,000 live births. Highest under-five mortality rate was observed in Uttar Pradesh, i.e., 78 deaths per 1,000 live births and the lowest under-five mortality rate was observed in Kerala (7 deaths per 1,000 live births).
Source: Department of Health and Family Welfare


  • For Puducherry, Kerala, Lakshadweep, and Tamil Nadu almost 100% of births were delivered in a health facility. For the northeastern states, only one-third of births were delivered in health facilities.
Source: Department of Health and Family Welfare


  • Few states of India, i.e., Manipur, Bihar, and Meghalaya have the lowest usage of contraceptive methods, i.e., 24% and Punjab has the highest usage of contraceptive, i.e., 76%. About three-fourths of women (72%) read or heard about family planning communication in the last few months, i.e., 18% through radio, 53% on posters or hoardings, 59% on television). Contraceptive discontinuation rates are lowest in Andhra Pradesh, i.e., 4% and highest in Punjab and Jammu & Kashmir, i.e., 47%. For any spacing method, the discontinuation rate is highest in Goa, Karnataka, Andhra Pradesh, Tamil Nadu, and Kerala ranging between 60% to 64%. Unmet need for family planning increases with increasing years of schooling, from 11 % among currently married women with no education to 17 % among those who have completed 12 or more years of education. Unmet need for family planning is 20 % or more in Manipur, Nagaland, Sikkim, Arunachal Pradesh, Meghalaya, Bihar, Mizoram, and Daman & Diu. Unmet need is less than 10 % in Andhra Pradesh, Punjab, Chandigarh, Telangana, West Bengal, Puducherry, and Haryana.
  • The percentage of children between 12-23 months of age who have obtained all necessary vaccinations rose from 44% to 62% during 2005-06 to 2015-16. During this period, maximum increase, i.e., 22% was observed in rural areas than in urban areas. Only 6% of children have received no vaccinations in 2015-16.
Source: Department of Health and Family Welfare


  • During 2005-06 and 2015-16, the prevalence of treated cases of tuberculosis declined from 418 to 305 persons per 100,000. During this period, the prevalence of treated cases of tuberculosis among men declined from 526 to 220 persons per 100,000, but, among women, prevalence has risen from 309 to 389 persons per 100,000. Among the states, the prevalence is lowest for Goa, i.e., 74 persons per 100,000 and highest for Arunachal Pradesh, i.e., 799 persons per 100,000. Manipur, Nagaland, and Bihar also have a higher prevalence of tuberculosis cases, i.e., 715, 640, and 637 persons per 100,000. All the states in the North and the West have prevalence levels well below the national average
  • During 2005-06 and 2015-16, awareness of HIV/AIDS has also risen among women than men. For women, awareness of HIV/AIDS has risen from 61% to 76%, by 15 percentage points, and for men, awareness of HIV/AIDS has risen marginally from 84% to 89%, i.e., five percentage points. In urban areas, among women, prevalence of HIV/AIDS has risen from 0.29 % in 2005-06 (Confidence Interval i.e. CI ~ 0.18%-0.40%), to 0.36 % in 2015-16 (CI ~0.27%-0.45%), and in rural areas, among women prevalence stayed almost unaffected 0.18% in 2005- 06, (CI ~0.14%-0.23%), and 0.17 % in 2015-16, (CI ~0.14%-0.20%). During this tenure, among men, in both urban and rural areas, HIV/AIDS prevalence has fallen significantly, but higher improvement was observed in rural areas from 0.32%, (CI ~0.24%-0.41%) to 0.17% (CI~0.14%-0.21%), than in urban areas from 0.41% (CI~0.28%-0.54%] to 0.39 % CI ~0.28%-0.51%).

The NFHS 4 results show that for many critical indicators the improvements are noteworthy, but there are substantial disparities among rural, urban and states.

Health is an affair of states, and the lack of improvement in critical indicators are associated with (i) inadequate investment, (ii) inefficient spending and (iii) low baselines by states. The data and our analysis also highlight that India is going through an epidemiological and demographic shift and hence lifestyle-related diseases are on the rise. There is also a considerable impact of non-health elements like education, level of income, nutrition, sanitation and access to cleaner water, cleaned fuel, etc., which have a substantial effect on health status.

Actions to provide better health services demand significant integration of multi-sector initiatives, data highlights that there should be a focus on few parameters and specific support is required to the states/uts to boost their health care system based on the requirements proposed by the NFHS data.

The primary focus should be on improvement of health systems, maternal health, newborn health, child and adolescent health, interventions and control of communicable and non-communicable diseases, etc. Based on the challenges and issues which have emerged out of NFHS 4 data, has resulted in GOI to take many initiatives recently like:

  • More focus on Swachh Bharat Abhiyan
  • A collaborative effort has been adopted by the Ministry of Health & Family Welfare and the Ministry of Drinking Water and Sanitation, i.e., Swachh Swasth Sarvatra (SSS),) to resist the challenges of health and cleaned water to maximize the health benefits of the citizens.
  • “Mission ParivarVikas” has been launched in 145 high focus districts having higher total fertility rates(TFR) in the country
  • Launching Mother’s Absolute Affection (MAA) Programme
  • Launching of Pradhan Mantri Surakshit Matritva Abhiyan,
  • Launching of Pradhan Mantri National Dialysis Services Programme,
  • Introduction of Rubella, Rota virus, Adult JE vaccines.
  • Ayushman Bharat i.e. National Health Protection Scheme
  • Basket of choices, for contraceptives, has been offered by the government like Centchroman, Injectable contraceptive, and Progestogen Only Pills (POP).
  • A universal population-based screening programme has been launched for early detection, control, and management of common non-communicable diseases.

While the Government of India has made significant progresses in the right direction relating to healthcare, there is still a lot to be looked-for. Prevention is key to ensuring good health, which the government has adequately focused on. Preventive health also becomes critical these days since both communicable and non-communicable diseases are intensifying, and addressing these issues can assist to prevent many associated complications. Government has intensified the programs related to reproductive, maternal, newborn, child, and adolescent healthcare. Government is also focusing on affordable and accessible healthcare which is also the need of the hour. We’re expectant that more policies will be put in place for uplifting healthcare sector in India, providing citizens with decent healthcare, regardless of socio-economic background.

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