India’s latest National Family Health Survey (NFHS-6) records gains in child nutrition, maternal care, institutional births and women’s internet use. But its preliminary fact sheet is also thinner than the last round, with 101 indicators compared with 131 in NFHS-5.

Which indicators were removed from NFHS-6?

Key indicators such as anaemia, mortality, sex ratio at birth, sanitation, and clean cooking fuel have been removed from the survey.

The Union Health Ministry released the fact sheets of NFHS-6 on May 29, covering 2023-24. The survey recorded data from nearly 6.8 lakh households across every State and Union Territory except Manipur.

Preliminary findings report clear gains on several measures, including mothers getting at least four antenatal check-ups, up about seven percentage points from NFHS-5, an increase in institutional births and women’s internet usage. It also points to declines in several metrics, such as exclusive breastfeeding of infants under six months, down nearly eight percentage points, and the use of modern contraception, down to 52.7% from 56.4%.

The NFHS is commissioned by the Ministry of Health and Family Welfare, which designates the International Institute for Population Sciences (IIPS) to conduct the survey. Over the years, the scope of the survey has been additive by design, retaining the previous questionnaire and adding to it.

NFHS-4 in 2015-16 introduced district-level estimates and tablet-based digital interviewing for survey collection. NFHS-5 pushed the indicators further, including new topics, such as preschool education, disability, access to a toilet facility, death registration, bathing practices during menstruation and methods and reasons for abortion. It also extended blood pressure and blood sugar measurements from adults aged between 15 and 49 to all adults aged 15 and above. The survey measured 131 key indicators, up from 114 in NFHS-4.

While the HIV testing component was dropped from NFHS-5, it retained questions on HIV/AIDS knowledge, attitudes, prior testing, sexually transmitted infections, and sexual behaviour. In NFHS-6, biological HIV testing has been brought back as part of the clinical, anthropometric and biochemical testing schedule.

The NFHS-6 fact sheet does not separately spell out whether all HIV/AIDS knowledge and attitude questions were retained.

NFHS-6 also added new questions on direct benefit transfers, self-help group memberships, digital literacy and financial transactions. It also includes testing for Hepatitis-B and Hepatitis-C among women and men, as well as dried blood spot collection from children aged 4-5 for Hepatitis-B testing.

But for the first time, the survey has also subtracted overall, showing a net reduction of 30 indicators in the preliminary results. Among the dropped indicators, the most notable ones, such as anaemia, infant and child mortality, sex ratio at birth, clean cooking fuel use, and sanitation, have all appeared since at least NFHS-4.

Why was anaemia dropped?

The case for removing anaemia is related to how it was measured. The indicator had long shown a worsening picture. Between NFHS-4 in 2015-16 and NFHS-5 in 2019-21, anaemia rose across the board. Among children, anaemia prevalence went up from 58.6% to 67.1%, among women aged 15-49, it rose from 53.1% to 57%, and among pregnant women, anaemia rose from 50.4% to 52.2%.

The rise in anaemia was near-universal across the country, with child anaemia increasing in 28 States and Union Territories, and in some cases by big leaps, from 35.7% to 68.4% in Assam and 19.3% to 46.4% in Mizoram. Such deterioration was reported despite the government launching the Anaemia Mukt Bharat campaign in 2018, aimed at tackling anaemia. The reason for dropping it as an indicator then boiled down to how the data were being collected.

NFHS measured haemoglobin from a finger-prick blood sample read on a portable analyser, which several nutrition researchers contend overstated anaemia compared to the venous blood drawn by other surveys. IIPS dropped the anaemia questionnaire when NFHS-6 fieldwork began in 2023. The official position is that the condition will now be tracked separately, through a dedicated Diet and Biomarkers Survey under the National Institute of Nutrition using a method its proponents consider more accurate.

The Diet and Biomarkers Survey in India was not a hurried replacement and was launched in December 2022, before NFHS-6 fieldwork began, at the ICMR-National Institute of Nutrition in Hyderabad.

The survey recorded data on individual dietary intake across age groups, paired with blood and urine biomarkers.

It also built upon nutrition deficiencies and tracked obesity alongside anaemia, a first, according to the organisers. For anaemia, data were collected from venous blood instead of the finger-prick method that NFHS used. Data collection is complete, but hasn’t been released yet.

What other changes were made?

A line-by-line comparison of the two fact sheets from NFHS-5 and NFHS-6 shows that the net fall of 30 actually combines 43 indicators dropped and 13 added. Several of the deletions were long-running series, and a few are closely related to the government’s signature programmes.

Prime Minister Narendra Modi’s government in 2019 had announced that India would be open defecation-free. NFHS-5 recorded 70% of the country’s population living in households with access to sanitation facilities. That data point has also been dropped.

The share of households using clean fuel for cooking, 58.6% in NFHS-5, is gone — a direct measure of the success of the Pradhan Mantri Ujjwala Yojana.

The three mortality indicators — neonatal, infant and under-five — have also been cut, but these will be tracked by the Sample Registration System, whose latest bulletin put infant mortality at 24 per 1,000 live births.

The Registration System, however, does not carry district-level data and socio-economic breakdowns that are available in NFHS.

The sex ratio of the total population and the sex ratio at birth, 929 females per 1,000 males in NFHS-5, are both absent, removing a standard signal of sex-selective practices. Four cancer-screening indicators, covering cervical, breast and oral cancer, introduced only in NFHS-5 are gone after a single round.

A few changes are redefinitions rather than cuts. Women’s individual ownership of a house or land has become a household-level measure. Three-dose hepatitis B line has become a birth-dose measure, and pre-school attendance has shifted age bands, targeting a younger demographic. IIPS has not published a rationale for the wider list.

Together, the removals leave no current survey-based national figure for infant mortality, sanitation coverage, sex ratio at birth, cancer screening rates or comprehensive HIV knowledge, gaps that no other single source fills at the same scale.

How did survey results change between NFHS-5 and NFHS-6?

NFHS-6 reported a drop in the number of women who have experienced spousal violence, down to 22.3% from 29.3%. The number of children aged five or below who are stunted declined too. The drop from NFHS-4 to NFHS-5 was just under three percentage points, but NFHS-6 saw a drop of over six percentage points.

State-level changes are sharper for certain indicators.

Health insurance coverage rose the most in West Bengal, from 33.7% of households in NFHS-5 to 88.2% in NFHS-6. Women’s internet use saw its largest increase in Andhra Pradesh, from 21% to 63.6%. Haryana recorded the steepest fall in exclusive breastfeeding among infants under six months, from 69.5% to 41.2%. The share of women classified as overweight or obese increased in every State.