National Family and Health Survey: More women than men in India for the 1st time

India now has 1,020 women for every 1000 men, is not getting any younger, and no longer faces the threat of a population explosion.

All three radical findings are part of the summary findings of the fifth round of the National Family and Health Survey (NFHS), which were released by the Union health ministry on November 24. To be sure, NFHS is a sample survey, and whether these numbers apply to the larger population can only be said with certainty when the next national census is conducted, although it is very likely that they will in the case of many states and Union territories.

The numbers indicate that India can no longer be called a country of “missing women”, a phrase first used by Nobel Prize winning economist Amartya Sen in a 1990 essay in the New York Review of Books. Back then, there were 927 women per 1,000 men in India. According to NFHS-3, conducted in 2005-06, the ratio was equal, 1000: 1000; it went down to 991:1000 in 2015-16 in NFHS-4. This is the first time, in any NFHS or Census, that the sex ratio is skewed in favour of women.

“The improved sex ratio and sex ratio at birth is also a significant achievement; even though the real picture will emerge from the census, we can say for now looking at the results that our measures for women empowerment have steered us in the right direction ,” said Vikas Sheel, additional secretary, Union ministry of health and family welfare and mission director, National Health Mission.

To be sure, the gender ratio at birth for children born in the last five years is still 929, which suggests that son-preference, in its various macabre forms, still persists, but the sex ratio is a significant milestone achieved on the back of policies aimed to curb sex selection practices that were once rampant and female infanticide, and on the fact that women in India tend to live longer than men.

The average life expectancy at birth for men and women was 66.4 years and 69.6 years respectively in 2010-14, according to data from the Census of India website.

There are other interesting read outs from the survey.

The share of population under the age of 15 years, which was 34.9% in 2005-06, has come down to 26.5% in 2019-21. India is still a young country -- a median age of 24 years in 2011 according to the Census figures -- but it is ageing, and that comes with the associated policy challenges.

“The fact that we are now an aging population suggests that our approach to women’s health needs a more holistic life cycle view rather than one that prioritises reproductive health only,” Yamini Aiyar, president of the Centre for Policy Research, said. “The fact that more women have completed ten years of schooling in 2019-20 than previously coincides with a drop in female labour force participation points to significant structural challenges in India’s labour market. These need to be urgently addressed if India is to make progress,” Aiyar added.

Finally, the total fertility rate (TFR), or the average number of children per women in India, is now just 2, which is below the internationally accepted replacement level fertility rate – the point at which a population exactly replaces itself from one generation to the next -- of 2.1. This means, India’s population may have peaked -- another data-point that can only be established by the Census, but which is almost certainly for at least the southern states, as well some of the richer ones.

“There is usually a gap of 30-40 years between total fertility rate falling below replacement levels and a decline in overall population, because the population which will give birth in the next 10-15 years has already been born in the past when fertility levels were higher,” said Dr KS James, director and senior professor at the International Institute for Population Sciences. “Of course, the population growth in southern states is going to fall at a faster rate than the rest of the country,” he added.

NFHS-5 was conducted in two phases between 2019 and 2021, and covered 650,000 households from 707 districts of the country. The States and UTs that were surveyed in Phase-II are Arunachal Pradesh, Chandigarh, Chhattisgarh, Haryana, Jharkhand, Madhya Pradesh, NCT of Delhi, Odisha, Puducherry, Punjab, Rajasthan, Tamil Nadu, Uttar Pradesh and Uttarakhand.

The findings of NFHS-5 in respect of 22 States & UTs covered in Phase-I were released in December 2020.

NFHS is the most comprehensive database on a host of socioeconomic and health indicators with a focus on women – NFHS-5 covered 720,000 women and just above 100,000 men – and its basic results can be compared to the previous four rounds which were conducted in 1992-93, 1998-99, 2005-06 and 2015-16.

To be sure, successive NFHS rounds have expanded their coverage both in terms of their sample size as well as number of indicators on which information is collected.

While the statistics quoted above are a watershed moment in India’s socio-economic and demographic transformation story, other findings of NFHS also convey a similar message. Socio-economic challenges facing India, going forward, will need to be dealt with more nuance and some of the stereotypes and political beliefs (such as the political obsession with population control laws) which dominate the public discourse will need to be shelved.

For example, balanced diets need as much attention as adequate diets as obesity and anaemia (more than half of women and children suffer from it) are on the rise, even as undernourishment continues to decline at the national level. To be sure, there is some evidence to suggest that the fight against undernutrition has lost momentum.

“Overall, the NFHS-5 shows a reduction in stunting, which is an indicator of chronic undernutrition, from 38.4% to 35.5%, which is only about 3 percentage points in five years, about 0.6 percentage point a year. Between NFHS-3 and NFHS-4 we saw a improvement from 48% to 38.4%, roughly 1 percentage point a year. So there is definitely a slowdown in improvement and this is much below the goals set under Poshan Abhiyaan,” Dipa Sinha, an assistant professor of economics at Ambedkar University who is also associated with the Right to Food campaign, said. “We also know that in some states stunting has actually shown a reversal, so a more detailed analysis will be required. The other concerning findings in NFHS-5 related to nutrition are the increase in anaemia as well as the increase in overweight/obesity,” Sinha added.

“The findings on fertility decline are good news for maternal and child health and nutrition outcomes. However, the high fertility-high undernutrition states of Uttar Pradesh, Bihar, and Jharkhand still need to see more progress on fertility reductions – improvements in those high burden states are essential to move the all-India average for all outcomes,” said Purnima Menon, senior research fellow at the International Food Policy Research Institute. “The undernutrition improvements in UP and Bihar that are signalled in the NFHS-5 are also really promising and need deeper analyses to understand further,” Menon added.

Despite the government’s claims of at least two of its policy-level programmes achieving the targets of eradicating open defecation and ensuring a switch to clean fuel, gaps remain on both these fronts: 70.2% and 58.6% of households use an improved sanitation facility and clean fuel for cooking, respectively. These numbers still mark a huge improvement over data from the previous round of the survey -- 48.5% and 43.8%, respectively.

Other schemes such as promotion of financial inclusion and health insurance coverage seem to have worked well. The share of women who had a bank account they themselves use went up from 53% in NFHS-4 to 78.6% in NFHS-5. Similarly, health insurance coverage has increased from 28.7% to 41% (the NFHS-5 might not have covered the full gains of the central government’s health insurance programme, the ministry said) between NFHS-4 and NFHS-5.

The government is yet to release the full database of NFHS-5. Detailed all-India report and reports for the states and Union territories which were canvassed in the second round and the unit level data had not been released at the time of writing this story. This means that a disaggregated analysis by caste, wealth levels and religion, etc, is not possible at the moment.