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This article provides an overview on National Family Health Survey (NFHS 1 & 2).
Objectives of the National Family Health Survey 1 and 2:
The objectives of NFHS 1 and 2 are as follows:
1. The primary objective of NFHS-I was to gather information about fertility rates, trends in family size, demand for family planning devices, knowledge regarding family planning and various methods of family planning.
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2. To obtain information about breast-feeding and food supplement, non- desired fertility level, use of health services prior to delivery, etc.
3. To obtain information about child nutrition and health, vaccination, infant mortality and neo-natal mortality rates.
4. The other objective of NFHS-1 was to obtain knowledge regarding fertility rates, family planning and to know about socio-economic and demographic indicators of children’s and mother’s health.
5. The questionnaire used for NFHS-1 was the same for all the states. But in order to know about peculiarities of some states, some additional information about them was obtained. It related to question about tendency of people of Rajasthan for child-marriages, questions regarding knowledge of AIDS, sex-determination tests in Punjab, international migration from Punjab and Kerala were included in NFHS-1 questionnaire.
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6. The main objective of NFHS-2 was to provide estimates about birth rates, family planning system, infants and child mortality rates, health of mothers and children, and health facilities available to them.
7. To obtain information regarding status, education and living standard of women in society, health and family planning services, health problems of women and domestic violence and atrocities to them.
8. In NFHS-1, information about weight of children only was collected, while in NFHS-2 similar information about eligible women was also gathered.
9. To know about nutrition level of women and children in NFHS-2.
10. One objective of NFHS-2 was to test blood through Hemocu device to know about hemoglobin levels among women and children below 3 years and to know about incidence of anaemia in entire India.
11. To have an additional test in two metropolitan cities of Mumbai and Delhi in order to know about the levels of lead in the blood of children below 3 years.
12. An objective of NFHS-2 was also to known about the quantity of iodized salt used in cooking by families in India.
National Family Health Survey-1:
The National Family Health Survey-1 was undertaken in 1992-93, which was the first large demographic and health survey in India. It gave information about 89,777 married women of 88,562 families, who were in 13-49 age group. It covered 99 percent of total population of India in 24 states and union territory of Delhi.
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NFHS-1 was conducted uniformly in all the states except Kashmir, Sikkim and some small union territories. One of its features was that it gave estimates about rural and urban areas separately. It proved to be highly useful to Indian planners in taking decisions about demographic and people’s health.
The International Institute for Population Sciences (IIPS) of Mumbai was selected by the Health and Family Planning Ministry as a nodal institute for providing technical guidance and co-ordination for NFHS-1.
National Family Health Survey-2:
In the NFHS-2, about 90,000 eligible women from 26 states in 15-49-age groups were selected in the representative sample. It covered more than 99 percent of total population of India. The NFHS-2 was undertaken in two stages- November 1998 and March 1999 and was completed in June 1999.
It provided state level demographic and health data. It also gave information about the socioeconomic factors necessary to bring about derived changes in the prevailing demographic and health situation in India and also about the implementation of the programmes related to them.
NFHS-2 gave estimates about the rural and urban areas of almost all the states, regional estimates of 5 states—Bihar, Jammu and Kashmir, Madhya Pradesh, Rajasthan and Uttar Pradesh, and separate estimates for 3 metropolitan cities of Chennai, Kolkata and Mumbai and also for the slum areas of Mumbai.
A uniform pattern of questions, sample design and field procedure was adopted in NFHS-2 so that the available data could be easily compared and high quality data could be obtained. After the survey, the primary reports for all the states were prepared and were handed over to the planners and the authorities concerned with family planning and health.
The first All India Report of NFHS-2 was published in October 2000. In March, 2003,52 reports containing more than 6,000 pages were published which contained 20 Primary Reports, All India Reports, Key Finding Reports and 24 Final State Reports. All the reports covered 26 states including newly created states like Jharkhand, Uttaranchal and Chhattisgarh.
The NFHS-2 was provided financial assistance from ORC Macro, United States of American and United States Agency for International Development (USAID). It also got additional financial aid for nutrition survey from UNICEF. The Health and Family Welfare Ministry had appointed the International Institute of Population Studies (HPS) of Mumbai as the nodal agency.
The task of numeration of houses and data collection under NFHS-2 was entrusted to 13 well known Field Organisations (FOs) including 5 Population Research Centres. For Gujarat, Population Research Centre of Vadodara was selected as the Field Organisation. During the entire survey work, technical assistance was provided by ORC Macro, Calverton, Maryland, (USA) and East West Centre, Honolulu, Hawaii, (USA).
A contract was made with each institution selected by the HPS and the field organization was provided Rs. 575 per eligible women. In NFHS-1, this rate was Rs. 325. The incurred rate was due to rise in cost as well as the additional information that was to be collected, viz., blood test, salt-testing, measurement of weight and height. In NFHS-1, data about height and weight were not collected on a large scale.
The following table gives the number of questions regarding women in NFHS-1 and 2 about various types of status:
Its Findings:
NFHS-2 provided state level and national estimates of fertility, the practice of family planning, maternal and child health, availability and utilisation of health services etc. It also provided indicators of the quality of health and family welfare services, women’s reproductive health problems, and domestic violence, and information on status of women, education, and the standard of living.
(i) High Fertility Rate:
India’s population crossed the one-billion mark on May 11. 2000 growing from just under one quarter billion at the beginning of the last century. Almost two-thirds of India’s population growth in the 20th century took place after 1971 with the growth rate peaking in the period 1961-81.
Though the country’s overall total fertility rate (TFR) declined over the last two decades, it was still quite high at 2.9. According to the Survey, if the TFR declines to 2.1 by 2010 and remains constant, India’s population will increase by one and a half billion by the mid-century and continue to grow. Only if the TFR drops below 2, will the population size stabilise by 2050.
The high TFR was on account of a number of constraints. Despite increase in the use of contraceptives, only 48 per cent of the currently married women (age 15-49) were using contraceptives and female sterilisation dominated the contraceptive use. Despite desire on the part of young women to be able to space their births, spacing methods were not being widely promoted and used much by women.
Few women were given an opportunity to make an informed choice about the method that would best suit their needs. This was more so in rural areas. Besides, early marriage is almost universal in India, 37 per cent of women of age 15-19 were already married.
Women in the age group 25-29, almost all (94 per cent) were married. Almost one-quarter of women were married before the age of 15 and half before the age of 18. In Bihar, Rajasthan and U.R this ratio was much higher.
(ii) Regional and Socio-Economic Disparities:
The variation in the demographic and health status of the population in different states of India was glaring. States such as Kerala, Goa, Himachal Pradesh and Tamil Nadu were fairly advanced. Andhra Pradesh, Delhi, Maharashtra and Punjab were making good progress. However, Bihar, Orissa, Rajasthan and U.P. continue to lag far behind.
Even within states, there were large disparities between different socioeconomic groups. Rural areas lagged far behind urban areas. Scheduled-tribe populations, followed by scheduled caste, were distinctly underserved.
Similarly, religious groups differed greatly in their fertility levels, family planning acceptance rates, infant and child mortality, and utilisation of maternal and child health services.
In every state, special efforts were needed to reach rural women, illiterate and poor women, scheduled tribes women, who continue to be left out of the process of national development. Households with a low standard of living perform distinctly worse on most demographic and health outcome indicators than those having relatively high standard of living.
(iii) Literacy, Health and Nutrition:
Thirty-seven per cent of India’s population (age 6 and above) was still illiterate. Illiteracy was twice as high for rural areas (43 per cent) as for the urban population (20 per cent). Overall 49 per cent of females and 26 per cent of males were illiterate.
In rural areas, this ratio was 56 per cent and 31 per cent. Among population age 20-29, only 31 per cent had completed atleast high school. Though illiteracy was declining, it was still quite high.
Under nutrition among women and children continue to be a serious problem. More than one-third of women of age group 15-49 were undernourished (according to body mass index) and almost half the children under age 3 were underweight or stunted. The prevalence of anaemia among women and children was very high. More than half the women of age group 15-49 and almost three- fourth of the children of age group 6-35 months were anaemic.
These were disturbing findings which emphasised the need for stepping up social sector allocations at the national and state levels.
Merits and Demerits of NFHS-1 and 2:
The NFHS-1 and 2 are considered as the milestone in obtaining reliable estimates of demographic variable in India. According to Pravin Visaria and S. Irudaya Rajan, “NFHS is a precious asset for understanding demographic dynamics of Indian society.”
The merits and demerits of NFHS-1 and 2 are as follows:
Merits of NFHS-1 and 2:
1. The main reason for the success of NFHS-1 was that the interviewers were given a two weeks training by the HPS and Macro International. As the staff was more efficient, the data could be obtained in a better way.
2. The questionnaire of NFHS-1 was prepared after several meetings and workshops due to which some questions that were not included earlier could be included and all the questions were given detailed thought.
3. Some researchers of the Population Research Centres had undergone training in India and abroad so as to increase research efficiency of the centres during NFHS-1. Due to this, all the data obtained were highly reliable.
4. Another feature of NFHS-1 was that the Preliminary Reports were published within a year of completion of the survey, while the Final Reports were published within 2 years of completion of the survey.
5. A feature of NFHS-2 was that it included questions on domestic violence, reproductive health and quality of health care about the married women of 15-49 age group.
6. Questions like “After how many months of giving birth, they had sexual relations?” were asked to the women who had given birth to children before 3 years of the survey. Such questions are helpful in taking decisions about reproduction and health.
7. In NFHS-2, the questions regarding autonomy of women and domestic violence were asked for the first time. It was known through this survey that one out of every 3 women above 15 years had experienced domestic violence, which can be considered very serious from the point of view of women’s autonomy.
Examining state wise data on this, it was found that in Tamil Nadu, the percentage of women becoming victims of domestic violence was 40 per cent while the least was in Himachal Pradesh (6 percent). Comparing the extent of domestic violence with the literacy rates, it was found that in Tamil Nadu the extent of domestic violence is high even though the literacy rate is 64.55.
Of course, regarding autonomy, as compared to other states, and in Tamil Nadu, the women do not have to take permission for going to the markets or to friend’s house.
8. One thing is clear regarding India that no systematic information was collected by the various agencies about the tendency of people regarding health. The NFHSs collected information on habits like chewing tobacco, drinking liquor, smoking cigarettes, etc.
Such information helps the researchers and planners to know how far these habits are harmful to health and to take policy decisions regarding what steps are required to free the affected population from this addiction.
9. These two surveys help in understanding the socio-economic conditions of the Indian population. It is possible, for example, to know to what extent the Indian families are able to get the primary facilities and how many families are deprived of these? What is its extent in different states? What are the levels of availability in the rural and urban areas? What is the extent of child labour at the family level? What is the labour participation rate among the women? etc.
On this basis, the state governments can take policy decisions and administrative measures to implement them to bring about improvement in the socio-economic conditions of the population.
Demerits of NFHS-1 and 2:
1. One demerit of the NFHS-1 and 2 is that the expenditure made on them was much larger than that of the surveys conducted by the National Sample Survey Organisation (NSSO). This has been supported by Pravin Vesavia and S. Irudiya Rajan also.
The total expenditure on filling up one questionnaire of the NFHS was Rs. 1550 which was almost 4 times that of the NSSO, which was only Rs. 350. Even after spending this much, questions have been raised about the quality of some data.
2. Another limitation of NFHS-2 is that 2 years before this survey, the maternal mortality rate was 540 per lakh live birth at all India level, while 2 years before the NFHS-I, it was stated to be 424. This means that the maternity mortality rate had gone up in 1998-99 as compared to 1992-93. So the planners of NFHS-2 should have given due attention to this.
3. In NFHS-2, information regarding health of women and children was collected especially but comparatively the data regarding men are not given much attention. The survey is completely silent on the health of men and their contribution to family.
So, the NFHS should have been named the National Women and Child Health Survey, because it is a matter of concern that men are excluded from ‘family’. On this point, the NFHS states that when the investigator goes for filling up the questionnaires, men are mostly absent and so their opinion cannot be known.
But this argument is wrong because 40 percent of the questionnaires were filled up by the family members. It is hoped that in the NFHS-3, this limitation will be removed.
4. NFHS-2 spent Rs. 1550 per questionnaire. So the question arises – Is it necessary for a country like India to spend this much? Because the information collected through the NFHS is also collected by the NSS, Simply Registration System, Multiple Indicator Survey and Reproductive Health Survey.
As the same information is collected by these various agencies, sometimes their conclusions on some aspects are different. When the researcher or planner gets different information on the same aspect, he is a bit confused while taking policy decisions.
So one may suggest that there should be coordination between all the survey agencies, and subject and areas of the study should be selected beforehand and all the data collected by the agencies should be coordinated and integrated so that both time and money are saved and one gets reliable data, as there will be no multiple conclusions on one aspect of the study.
5. NFHS-2 underscored the need for giving high priority to poverty reduction and investment programmes by the centre and states that increase the access of households to basic amenities. There is need to further improve the coverage and quality of health and family services.