What is lost and gained in NFHS-6

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

Which indicators have been removed from NFHS-6?

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

The Union Health Ministry released the NFHS-6 Fact Sheets on May 29, covering the year 2023-24. The survey recorded data from nearly 6.8 lakh households from all states and union territories except Manipur.

Preliminary findings show clear gains on several measures, including mothers getting at least four prenatal visits, about seven percentage points more than the NFHS-5, increases in institutional births and women’s Internet use. It also points to declines in several metrics, such as exclusive breastfeeding of infants under six months, down nearly eight percentage points, and use of modern contraception to 52.7% from 56.4%.

The NFHS is commissioned by the Ministry of Health and Family Welfare, which commissioned the International Institute of Population Sciences (IIPS) to conduct the survey. Over the years, the scope of the survey has been designed to maintain the previous questionnaire and to supplement it.

NFHS-4 in 2015-16 introduced district level estimates and digital polling on tablet for survey collection. NFHS-5 took the indicators further, including new topics such as pre-school education, disability, toilet access, death registration, bathing practices during menstruation, and methods and reasons for abortion. It also expanded the measurement of blood pressure and blood sugar in adults aged 15 to 49 to all adults aged 15 and over. The survey measured 131 key indicators, compared to 114 in the NFHS-4.

While the HIV testing component was dropped from the NFHS-5, questions about HIV/AIDS knowledge, attitudes, prior testing, sexually transmitted infections, and sexual behavior remained. In NFHS-6, HIV biological testing was reinstated as part of the clinical, anthropometric, and biochemical testing plan.

The NFHS-6 fact sheet does not separately indicate whether all questions on HIV/AIDS knowledge and attitudes were retained.

NFHS-6 also added new questions on direct benefit transfers, self-help group membership, digital literacy and financial transactions. It also includes testing for hepatitis-B and hepatitis-C in males and females, as well as taking dried blood spots from children aged 4-5 years for hepatitis-B testing.

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

Why did anemia decrease?

The case for eliminating anemia has to do with how it was measured. The indicator showed a worsening picture for a long time. Between NFHS-4 in 2015-16 and NFHS-5 in 2019-21, anemia increased across the board. In children, the prevalence of anemia increased from 58.6% to 67.1%, in women aged 15–49 from 53.1% to 57%, and in pregnant women, anemia increased from 50.4% to 52.2%.

The increase in anemia was almost universal across the country, with childhood anemia increasing in 28 states and union territories and in some cases by a large jump, 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 Anemia Mukt Bharat campaign in 2018 to combat anaemia. The reason for discarding it as an indicator then boiled down to how the data was collected.

The NFHS measured hemoglobin from a fingerstick blood sample read on a portable analyzer, which several nutrition researchers say overestimates anemia compared to venous blood taken by other surveys. The IIPS dropped the anemia questionnaire when the NFHS-6 field survey began in 2023. The official position is that the condition will now be tracked separately through a specialized Diet and Biomarker Survey within the National Institute of Nutrition using a method that its proponents believe is more accurate.

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

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

According to organizers, it also built on nutritional deficiencies and tracked obesity along with anemia, for the first time. For anemia, data was collected from venous blood instead of the finger prick method used by the NFHS. Data collection is complete but not yet published.

What other changes have been made?

A line-by-line comparison of the two fact sheets from NFHS-5 and NFHS-6 shows that the net decrease of 30 actually combines 43 decreased and 13 added indicators. Several launches have been long-term streaks, and several are closely related to government signature programs.

Prime Minister Narendra Modi’s government announced in 2019 that India would go defecation-free. NFHS-5 noted that 70% of the country’s population lives in households with access to sanitation facilities. This data point has also been cancelled.

The proportion 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.

Three mortality rates – newborn, infant and under-five – have also been reduced, but these will be tracked by the sample registration system, whose latest bulletin puts the infant mortality rate at 24 per 1,000 live births.

However, the registration system does not carry district-level data and socio-economic breakdowns that are available in the NFHS.

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

A few of the changes are redefinitions rather than cuts. Individual ownership of a house or land by women has become a household-level measure. The hepatitis B three-dose line became the benchmark for birth doses, and preschool attendance shifted age bands to target younger demographics. IIPS has not released the rationale for the broader list.

Together, the removals leave no up-to-date national survey-based data on infant mortality, sanitation coverage, sex ratios at birth, cancer screening rates, or comprehensive knowledge about HIV, gaps that no other source fills at the same scale.

How have survey results changed between NFHS-5 and NFHS-6?

The NFHS-6 reported a drop in the number of women who experienced spousal violence down to 22.3% from 29.3%. The number of stunted children under the age of five also decreased. The decline from NFHS-4 to NFHS-5 was just under three percentage points, but NFHS-6 saw a decline of more than six percentage points.

Changes at the state level are sharper for some indicators.

Health insurance increased the most in West Bengal, from 33.7% households in NFHS-5 to 88.2% in NFHS-6. Internet usage by women saw the largest increase in Andhra Pradesh, from 21% to 63.6%. Haryana saw the steepest decline in exclusive breastfeeding among infants under six months, from 69.5% to 41.2%. In every state, the proportion of women classified as obese or overweight increased.